Welcome to 2013!

Every man should be born again on the first day of January.  Start with a fresh page.  Take up one hole more in the buckle if necessary, or let down one, according to circumstances; but on the first of January let every man gird himself once more, with his face to the front, and take no interest in the things that were and are past.  ~Henry Ward Beecher

The Old Year has gone.  Let the dead past bury its own dead.  The New Year has taken possession of the clock of time.  All hail the duties and possibilities of the coming twelve months!  ~Edward Payson Powell

We will open the book.  Its pages are blank.  We are going to put words on them ourselves.  The book is called Opportunity and its first chapter is New Year's Day.  ~Edith Lovejoy Pierce

One resolution I have made, and try always to keep, is this:  To rise above the little things.  ~John Burroughs

Merry Christmas!

Gifts of time and love are surely the basic ingredients of a truly merry Christmas-Peg Bracken

There has been only one Christmas, the rest are anniversaries-W.J. Cameron

Quick Math

Mr. P., an 82 year old, has insomnia.

"It makes for a long night, doesn't it?" I said.

"It sure does. I try to pass the time by counting all my money and savings in my head. It's just that I don't have a whole lot and can finish in a few minutes," said Mr. P. (as he laughed).

Not so common lately

Calvin E. Stowe (1802-1886) was an American biblical scholar who is quoted as saying, "Common sense is the knack of seeing things as they are and doing things as they ought to be done."

It's amazing how one short sentence can offer such wisdom.

Old faithful

Mr. M. let me know that he would never try to be intimate with the women who sleeps in his bed at night and helps him throughout the day because he has never cheated on his wife.

Mrs. M., his wife of over 60 years, is his 24/7 caregiver.

As his dementia became more advanced, Mr. M. started to think that Mrs. M. is just a women who is there to help him. He's not sure what happened to his wife.

Mrs. M. gets a little teary eyed talking about it but she also realizes he was always good to her and never gave her any reason to think he was being unfaithful. In some ways he has more than confirmed that he has always been a "good man."

I agreed.

Good thinking

Mr. M. has advanced dementia.

He was sitting back in a recliner with two, three year old, chiwawas by his side on my arrival-one sitting on his chest and the other between his legs.

I finally asked him their names.

"Come here," said Mr. M..

Before I could ask any further questions his wife let me know they weren't given "official" names because of his poor memory.

"He just calls them come here. They never leave his side."

"Come here makes perfect sense," I said, "but are they at least come here 1 and come here 2?"

"No, just come here," confirmed his wife.

I smiled, Mrs. M. chuckled and Mr. M. sort of laughed.

All involved sure seem to be content.

Good advice!

THE WINTER OF MY LIFE

You know. . . Time has a way of moving quickly
And catching you unaware of the passing years.
It seems just yesterday that I was young,
Just married and embarking on my new life with my mate.
And yet in a way, it seems like eons ago,
And I wonder where all the years went.
I know that I lived them all...
And I have glimpses of how it was back then and of all my hopes and dreams...
But, here it is... The winter of my life and it catches me by surprise...

How did I get here so fast? 

Where did the years go and where did my youth go?
I remember well...
Seeing older people through the years and thinking that those
Older people were years away from me and that winter was so far off
That I could not fathom it or imagine fully what it would be like...
But, here it is...
My friends are retired and getting grey...
They move slower and I see an older person now.
Some are in better and some worse shape than me...
But, I see the great change...
Not like the ones that I remember who were young and vibrant...
But, like me, their age is beginning to show and we are now those
Older folks that we used to see and never thought we'd be.


Each day now, 
I find that just getting a shower is a real target for the day! 
And taking a nap is not a treat anymore... it's mandatory! 
'Cause if I don't on my own free will... I just fall asleep where I sit!
And so, now I enter into this new season of my life unprepared
For all the aches and pains and the loss of strength and ability
To go and do things that I wish I had done but never did!!


Yes, I have regrets.
There are things I wish I hadn't done...
Things I should have done, but indeed,
There are many things I'm happy to have done. 
It's all in a lifetime...
So, if you're not in your winter yet...
Let me remind you, that it will be here faster than you think.
Whatever you would like to accomplish in your life, 
please do it quickly! 
Don't put things off too long!!
Life goes by quickly.  So, do what you can today,
As you can never be sure whether this is your winter or not!
You have no promise that you will see all the seasons of your life...
So, live for today and 
say all the things you want your loved ones to remember...
And hope they appreciate and love you for all the things
You have done for them in all the years past!!


Life is a gift to you.


The way you live your life is your gift to those who come after.
Make it a fantastic one.


~ And, Remember ~


"It is health that is real wealth
And not pieces of gold or silver."
~Author, Unknown

Sandy Hook post script

twas' 11 days before Christmas, around 9:38
when 20 beautiful children stormed through heaven's gate.
their smiles were contagious, their laughter filled the air.
they could hardly believe all the beauty they saw there.
they were filled with such joy, they didn't know what to say.
they remembered nothing of what had happened earlier that day.
"where are we?" asked a little girl, as quiet as a mouse.
"this is heaven." declared a small boy. "we're spending Christmas at God's house."
when what to their wondering eyes did appear,
but Jesus, their savior, the children gathered near.
He looked at them and smiled, and they smiled just the same.
then He opened His arms and He called them by name.
and in that moment was joy, that only heaven can bring
those children all flew into the arms of their King
and as they lingered in the warmth of His embrace,
one small girl turned and looked at Jesus' face.
and as if He could read all the questions she had
He gently whispered to her, "I'll take care of mom and dad."
then He looked down on earth, the world far below
He saw all of the hurt, the sorrow, and woe
then He closed His eyes and He outstretched His hand,
"Let My power and presence re-enter this land!"
"may this country be delivered from the hands of fools"
"I'm taking back my nation. I'm taking back my schools!"
then He and the children stood up without a sound.
"come now my children, let me show you around."
excitement filled the space, some skipped and some ran.
all displaying enthusiasm that only a small child can.
and i heard Him proclaim as He walked out of sight,
"in the midst of this darkness, I AM STILL THE LIGHT."

Written by Cameo Smith, Mt. Wolf, PA

It's beginning to sound a lot like Christmas

Check out this flash mob when you get a chance:

http://www.youtube.com/watch_popup?v=Vnt7euRF5Pg&vq=medium

Gold exchange

Mr. P. is 83 years old and still has a great sense of humor.

As I was getting ready to leave his home he wanted to remind me of something:

"You know how everyone says these are supposed to be my golden years. I'm learning real quick that they are only the golden years for the doctors. They get to take all the gold from us old folks."

He laughed and so did I but it's also sad...but often very true.

"Y" Oscar?

Oscar is a morning fixture at the Crosby YMCA every morning.

The local television station ran a short segment on him today.

Here's the site:

http://www.cfnews13.com/content/news/cfnews13/news/article.html/content/news/articles/cfn/2012/12/14/_93_year_old_inspire.html

I always used to ask him how he could get to the "Y" so early everyday (by about 5 AM).

"It's easy," he says, "I've been up since 3:30 AM."

Good answer.

He's a friend to all and an amazing man.

Won't forget the picture, will you?

Mr. O. is sure to find some nail particles around his living room for some time to come.

The living room was the room he choose to have his toenails clipped for the first time in a couple of years yesterday.

I did my best to keep the clippings from flying away but every once in a while I would hear a piece landing a second or so at a distant site after the "snap" of the clippers.

He had onychogryphosis, also known as Ram's horn nails.

It's a tough word to remember.

It's easier to remember of picture (this was not my patient but was very similar):

Simple pleasures

Mr. O. has been bed bound for awhile.

I spent part of our visit trimming his toenails that hadn't been cut in a very long time.

My nurse had given me a heads-up and I was able to borrow a heavy duty pair of clippers from the podiatry department before going to his home.

Mr. O. is a very ill man with multiple medical problems.

There's no cure or hope for significant improvement for most of his medical concerns.

Cutting his toenails, however, sure seemed to make his day.

Seeing how thankful he was to have such a simple thing done sure made mine.

None for me

The months issue of Men's Health is packed full of Christmas ideas:

The RoadID is a rubber bracelet worn by an individual who runs and "may get into trouble" because of distracted drivers, loose dogs, chaotic intersections and the unknown. It has all your identifying information, I gather, so that if you are down and nonverbal, the driver who accidentally hit you can identify you when, hopefully, he/she calls for help.

Fresh Balls is a product for men designed specifically to relieve the moisture and uncomfortable feeling of sweaty balls (I'm not kidding). It's recommended to be part of your daily grooming routine (www.freshballs.com).

Finally the Cocksox looks like bikini underwear but reports to being great support for sports while supplying ultimate comfort (www.cocksox.com). The advertisement doesn't  mention sizes available but I would suspect most men would only want it ordered in large, even if they didn't need it.

I don't run outside (it didn't say it was recommended for walking outside), I've never had the sweaty balls concern (or at least been uncomfortable by it), and I've never liked constricting underwear.

Maybe the next issue will have some other ideas?

A change of heart

A car with darkly tinted windows yesterday was stalking me, for my parking space, as I walked to my car.

I hate the feeling although I had to admit that the spot I was getting ready to vacate represented the only soon to be open spot.

I said various curse words under my breath.

I had an armful of things-briefcase, two cell phones, beeper, notebook, etc..

I accidentally drop everything prior to getting into my car.

I cursed out loud and gave the driver of the car stalking me my meanest look.

I thought I picked up everything.

About an hour later I realized I didn't have my wallet.

I returned back to the office.

I looked in and around the car that had taken my place.

Finally I stopped at the security desk of the building.

My wallet was there-all contents intact and accounted for.

My arch-enemy car stalker had turned it in.

I no longer cursed this individual.

I was pretty darn thankful!

Hold on to them there teeth!

Ever wonder why dentists work so hard to help patients retain their natural teeth for as long as possible? Would not it just be better, in many patients with poor teeth, to just pull them all and replace with full dentures?

Full dentures have only 10% the chewing power of natural teeth, and it’s difficult to get them to fit satisfactorily, particularly in the lower jaw (mandibular arch). Even if a patient retains one tooth, that will contribute to the denture’s stability. However, retention of just one or two teeth in the upper jaw does not contribute much to the overall stability of the denture, since a full upper denture tends to be very stable, in contrast to a full lower denture. It’s thus advised that patients keep their natural teeth as long as possible, especially their lower teeth.

I sort of find this information interesting, don’t you? I’ll end here to go floss.

1/2 man

Mr. B. is only 63 years old but he remarks that he is half the man that he used to be, and then laughs.

He had bilateral above the knee amputations due to severe peripheral vascular disease during his late 40's.

He kept me laughing during most of our visit together.

He may be half a man but he appears to have a better outlook on life than most complete men I come across these days.

He clearly doesn't sweat the small stuff.

In fact, he let me know he thinks it's weird that he only sweats on the upper half of his body.

Yup, he then let out a hearty laugh again, and so did I.

Organized to a fault

95 y/o Mr. F. knows he's a hoarder but he doesn't like to think in those terms.

He prefers to call it "pride of possessions."

The only furnishings in his one bedroom apartment are a recliner, one bureau, two desks and a stool (where I sat).

The rest of the apartment is basically floor to ceiling home made shelves with carefully marked and stacked plastic containers and isles just wide enough to walk through.

I so wanted to ask his permission to take a picture but it would not have done it justice.

He seems to know exactly where everything is located.

Even screws are boxed according to length-listed both in inches and millimeters.

I reached for my pen to write a note and realized I had left it in my car.

No worries-right next to the recliner-that serves as his day chair and his bed-were 5 containers marked 1.Pencils 2. Black ink stick pens 3. Blue ink stick pens 4. Click pens and 5. Felt tip markers.

I guess he thought I looked like a click pen sort of guy.

As I was using it I couldn't help but ponder what year it might have been made.

Welcome to the poo

There was a sign near the front door of the home of Mr. P..

"Welcome to the Zoo."

I could hear dogs barking once I rang the doorbell.

Once inside I met the three border collies, three cats, and periodically ducked as the two cockatiels, who had free reign of the house, flew by.

Mr. P. had a good size spot of bird droppings on the left shoulder of his T-shirt.

It didn't seem to bother him so I wasn't going to let it bother me.

Mr. P. was happy, in relatively good shape given his assortment of medical problems and all nine inhabitants of the home seem to get along well together.

I did find a mirror on my return to the office, however, to make sure I was poo free after my visit to the zoo.

Early TV death?

Researchers from the University of Queensland report that for every hour of TV watched, after age 25, life expectancy dropped by 22 minutes. By comparison, smoking one cigarette reduced life expectancy by 11 minutes.

Those who watched the most TV a day-six hours-lived 4.8 years less than those who watched none.

One letter to the editor questioned if it’s just a coincidence that for every hour of TV, approximately 22 minutes are advertisements.

So…if/when enjoying a night of relaxation watching TV, every time a commercial comes up, drop to the floor and do some push-ups, sit-ups or run in place. Just don’t run to the kitchen for more snacks (my recommendation only).

Reference: Br J Sports Med doi:10.1136/bjsm.2011.085662

NEAT

Cumulative exercise throughout the day contributes to weight loss in significant ways. Science supports a concept called NEAT-non-exercise activity thermogenesis-the number of calories we burn when we’re not eating, sleeping, or doing sustained exercise. NEAT includes every movement you make, from momentary activities like bending over to tie your shoes and gesturing during conversations to conscious activities like walking a few more blocks and taking the stairs instead of the escalator/elevator.

I've been wearing loafers less often lately and untying/tying my shoes a lot. I think I've might have dropped a 1/2 pound already!

Wise owl

Mr. F. is 95 years old.

He is a wealth of information and clearly loves to reminisce.

After serving in the military he went to a trade school.

He then had a very successful career in the construction business.

He wanted me to know that he had come across "a lot of very smart people over the years who were not very wise."

I decided to just listen and not talk very much during our time together.

It was a good choice for a couple of reasons:

1. He was quite hearing impaired so it was easier to listen than to try and get him to understand what I was saying

2. He wouldn't have any significant information on me to know if I fell into the smart but not very wise category

A right thumb holder?

I ordered a pair of L.L.Bean 5-pocket jeans today from their catalog.

I'm sure I would have ordered them if they were only 4-pocket jeans as well.

It got me thinking...what's the purpose of the 5th pocket, the tiny little pocket, usually just inside the upper right front pocket?

Do you know?

Have you ever put anything in it other than a thumb?

I'm not kidding

My wife and I ventured out for the first time today for some Christmas shopping together.

We took a fairly long drive to go to a Dick's sporting goods store that was having a good sale.

It was right next door to a BJ's warehouse store.

Obviously, we shared a laugh together concerning the names of the two stores.

I'm sure we weren't the first but it didn't matter.

It made our "Black Sunday" outing a little more memorable.

Mind preservation

Mrs. N. recently spent some time in a Nursing Home to rehabilitate after heart valve replacement surgery.

"I sure don't want to spend any more time in a Nursing Home," she said. "It's depressing and embarrassing to sit around all day waiting for your 1/2 hour of therapy next to people who have lost their minds. Men and women sitting around saying the same things over and over again holding baby dolls, combing and stroking the hair on the dolls. It's OK, I guess, if you've already lost your mind when you get there. I was pretty sure I was going to lose mine if I didn't get out of there as soon as possible."

She's 83 year old, back home and still of sound mind.

Life extenders

A VA research study has concluded that loneliness can shorten your life.

"Psychological stresses brought on by loneliness, including anxiety and depression, can boost heart risks," the author of the study noted.

Why is it that some folks stay single and unattached their whole life?

I'm not really sure but I suspect some spend so much time trying to find the perfect match that they always think something better than they currently have is just around the corner.

Andy Rooney once stated that "no one is perfect until you fall in love with them."

He also stated that "life is like a roll of toilet paper. The closer it gets to the end, the faster it goes."

And finally, he noted that "no matter how serious your life requires you to be, everyone needs somebody to act goofy with."

I couldn't agree more.

My wife fills that role.

I'll have to let her know she may be extending my life.

Maybe she'll be less annoyed with me once she finds out!

Two reasons

My son had a few away soccer games this past week.

We got home late all three nights.

One morning I decided to change my routine and sleep-in until 6:30 AM but I forgot to tell my wife.

My alarm went off seconds before hers.

I was still in bed.

"Geez...you're home (said with clear utter disappointment in her tone)?"

"Well good morning to you also," I replied.

Later she let me know her response was due to 1. thinking she had another hour to sleep since I usually get up at 5:15 AM and 2. having to share our bathroom for the "morning routine."

We laughed.

I understood.

Walking the talk?

The daughter of a patient of mine said the following:

"We re-elected the devil, what's wrong with all the people who voted for him, our country is going down the drain."

At the conclusion of our time together I thanked her for everything she was doing for her father. I let her know that many others would not do the same in caring for him at home due to the complexity of his medical condition.

She replied,"It's all in Gods hands. In everything I do, and in everything that happens in life, I just always remember that God is in control."

I decided to not re-visit her first statement about the devil but I did ponder it on my drive back to the office.

Even worse?

A daughter of a patient of mine made the following statement:

"When my son went off to college he was a happy, Christian, all-american boy. When he graduated 4 years later he was an angry, agnostic, alcoholic man. Even worse was that I paid for it to happen."

I wasn't sure what to say at the time.

On reflection, I think she could have left out the "even worse."

Veterans Day

A Veteran is someone who, at one point in his/her life, wrote a blank check made payable to The United States of America for an amount of  ‘up to and including my life.’

Aging and risk for heart disease

A study conducted in Denmark, by the University of Copenhagen, has linked heart disease to six signs of aging: baldness at the crown of the head, receding hairline at the temples, gray hair, wrinkles, earlobe creases and fatty deposits around the eyes.

The study concluded that the presence of visible signs of aging signaled an increased risk for heart attacks and heart disease.

What a shocker (I'm being sarcastic)!

I haven't done a research study on the topic yet but it also seems to me, from my experience, that heart disease is also probably linked to cataracts, hearing loss, decreased muscle mass, love handles, arthritis and erectile dysfunction.

Here's my own conclusion: The older a person is, the greater the risk for heart attacks and heart disease.

So here comes the big question: is it best to allow your doctor to see your visible signs of aging or to undergo hair transplants (for balding and receding hair), dye your hair, and see a dermatologist or plastic surgeon to correct the wrinkles, earlobe creases and fatty deposits?

I wonder if a person who uses Grecian Formula might sue the hair dye company for making it harder for his doctor to consider if he might have heart disease?

Maybe a warning will need to be put on the products?

Warning: the use of hair dye might make it harder for your doctor to know if you have heart disease. Use at your own risk. You should notify your doctor, and anyone else you are trying to fool into thinking you are younger than you really are, if you are using a hair dye product.

A good start to the season

The high school soccer season started this past week.

The WPHS boy's team got some coverage from a local sports network:

http://www.cfnews13.com/content/news/cfnews13/sports/article.html/content/news/articles/bhsn/2012/11/9/oviedo_and_winter_pa.html

There's also a video link on the same page.

Only 1 out of 4

Mr. R.'s daughter showed me a few pictures from June 18, 2011.

It was Mr. R.'s 90th birthday celebration.

He appeared to be the picture of health: socializing, singing and dancing.

She reported that at the time he was still walking 2.5 miles and doing 200 push-ups a day.

Unfortunately, he fell in February, 2012 and sustained a left hip fracture.

A year and a half later he remains significantly disabled.

Hip fractures are never a good thing in the elderly.

Within the year after a hip fracture, 25% have died, 25% remain in a long term care facility, 25% are home but disabled and only 25% have returned to close to the activity level and functionality as prior to the fracture.

Only 1 out of every 4 return to close to their baseline.

Mr. R. was always the picture of health and loved to exercise.

Unfortunately, it again confirms the statistics.

A small estate

A lot of housing developments around here use the word "estates" in their title.

The most common definitions of estates (as pertaining to real estate) are:

1. A extensive area of land in the country, usually with a large house, owned by one person or organization and 2. An area or amount of land or property.

I drove by "Leisure Estates" yesterday-a complex of single wide mobile homes for those 55+. It's an example of definition #2:

A double-take sign

I went to a Assisted Living Facility (ALF) today that was in a rural area.

The sign at the entrance had the following quote under the name of the ALF:

"You deserve the best but we are the best"

I decided not to ask any staff about it but pondered the wording on my way back to the office.

I'm fairly certain the "but" should have been an "and."

Once they realized the error maybe they got a discount and decided to keep it as is?

Maybe I'm the first person to question the wording since they opened for business in 1997?

Maybe they did it on purpose so folks like me would ponder it awhile and not forget their name?

I'll just ask someone next time I visit.

Unhappily ever after

Mr. and Mrs. Z. are both 78 years old.

They have known each other since they were 12 and started dating when they were 14.

They have been married for 58 years.

They both profess to having dis-liked each other for years. In passing, they even mention to hating each other.

When asked if they have ever considered a divorce they both state, almost in unison, "of course not, we've been this way for years!"

Some would ask why they have stayed together this long. They wonder how they possibly could have "wasted" their life together.

They raised 5 children, have a boat load of grandchildren and a few great-grandchildren.

They have a house crammed full of family pictures and memories.

I've come across a lot of adults who never married and never had children who would, in retrospect, preferred to have wasted their life like Mr. and Mrs. Z..

From your nose?

A staff member called to let me know she had been vomicking all night.

I've heard this term by many patients over the years; just never by a health care professional.

I just always assumed they were substituting for the word vomiting.

It's listed in the urban dictionary however:

"The act of spewing forth your stomach contents from your nose"

So, if/when I hear this word in the future I'll make sure to ask the follow-up question: "Did you vomit out of your nose?"

If/when someone answers in the affirmative, I'll be sure to ask the next question: "Why?"

There should be NO reason why anyone would prefer the nasal route to the oral route, unless of course you're vomiting and vomicking at the same time.

Those folks will have my undivided attention and empathy.

Happy Halloween!

I've been busy lately but do need to find time to get a haircut when possible.

My staff is saying I look like Weird Al lately-I don't understand why?

A devastating 1

Hurricane Charley occurred in August 2004 (shown below).



By the time it crossed central Florida (and my town) it had luckily weakened somewhat to a category 1 storm with winds at just over 90 MPH.

I witnessed the destruction that a category 1 could cause (winds of 74-95 MPH).

Before experiencing this I probably would have said "only" a category 1. After all, the rating system goes all the way up to a 5 (winds of greater than 155 MPH).

I haven't said "only" a category 1 since 2004.

My thoughts are with a lot of family and friends who live in the path of Hurricane Sandy tonight (currently a category 1).

I'm hoping for the best possible outcome.

Wanting to give Zoots the boot

Mr. G.'s history lesson continued.

"I was sort of black-balled in the business industry for a number of years because I wore a Zoot Suit (a men's suit, that became popular in the 1940's, with high-waisted, wide-legged, tight cuffed, pegged trousers, and a long coat with wide lapels and wide padded shoulders) and so did my friends."

For some reason, I just nodded and in doing so, pretended I knew what he was talking about.

Some quick research revealed that due to the amount of material required to make Zoot Suits, the U.S. War Production Board said that they wasted materials that should be devoted to the World War II effort. It was considered unpatriotic in wartime and was a factor in the Zoot Suit Riots.

The U.S War Production Board was in operation from 1/16/1942 until it was dissolved in 1945 (just after the surrender of Japan).

It was given the task of regulating the production of materials and fuel during WWII.

It would seem that their concern regarding the Zoot Suits arose during a time when, for whatever reason, they had a lot of free time on their hands.

If not, and if they were still operating today, think how busy they would be given today's style of clothing.

Good advice

"Harboring resentment and bitterness is like drinking poison and expecting somebody else to die. Forgive."

Author unknown-have seen it attributed to more than one person

Grandi sapori (tastes great)!

Mr. G. is in his late 80's.

He grew up in Rochester, NY.

He reported an Aunt and Uncle started the Ragu company many years ago in Rochester.

"Ragu," by the way, means meat sauce in Italian.

He reported taking bottles to different shops around town on the back of his bicycle and leaving them there on consignment.

When their stock increased, which was mainly dependent on the number of bottles they could obtain, he reported often helping his Uncle sell them from the trunk of his car.

It was quite a story with remarkable details because, obviously, he was there.

He does have some cognitive impairments, however, so I decided to do some fact checking on my return home.

Sure enough, information available on the internet reports "in 1937, on the streets of Rochester, Giovanni and Assunta Cantisano, their son Ralph and relatives started selling their homemade Ragu brand door-to door."

Mr. G. was 11 years old in 1937 and was a relative.

Unlike President Obama and Governor Romney during the Presidential debates, all his facts checked out.

I'm also sure he has had his fair share of amazing Italian food over the years!

Feeling kicked in the groin

I saw the big billboard again today on the interstate that advertises "Vasectomy: No-Scalpel and No-Needle."

I was finally able to see the website address so I checked it out this evening.

Under the technique section are the following lines:

"An anesthetic solution is injected with a tiny needle to numb the scrotal skin and the vas tubes if the topical spray-on anesthetic is not adequate."

"The Dr. uses the No-Scalpel technique, exposing each vas in turn through tiny openings in the frontal scrotal walls. The tiny openings are made with a pointy hemostat."

"Once each vas tube is lifted through the small skin opening, it is divided under direct vision with fine surgical scissors. The ends of the divided vas are then placed out of alignment by applying a tiny clip to the sheath surrounding the vas."

I think the ad needs to be changed to the following:

"Vasectomy: No Scalpel (Pointy hemostat, Surgical scissors & Tiny clips only)and No-Needle (unless a tiny needle is needed for better anesthesia)."

I had a Vasectomy back in the Scalpel and Needle days.

The surgery, for me, wasn't the painful part.

The post-op feeling of being kicked in the groin for a few days was the most memorable part for me.

Oh yeah, I forgot!

The daily calender, inside an elevator, at an assisted living facility lists "Vespers: 7 PM."

This will sound pretty lame but I asked my wife, on my return home that night, what she thought vespers meant.

"For Pete's sake," said my wife, "you grew up Catholic!"

"It's evening worship Dad, evening prayers," said my 18 year-old son.

"Oh yeah, now I remember."

I grew up Catholic and also took three years of Latin in junior high school.

It derives from the Latin word vesper which means evening.

Honestly, however, I was never a Catholic Latin scholar, so I told my wife and son to only start worrying about my memory if/when I can't remember what evening worship or evening prayers means!

Impressive stacks

Mr. B. loves stacks.

At least that's just my initial observation.

I only spent a very brief time in his apartment the other day.

He preferred to talk in a common area of the senior complex where he lives.

The stacks were impressive-most were one and a half to two feet in height.

Stacks of unopened or previously opened cigarette packs; also VHS tapes, CD's, cassette tapes, and records were all neatly stacked throughout his apartment.

It was definitely a "you need to see it to believe it" type of thing.

I couldn't help but wonder the time involved to retrieve, for example, a tape at the bottom of a stack.

I'm sure he has a very orderly way of taking down and then rebuilding the stack effected.

I suspect he recognizes it's odd and that's probably why he doesn't want folks to spend a lot of time in his apartment.

Most of us have some minor OCD issues that we deal with on a daily basis.

He's a stack man.

Time efficient Rosary

Mr. G. has been saying the Rosary everyday for, he estimates, the last seventy years.

"How long does it take you to get through it?" I asked (I grew up Catholic but couldn't remember).

"I've got to where I can do it in 26 minutes," he replied.

"Wow," I said, "you sure talk fast."

"I need to, I'm not sure how much time I have left (he laughed)."

Here's some quick math:

26 minutes/day OR 9490 minutes/year OR 664,300 minutes over the course of 70 years

There are 525,600 minutes in a year so he has spent 1.26 years of his life saying the Rosary.

He's 86 years old, cognitively intact and, obviously, still has a great sense of humor.

It appears to be time well spent.

http://www.theholyrosary.org/

Paper endorsement

The Orlando Sentinel recently announced their pick for president:

http://articles.orlandosentinel.com/2012-10-19/opinion/os-ed-endorsement-president-mitt-romney-101912-20121018_1_trillion-deficit-reduction-plan-mitt-romney-obama-s-republican

A classic with a nonfunctional convertible top

Mr. G. is an amazing 86 y/o man.

One of his concerns is that he has a phimosis-a condition, in uncircumcised men, where the foreskin cannot be fully retracted over the glans (head) of the penis.

He had seen a urologist who recommended a circumcision.

Mr. G. wasn't so sure.

He had not been sexually active for over 7 years since his wife died.

"What's your understanding of a phimosis?" I asked.

"The way I look at it, my convertible has become a hard-top. I've just got to decide if I want to have the roof permanently removed (he laughed)."

"It's got to be a tough decision for you since you've been riding the same car for the last 86 years (we both laughed). It's not an emergency. We can discuss it again the next time I see you but let me know if you have any problems before then as well."

He agreed.

His classic remains intact for the time being.

Your blessings are appreciated!

It's an odd tradition in English-speaking countries to say "God bless you" whenever someone sneezes. There are various theories as to the origin. The reason I was given, when growing up, was because your heart stopped beating when you sneezed-this is false by the way! "Gesundheit," the German word for health makes more sense. It just doesn't roll off your tongue as easily as "God bless you" and to be perfectly honest, I never knew how to spell it until a few minutes ago. I think I'll stop here and just continue to rack up as many blessings as possible. I sneeze pretty darn often. I'm a blessed man.

Up in smoke

This is a picture of Winnie Langley using the candles on her 100th year birthday cake to light yet another cigarette:



It's been estimated that she smoked more than 170,000 cigarettes in her lifetime and outlived her husband, son and 10 step-children. She died one month shy of her 103rd birthday.

I suspect she also outlived most of the healthcare professionals who advised her to quit over the years as well.

The picture makes me smile.

Quality time

Yesterday was a beautiful day-perfect, weather-wise.

It was the last game for my son's fall club soccer season.

It may be his last, ever.

High School try-outs start tomorrow and he's not sure if he will play for his club team in the spring.

He likes being a goalie but few would ever consider it to be a fun position.

Next year, he's off to college.

My wife and I have spent many a weekend traveling to and from games for him.

It's potentially another last for us as well.

It's something all involved parents are faced with and need to accept.

Folks without children often have a hard time understanding the amount of time invested into children.

It's sometimes even harder to explain to them why you would possibly miss spending most of your free time taking your kids to and from his/her chosen sports/hobbies.

Down and out

One of the Nurse Practitioners I work with let me know that an 81 year old patient of ours ended up in the Emergency Room last night.

One of his two malleable Penile Prosthesis Rods had fully dislodged (come out).

I don't have any further details yet.

No clue to as if it became dislodged before, during or after being called into action or if it just worked it's way out while hanging around.

It doesn't really matter.

Regardless, it's a very bad day for this poor fellow and he's sure to be down and out for at least awhile, if not permanently.

Shown below is an example of the Penile Prosthesis Rods that are placed when a male selects this form of intervention for Erectile Dysfunction-it's not something I could ever accept but many do. If and when the time comes that I would need to ponder such a device, I think I'll just consider this one part of my body to be retired.

TV Krispies

"What seems to be the problem," asked the cable repair man.

"I'm not sure what you call it but the picture on the TV periodically gets scrambled and snaps, crackles and pops (and I immediately felt even stupider basically describing my poor TV reception as Rice Krispies).

"OK, let me check some things out."

"I found the problem," he said a short time later, "things look fine now. The signal was getting lost in an amplifier in the attic and I replaced it. You shouldn't have problems with pixelization anymore."

Pixelization.

Cool word.

It's actually a technique used primarily for censorship.

Makes sense...it just that we weren't watching anything that should have been censored.

The Golden rule

Al (Mr. V.) has advanced Parkinson's disease.

Many family members, neighbors, health care professionals and even church friends have advised Mrs V. to place him in a Nursing Home.

She politely declines.

"I may not have all the certificates and degrees of a nurse but nobody can take care of Al like I can take care of Al. I've seen a lot of Nursing Homes. They do the best job they can under difficult circumstances but I would never want to live in one, would you? If they're not good enough for me, they're not good enough for Al."

I nodded in agreement.

I could have said "Amen!"

What...something to cut health care costs?

Some drugs remain effective well beyond expiration date:

"Twelve of 14 compounds analyzed met government requirements for potency up to 40 years after the drugs' expiration dates, according to a study published in the Archives of Internal Medicine. Requiring drug makers to base expiration dates on long-term stability tests could save consumers money and help alleviate drug shortages, said researcher Lee Cantrell. However, the findings do not mean that ALL drugs are safe or effective past their expiration dates." 

Saving money, alleviating drug shortages-I suspect the above information is not music to ears of many Pharmaceutical companies!

http://www.reuters.com/assets/print?aid=USBRE89712R20121008

Priceless!

Usually when other adults find out that my daughter is an Equestrian I get asked the same question, "Isn't that expensive?"

The simple and honest answer is "yes (but then again so are a lot of other things)."

But when I catch a glimpse of her posting these pictures on her Facebook page from the National Finals show from three weeks ago...

... with the words "the greatest experience of my life so far," it's, as the commercial says, Priceless!

Where everybody knows your name

Mr. K. lives at an assisted living facility (ALF) "out in the country," in Tavares.

It's a beautiful part of Florida and only about 30 miles outside of Orlando.

There's a noticeable difference in all business. It makes me want to go inside and start looking at name tags to figure out who the owner is. I can honestly say I never have the same urge at the big chains. Here's a quick sampling of the area around where Mr. K. lives, compared to Orlando.

Orlando: 7-11, Publix, Chilli's, Outback, Friday's, Denny's, Terminex, Re-Max, Century 21, U-Haul Storage Center

Tavares: Jimmy's General Store, Scott's Country Market, Charlie's Grille, Billy's Cafe, Mary's Kountry Kitchen (spelled exactly that way), Shelley's Exterminator and Septic Service, Lou's Realty, Bob's Self Storage         

She walked the talk to the very end

"You matter to the last moment of your life, and we will do all we can, not only to help you die peacefully, but live until you die," said Dame Cicely Mary Saunders, widely acclaimed as the founder of the modern day hospice movement.

Well stated!

Dame Cicely died of cancer at the age of 87 (in 2005), at St. Christopher's Hospice, the hospice she founded.

Tap, tap, tap

I saw an 82 y/o patient today who had a positive Myerson's sign.

The inability to resist blinking when tapped repetitively on the area above the nose and between the eyebrows constitutes a positive sign.

A positive Myerson's sign can be seen with Parkinson's disease as well as early dementia and other progressive neurological illnesses.

I'm sitting here chuckling over the thought of some who are going to try and find a mirror to test themselves after reading this.

Stop blinking!

WAW

The Orlando Sentinel reports: police arrested four suspects in Sunday's fatal shooting of three members of the Warlocks motorcycle club. The shooting occurred at the VFW post in Winter Springs.

Officers quickly detained 12 people, including four men identified as members of the "Philly" Warlocks, who were later charged with the multiple counts of murder.

A search of the dozen detainees and the parking lot recovered 13 firearms, 23 knives and other weapons.

The Florida Warlocks insignia is a symbol of a Phoenix rising from the ashes as their national symbol. Their mottos (according to Wikipedia) include: "our business is none of your fuc-ing business," "To find us, you must be good; to catch us, you must be fast; to beat us, you must be kidding,"and "Warlocks forever, forever Warlocks." Their colors are Black, Red and Yellow.

The "Philly" Warlocks insignia is a Harpy, a legendary winged creature in Greek mythology best known for constantly stealing all food from Phineus. I won't record their motto here. Their colors are Red and White.

The paper reports that men representing a Warlocks chapter in Philadelphia arrived in Central Florida several months ago and planned to start their own chapter.

Obviously a turf battle was looming,

All involved appear to have been well armed Warlocks (WAW).

All the men ranged in age from their late 30's to early 50's.

Unfortunately, I suspect similarly aged members from both clubs will be getting newspaper reports, and obituaries, in the weeks to months ahead.

Merci!

I had a patient recently who had extreme flexion of the thoracolumbar spine that was partially relieved by support  and completely relieved by lying down. The pictures below are not of my patient but he looked very similar.

The term for this clinical finding was on the tip of my tongue but I couldn't remember it until I got back to the office to look up.

Camptocormia, how could I possibly have forgotten?

We can all thank Alexandre-Achille, a French neurologist for the term.

To be honest, however, I'm not sure how long I'll remember this time.At least I'll have a quick reference for the next time I forget by looking here.

The pictures below are from the article "Parkinson's disease: clinical features and diagnosis," by Professor J. Jankovic.

Another Big C

The CDC has recommended that every American born between 1945 to 1965 get tested for exposure to hepatitis C, which can lead to liver damage and liver cancer.

There are multiple reasons why those born in this age group are at risk including the sexual revolution and drug use experimentation.

I was born in 1959.

I don't have either of the risk factors noted above but I was in medical school from 1981-1985 and Universal Precautions were not firmly adopted until about 1987-1988. I had many exposures to patients blood and body fluids during the course of medical school and residency training.

Fortunately, I've always tested negative.

The test  for antibodies to hepatitis C did not become readily available until the mid 1990's.

It's estimated that if all baby boomers were tested, more than 800,000 infections would be detected. It's also estimated that 120,000 lives could be saved.

That's a lot of saves!

Huff, The Magic Dragon

Mr. L., a 63 y/o, finally admitted to huffing.

Huffing is a common term used for inhalant abuse.

The staff at the Assisted Living Facility (ALF) where he lives had suspected possible abuse.

I previously went to see him there and he did have glue and computer-cleaning duster products around his room BUT he was also a hobbyist with a room full of electronic parts, old computers and models.

He denied huffing.

I believed him.

Last week he was literally caught by staff members with the straw of the computer-cleaning duster up his nose.

He admitted to a problem.

He didn't even try to convince the staff there was some dust up his nostril that needed to be cleaned.

Like most chemical addictions (difouroethane in computer-cleaning dusters), it's a pathetic way to spend your life.

We will try to get him some help but I'm not sure what the success rate will be in terms of long term abstinence.

If I can't find any data, I'll have to take a straw poll from some addictionologists.

Could have been a costly "No"

In 2002 the Skene's gland in a female, also known as the paraurethral gland, was officially renamed the female prostate by the Federative International Committee on Anatomical Terminology.

I graduated from medical school in 1985.

I've always been proud of the fact that I've kept up with continuing medical education over the years.

I can honestly say I was not aware of this change until today.

I wouldn't have even thought to use a "life-line" if I was on a game show and was asked "is there such a thing as the female prostate?"

I would have said "NO!"

I could have lost a lot of $$$.

Love is in the air

It's love bug season season again. My car looked like the cartoon below after returning from seeing a patient in the Daytona beach area today. The August-September emergence is called the summer generation while the April-May emergence is the winter generation. The adults only have a life span of 3-4 days. The males prefer the larger and heavier females. When coupled the male faces the opposite direction (backwards) and after a courtship of  only 1.5-10 minutes (with no eye contact!) begins copulating. When coupled and copulating they disperse. After dispersing the male dies and the female deposits as many as 600 eggs under decaying leaves or grass before also dying. It's such an odd life cycle. The larval and pupal stage for the winter generation takes 8-9 months (3-4 months for the summer generation) before becoming an adult to have sex for three or four days (or less when they smash into the windshield of your car) before dying. They have had many nicknames over the years: honeymoon fly, kissing bug, double-headed bug, etc.. I think I'll just start referring to them as "CCD" bugs: coupling, copulating and die bugs.

Have you ever spent time punding?

In researching an article on Parkinson's disease, I came across an interesting term: punding. Learn something new everyday!

From the Urban Dictionary-Punding : Punding is human activity characterized by compulsive fascination with and performance of repetitive, mechanical tasks, such as assembling and disassembling, collecting, or sorting household objects. For example, punding may consist of activities such as: - Collecting pebbles and lining them up as perfectly as possible, - Disassembling doorknobs and putting them back together again, People engaging in punding find immersion in such activities comforting, even when it serves no purpose, and generally find it very frustrating to be diverted from them. Punding is the result of dopamine overactivity. It is commonly associated with side effects of drugs used against Parkinson's disease and with the use of methamphetamine (in which context it is known as tweaking), which increases dopamine release and blocks its uptake. In Parkinson's Disease it can be cured by lowering the medication dose, or adding (atypical) antipsychotics, which act by counteracting the effect of dopamine. Punding is also similar to behaviors associated with autism.

Twenty years!

My wife and I have been together since 1989 (groovy shorts and glasses back then!). Tomorrow we will have been married for twenty years. It's a good thing she said yes before my metamorphosis started. I think most guys can relate. I'm a lucky guy!

Just one of many

My son had a club soccer game this past weekend.

I know one of the Dad's from past club teams as well as from our sons playing on the same high school team for the last couple of years as well.

"Is your son looking forward to the high school season?" I asked, knowing our boys are now seniors.

"Justin isn't sure he is going to play this year," said the Dad, "He's got a part-time job and I think he might use it as as excuse to not play this year. He hasn't really wanted to play soccer since the 8th grade but his Mother and I would never let him quit."

"Oh, that's understandable," was all I could of saying at the time.

Afterwards, I thought a lot about what he said.

It just seems so odd or such a foreign idea to me to make your kids do something they don't want to do when it comes to extracurricular activities.

It's got to be hard for a teenager to figure out what his/her passion might be if/when you are being forced to do something you really don't want to do for years.

Actually, it's sort of sad.

Even sadder is that there are probably quite a few Justin's out there, all stuck in the same predicament.

The game of Life

Here are the latest life expectancy statistics for the United States:

Life expectancy at birth: Overall 78; Male 76; Female 81.

We're ranked 38th as compared to other Countries.

Japan is 1st: Overall 82; Male 79, Female 86 but there is some speculation that their data may be faulty (infant death being counted as stillborn, for example).

Regardless, there's not a huge difference among the top countries.

Greece is ranked number 20. Their overall life expectancy is just one year greater than ours at 79.

So what's the point.

Well, occasionally I overhear in depth discussions on how we need to improve the diet of, for example, a 92 year old male.

My viewpoint is that they should probably just continue whatever it is they have been doing up until now.

They have already won in the game of life (expectancy).

If they consume a huge bowl of ice cream every night my advice is simple: Continue to consume a huge bowl of ice cream EVERY night!

It's Elementary

I ran into Jim, a friend, last night.

He and his wife had recently dropped their 18 y/o son off at college and were about 4 hours into their 8 hour drive back home.

Their son called his wife's cell phone.

He left a message before she was able to answer it.

"I've made a mistake, I don't want to go to college here. I feel sick, nauseous. Please come back and pick me up. I want to come home and go to college locally."

"What should we do? " asked his wife.

"Turn off your phone," said Jim.

They drove the rest of the way home in silence.

Jim has been an Elementary School Teacher for over twenty years. He's well versed in dealing with separation anxiety.

Their son called back about a week later. They saw it was him and answered.

"Thanks for not coming back to pick me up," he said, "I think I'm really going to be happy here."

I'm sure Jim and his wife had their best night of sleep in a week.

A Spiritual snooze

In the midst of looking through some hospital records I read a chaplains note that gave me a brief chuckle.

I'm easily amused.

"Stopped by and visited with patient today and said prayers at the bedside together. The patient's theological position was respected at all times and no effort was made to proselytize. The patient was sleeping soundly."

Here's my interpretation: "Stopped by and visited with a patient who was sleeping today and said prayers at his bedside, along with God. I did not wake the patient to ask his faith or try to convert him to my faith. A good time was had by all."

All dried up

I was sworn in today to give testimony in a court proceeding.

The last time I was sworn in was in 1986.

At that time, I could barely speak, I was so nervous.

I have vivid memories of how badly my voice was cracking.

I also remember the waterfalls coming from my armpits.

Neither happened today.

It's one advantage of getting older.

Either my confidence is much better OR my "fight or flight" nerves have down-regulated and my axillary sweat glands are drying up.

Either way, it was a total bonus!

I don't want to be a foreskin!

90 y/o Mr. H. grew up in a household where a lot of Yiddish was spoken.

We talked a lot about his past, including a very interesting social history.

He has had a wide assortment of experiences and, in the midst of our conversation, mentioned he has come across a number of "schmucks" and "menschen" over the years.

A quick check in a Yiddish dictionary, on my return to the office, allowed me to be more informed.

A mensch is a good person, a person of integrity and honor. 

A schmuck is a prick, that portion of one's penis which is cut off during circumcision (the foreskin), a moron, an idiot, an obnoxious, contemptible or detestable person or one who is stupid or foolish.

I'm sure hoping he won't describe me as being a schmuck if any family members inquire how our visit went!

Needed: raiders of the lost art

Mr. K. is 78 years old.

He converted his garage into an art studio years ago and it's pack full of his beautiful drawings-pencil and water color (many framed, others not).

He lost count of the number years ago.

I would estimate easily in the few 100's.

A few years ago he exhibited many for a month at the local City Hall. Many of the drawings are from sites around town.

He's a widower. They had no children. He reports no living relatives.

He mentioned that he suspects whoever buys his house, when he dies, will just throw them all away.

He would love for them to be passed on.

I gave him some ideas on how to try to distribute many of his "master pieces" before he dies.

I hope he will look into some of the ideas.

I'll have a social worker see him to assist as well.

They belong on walls, not a dumpster.

Risky business

This weekend I received a notification (through the mail) from a drug company about a new indication for a medication.

The medication Truvada is now indicated for pre-exposure prophylaxis, in combination with safer sex practices, to reduce the risk of sexually acquired HIV-1 in adults at high risk.

Included in the information was also about a four page list of the side effects and warnings of use.

High risk individuals are defined as those who have sexual partners known to be HIV-1 infected or engaging in sexual activity within a high prevalence area or social network and one or more of the following: inconsistent or no condom use, diagnosis of sexually transmitted infections, or exchange of sex for commodities (such as money, food, shelter, or drugs), use of illicit drugs or alcohol dependence, incarceration, or partner(s) of unknown HIV-1 status with any of the factors listed above.

Wow, that's quite a list.

Honestly, it makes me sort of queasy. Not because I have a problem caring for or treating high risk patients. It's just because my son just turned 18 this weekend and he goes to college next year-my daughter the year after.

I just hope/pray that neither will ever become a high risk individual.

All parents can empathize.

W cubed

There have been a number of recent new articles and reports about a medical condition called Normal Pressure Hydrocephalus (NPH), and other conditions, as being misdiagnosed as Alzheimer's disease.

The reports emphasize that in 30% of the time, doctors get it wrong, saying a patient has Alzheimer's when the patient really does not.

There's a specific treatment available for NPH that helps in some cases.

The big three to remember for NPH are: dementia (memory concerns), ataxia (trouble walking) and urinary incontinence-also more easily remembered by the phrase "wacky, wobbly and wet (W cubed)."

Other conditions include small silent strokes, depression, vitamin deficiency, medication side effects or alcoholism.

This is good stuff to consider and for you to remember...if your memory is still intact!

Happy 84th

My Dad (shown holding his granddaughter, Ellie, in 1996) would have been 84 years old today. He died in 2001. Parkinson's disease adversely impacted a good many of his adult years but I hope I have been able to teach my kids close to the many life lessons he taught us over the years. Probably the biggest was to always treat others as you would want to be treated. He was a very good man.

Aging ink

I had a funny thought today. What will folks, who decided to get so many tattoos, body piercings and hubcaps done when they were young adults, be saying years from now? Sure enough, some cartoons seem to say it all:

Batman and Robin

My son, Tom, is 18 years old today. He just finished the last section of his college application for next year. The superhero days, with his sister Ellie, seems like yesterday:

A picture is worth a thousand words

My daughter has been away since this past Monday.

It seems a lot longer.

It's always sort of sad to meet folks who, for whatever reason, are estranged from their children; often for decades.

I saw Mr. L., a 63 y/o, who has not seen his daughter or son for over 35 years.

He reports he and his wife had an unpleasant divorce.

She had custody and he had visitation rights but a job forced him to re-locate to Florida.

The last few times he saw his kids he felt as if they had turned against him and then days turned into months and months turned into years without any contact.

He had a number of pictures on a wall in his room at the assisted living facility where he now resides due to having had a stroke.

He informed me they were pictures of his daughter.

He found her on Facebook and luckily her pictures were not "blocked" for him to see and copy (some choose not to only allow their 'friends" to see the pictures that are posted).

He got a little teary eyed when he talked about her but he was also smiling while stating what a beautiful woman she is.

They were really nice pictures.

My poo is not worthy?

A treatment which involves the transplantation of human waste, to treat cases of C. difficle infection of the colon, continues to periodically be in the news.

C. difficle overgrowth is a bacterial infection that can lead to severe cases of colitis and has been linked to deaths as well.

C. difficle is usually kept in check by "good" bacteria in the bowel. Problems usually arise when a person is treated with strong antibiotics for an infection in the body. Sometimes the good bacteria are killed and the C. difficle is then able to flourish and cause symptoms.

The procedure involves getting a close relative of the patient, such as a sibling, to donate several days worth of stool. If the sample is negative for certain diseases, it's then mixed with saline to create a liquid feces that is administered through an enema or a colonoscope.

It brings up a question: How would the stool donor feel if he/she is told his/her sample is not acceptable?

A colleague stated he/she would just need to be told that "you're not worth a poop."

Now that's got to be a pretty bad day!

Finally there

My daughter Ellie and her horse Blues are at the Nationals this week in Upstate New York.

They have had an amazing year. They're entering the finals ranked third and 6th in their two events.

Regardless of how they do, it's an awesome accomplishment to be a top ten qualifier in both events.

I've always referred to Blues as our "JC Penny Thoroughbred (he was considered a bargain when we bought him)."

They competed all year long against some "Neiman Marcus Thoroughbreds."

They have been an amazing team since the first time they met and obviously bring out the best in each other.

No price could ever be attached to that fact.

Petite Red

I've crossed paths with some folks named "Big Red" over the years.

All have been tall, burly men with red hair.

I saw Mr. D. in his home recently.

He had old framed pictures scattered around his bedroom.

The first one to capture my attention was a picture of his boat named "Big Red."

"Big Red," I said out loud.

"I named the boat after my wife (who died a few years ago), " he said.

Honestly, my first thought was that he had been married to a tall, full figured woman with red hair.

I then noticed other pictures around the room of him with a VERY petite woman but whose red hair added about another foot to her height.

I knew I was looking at "Big Red."

Her nick-name was perfect.

Day at the Museum

Mr. M. seems to save everything.

He lives alone.

His three bedroom home is packed full of stuff.

It's pretty cool to look around and take it all in.

He's only 9 years older than me, so it brings back a lot of memories: different types of clocks, stereos and turn-tables, records, 8-track and cassette players, different types of musical instruments, black and white and console TV's, etc..

It's all very well organized.

There's plenty of room to walk around.

I wouldn't use the word "hoarder" to describe it all.

"You sure have a lot of stuff in your home," was all I could think of saying.

"My father, before he died, always said my home as like a museum. I've always bought real good quality things and I've always tried to keep them in real good shape. I'm just not sure what will happen to it all when I die because I don't have any children."

"I'm not sure either but you have a lot of history in your home. There has to be collectors or museum curators out there who will really appreciate what you have accumulated here in your home."

"Your dad was right. Your home is a museum."

A white out

Mr. R. could be described by some as being a "grumpster."

He's 92 and he's got a full head of white hair.

He hit me with a few zingers the last time I went to visit him.

My favorite was the following:

"You look as old as I do. What can you possibly do to help me at your age. Can't I be seen by a younger doctor?"

I laughed.

He didn't.

I'm only 52, but in his defense, I also have a full head of white hair.

Double stone planning

I spent some time recently with Mr. and Mrs. R..

They're both in their 90's and have been married to each other for the last ten years; a second marriage for both.

I asked if they had given any thought to end-of-life issues.

Mrs. R. responded, "You bet, it's all taken care of. My ex-husband is buried in Kentucky. When he died we bought a double (head) stone and plot. Mr. R. also has a double stone and plot where his wife is buried near here. Neither of us were expecting to end up married again. We decided when we got married to be buried next to our first spouse. They're both already paid for. There's no reason to spend any more money than we need to spend."

I actually wasn't expecting this answer but it made sense.

The purpose of my question was to inquire about advance directives (living wills, etc.).

It took me a second or two to get my thoughts together to carry on with my initial intended discussion.

Have a great Labor Day!

"A mind always employed is always happy. This is the true secret, the grand recipe, for felicity." Thomas Jefferson

Definition of felicity (added so I'll remember years from now): the state of being happy, especially to a high degree; bliss; a source of happiness

The lucky ones

Connie is a certified nursing aid who has worked for Mrs. L., a 95 year-old, 8 hours/day, 6 days a week, for the last 5 years. She does the daily routine for Mrs. L.: bath, exercise intermittently through-out the day, dress for the day, prepares breakfast, lunch and dinner, oversees medications, runs errands for groceries and to pick up supplies, cleans and does a load or two of laundry, and dresses for bed. She lives in the same housing complex as Mrs. L.. Mrs. L. called her after seeing an advertisement Connie had placed in their club-house. They agreed on a price of $10/hour 5 years ago. Although Connie knows she has earned a raise, she has never asked for one because she knows Mrs. L. is financially strapped. She also takes a lot of pride in her worked and knows Mrs. L. would not be able to stay home without her. She also arranged for a friend to come the one day of the week she's off.

Kesha, also a certified nursing aid, has worked for Mrs. O., a 61 year old home-bound patient, for the last 3 years, 6 days a week, 6-8 hours/day. A "friend of a friend" hooked them up. Kesha refers to Mrs. O. as "Mom." Her daily duties are very similar to those of Connie. They agreed on a price of $10/hour three years ago. Many others have tried to hire her to work for them, but Kesha would never think of leaving "Mom." She arranged for another woman to come in on the one day she isn't there, but only has her do the basics. Kesha is very particular about things like wound care dressings, etc., and only wants to do it herself.

Mrs. R. lives in a retirement community. She's 78 years old and has severe degenerative joint disease. She needs help but can't seem to find anyone she can afford. She has called multiple home health agencies but the lowest price she has been quoted for a nursing aid is $24/hour.

Connie and Kesha don't work for an agency.

The agencies pay their nursing aids about $10-12/hour. They tack on a 50% administrative fee.

That's the part that most folks have trouble paying.

Only a few are lucky enough to have found a Connie or a Kesha.

Go ahead, make my day

A colleague recently started to read this blog.

He sent me a simple note: "Bill, I have to say your blog is amusing, touching, and insightful. I hope you have lots of readers."

All three terms used, in the first sentence, are exactly why I enjoy writing. I enjoy humor, I enjoy reflecting on patient encounters and I enjoy putting these reflections down on paper. The social interactions with patients and the ability to witness how resilient most folks are has always been the most enjoyable and uplifting part, for me, of my chosen profession. It's a privilege.

I can't say the second sentence is true and that's OK. I've always told anyone who enjoys writing to just go ahead and start without having an expectation that anyone will read what you write. If/when they do, and drop you some feedback, however, it's much appreciated.

Almost zero growth for a change

Having lived in Florida since 1993, I've driven through some towns with odd names: Cadillac, Christmas, Festus, Frostproof, Early Bird, New York, Sopchoppy, Wacahoota and Two Egg, Florida to name a few.

This past week I drove through Okahumpka, Florida.

How was the town named?

Some quick research shows the name derives from an Indian term for "lonely or bitter waters."

The most recent census in 2010 reports a total population of 267.

The previous census in 2000 reported a total population of 251.

Only 16 people were added to the census in the last ten years!

Maybe that's what the forefathers who named the town planned all along...a town that never grows!

To steal (and alter) a line from a great movie, The Field of Dreams, "If you name it Okahumpka, they will not come."

Or maybe, it's just too lonely there and the water really is bitter!

Medicines cheesy future?

The Cheesecake Factory and possible ways to enhance medical care in the future seems like an odd combination. Take the time to read the attached article from The New Yorker. It's long but excellent:

http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande

A rural health food stand

I drove through a pretty rural part of Florida today on my way to see a home-bound patient.

A few miles before the turn-off for her home there was a roadside stand.

The offerings included (there were home-made signs about every 20 feet, for 2 miles, before the stand):

* Tomatoes
* Sweet peaches
* Boiled P-nuts
* Gator jerky

I didn't stop coming or going but had a thought.

If they would make it a Gator jerky sandwich and serve it and all the other offerings with a glass of milk, they would cover all 5 food groups (vegetables, fruits, protein, grains and dairy).

Maybe I'll put a copy of this blog entry into a bottle and toss it out the next time I head up that way and pass the stand.

I'm sure they would really appreciate my suggestion.

Confession of a narcotic over-prescriber

I graduated from Medical School in 1985.

Here are some of the reasons I was so accepting of narcotic use for the treatment of chronic noncancer pain (CNCP) starting in the late 1990's.

      * The World Health Organization developed the 3- step ladder for cancer pain relief in 1986 (over time it became widely used for the treatment of all types of pain).

      * A study of 10,000 dying patients published in 1995, in JAMA, in which researchers found that almost half of the patients died in severe pain.

      * In 1998, a working group in Congress was established to examine what role the federal government should play in alleviating pain and in other end-of-life issues.

      * Position statements by various organizations that usually included a summary statement such as: “narcotics are underused and have low addiction potential when used for CNCP.”

      * Numerous CME conferences for catch-up education. No "ceiling dose" for narcotics was emphasized. I remember how impressed I was at one particular case study in which an elderly woman was taking over 1000 mg of morphine/day, for severe DJD,  and remained functional and independent.
      * Mini-fellowships for the treatment of pain became available. In the early 2000’s, a colleague became a "pain specialist" after spending 4 days with a pain team.
      * There was little noticeable support for primary care providers in the early days.
      * Private pain clinics appeared in abundance. For awhile, there were more pain clinics than cash-advance shops or pawn shops around our city.
      * Non steroidal anti-inflammatory (Vioxx, etc) and acetaminophen (Tylenol) scares.
      * Delays in obtaining many complimentary services (PT, pain anesthesia) and the unavailability of many other services (chiropractic, massage, etc.).

So, fast forwarding to now.

A quote by Maya Angelou is very appropriate: “I did then what I knew how to do; now that I know better, I do better.”

The efforts by various authors/educators have been very helpful, including an article this month in American Family Physician: Rational Use of Opioids for Management of Chronic Nonterminal Pain.

The efforts by Physicians For Responsible Opioid Prescribing (PROP) are also greatly appreciated.

One member, Jane Ballantyne MD, a pain specialist from Seattle, WA has stated, “we started on this whole thing because we were on a mission to help people, but the long term outcomes for many patients are appalling, and it’s ending up destroying their lives.”

I now have access to vastly improved pain management services.

As a Primary Care Physician, it feels as if the pain cavalry has finally arrived.

A full day of activities

I recently went to see a patient who was living in an Assisted Living Facility.

In many locations, around the facility, they had the weekly activity calendar.

I grabbed one on my way out.

Here's a sampling of just one day's activities (this is from a Tuesday). I added my thoughts in the ( )'s:

8 AM: Car Detailing (I wonder if folks without a car can join in?)
9 AM: Blood Pressure Checks in the Activity Room (I wonder if they'll be doing an activity at the same time?)
9:30 AM: Coffee Social (it's good to wait until after the blood pressure check)
9:45 AM: Aqua Fitness with Mindy-meet at the pool (good thing they clarified "the pool"-someones tub might have been crowded)
10:30 AM: Stretch and Flex with Myriam-Dining Room 2 (I guess Mindy is still water-logged)
11 AM: Meeting for Residents with Power Chairs (sort of sounds exclusionary to me unless it's just to discuss all the scuff marks on the walls)

1 PM: Wii Bowling with Myriam (seems like a reasonable post-lunch activity)
2 PM: Yahtzee with Myriam (I love Yahtzee!)
2:30 PM: Scrabble with Merry K (can folks with dementia bring a dictionary?)
3 PM: Dominoes with Merry K (sounds like fun!)
3:30 PM: Jackpot Bingo with Myriam (1. Myriam's a busy lady! and 2. what's the jackpot?)
4 PM: BYOB (bring your own booze or own body?)
6:15 PM: Bridge (I sort of remember Bridge games causing some arguments for my parents and their friends from years ago--->see 7 PM activity)
7 PM: Bible Study (to give thanks for the day and to ask for forgiveness for any arguments that may have occurred during the days activities)

Man, I'm ready for bed...what about you?

I bet it's a lot of fun

I'm usually pretty good with clues...

So after the third car sped past me on the interstate today, with the passengers wearing customes and the cars deck out with slogans and memorabilia, I knew someone was up.

Sure enough, a quick internet search announced that "Star Wars Celebration VI" was taking place in Orlando this weekend.

The site does remind anyone interested that the celebration doesn't have a permanent home-instead it travels around the world to avoid imperial detection (that sure was reassuring!).

It's been a 4 day event with guests including Mark Hamill (Luke Skywalker), Carrie Fisher (Princess Lela), and many others.

Some of the other events include: collectors showcase, fan tables, a costume pageant, Star Wars laser tag, a Star Wars Tattoo Pavilion, and for those consenting adults, a Star Wars speed dating event.

It would have been a fun thing to check out but for probably just part of a day.

"May the force be with those who are attending!"

Time is money

Mrs W. is 95 years old.

She married a younger man 65 years ago. Mr. W. is only 91 years old.

They have had paid nursing aids 14 hours a day, from 8 am until 10 pm, 7 days a week, for the last 4 years.

They also know they are very fortunate because they "only" pay all $10/hour.

They found all their help privately, without the use of a managing service/company. Costs would be close to double what they currently pay if they had.

The math is easy to do-$140/day, $980/week, $4200/month.

They also have the other usual expenses-water, lot rent for their double-wide home, food, medications, etc..

Mr. W. reports to being a worry-wart.

He really "stresses over finances."

He's worried they will run out of money.

It's a valid concern...they report both sets of their parents lived to be greater than 100 years old.

I'll assume they might

My son goes to college next year; my daughter the year after.

"During the first few weeks of college, students, especially freshman, are at highest risk of alcohol-related harm. We see a spike then because anxiety is high, and the rigor of course work hasn't yet taken hold," said Michael Cleveland, researcher at Penn State's Prevention Research Center.

"Every year, college drinking leads to 1,825 deaths among students age 18-25, according to the college task force report to the National Institute on Alcohol Abuse and Alcoholism. Drinking also contributes to 599,000 injuries, 696,000 assaults and 97,000 cases of date rape on college campuses each year."

Man...those are some scary statistics, especially for parents who were sure an alcohol related incident would never involve their child. I can't imagine their grief if/when they have to attend their child's funeral...every parents worst nightmare.

I've got great kids who have made great choices to date. However, I won't pretend that they won't possibly experiment some while in college. I'll emphasize that if they do, I just hope (and pray) they will do it responsibly.

I'd rather assume they might and be wrong, than to assume they won't and be wrong!

Reference: Drinking Spikes As Freshman Taste Freedom At College-the Orlando Sentinel