Friday, May 31, 2013

Over 800 caps and gowns

I always found it sort of odd that my son did not know all the kids in his high school class (obviously I went to a much smaller high school).

But it made complete sense after looking down at all the graduates yesterday from the balcony during the graduation ceremony:

That's one big A__ class!

Thursday, May 30, 2013

The prostate be continued

From the Orlando Sentinel:

"Prostate cancer is a disease many men die with, not of.

No good study shows that PSA testing saves lives. However, much evidence exists to indicate that men who get treated have a high incidence of infection, incontinence and impotence. They also have a 1.5% chance of death from treatment.

Last month the American Urological Association raised its age guidelines for PSA tests from age 40 to age 55. After age 55 it's recommended that men make an informed decision about the potential benefits versus the harms of biopsy and surgical side effects.

A local urologist disagrees. "What's lost in the debate is that we're taking away a man's right to know he has prostate cancer.""

And there we have it. Another perfect example of why we far and away lead the world in health care dollars spent but are 13th in the world in quality of life ratings and 37th in the world in life expectancy.

Wednesday, May 29, 2013

Be slow to talk

It's high school graduation for my son.

We had an event last night: the Baccalaureate.

We ran into parents we hadn't seen for years.

With many I could just say,"hey, it's great to see you," and they would proceed to give me the full update on their kid (scholarships earned, what great school they are going to for college, if they had been accepted into the honors program, etc., etc.).

It seemed like many wanted a "can you top this type of discussion."

I've got a great son but I kept relatively quiet.

It just didn't seem like an appropriate time to brag.

My wife was surprised and actually quite pleased with my behavior for the night.

Hopefully it will be more of the same tomorrow for the actual graduation day!

I'll do my best.

Monday, May 27, 2013

Painful steps

Mr. M. is 60 years old, 5'9" and weighs 493 pounds.

His BMI is 72.8.

He wishes (and actually needs) to have an elective surgery performed.

He was told by the Plastic Surgeon that he requires a BMI of 38 or below before he will be a candidate for the surgery.

He will need to get down to 258 pounds or less-he needs to lose 52.3% of his current body weight.

I'm not sure he really has any idea just how difficult a task this will be to accomplish.

I decided that now was not the time to remind him of that fact.

He needs to just take one step at a time-even though each step is painful due to his severe knee arthritis.

Memorial Day 2013

Much thanks to ALL active duty servicemen and Veterans!

Saturday, May 25, 2013

Stroke, stroke!

An athlete is defined as a person possessing the natural or acquired traits, such as strength, agility and endurance that are necessary for physical exercise or sports, especially those performed in competitive contests.

A coxswain, on a crew team, is the person in charge of navigation and steering. The literal meaning is boat servant.

We have an acquaintance who has a relative who is a coxswain. My wife and I overheard a conversation in which this person was going on and on about what a great athlete her relative had become since becoming a coxswain.

So the question arises: does a coxswain fit into the currently accepted definition of an athlete?

Clearly it's even a source of contention among the coxswains.

One internet company sells T-shirts with the logo, "I do not look like an athlete, but I am a coxswain on a crew team."

It's a wonderful life!

Mr. B. is 93 years old.

Two years ago (at age 91) he fell out of a bed, during a stay at a rehab facility, after his third major cardiac surgery. He broke a hip and continues to walk slowly and only with the assist of a walker.

Litigation against the facility is ongoing. A settlement has been offered but not accepted by the family's lawyer.

Over the years, prior to this surgery and fall, he had suffered two heart attacks, three strokes, had a partial colectomy for colon cancer, had been diagnosed with prostate cancer and had major orthopedic intervention after two serious car accidents.

His wife feels the fall was a result of negligence on the part of the facility and that "his life has been ruined" as a result of the fall.

I did my best to appear empathetic.

Thursday, May 23, 2013

Heavy genes

Here's a good short article from 2009 on obesity. It emphasizes empathy and understanding. For many, being obese represents much more than a lifestyle choice.

Wednesday, May 22, 2013


Mr. C. wanted to let me know that there are only two types of people in the world. "Those who are Italian and those who want to be Italian."

"Why," I asked.

"Because we (he was Italian) have the best skin, the best looking woman, the best food and the best music."

He's 83 years old and has advanced dementia.

I just nodded to show I agreed (I love Italian food!).

He smiled.

Friday, May 17, 2013

The Necco king!

Mr. W. is now 93 years old.

He's from Massachusetts and has been a life-long Necco Wafer lover.

He can't remember when he hasn't eaten close to a roll a day.

Necco stands for New England Confectionary Company and the wafers, it's core product, were first produced in 1847.

During the Civil War they were carried by Union soldiers and were referred to as hub wafers.

They were renamed Necco wafers in 1912.

Each roll of Necco wafers contains eight flavors: lemon (yellow), lime (green), orange (orange), clove (purple), cinnamon (white), wintergreen (pink), licorice (black) and chocolate (brown).

My favorite has always been the black.

Mr. W. doesn't have a favorite.

His daughter has a lot on her mind as his caregiver but luckily has found a local store that makes sure to keep the Necco's in stock now that Mr. W. lives with her in Florida

He currently has a plastic bag with rolls on his bedside table-it looked like at least a two week supply.

Thursday, May 16, 2013

The computer sees nothing!

Mr. C. is 86 years old and had a stroke years ago that left him completely paralyzed on his left side-his left arm and leg are atrophied and contracted.

I received a follow-up note from a cardiologist who had seen him recently.

Under the general physical exam section it noted that "no sensory abnormalities were noted and no motor dysfunction was seen."

There are only two possible explanations:

1. The cardiologist examined Mr. C. with his eyes closed
2. The computer generated template was not amended with the correct information

Since this seems to happen so often these days, I suspect that #2 it is!

I'm pretty sure an excuse of "the computer made me do it" will not cut it in court.

The note was signed at about 11 PM...obviously a long day for the cardiologist...just what most litigation attorneys hope for...mistakes.

Wednesday, May 15, 2013

The status-quo

While reviewing some old records, on a 78 year old patient, I came across an assessment by his previous physician:

"Overall, the patient is status-quo in a state of chronic well compensated ill health."

I didn't mention anything to the patient...I was having enough trouble trying to figure out what it meant on my own!

Tuesday, May 14, 2013


Mrs. K. has a valid complaint.

She's the caregiver for Mr. K..

"I take care of him all day long. He keeps me up a lot of nights hollering out in his sleep and getting up to pace around the house. I have no interest in being intimate with him but he wants to try and have sex almost every night."

Years ago I read an article by a sex therapist.

She noted that for many men, foreplay often consists of walking across the threshold to the bedroom. For many woman, foreplay consists of everything that has happened in the previous 24 hours.

This is a perfect example.

Things aren't looking too promising for Mr. K..

Saturday, May 11, 2013

It's a great idea!

My wife sent this to me at work. I don't know if it's true but I like it nonetheless.

The last wishes of Alexander the Great:

On his death bed, Alexander summoned his generals and told them his three
ultimate wishes:

1. The best doctors should carry his coffin
2. The wealth he has accumulated (money, gold, precious stones) should be scattered along the procession to the cemetery
3. His hands should be let loose, hanging outside the coffin for all to see

One of his generals, who was surprised by these unusual requests, asked Alexander to explain.

Here's what Alexander the Great had to say:

1. I want the best doctors to carry my coffin to demonstrate that, in the face of death, even the best doctors in the world have no power to heal
2. I want the road to be covered with my treasure so that everybody sees that material wealth acquired on earth, stays on earth
3. I want my hands to swing in the wind, so that people understand that we come to this world empty handed and we leave this world empty handed after the most precious treasure of all is exhausted, and that is TIME

*  We do not take to our grave any material wealth, although our good deeds can be our travelers' checks. TIME is our most precious treasure because it is LIMITED. We can produce more wealth, but we cannot produce more time
*  When we give someone our time, we actually give a portion of our life that we will never take back. Our time is our life!
*  The best present that you can give to your family and friends is your TIME. May God grant you plenty of TIME and may you have the wisdom to give it away so that you can LIVE, LOVE and DIE in peace

Stiff man

I evaluated a patient yesterday with advanced Parkinson’s disease.

Dyskinesia (the presence of involuntary movements) is a well known complication of long term levodopa therapy.

The dyskinesias are often considered more bothersome to the family members (and health care providers) than they are to the patients.

One possible way to lessen the extent of dyskinesia is a levodopa dose reduction. However, this often results in worsening of parkinsonism symptoms and increasing “off” periods.

It’s important to remember that patients often prefer the mobility associated with dyskinesias to the immobility associated with no dyskinesias.

Try standing frozen like this for awhile…most will find it’s not a whole lot of fun!

Thursday, May 9, 2013

He got dat right!

Some wise words from Hippocrates (c. 460 BC-c. 370 BC):

“Everything in excess is opposed to nature”

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health”

“Walking is man’s best medicine”

“Our food should be our medicine. Our medicine should be our food”

“It’s far more important to know what person the disease has than what disease the person has”

Wednesday, May 8, 2013

That's all he had to say about that

I asked 92 year old Mr. H. if he had any hobbies.

He said "what exactly do you mean?"

I said "you know, are there any things that you enjoy doing or that bring you joy?"

He said "I like staying alive. I like to go outside occasionally and sit on the swing. If I get thirsty I like to drink some water. "

He smiled.

I smiled.

I decided to move onto a new topic.

I didn't ask if he was related to Forrest Gump.

Monday, May 6, 2013

Gotta love the chompers!

Me (while doing a review of systems on a patient I had never met before): Do you still have your own teeth?

Patient: Yeah, I've got two sets (of upper and lower dentures).

He was serious.

I couldn't help but grin.

I let him know why.

I'm not sure he completely understood what I thought was funny but he grinned nonetheless.

Saturday, May 4, 2013

A possible solution for families?

An elderly demented person who likes to wander poses a problem for families. Even the most watchful of caregivers can have a temporary loss of concentration and/or get distracted and lose a loved one who was under their watch.

Leases are often used for kids and considered acceptable, in some settings, by many:

Maybe we can come up with an adult-sized version? Just be prepared for a possible reaction when you try to attach the leash to your loved one with dementia:

Grandpa, it's me, stop doing that

There's no easy answer to the question:

What can be done about the elderly demented folks who like to wander, escape or who have severe behavioral symptoms associated with dementia (aggressiveness, episodes of anger, psychosis, hallucinations, inappropriateness-walking around nude, urinating or defecating in public, masterbating in front of others, etc.)?

Family members can take turns watching 24/7 but most scattered families don't have the ability to do this.

Families can hire 24/7 care (basically sitters) at a cost of anywhere from $10/hour (for those hired privately) to over $20/hour (for those hired through a licensed, bonded company) for a total cost of approximately $7000-$14,000/month or they can place their demented loved one in an ALF (that accepts demented patients) or a Nursing Home.

The use of physical restraints (posey vests, etc.) by facilities is no longer acceptable, and if used will generate an ACHA evaluation, and the use of chemical restraints (sedative medications, anti-anxiety medications, anti-psychotic medications) is associated with adverse events (falls, hypotension, increased mortality, decreased cognition) and if/when used by facilities will often lead to the appearance of a malpractice attorney representing the family of the "victim," if there's an adverse event.

It's all actually quite depressing.

Dementia runs in my family. I'm hoping that if/when I become demented I will keep my social graces and behave so I can stay at home and not be a burden to my family.

In the old days, elderly family members were taken care of by the daughter or the daughter-in-law.

With more women working, and smaller families in general, this often is no longer an option.

I do think we need to get back to multi-generations living in the same home again. I know this goes against the American Dream of leaving home and starting your own life but no-one can usually re-orient a demented older person acting out better than a family member.

Also, often one or two of the  family members may be having a problem finding gainful employment.

Splitting up the $168,000 it takes to hire 24/7 care through a licensed company isn't too bad of an income.

Friday, May 3, 2013

Surgical scars

I know my medical records are not perfect but occasionally I get a chuckle when reading records, from other physicians, on a patient of mine.

Here's one from today:

Under the Past Medical History (PMH) section:

     Surgical: No previous surgery

Under the Physical Exam section:
     There are scars consistent with the previous surgeries listed in the PMH.

What made it really amusing was that I looked over notes from monthly visits for 6 months.

All notes had the same verbiage.

I know why it generated templates!

Its actually probably easier these days to be a medical malpractice attorney than it used to be.

Everything is computer generated, printed and easier to read.

Obviously, mistakes are still possible.

It's the element of fraud (to increase billing codes), however, that needs to be held in check.

It's OK to use templates but sections that were not done need to be _______ (deleted).

Thursday, May 2, 2013

His brothers keeper

Mr. C.'s in pretty bad shape for only being 63 years old.

He has congestive heart failure and prostate cancer.

He never married and has no children.

He and his older sister, Mrs. N., were never particularly close.

Her husband was career Navy and they moved around a lot.

They raised three children and then became certified foster home parents.

When his health failed, Mr C. had no where to turn.

His sister stepped to the plate.

She and her husband finished a room over their garage and made a nice apartment for him over 4 years ago.

They're close now.