August 2008

A lady who works at the local Starbuck’s says that one of her customers, a woman, always orders an 8-shot mocha. That’s a lot of caffeine, the equivalent of eight regular cups of coffee, or roughly 1200 mg of caffeine.

You may get anxiety or a tremor from an 8-shot mocha, but 8-shot mocha lady probably can’t get her groove going in the morning without it. There is even a caffeine withdrawal syndrome, with headache as one of the most common symptoms.

Many coffee drinkers who have had surgery know about this. Being “NPO after midnight” forces you to miss your morning coffee. NPO (nil per os) is Latin for an instruction to withhold food and fluids from a patient. This is a standard instruction given to make sure the patient has an empty stomach prior to surgery so as to prevent vomiting and aspiration during anesthesia.

So skipping your regular coffee on the day of surgery often causes a headache. An anesthesiologist even proved that intravenous caffeine prevents caffeine-withdrawal headaches in coffee drinkers on the day of surgery. Intravenous caffeine is available but is rarely used.

Whenever I have surgery, I cheat. Unwisely perhaps, I have an expresso on the morning of surgery. When the nurse asks if I’ve had anything to eat or drink since midnight, I confess that I had a sip of coffee in the morning and hold up my hand with my thumb and index finger an inch apart. She says “That’s OK” and smiles. You, of course, should not do this.

Worm therapy. Intentional infection with worms to treat another disease. Now that’s appealing, isn’t it? But worm therapy has some real benefits in inflammatory bowel disease and maybe in some other diseases.

Inflammatory bowel disease includes ulcerative colitis and Crohn’s disease. These two diseases cause diarrhea, abdominal pain and bleeding.

Helminths are parasitic worms which infect more than a third of the population of the world, usually in warm climates in underdeveloped countries with poor sanitation. Inflammatory bowel disease is less common in these areas and is more common in developed countries with better sanitation and lower rates of infection with intestinal parasites.

It is thought that intestinal parasite infections benefit patients with inflammatory bowel disease by suppressing the overactive immune system which causes these diseases. Infection of patients with the pork whipworm has shown benefits for patients with Crohn’s disease. Infection with the same parasite had similar benefits in ulcerative colitis.

According to an urban legend, possibly true, in the past people swallowed parasite eggs to set up an intestinal infection to cause weight loss. There is no medical documentation that this is safe or effective.

Is the Patient the Enemy?

One of my colleagues recently said “A doctor has three enemies: the insurance company, the hospital, and the patient.” I found this statement very disturbing. It isn’t news that insurance companies and hospitals view us as cash cows at best. At worst, they would like to cut our throats as long we could keep working afterwards. Of course, patients can sue you and cause other problems. But the patient as enemy? Are things that bad? I can see patients that way only rarely or occasionally.

Imagine viewing your patient as an enemy as you try to diagnose a medical problem. Research shows that doctors typically juggle several diagnoses in their heads at one time, discarding some and adding others as they go along. This would be difficult if you were anxious and fearful, that is, if you are paying more attention to yourself and your own needs than to your patient’s.

Above all, dedication to the best interests of the person seeking your care comes from commitment and from years of training and indoctrination. The patient as enemy? I can’t see it. We aren’t there yet.

And it’s hard to beat the satisfaction of hearing “Doctor, my headaches are gone. I feel great.” Even “Doctor, you saved my life.” Few professions offer the personal satisfaction of being a physician. For that reason, medicine will long be an attractive profession, even as the rewards decrease and the hassles increase.

Kitchen Utensils Used as Surgical Instruments in Kosovo

“Necessity is the mother of invention.”   Plato

War started in Kosovo in 1999, leaving a number of surgeons and medical personnel with limited supplies. Makeshift operating rooms were set up and kitchen spoons were used as surgical retractors. Many major lifesaving operations were performed.

Most patients prefer that their doctors wear white coats. It’s traditional, it makes it easier to tell who the physicians are, and the white coat signifies purity, cleanliness, and other virtues. Many doctors still wear them.

I never wear a white coat, mainly because they’re hot and uncomfortable. The white coat is almost always ornamental and is rarely worn for function or comfort. More important are the cultural and class roles symbolized by the white coat. Along with the rest of our health care system, these roles have completely changed. The physician now serves at the beck and call of a corporation or government bureaucracy. These businesses and bureaucracies have a variety of agendas which are often opposed to the best interests of the individual patient.

Would it be accurate to say that the medical profession has been proletarianized? Are physicians “1) the lowest social or economic class of a community, or 2) industrial workers who lack their own means of production and hence sell their labor to live?” No to the first definition, absolutely yes to the second. The physician and his treatment of the patient are now largely controlled by insurance companies and the government. That the delivery of decent care is usually not obstructed is irrelevant. If there is a conflict between the patient and the bureaucracy, bureaucratic diktat almost always wins out.

Medicine is a decidedly middle class pursuit. Do you ever read about the society weddings in the Sunday New York Times Style Section? In the 1960s and 1970s, the couples were almost all WASPS. Now the couples are ethnically and religiously diverse, but the common denominators are still elite schools, big jobs, and big money. Careers are almost always in business and law. Very few doctors.

In fact, the physician’s white coat has always had some blue collar overtones. For one thing, as you ascend the occupational scale in the direction of increasing income and status, the uniform is almost always business attire. After all, butchers and Xerox repairmen wear white coats. Most physicians don’t have a problem with these class, status, and income considerations and decided long ago that being a physician was more fun than a job on Wall Street. I also think that most physicians could do well in a Wall Street career, but the reverse isn’t necessarily true.

Formerly, doctors were independent professionals. They were respected and affluent, to be sure, but were deeply committed to the individual patient. The independence is no more, and the status and income are declining along with the commitment.

I share an office with a physician from Hungary. He has taught me much about life under Soviet Communism. He believes that our health care system is becoming increasingly like the Soviet system. Physicians are proletarians in that system, but it’s a “dictatorship of the proletariat,” so it’s OK, right?

In the Soviet health care system, it was necessary to tip health care workers and physicians in order to get decent care. If physicians and health care workers in the US aren’t underpaid and overextended now, they will be soon. I predict that Americans will soon find themselves greasing palms in an effort to get decent health care. It’s probably a good idea to start doing so now.

The biggest organized criminal enterprise in America is the health insurance industry. They take your cash, then occasionally dribble a little of it back to you, enough to keep themselves in the money, out of court, and out of trouble with the government which has set up the whole scam.

Be sure to see the movie “Damaged Care,” an expose of the health insurance industry. The movie is based on the experiences of Linda Peeno, a physician who worked for several insurance companies. She became a critic of managed care and testified before Congress in 1996.

I wish to begin by making a public confession: In the spring of 1987, as a physician, I caused the death of a man. Although this was known to many people, I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was “rewarded” for this. It bought me an improved reputation in my job, and contributed to my advancement afterwards. Not only did I demonstrate I could indeed do what was expected of me, I exemplified the “good” company doctor: I saved a half million dollars.

Paramount Pictures wouldn’t give me permission to post a clip from “Damaged Care,” but you can get it through Amazon.com and at many video rental stores. Everyone who works in health care or is interested in health care should see it.

Just some tidbits which might be of interest to you, including a report of 13 people allegedly using voodoo to shrink or steal other men’s penises ….

Woman Delivers Baby, Never Knew She Was Pregnant

It happens. The MDOD blog gives a Rabelaisian account of this phenomenon, women who deliver babies, never having suspected they were pregnant, which account will not please “Our Bodies, Ourselves” womyn.

John Holmes - Call Your Office

In Kinshasa, Democratic Republic of Congo, police arrested 13 people for allegedly using voodoo to shrink or steal other men’s penises. Rumors of penis theft spread throughout the city, and there were a number of attempted lynchings of those believed guilty, leading to the arrest of 14 of the victims. The victims said that the perpetrators just touched them and their penises shrank or disappeared. Rumors of a massive airlift of Viagra could not be confirmed. (Internal Medicine News 5/5/08)

John Kerry Call Your Office

In laboratory experiments, three days after Botox was injected into the whisker muscles of rats, the Botox was detected in the rats’ brains. Previously, it was thought that injected Botox remained at the injection site. This finding raises the issue of whether Botox injections in humans might also end up in the brain, possibly causing adverse effects. (Internal Medicine News 5/5/08)

After Possible HIV Exposure, P24 Test Should Be Done

A needlestick or sex can result in HIV infection. If the source of a needlestick or sexual exposure is HIV-positive, a short course of anti-HIV drugs soon after the exposure can prevent infection. In this situation, it is desirable to know if the source of the exposure is infected with HIV to know whether this course of drugs, called post-exposure prophylaxis (PEP), or the “HIV morning after pill,” is needed.

However, if someone has been infected with HIV for less than 3 months, the HIV antibody test may be negative, but the P24 will usually be positive. Both tests should be done after a possible exposure.

Say you stick yourself with a needle used to draw blood from someone or you have sex with someone who may have HIV. Both the antibody and the P24 tests should be done on the person to whom you have been exposed, if possible, to see if the anti-HIV drugs (PEP) are needed. PEP should be given as soon as possible after the exposure, because after the HIV infection is underway, PEP is not effective.

“Every normal man must be tempted at times to spit upon his hands, hoist the black flag, and begin slitting throats.”  H.L. Mencken

Several years ago the Centers for Disease Control (CDC) changed some of the terminology used to report AIDS statistics. “Men who have sex with men” (MSM) replaced “male homosexuals” and “gay males.” “Injection drug users” replaced “intravenous drug abusers.” “Commercial sex workers” replaced “prostitutes.” CDC officials justified the changes by claiming that the old terms unfairly labeled and demeaned people who were not responsible for their plight. Welcome to the no-fault universe. Recently, the CDC continued in the same vein by throwing out the term “lesbian” and replacing it with “women who have sex with women” (WSW). Although many of the terms used a century ago to describe different racial and ethnic groups now strike us as nasty and brutish, has this gone too far? Is saying that a woman is a lesbian disparaging? Doesn’t the term have an element of gentleness, evoking the poetess Sappho, the island of Lesbos, and Greek antiquity? And were the other discarded terms so awful? Why do we discard terms as mean and insensitive only with passing years? Is our current terminology unfairly stigmatizing? If so, shouldn’t we get rid of it now? Do we ditch hateful language only by acquiring the wisdom to see it as unfair? Doubtful, says the eight-ball. It seems more likely that what is going on here is that many of the bedwetting, busybody do-gooders in the medical profession need to stay busy finding new examples of supposed unfair discrimination. Here’s another obnoxious example of the same thing. At the Barnes and Noble bookstore yesterday, I noticed that the “Lesbian/Gay” section had been relabeled “Lifestyle.” I doubt B&N did this because they wanted to make that section of the store less conspicuous. More likely, “gay/lesbian’ is out, “lifestyle” is in. So don’t you feel as if you’re walking on eggshells, afraid you’ll say something politically incorrect? Aren’t you afraid to even let out a peep at work, for instance? You’re not? So you still say handicapped, not handicapable, and it’s mentally retarded, not cognitively challenged, or some other idiotic euphemism? Good. Now we’re getting somewhere.

Doctors announced May 20 that Ted Kennedy has a malignant brain tumor. The tumor is a glioblastoma which has a very poor prognosis. Survival for patients with a glioblastoma averages 12 to 15 months. Treatment usually includes surgery, radiation, and chemotherapy.

A timely review article about malignant brain tumors in adults was published in the 7/31/08 New England Journal of Medicine. The article provided information on some new and innovative treatments which could give better results than older therapy. However, even these newer treatments seem unlikely to produce prolonged survival for glioblastoma patients.

Whatever one may think about Mr. Kennedy as a person and as an elected leader - for my part, not very much, his life and illness are instructive. Mr. Kennedy was first treated at Harvard’s Massachusetts General Hospital and then at Duke University Medical Center. Both are world-class medical centers. It is obvious that the rest of us would not get such prompt, high quality care in the government-run health care system Kennedy has been trying to force on the rest of us for decades. The nature of government health care systems is clearly evident in countries all over the world, but the many drawbacks of such systems would be for the “little people” to endure, not for Mr. Kennedy.

Even so, while Mr. Kennedy was born into wealth and privilege, he has known much suffering and tragedy, beginning with the abuse inflicted on the entire family by his tyrannical father, Joseph Kennedy. It is time for many of us to bury the hatchet and extend our prayers and wishes for the best possible outcome to Mr. Kennedy and his family.

To those of us already fighting the flab and wrinkles of middle age, willfully seeking disfigurement seems incomprehensible. An article in the 7/31/08 New York Times describes a group of mixed martial arts enthusiasts who seem to be bucking our culture’s obsession with health and appearance. Some of these athletes intentionally leave their ear injuries untreated in order to develop cauliflower ears. This condition occurs when force or a blow to the ear causes bleeding which, if not treated immediately, can cause permanent deformity. The result can be a “cauliflower ear” or “wrestler’s ear,” a shrunken, scarred, deformed ear. The mixed martial arts practitioners are said to proudly wear these shriveled, scarred ears as a sign of machismo.

Techniques of mixed martial arts are holds, throws, kicking and punching. This art has become popular in professional matches and for amateurs. Mixed martial artist Nisar Loynab, 15, from Alexandria, Virginia, was interviewed for the article. According to Nisar, “When you get cauliflower, you’re really a man.” He has left his injured ears untreated in hopes of acquiring cauliflower ears like those of his father, Abubakr Loynab, 43, who trains at the same gym as his son. The elder Loynab says “In my family, we’ve had boxers and stuff, and it’s just one way you toughen up the kid. There’s some people in here that he looks up to. He’ll go up and show them, ‘Look, I’m starting to get the cauliflower ear.’ ”

I’ve participated in a variety of martial arts for over ten years, and I doubt any martial artists I’ve known would welcome such a visible and conspicuous deformity. Is it possible that the obviously not so bright Loynabs are not typical of mixed martial arts enthusiasts? Such a misrepresentation would be consistent with the prejudices of the New York Times against martial artists, gun owners, and other groups lumped together in the unenlightened and unwashed masses category. It’s true that the reporter interviewed an older mixed martial arts coach who was critical of seeking cauliflower ears to gain “tough guy” status, but his comments were brief and were located at the tail end of the article.

The article even throws in an annoying and predictable plug for government health care, with the assertion that “Many young men cannot afford medical care.” This is supposed to be one reason why their ear injuries aren’t treated by a physician. They seem to be able to afford monthly martial arts club dues, martial arts equipment, food, clothing, and so on, but health care? No way.

I guess I’ll head down to the martial arts gym and try to get a hard elbow shot to one of my ears.