The Dinosaur Speaks

You've read my words; you've seen my face. Now hear my voice. Many thanks to Greg Friese of Everyday EMS Tips (and to Rogue Medic for the referral) for interviewing me on his blog, as well as for the very nice write-up.

My recent lack of writing in general (and book-related activity in particular) is a source of shame. I understand that virtually all writers have day jobs (as I opined they should; listen to the interview), but I don't think the words "flu season" have quite the same impact on those who don't have to worry about disappearing needles. Still, my promise to all you sharks out there (well, one in particular) is that I will be getting back on the stick, butt in chair, and fingers applied to keyboard post haste.

Out of Network

Last patients today: a husband and wife with an infant under six months of age for their H1N1 shots.

Wife: "Can I ask you a question?"

Sure, why not. Turns out her neck had been bothering her for a week or so. Nothing much to get excited about (nor was there much to do for it), but I rubbed it for a few moments with moderate relief. She sighed and said, "Can you please write a prescription for my husband to do that for five minutes every night?"

Husband's response: "I don't take your insurance."

This One's for AD

Saw this and thought of you, dude:

Hinny Shots and Anal Puckering

As some of you may know, there is a novel flu strain out there called H1N1, or, less accurately, Swine Flu. As others of you may also know, there is a vaccine available that is recommended for the following high risk groups:

• Children/young adults between the ages of 6 months and 24 years
• Household contacts of infants less than 6 months old
• Pregnant women
• Health care workers
• People with health conditions (asthma; diabetes; etc.) putting them at high risk for flu complications

For those of you who have been hiding under a rock since Fall, the vaccine is being purchased and distributed by the government. This is as good an explanation as any as to why I have not been able to get ahold of any of the stuff.

Until now.

Finally, at long long last, I received an email from the state department of health notifying me that my order of 200 doses of H1N1 vaccine had been approved. Unfortunately, they were unable to provide me with a shipping date. They also sent me another mass email informing me that as of 12/11/09, they would be suspending all shipments (ostensibly, "for the holiday") and would resume 1/4/10.

Shit.

Then two days ago, I received a box from UPS. Inside, I found a plastic box. It was a sharps receptacle, a container specifically designed for safe disposal of hypodermic needles. I examined the package at length; the only other thing in the box was a sheet of paper naming the company that had sent the thing. The name rang a bell; sure enough, it was the company distributing H1N1 for the state. Given that the government was not only going to be providing the shots but also all the equipment and supplies for its administration, this was a very good sign indeed.

The next day brought another good sign: another delivery consisting of one box containing two plastic pouches, each containing one hundred syringes with attached needles, alcohol wipes, and little cards upon which flu shot administration could be documented and given to patients. This was an excellent sign!

Then earlier today, UPS came again. This time, the cardboard shipping box contained another box made of styrofoam. Hidden within, nestled among half a dozen cold packs, sat two shrink-wrapped packages of ten little cartons containing vials with 10 doses each of H1N1 vaccine. I'm in business!

(Eventually, I got back to check my email, and discovered that I had to print out and complete reporting forms for each dose given, and then send them back to the health department "in a timely fashion." I knew it couldn't be that easy.)

I was just finishing up with a patient as the vaccine was being delivered. Realizing what the package was likely to contain, and aware that the patient was undergoing cancer chemotherapy (a definite indication for H1N1 vaccination), I grabbed her before she could leave so I could get her immunized.

I tore open one of the government-supplied packages of syringes, and freed it from its paper overwrap. It was an unfamiliar design, but I figured that the basic idea is pretty universal. I drew up the first dose, half a milliliter of the treasured serum, and approached the patient's bare left upper arm.

I need to interject at this point that I'm damn good at giving shots. What I do is say, "Count to three" AS I'M GIVING THE SHOT. By the time they start to count, it's already done. I've given out about 300 seasonal flu shots this year so far, and the most common response to my injection technique is, "Was that it?" Even though I hadn't ever used this particular model of syringe/needle combo, I saw no need to alter my technique.

I swiped the site with alcohol and inserted the needle as I began to say, "Count to three." I depressed the plunger and watched as the vaccine disappeared into the tissue where it belonged. Suddenly, there was a loud SNAP as I finished the injection, and to my horror, there was no needle at the end of the syringe!

It is the essence of professionalism that the expression on my face never changed as the words, "Oh my fucking god, where did the needle go? Oh my fucking god, did I break the needle off in her arm??!? Oh my fucking god please no no no no no where did that fucking needle go???!?" raced through my mind, and my lab coat sucked all the way up to my splenic flexure.

I peered carefully at the patient's arm. Nothing out of the ordinary. But how could I tell if there was a needle broken off all the way under the skin? I poked at it gently.

"Does that hurt?" I asked the patient.

"A little," she answered.

I've had tiny glass shards stuck in my foot and they hurt like a mofo with the slightest pressure, so I thought it was unlikely that a broken-off needle would hurt just "a little."

Next I examined the syringe in my hand. I noticed that there was a stretched out spring within the barrel that I didn't remember seeing there earlier. Eventually, after a great deal of quizzical staring, I finally made out the needle and its clear plastic hub nestled safely within the syringe's hollow plunger. Clearly a brilliant design from the point of needle safety. On the other hand, it was downright hazardous to my cardiac health. The time it took to convince myself that I hadn't left an inch-long metal sliver in my patient's arm was marked by asystole and an adrenaline burst the likes of which I hadn't experienced in decades.

Finally, I began breathing again. First, I exhaled. Then I broke out in a sweat. Eventually I calmed down enough to get on with my day. I used the new syringes to give out several more shots, and even though I now knew what to expect, that SNAP still got me every time. I can only hope that I get used to it.

In the meantime, though: Hey everyone, I have H1N1! Come and get it.

Miscellaneous Observations about Sweden

First miscellaneous observation about Sweden: They really do have style.

Everywhere you look, the little details on buildings, furniture, and clothing all scream Scandinavian sophistication. Sitting in the hotel, whether the restaurant, the lobby or the room, feels like you're sitting in an Ikea store. The curved benches in the airport waiting areas; the clean, simple lines of -- well, of everything! There's the inescapable sense that these people know how to put things together visually.

Second miscellaneous observation about Sweden:

Although the hotel room had one large bed (queen size), it was made up with two individual twin-sized down-filled duvets, folded neatly on each side of the bed. At first, I thought it looked like they had just shoved a pair of twin beds together, though closer inspection revealed the truth. What a fabulous idea for sheer comfort it turned out to be.

See, one of the problems sharing a bed -- or more specifically, bedding -- with a larger individual is that the shared blanket doesn't drape down all the way around the smaller body (in this case, mine), allowing in drafts of chilly air. Whereas with this particular configuration of bedding, one can still share a bed yet still be wrapped comfortably against the elements. This needs to be further explored upon the return home.

Third miscellaneous observation about Sweden: People-watching is universal.

We spent a lot of time watching people. Alone in the airport the first day, I had ample opportunity to observe all kinds of travelers in assorted phases of travel. Once Darling Spouse arrived and we trekked into Stockholm, we watched people in train stations, on buses, walking the streets, and perusing museums. Both of us were struck by the variability of heights, weights, hair color, dress; everything. Until you heard people speaking the lovely, lilting, vaguely Germanic-sounding language that is Swedish, you wouldn't have been able to tell you weren't in any other city on earth. Commuters; tourists; teens; indistinguishable from those in the good ole US of A. The trains may have been cleaner, but the people were all the same. Reassuring, in a curiously humanistic way. Just helps to reinforce the old truism: Wherever you go, there you are.

Thus endeth the travelogue. We now return to (ir)regularly scheduled blogging.

One of the Biggest "Oh, Shits!" in Maritime History: The Vasa

The time: 1628
The place: Stockholm shipyard
The event: the launching of the magnificent warship, the Vasa, commissioned by King Gustavus Adolphus

Majestically it begins its maiden voyage, all sails deployed, flags flying proudly! The shore is packed with spectators, including the curious, the well-wishers, and the foreign dignitaries there to pay homage to the great and mighty Vasa, the greatest and mighiest warship of the great and mighty Gustavus Adolphus.

Meanwhile, back on shore:

Whiny little assistant to the Chief Designer in charge of the Vasa: Sir, Accounting needs you to sign off on these invoices for the final material delivery for the Vasa.

Chief Designer (peering over the sheaves of paper): Hmm, let's see: that looks like the right amount of timber for the masts and decking. The bill for the sails looks right. Wait a minute; how much ballast was put in?

WLATTCD: It says so right there, sir. What's the matter?

CD: It's missing a zero.

WLATTCD: So what? A zero is nothing, isn't it?

CD: No, you idiot. It's missing a zero at the end.

WLATTCD: What does that mean?

CD: It means the ship may not have enough ballast.

WLATTCD: So? What's the worst that can happen?

CD: What's the worst that can happen? If there's not enough weight in the bottom of the hull to balance the weight of the ship, the masts, sails, rigging, provisions, the sixty-four cannon with all their ammunition, and everything else, it can tip over in the slightest wind, letting water pour in through the gunports. It could even sink!

Meanwhile, back on shore:
The ship starts to heel over, water pours in through the open gunports and:

the whole thing sinks in over 100 feet of water, all sails rigged, flags flying proudly.

Here is a depiction of the general reaction to the event*:

Fast forward to 1961, when the Swedes spend another shitload of money to raise the thing, preserve it, put it into a building shaped like a ship:

and call it the Vasamuseet.

Actually, it's pretty cool. The central hall is dominated by the actual ship, surrounded by exhibits about the disaster itself:

life aboard the ship (dominated by the military; the crew consisted of 164 sailors and 300 soldiers),

the artwork (hundreds of carvings originally painted in brilliant colors),

and the restoration (including fascinating reconstructions from the bones of some of the 30 people who died when the ship went down).

So, to recap the history of the Vasa:

• Two years to build the thing
• Five minutes of sailing
• Submerged in over 100 feet of water for 333 years
• Raised to the surface and painstakingly restored over 17 years
• Enjoyed today by Dino and Darling Spouse

And that's the way it was.


* Actually, that's a reconstruction of the carving inside the gunports, visible to the outside when said gunports are open for business.

Greetings from Stockholm

Today was our first day in Stockholm. That is, if you don't count yesterday, when I spent the entire day having quality time getting to know all the ins and outs of the airport from the time I arrived at 10:30 am until DS's plane arrived from Manchester at 10:10 pm (except that his flight was canceled so he had to fly through Copenhagen and didn't arrive until 1:00 am today). What can I say? It's an airport.

Today, though, was a day of fast trains, city buses, subways, sights, museums, and aching feet.

Here's the fast train:

Here's a lovely shot of downtown Stockholm across the water -- of which there is plenty, given that the city is built on several hundred tiny islands:

Here are some pictures of museums:

into which we did not go. The museum in which we spent most of the day (and took most of the pictures) will be getting its own post.

After dark, ie about 4:00 pm, we made our way to Stockholm's Old Town, a cobblestoned island called Gamla Stan. We toured the Royal Armory (or, as they call it, the Armoury) and the Christmas Market, by which time it had begun to snow. Interestingly, this did not change the status of the weather, which remained "perfect." Not much wind, and brisk without being uncomfortably cold.

In between those adventures, we wandered the city in search of the subway stop where this was filmed:



We found the right place,

but alas, the keyboard had vanished. Still, the expedition allowed us to travel by subway and wander several other interesting neighborhoods. DS commented that it could have been Philadelphia. I demurred, feeling that although one of the large boulevards we walked did bear a passing resemblance to the Ben Franklin Parkway, many of the architectural touches were so quintessentially European: the high, wide doorways; the external downspouts; the sequential numbering as we walked up the street (as opposed to odds and evens facing each other). It didn't feel American; which is to say, it was somewhat exotic.

Trudging through the snow as the flakes got bigger, we found our way back to the train and made our way home(ish):

reflecting on our wonderful day.

It's All Terry's Fault

Blame Terry.

Darling Spouse had to go overseas on business about two months ago, and it was a long, difficult two weeks. I felt like all I ever did was walk (roll) the dog, take care of the cats' I/O, and work. Not much sleep (since the dog needed to be rolled twice a day), and not much in the way of cooking or eating either. Just keeping the house and office going singlehandedly. I've done it before (albeit with only a single cat and no dog), but it's so much nicer not to have to. It was a rough two weeks.

Then they told him that he had to go again! Same deal: a week in the UK and a week in Sweden, in early December this time. Bummer!

So I tell all this to my friend Terry, who lives around the corner from my office and comes in once a week for allergy shots. And Terry begins to berate me: "You have to go with him this time!"

I roll my eyes and invoke my reality. I can't go with him. I'm self-employed; no work, no eat. I have the dog, and the cats, and the house. Besides, he'll be working. What would I do all day for two weeks?

"Those are nothing but excuses! You have to go!" continues Terry.

I smile.

Then I go home, and I tell DS about seeing Terry, how Terry yelled at me, and so on. We agree that I can't get away for two whole weeks, but we begin to hem and haw a bit; see what we can work out. He sits down at the computer and researches (really cheap) flights; he realizes he can shift his hotel arrangements around a bit, and voila!

The dog is being boarded; the cats and house are being sat; coverage is arranged; later this afternoon, I am outta here. I've got my camera, and this adorable little netbook for surfing, blogging and the like. It even has a port for the card from my camera, for convenient picture posting.

I'm going to Stockholm for the weekend.

And it's all Terry's fault.

Thank you, Terry.

Best Answer Ever

Facebook exchange:

Friend F (gay) requests an explanation of what the homosexual "agenda" consists of.

Response from Friend L (straight):

It starts with an appetizer of baked brie and whole wheat crackers, then a refreshing sparkling drink, then a discussion of possible Oscar-contenders and finally, the last item on the agenda is a vote to determine which restaurant will be patronized that evening. At least, that was the agenda for all of the homosexual events I've been to.

Self-Linking

Many thanks to KevinMD for publishing my Guest Post on his blog the other day. Stay tuned for a somewhat snarkier take on the issue of the new USPTF breast cancer screening guidelines.

Another Idea to Limit Unnecessary Testing

Defensive medicine, defined as "additional and often unnecessary tests to avoid lawsuits"(1), is widely acknowledged as one of the biggest factors in spiraling health care costs. The problem is more than just testing specifically to defend against potential litigation. At issue is what to do when patients request/demand inappropriate testing. This has been driven home to me at least three times just in the last week.

From patients with no family history of anything and perfectly normal blood tests (cholesterol panels, blood sugars) a year ago who "really want it done again" despite the USPTF recommendation of 3-5 year intervals for these screenings, to women who demand annual paps "just to make sure everything's okay in there," I find myself struggling to explain the downside of unnecessary testing. "But the insurance will pay for it," they respond. "What's the harm?" Sometimes I do it; sometimes I stand my ground; but the encounters often leave me drained and upset. How much is my inability to explain these things adequately, and how much is it the deeply ingrained American idea of "more is better," "better safe than sorry," and so on? There seems to be no way to tell.

So how about trying out this idea to reduce expenses from unnecessary testing:

Third party insurances will only pay for tests not designated as "medically indicated" by a physician if they are abnormal.

Although one might propose requiring a physician's version of a "certificate of necessity" (which we sort of already have; you can't get a test without a physician's order) whereby patients can get any test they want if they pay for it themselves, it looks really bad when that test comes back showing something unexpected. If insurance companies only pay for abnormal tests, patients have a little more skin in the game by taking on the risk of having to pay for negative tests. As most of them claim to only want the testing for "peace of mind," it stands to reason that many of them would also be willing to pay.

This is philosophically similar to the concept of "loser pays" litigation, although a more familiar and less arbitrary-seeming example would be the NFL rule for charging coaches a time-out for challenging penalties that are subsequently upheld. However you look at it, increasing the potential risk -- even only financial -- to patients demanding unnecessary testing, while not penalizing them for the occasional accidental finding, is at the very least a novel idea for controlling health care costs that I believe deserves serious consideration.


Footnote:
(1) Baker, Ninja; Malpractice Tort Reform; 1 December, 2009; policy paper for HS104a American Health Care, Professor Altman; Brandeis University; page 3 (comment from TA HKI: "good definition.")

Requesting Blood Tests: The Right Way and the Wrong Way

Attention Partialists*; listen up!

Despite what you were taught in training, patients have more than just one organ. Yes, yes; I know your organ is of course the most interesting and important. Still, there is more to most patients than an eye, a heart, a pair of lungs or kidneys, or even a prostate.

Most of you have learned that there are times when findings in your organ implies that something may be wrong with one or more of the patient's other organs. Although your usual response is simply to shuffle the patient off to your buddy, the OtherOrgan specialist, there have been occasions out in the community when, your hands tied, you send them back to me instead. As a public service, I would like to take this opportunity to describe the right way to do this, as well as the wrong way.

Right way

Pick up the phone and say:

Dr. Dino, I saw this weird ditzeloma in the back of our mutual patient's eye. It can sometimes be associated with diabetes, so could you please take a look and see if that might be the case here?

Wrong way

Send me a fax on a safely prescription pad (which comes across the fax as almost completely black) saying:

Complete blood test to rule out metabolic diseases.

I'll give you a hint: "Rule out [a whole freaking class of conditions]" is not an appropriate way to format a request for either a blood test, or a consultation to evaluate for the condition about which you are concerned -- which is what this patient really needs.

Oh, and while we're at it, could you please refrain from recommending that my patient with no cardiac risk factors ought to be on a cholesterol medicine for a total cholesterol of 255, when I have already determined that her LDL is only 120, her triglycerides only 125, but her HDL is a whopping 110, and I have told her she is fine? Remember you're a surgeon; it's not like you're a doctor anymore. M'kay?





*A fabulous term from one of the AAFP ListServes referring to our colleagues who only take care of portions of patients.