Consilience

Unity of Knowledge

This page is powered by Blogger. Isn't yours?
Monday, May 01, 2006

Accidental Creamy Sauce
 
After boiling a few carrots yesterday, I decided not to throw away the broth. I added some flour and a few table spoons of fat-free yogurt to achieve a creamy consistency. After spicing it with some garlic salt, we had a wonderful cream sauce.

Heated, it should be great as an alfredo-like sauce on pasta, but we decided to use it cold as a ranch-like dip.


Sunday, December 25, 2005

Apology for Slavery
 
Despite my better instincts, I ended up watching Something the Lord Made, a movie about Vivian Thomas, a black lab technician for Alfred Blalock. You see, I don't watch serious movies. Life's depressing enough as it is without me having to think that had this man been born white, he would have been a famous surgeon. I'd rather watch Adam Sandler get knocked in the crotch a couple of times.

Anyway, my dad is so shocked that the government of the United States has yet to apologize for slavery and years of discrimination. I told him that there was some talk about apologizing for slavery, but no one had the guts for doing the right thing.

Bill Clinton, that jackass Republican posing as a Democrat, refused to apologize for slavery, but even his mild expressions of regret were too much for the Neo-Nazis in this country. You see, the U.S. can do no wrong, and even something as horrendous as slavery isn't a big deal, as long as it was committed by the U.S. of fuckin' A., the greatest country that ever was. Bill Clinton was denounced for his so-called "apology tour" of Africa back in 1998. Indicted money launderer, Tom DeLay, was disgusted by President Can't-Keep-It-In-My-Pants' expressions of regret about slavery: "Here's a flower child with gray hairs doing exactly what he did back in the '60s: He's apologizing for the actions of the United States. ... It just offends me that the president of the United States is, directly or indirectly, attacking his own country in a foreign land."

Well fuck you, Tom Delay. Pat Buchanan, that great fat ass of True Conservatism, wrote that Clinton had "groveled" in Africa. Robert Novak called the apology for slavery "ridiculous." Why is this even a question? The U.S. has been built on the blood sweat and tears of Black Americans, and here we are, still refusing to apologize for it. Jesus.

It's good to put things into perspective every once in a while. Here I am, all stressed out about the opinion of some stupid radiology program director who hasn't even read all of my file, while just 50 years ago, someone as talented as Vivian Thomas was toiling away in obscurity, being turned away and humiliated because he was black. Life's too short, and the history of injustice and crime is too long.


Thursday, October 06, 2005

Black and White Women
 
There's a picture of Dr. C's graduating medical school class on his wall. It's the typical panoramic shot, the kind where if the photographer isn't paying attention, you can run from one end to the other and end up in the picture twice.

It's an assortment of people in white coats, some with white belts and one with a large buckle. Some coats are short, some long, some have big buttons. Everyone's trying to look different. There's a guy with sunglasses, and another with a pyramid of hair. Everyone's trying to look different because they know in 100 years, if anyone still has this shot, they'll all be the same: dead.

They'll all be the same except for the 14th person from the right. She's the only woman in her entire class. I was transfixed by her. Wavy--maybe even frizzy--dark hair, and her long white coat open in the front showing off her long shapeless skirt. No one was going to mistake her for a man with long hair. 100 years from now, she seems to be saying, you'll wonder who I was.

I've been meaning to ask Dr. C. about her. Who was she? Was she accepted into the penisfest that was medicine 50 years ago? Were you mean to her? Did she drop everything when she popped out her baby.

I really want to know, because yesterday, in the middle of the typical "the world is going to shit" lecture I always end up getting from attendings with white hair, Dr. C. placed all the ills we currently suffer on working moms. Working moms and no prayer in schools, but mostly working moms.

"I'm not saying women shouldn't go to university and work," he said.

"I'm not saying all gays should be burnt at the stake," I thought.

"It's just that when they have children, they need to stop and dedicate their lives to raising their kids, and their education to educating their kids."

The MS3 me would've smiled and nodded. The pre-med me would've one-upped Dr. C. "Barefoot and pregnant all the way!"

But: "My residency apps are in." "There's no way Dr. C. is going to fail me." "All I need is a pass at this point." And most importantly, "I really don't care anymore. "

"I just need a pass at this point," I repeated to myself. The mantra of the MS4.

"Their husbands perhaphs could pitch in," I said trying to pass off my sarcasm as just an innocent suggestion.

Dr. C. then went on to describe a woman she knew (a case study with n=1) of a high-powered dermatologristrix whose husband had agreed to raise the kids because she was going to be amking more money. Painfully logical. But this dude started feeling inferior and emasculated by his girly role, and their marriage fell apart.

"Their family exploded." He mimed what looked like a burp with his hands.

"Now she's a successful dermatologist, but she has no family."

I didn't accept his case study's conclusions, but seeing how he was trying to publish in International Journal of the Man, and I was the editor of The Journal of Whatever, I didn't feel like debating any further. A lot of people do feel that raising kids should only be done by women, but a lot of people also like Britney Spears (who stopped her career to raise her kid, by the way). Fifty Years after black and white woman took her class photo, most women are probably not much better off than she was.

Then we got to the whole part about prayer in school. I explained that I grew up in a country where we prayed in school, where the government was run by religious opportunists much like Pat Robertson and the rest of his suit-wearing Ayatollahs.

He sensed that I had him beat on the religion front. After all, I'd been through religuous education, and I'd proven that I didn't know jack about Islam just earlier that day. A Muslim patient had explained to him that she was fasting (I didn't even know it was Ramadan again). He asked me what the whole fasting thing was about, and I told him that you ate a huge breakfast, then ate a huge dinner, fasting in between. The next Muslim patient explained to him that you only ate once a day. Boy, was my face red!

What the crap do I know? The first patient had asked me if I was fasting.

"I'm not."

"But your parents are." she told me.

"Nope." Maybe it was because she was hyperthyroid, but her eyes widened.

After seeing how years of religous teaching in school had failed to make any impression on me, he changed the topic to catholic schools, and how they taught their students to behave. I retorted with my case series of 4 kids who went to catholic/private high schools, and all the drugs they had around, contrasting it with my own pure body (at least until medical school).

He soured slightly just as I realized that maybe his kids had gone to private schools and that I had just accused them all of being junkies.

He went on to explain how kids these days don't respect their elders. I took that as a gentle hint that maybe I should just shut up.


Tuesday, October 04, 2005

Thyroglobulin and Thyroid Cancer
 
I saw Mr. S. walk into the examination room as I was looking at the chart for the next patient. He was a small man with wiry white hair, combed over to cover his bald head. I assumed he was the patient. I didn't have time to look at it in much detail, as Dr. C grabbed the chart and walked into the room.

In the room was Mr S' wife. She looked about 60 (she was actually 80). Wearing a little too much make-up, but wearing it well. She was the patient, and she was nervous. Dr. C, who usually makes a point to look through the chart and explain the patient's history to me before going in, had only looked at the name. He started flipping through the chart right there, explaining the history as much to himself as to me. I served as a useful prop. A fig leaf for him to refresh his memory. Mrs. C. was wringing her hands. She was waiting for something from Dr. C., and he wasn't delivering. I wished he had gone through the chart beforehand, so that his performance would not be so amateurish. No one wants to feel that their doctor doesn't know them, so I was glad to be used as a prop.

It turned out Mrs. S. had had a bout of heavy pneumonia a while back. They ended up doing a PET scan to look for pulmonary malignancy because her pneumonia wasn't responding to treatment. They found a mass in her neck, and a thyroid scan with radiactive Iodine (I123) showed a cold nodule, an area of decreased metabolic activity, in her thyroid. In any case, a cold nodule makes you worry about cancer. This was what was making Mrs. S. so nervous. This is why she was here.

Incidentally, because 84% of all thyroid nodules are cold on scan, and most thyroid nodules are benign, most cold nodules are benign. Some thyroid cancers (1-4%) are hot on scan. So, nuclear medicine scans don't reliably distinguish benign from malignant nodules, and are not indicated for the routine initial workup of euthyroid patients. In other words, they suck as screening tools, but if you see one, you need to worry about cancer (Braverman and Utiger, 2000; Cox et al 1991). Radioiodine scan for all thyroid nodules have a sensitivity of 83% for thyroid cancer, and a specificity of only 25%.

Anyway, based on concern for cancer, they did a fine needle aspiration (FNA) of the nodule under ultrasound guidance (the nodule was too small to be palpated). The biopsy was negative for cancer.

"It's not cancer," Dr. C. said, telling Mrs. S. what she'd come here to hear. Mr. S. flashed his wife a thumbs up and a "thank you, Jesus" passed under his breath. Even I would have thanked Jesus under similar circumstances.

Mrs. S. brightened up, but was still tense, I guess out of habit. She had been dreading this visit the whole weekend, more likely since the biopsy. Now that the danger had passed, she wasn't sure she could relax yet.

Dr. C. continued reading her chart while all of us celebrated with smiles and nods. This was a doctor's office, after all. There's no voice recognition software that releases confetti and streamers from the ceiling whenever a doctor says the magic words, It's Not Cancer.

Our muted celebration was premature, as Dr. C. got to the lab tests. The thyroglobulin was elevated at 200 (normal <30 or so), which Dr. C. said was suspicious for cancer, especially considering the cold nodule. FNAs, to be honest, only take a small sample of tissue, so it's hard to know whether you've gotten a sample of tumor or a smudge of normal tissue. This is especially difficult when the nodule is too small to be palpated, as was the case with Mrs. S.

So, we all shut up with the celebration. I wished Dr. C. had looked through her chart before coming in. This was a crappy roller coaster ride we were taking these poor people on. I wondered if Mr. S. was now cursing Jesus, since, if He was responsible for the negative FNA, He should also be responsible for the "positive" thyroglobulin.

Dr. C. recommended that they go to a surgeon he knew. "He's the best," he said, and I marveled at the serendipity of the situation. Here was the best thyroid surgeon in the world, who just happened to be operating in the small regional hospital that was two blocks away from Dr. C's small suburban clinic. Thank you, Jesus, indeed.

This most awesome surgeon would take out the nodule, send it for biopsy right there while Mrs. S. was under. If it turned out malignant, he'd take the whole thyroid out. If not, just the nodule.

"He's the best?" Mr. S. asked.
"He's very good," Dr. C. corrected, perhaps becoming aware that he'd burdened this hapless surgeon with unreasonably high expectations. This hapless surgeon who was probably pretty good in the region was someone Dr. C. trusted, and there's a lot to be said for that. But I suspected royalty wasn't beating a path to his clinic whenever they felt a bump in their neck.

After some back and forth, they decided to go with surgery.

This whole thing left me wondering how reliable FNA and thyroglobulin are in diagnosing cancer. I asked Dr. C. about thyroglobulin when we left the room, and he said that if the patient has no anti-thyroglobulin antibodies, then serum thyroglobulin is a reliable way to detect cancer. I asked if it was a good screening tool in those cases, and he said that it was. Later at home, a pubmed search showed that thyroglobulin is useful in looking for recurrence of thryoid cancer. I didn't find anything on the diagnosis of thyroid cancer. ACP's PIER: The Physicians' Information and Education Resource says that thyroglobulin has a low sensitivity and specificity for diagnosis of thyroid cancer. I'll need to ask Dr. C. about this tomorrow. In any case, if this was my mom, and she had a cold nodule with an elevated thyroglobulin, I'd want to open it up and see what it really is. But, then again, I don't really know much about this stuff yet.

As Mrs. S. was the last patient of the day, I ran into her and her husband on my way out. Mrs. S. said that none of this would've happened if she hadn't gotten pneumonia. I mentally gasped as I heard myself say "everything happens for a reason." Did I believe this, or was I just saying it to comfort them after coming in for a Sunday drive, and finding themselves in the front car of the Texas Cyclone?

"It's good you believe that," Mr. S. said.

"It helps make sense of things," I replied, feeling for and finding my cynicism intact.

References

  • Braverman LE, Utiger RD, eds. The thyroid: a fundamental and clinical text. 8th ed. New York: Lippincott, 2000.
  • Cox MR, Marshal SG, Spence RA. Solitary thyroid nodule: a prospective evaluation of nuclear scanning and ultrasonography. Br J Surg 1991;78:90-3.



Billy is Back
 
"Billy" was my nickname in high school. Once I got to college, I dropped the "y" for a more mature, but equally fake, nickname. Now I'm "Billy" again.

Today was my first day back in clinic after 2 months of radiology. I'm doing required 4th year medicine at a community clinic. The clinic is a small, 1-doc operation. Dr. C. is a very nice man. Born in Colombia, and in the US for the past 40 years, he's a thorough, patient, and compassionate clinician.

So, I introduce myself, but he only hears the Bill and the last syllable of my last name "ee." For the rest of the day, he introduced me as "Billy." It's fine. As long as I don't become "Dr. Billy."

Billy is also back in another sense. After a long hiatus from this blog, I'm back at it. After doing a few more months of clinical rotations in my 3rd year, I decided on Radiology. It was hard to decide, but the technical aspects of the field, as well as its centrality to diagnosis and treatment, finally won me over. There was a transition period where I was thinking about applying to both Psych and Rads, but that passed. I'll just stick to counseling my friends on the side, pro bono.

There's a lot I need to look up tonight about the patients I saw today. I'll probably use the blog to do mini case presentations, mostly for my own benefit. Feel free to ignore them.


Wednesday, March 30, 2005

First call on general surgery
 
My first day and first call on the general surgery ward was pretty exciting. This is coming from someone who thinks anyone who goes into surgery is a masochist. I didn't even want to sleep, but I didn't know if the other student on call was waiting for me before she went to sleep (we only had one key to the call room), so I paged her, and then felt obligated to sleep when she called back. 2 hours of sleep just makes you groggy in the morning, anyway.

We had a van full of church mission people come in around 6:00 pm. Their van had been hit by a drunk driver and flipped onto its side in a ditch. All these nice ladies and their kids came in and we just made sure they were ok. Luckily all of them were fine.

Then we the drunk lady who had caused the accident was brought in. She was actually far worse off than the people she had hit. She had an open fracture, which was causing her a lot of pain. She was very uncooperative with the attending and residents (she had more than alcohol on board, we later learned). When I came in, I just saw this raving crazy woman screaming as they were casting her leg. I held her hand (she nearly broke it off), which helped her calm down a bit, and tried to treat her like a human being. The rest of the team, except for the other medical student, were treating her like she wasn't even there. I don't know what the hell is wrong with some of these doctors. They are nice people, and they go out of their way not to make us feel like complete idiots. But, when it comes to taking care of patients... Maybe it's the fact that they're angry and bitter that they picked a shitty residency (surgery), but they shouldn't take it out on their patients, no matter how drunk, poor, ugly, etc. they may be.

After that, I went back to the church ladies. One of them had a gash on her face, which I got to suture. It was pretty cool. I gave her 3 nice sutures, and I hope they come out well with minimal scarring. She thanked me for sewing up her face, and all I was thinking was thanking her for letting me sew her face. After a month of sewing up breasts with sub Q absorbable sutures, it was cool to use a simple stitch for a change.

Finally, I went up to the OR and scrubbed in on a butt abscess irrigation and drainage. I’m not squeamish, but this was gross. We had this lady's butt cheek opened up, and there was all this pus coming out. After dodging the second gob of goop, I quickly realized I should’ve maybe put on some shoe covers.

Well, that's all I have. I need to get some sleep. Looks like the possum who lives in my outside closet isn’t coming back from his/her late night outing. She came out, stretched, scratched itself, and then waddled over to the stairs and out into the complex. The neighbor had just come out of his apartment, and shood her away, but she’s just as blind as a bat. I'd close the closet door to keep her from coming back (I'm worried about her getting my cat sick), but I don't know if she has kids in there (honestly, I was afraid of that closet before the possum moved in (structural issues with all the junk I've stored in there), but the thought of a rabid possum defending her babies just freaks me out). I probably should read up on possums to see what their child-rearing habits are, but I feel guilty going to the bathroom without taking a medical book in with me. I don't know if I can handle unrestricted leisure reading.


Thursday, December 30, 2004

Space Center Houston
 
So, I'm as sick as a dog. I've been sleeping all day, so now that I need to sleep, I can't. On comes a Space Center Houston commercial. They're showing the Wizard of Oz on their gian screen, and you can meet the characters from the movie. One question pops up: "What the fuck does this have to do with space?"

The assholes who Disneyfied NASA's tour need to be shot. NASA went from being a cool place you could go and see nerds work, to a cheesy piece of crap on the side of the road, complete with a mascot and amusement rides. Until now, they've had sideshows that were remotely connected to, you know, SPACE! But the've been getting desperate recently, and have resorted to all kinds of even cheesier crap to draw in the lowest common denominator.


Sunday, November 28, 2004

The Failure of the Internet
 
So, Merck is in a lot of trouble. They seem to have held back data that showed Vioxx's cardiovascular side effects. One particularly damning document, titled "Dodge Ball Vioxx" is reported to have 4 pages of questions sales reps were to expect from MDs. At the end of each question was one word, "DODGE." This seemingly indicates that the reps were to dodge any such questions. Merck, implausibly, says that it was part of a training game that allowed the players to dodge the questions. Anyway, this would be easy to settle if we had the document, but somehow this doc is not on any web site. Maybe there's some legal reason for the docs to be unavailable, and this is where the 'net should come in. If you want music, movies, porn, anything, illegally, you go to Kazaa, BitTorrent, etc. But if you want any thing real, or of substance, it's not there. Another piece of the mainstream media that provides nothing substantial. Another piece that simply distracts people from what's really going on.