Sunday, November 21, 2010

Electronics, Part 3

This so far doesn't have so much to do with medicine. When my birthday came around this year I suggested to my wife a Kindle, and she agreed, no doubt happy to be off the hook figuring out what to get me. It took a while to get it, since they were on back order.

Now I've had it for a couple of months and it's cool. It's the Kindle 3, with just the wireless capability, good enough for me. Although I've used it a fair amount, I haven't bought much, just a German-English dictionary (two English dictionaries come with it), and one other book. So am I a slow reader?

Amazon has some free ebooks you can download, but they aren't so easy to find – takes a bit of searching. What I've found out is that you can download Kindle-compatible ebooks from Project Gutenberg, which is a project in the process of making available for free a large number of out-of-copyright books.

I've read Samuel Johnson's "A Tour of the Hebrides" (along with Boswell's "Journal of a Tour of the Hebrides"), written in the 18th century, and "Moby Dick" by Herman Melville. The latter was quite a surprise, as someone who had never read it, but thought I knew the story from the Hollywood version with Gregory Peck. For one thing, the book is BIG, and it takes quite a long time indeed to actually get to Moby Dick, with variably interesting diversions into whaling (a pretty gruesome thing in the 19th century). It occurred to me that if this book just came out, there might be compliments, but overall it would probably be panned as being bloated, with some contrasting styles of narration that don't necessarily go together. It's also said to be written by this Ishmael character, who alleges to have little education, but somehow spins a complex linguistic yarn with all sorts of references to classical and other literature.

I can recall from the movie version the scene where Ahab is pulled into the water by Moby, then resurfaces attached to the whale, his arm flapping as if beckoning the ship. Great scene, but not a part of the book – Ahab gets rather ignominiously yanked into the water, and that's the end of him. There are also very detailed descriptions of Queequeg's appearance and behavior that are nothing short of amazing.

Interestingly it was quite easier to read and understand Johnson's 18th century British English than Melville's 19th century American English. To say that it is flowery and obtuse is an understatement.

I took my Kindle on a trip lately, and tried out the idea of putting various reservation information on it, and it worked quite well, and so I had all of that in one place. When you don't need it anymore you just delete it.

I like the lightweight feel of it, and the physical size is about right. The battery life is great. They have what is said to be an "experimental" feature of a browser, but rather difficult to use, and legibility can be a problem, but browsing is not why I bought it, so for me not a big issue – after all, I have my smartphone now.

Sunday, November 14, 2010

Electronics, Part 2

On a more positive note than Part 1 is that I finally got a smartphone. It's not like I was just itching to get one for the longest time, I actually didn't feel I needed one until recently. What I had gotten by with was a simple phone, which most of the time was off, and some of the time wasn't even with me. The other part was having a beeper, yes the age-old beeper.

The reason for this was that, as I go through my day, I do not want to spend time answering the phone, to get messages, to answer questions about something or other. Even though some people had my cell number, it generally didn't do them any good, since I might not get a voice mail message for a week or two. Many doctors go on and on about not wanting patients to have their cellphones on when they're being seen, but at the same time, I've seen doctors interrupt conversations with patients to answer their phones.

Thus the beeper. Sends me a passive message, which might be about needing to call, but mostly not, but at any rate there isn't this expectation that I, personally, will be available to talk 24/7. The only bad thing about the beeper was the sound, which could be changed to one thing or another, but what couldn't be changed was the volume. The basic volume was Ok most of the time, but in a quiet room as you're resting, in the middle of the night sleeping, it was very annoying.

What finally happened was that, as part of the new world order of our group being bought up by the hospital, they agreed to continue our phone and beeper contracts until they were up, after which they would pay me $50 per month to get "whatever I wanted." There was no way that I was going to get a phone and beeper service, and hard to imagine I could pay only $50 in the process, so time to move on.

I had plenty of time to wait, see what's new with phones, with services. I had thought that surely I would want something with a keyboard, such as a Blackberry. But then there were iPhones, and later Android phones, which at first seemed not so good imitations of iPhones. But I'm not a fan of Apple and their business model, so I waited.

And then it becomes clear that the Android OS is rapidly evolving, and with the competition heating up between hardware manufacturers, things are getting better. Then this year as the switch comes nearer, Samsung comes out with their Galaxy S phones, and now I can see some sense in it.

Even so, I waited until I could figure out the transition from beeper-phone to smartphone. Finally I figure it out. I had already been having my office send an email about messages in addition to pages on the beeper, since there are missed pages, and missed pages are just missed.

The answer is smartphone and email, having a dedicated address for this phone, and dedicated just to office/answering service messages. Dedicated to keep the noise level down, noise being spam, and unimportant messages. And thankfully, when the email comes in, my phone chirps, just once, and I have control over the volume -- perfect!

It's been a little over a month now, and it's going well. I hadn't realized that my answering service could email as opposed to call or page (but they won't do more than one kind at a time), so that came as a great asset here. Meanwhile, I have gotten more familiar with other things like Epocrates, famous in the ranks of smartphone users. I'm also able to take advantage of other things, like the BMI calculator on my website.

The next thing I want to do is decide how to cut back on services. I started out with unlimited internet, but it's already clear I don't need that much, so we'll see.

Electronics, Part 1

This is going to be a series of posts on electronics as I use them in practice.
First, a sad report on the netbook I blogged about last year. It looked promising, and at least for a time its promise seemed fulfilled. It did all the things I needed to get done, making EMG reports, tracking my patient charges, keeping up on messages and emails, and because of its light weight, was very easy to carry around everywhere.

Durability has always been the main long term problem with laptops I have owned. Usually, it's the screen - flaky connection, or in one way or another the LCD display just failing. One laptop still at home collecting dust has a failed CD-ROM drive, a killer when combined with the absence of any other way of upgrading the OS, since it was made before one could ask the computer to boot from a USB drive. I tried switching out the drive, but this didn't help, so it must be the drive controller.

So what happened to this Dell Latitude 2100? Not quite sure, but it seems to be a motherboard issue. Most often, I try to start it up, lights flash, and then the Caps lock key is blinking and blinking and blinking. After various shaking maneuvers were tried, it seemed for a while that lightly tapping the case on the counter would allow it to boot. But then, putting it into sleep mode, carrying it somewhere, and it would be frozen. Sometimes freeze up while I'm using it (grrrrr!).

With time, it took more "aggressive" tapping (aided by frustration), but somewhere along the way, I noticed that twisting the case could be enough to work sometimes, but anything that worked only worked sometimes. Obviously, surgery, or at least internal investigation was in order.

Comment: Sending one of these things back to Dell is of course an option. However, I was now in post-warranty land, and past experience tells me that a trip to Dell costs $150 (probably more now) just to have them take a look at your computer. So for a computer that brand-new cost me $400+, spending half of its brand-new cost is stupidity in action.

Next stop, Dell's website. I've bought a number of Dell products over the years, and while I am always game to trying to get useful info once again, they did not fail to change my bias that there is little if any useful support on the Dell website. What I was looking for was some help with understanding how to dismantle the 2100. I did find a site from a Dell employee about changing the SDD drive, but he gave no clue as to how to open up the case.

No help? No problem. After all, what I had in my hands was an electric-power-consuming paperweight. What good is a laptop that you might be able to get working by hammering on the counter, might quit in the middle of what you're doing, and will almost certainly not maintain its usefulness when you suspend and carry to some other place?

So I fumbled my way through opening the case by removing all identifiable screws, still found it impenetrable, and managed to eventually snap off some internal posts. VoilĂ ! Case opened!

It would have been great to say that I found some loose part, some errant piece of metal debris shorting out some circuit, some obviously sick connection somewhere to instantly fix and resurrect this failed netbook. Alas and alack! No such luck. I mashed down on all he ICs I could see, brushed the motherboard from any unseen debris, no effect. And yet, twisting the motherboard could manage to allow this thing to fire up. [Disclaimer: you will see numerous warnings about disarming things you are taking apart, dire consequences of electrical shock, transmitting currents to various electronic components without adequate grounding. I'm careful, but I ignore such warnings. After all, to me this is a dead piece of electronics. Zapping the processor to some state of complete inoperability would actually do me a favor, allowing me to comfortably toss this amalgam of silicon and solder in the trash.]

Yesterday, I managed through googling to find some Dell information on disassembling the 2100. Still lacking in some important details, I was able to figure out that, as I had actually suspected, that the "key" to getting this sucker apart somehow rested in getting the keyboard dislodged. However, even after this revelation, I have learned nothing further. I can say that the motherboard problem lies somewhere in the region of the WLAN device, which seemed to be suspiciously loose, yet various maneuvers attempting to improve the WLAN card connection made no difference, even though some localized mashing down in that area could affect the ability to boot.

So, all of this internal investigation, and I remain in the same place. So it's now kind of an extra computer, has a way of being useful, but this laptop bought for its great portability only is useful by smacking it around to get it to boot, then must be treated ever-so-gingerly to not upset the delicate connections you have resurrected for a time.

OMG! What am I doing in the meantime? While I keep getting a steady stream of emails from Dell about "deals" on laptops or whatever, the deals seem to all be in $500-600 dollar land, at least, and most are more. Oh yes, I'd love to send you $600 for a laptop that I might need to replace in 18 months, conveniently after the warranty expires. What I found was a demo Lenovo laptop at Office Depot, for which I paid $360, having a dual-core processor and a 250MB hard drive, 4GB RAM. Its main issue was that some kid had shoved something across the keyboard so that the F10 key no longer would stay in place. (I can't recall any software that really needs or uses the F10 key, and besides the mechanism works, it's just that there is no key on top of it)

So, it's heavier to be sure. But now I have a faster computer. I can set up a virtual machine running Windows so I can interact with the hospital's software. Not such a bad trade. But it's still a laptop, subject to all the physical breakdown problems I've seen before.

Sunday, November 07, 2010

"You have a brain tumor"

You might think that for neurologists this is something we say "all the time", but it's surprisingly and thankfully infrequent. My guess is that even neurosurgeons don't even have to break the news very often, since they are seeing someone who has been referred because of the knowledge of a tumor.

A capsule of a recent event went something like this – I'm asked to see someone for some intermittent weird sensations in a hand and later also in his face. This comes and goes. Exam is quite normal in all respects, even for any signs that there is any loss of sensation in his hand. So, what is this? A stroke or TIA? I recently saw a woman with a similar story, also negative exam, and she had a thalamic stroke.

This time, a very obvious tumor. Keep in mind that, as far as medical terminology is concerned, "tumor" just means "some kind of mass". A blood clot in the brain is a tumor. A fatty deposit somewhere is a tumor. The tumor that most people think about medically would be called a "neoplasm".

At any rate, this man's MRI very strongly suggested a neoplasm. So now it comes down to breaking the news. I confess to some tossing and turning that night. I learned about the finding by phone in the evening, but there was no point in calling him on the phone, rushing into the hospital to spill the beans. How will he take it? Be upset? Be upset at me? Break down into inconsolable sobbing? You never know.

Like so many things that you cogitate about, worry about, feel your stomach churn about, it was something of a nonevent. Nonevent to me, but there can be no doubt it was an important event to him regardless.

My experience-based advice is this:

  • Do not shy away from this.
  • You must have control of your faculties when you break this news. You cannot be involved in your own internal conversation with yourself while you are divulging this kind of news.
  • Be attentive to body language and every other sign of severe distress. Many people simply clamp down emotionally when this sort of news comes, so the only sign of an intense problem may come from the involuntary things they do as you explain what you know.
  • Be in no rush to leave. Wait for a sense of how they are handling it. Wait for verbal reactions. Wait some more. Ask for some feedback, especially if you're not getting much.
  • Regardless of how complete you think your interaction was, you must plan to come back to ask if there are more questions. You have just hit this person with what amounts to a stun gun.
  • There is no reason to explain much of anything in detail. There is no value in sketching out the range of what this "might be". It is what it is, and what you need at this point is something definitive that will only come from the pathologist after a biopsy or resection.
Like so many of these things, it was not as bad as I had envisioned it could be in my ruminations, but nonetheless I needed those ruminations to prepare myself mentally.

Friday, September 10, 2010


My answer to the upcoming, Bible-thumping, OMG moment we have with the Koran-burning set for tomorrow. Even Obama weighs in on it now.

If I have this straight, all this amounts to is a pretty successful effort by someone wanting to get national and global newsplay about some insipid act of burning a Koran. Reminds me of the oft-carried-out US flag burning from years past. People stopped doing that when they realized that it became meaningless and the reporters failed to show up for it.

Here are some suggestions

1. Ignore these people. Let them burn one or more Korans.
2. Point out that burning the physical representation of one or more Korans does nothing to change or negate the message of the Koran, does nothing to negate the impact of Islam.
3. Establish 9/11 as a Koran Awareness Day, where passages from the Koran are read in public, read in churches, published in the press, online, on TV, to illustrate that this is a work that has withstood time, does not of itself provide the seeds of terrorism or intolerance.

In short, you provide antidotes to the reason why these people decided to do this. You draw attention away from them, you counteract religious intolerance, you proactively present positive images in the face of hatred.

Saturday, August 14, 2010


People ask me at times what I think of House or ER, or some other TV drama about medicine. When I say that these shows aren't very interesting to me, I suppose they think that it's because I think that I don't like them because they show some seemy dark side of medicine that we're trying to hide.

Aside from the fact that House is such a distorted portrayal of medical logic, the biggest problem I have is that these shows do not portray anything much resembling life as we know it, in-or-outside of medicine.

Perhaps the biggest complaint I have is similar to one of my reactions to the various Star Trek, where life in the 23rd or whatever century is portrayed as being honest, kind, fair, and in short, totally divorced from life as we know it.

Here is an example:

As I understand the technology of Star Trek, I cannot for the life of me fathom what happened to the human sense of making fun of other people. Let's imagine one of these meeting they show, with the table surrounded by the various officers, captain at the head. Surely, we might expect someone to transport a whoopee cushion to someone's chair as he/she sat down, with the whole table erupting in laughter as the person sits down to the sound of pffffffffffttttt!". This is human nature.

No, we can't have that. Everybody on Star Trek is serious. Frighteningly serious. The humor they do have makes news anchor humor seem like ROFL humor.

The real medical world contains all of the silly, stupid, offbase humor that goes on everywhere else. We know when to be serious, but we know how to have fun, too.

Saturday, July 31, 2010

Heat Stroke -- NOT!

I've seen 2 patients this summer misdiagnosed as "heat stroke" who actually had a "stroke stroke".

Heat Stroke

This is an unfortunate nomenclature which has nothing to do with strokes as an ischemic problem in the brain. What is happening in heat stroke is that you are exposed to heat for a prolonged period, and after a certain amount of time, your body's coping mechanisms break down, for one thing, your sweat glands peter out. Since
sweating is one of the primary ways that your body copes with heat, this leads quickly to a rise in body temperature. The other issue with temperature control is that it has its limits as well.

Your brain has something like a thermostat that reacts to body temperature.

This graph to the right in all of its imprecision is meant to illustrate how the brain responds. The "set point" of your brain is this trough in the middle of this curve. So whether your body temperature is going up or going down, to a certain extent your body will respond. But the important thing to see is that beyond some limit, that
response actually diminishes, so when body temperature gets too high or too low, there is a decompensation and associated dropoff in whatever response your brain has to a temperature which is too high or too low. So above or below a certain point, temperature continues to rise or fall. As we get older, the graph gradually flattens, which explains why the elderly are at higher risk for both hypothermia and hyperthermia.

The key elements of diagnosing heat stroke are an excessively high temperature and the absence of sweating, along with other physiologic results of hyperthermia.

If you do not measure an abnormal temperature, then the brain should be functioning normally. If it isn't, then you need to look further. Needless to say, if an MRI had been done in either of these patients, a stroke (as in stroke stroke) would have been diagnosed immediately.

Tuesday, July 27, 2010


About a year ago, after some 20+ years in practice, I was working harder than I ever have, and this includes my residency and yes, even internship.

Internship is marked by uncertainty more than absolute work, since at that stage, you never know what's coming.

The scenario of this late in career period of time was that I was the lone member of my group covering a particular hospital. Over the years the number of neurologists, neurology groups seeing inpatients had shrunk, so that the bulk of the work was being done by some self-proclaimed neurologist hospitalists, in other words, they were not under contract with the hospital, but having announced themselves as such, had adsobed much of the inpatient work.

A series of events ensued, one of which was that my group became employees of said hospital corporation. The other shoe dropping was that this hospitalist group of 2 broke up from internal issues, and the remaining member, "disenchanted", decided to abandon ship, i.e., leave this hospital for coverage.

Suddenly, a 400+ bed hospital had for all intents one neurology group for neurology consultations, and de facto I was the sole recipient of these daily consultations. As if a switch were flipped, my days were driven by the steady yet erratic influx of double-figure consultation requests. So my days began earlier and ran later, starting at 6am, running to 9pm, 10pm, 11pm, and even later as I tried to keep up with the influx. I might technically be done at 9pm, but then get a request at that moment, and yes, I could put it off until tomorrow, but overnight there might be 3, 4, 5 more, so better to just see that 9pm consult tonight so I go to bed with a clean slate.

At the time and even in retrospect, the most disturbing thing to me as this materialized was the content of my dreams was replaced by dreams of being in the hospital seeing patients. Entirely. I found this disquieting, since this became a 24/7 experience for me. I have to say, I would not have believed that daytime behavior could so radically affect dreams. One begins to fear for sanity.

I don't know what signs became apparent, but finally the other members of the group stepped in to pick up some of the pressure, and once again dreams were transformed, to something more recognizable as normal, but of course what is a normal dream?

Saturday, July 17, 2010


I can feel the rhythm now.
Sometimes I can hear the distant
drumbeats or organ-pedal tones
playing out their sequence of ominous low notes.

We've already heard the other shoe drop
long ago, and so many others have dropped
that each time we think the closet is empty
another falling shoe shows up.

So now we have this constant yet variable
queasiness in our solitude,
and we sometimes wonder if it's Sartre's nausea we feel,
even though he has long ceased those corporal feelings.
Did he pass it on?

Restless slumber, disquieting moments during the day
watching some interaction play itself out
to an incomplete resolution.
Another uncomfortable state of existence.

Thursday, July 15, 2010


One of the things neurologists do, of course, is assess memory, yet it's also something that all of us deal with on a daily basis unrelated to concern about some pathological disorder of memory.

There are many "memory experts" who have written about the ways they have little tricks to remember things, but there are so many potential things to remember that this only goes so far.

Recently, I saw a doctor that I hadn't seen in years, called out to him, and was hoping to use his name in the conversation, since it's always a good thing socially to not only remember that you know someone, but also show that you remember who they are.

The best I could do was Leonard. I knew that was right, he just looked like Leonard, but the last name? Yipes. The only thing that kept surfacing was Leonard Cohen, and if there was anything I knew, it was that I didn't personally know anyone named Leonard Cohen. But the harder I tried, the more times I tried, I could get past it. Bummer.

I ended up using his first name, which may have pleasantly surprised him enough that things were Ok -- after all, he never used my name, so he may have been having the same experience.

Later, I did what I often do in this situation, an alphabetical search. I start at the beginning of the alphabet, with Leonard A, Leonard B, Leonard C, and so on. And within no time I had it, and I'll say, it is not a common last name either.

So what is this, some mnemonic device? I would consider a technique, but it's certainly not like the usual sorts of methods that might more logically be called by that term. I would consider it a way of blocking intrusive and wrong memories. The problem I was having was my mind kept getting locked up in the kneejerk Leonard >> Cohen connection, so what this alphabetic search does is attempt to break that connection and force some other last name first letter in there. And it worked, really within less than a minute. It's always impressive when something works that well and that fast.

Sunday, July 11, 2010

Howard Schultz on Health Insurance

The first obvious question for many will be "Who is Howard Schultz?" He is the founder and CEO of Starbucks. The July-August issue Harvard Business Review has published an interview, most of which is about his return as CEO a couple of years ago in a successful effort to turn the company around.

I'm not a big consumer of Starbucks coffee, but his answer to one question in particular caught my eye:

What's an example of a decision you've made that Wall Street didn't like?

Health care.Our health care costs over the past 12 months were approximately $300 million. [Starbucks offers health care benefits to any eligible employee who works at least 20 hours per week.] The thought that we could cut that benefit -- I couldn't do it. Within the past year I got a call from one of our institutional shareholders. He said, "You've never had more cover to cut health care than you do now. No one will criticize you." And I just said, "I could cut $300 million out of a lot of things, but do you want me to kill the company, and kill the trust in what this company stands for? There is no way I will do it, and if that is what you want us to do, you should sell your stock."

If there were more CEO Howard Schultzes out their, we might still need health care reform, but it might not be such a difficult problem.

Thursday, June 03, 2010

Information Transmission in Organizations

This sounds like the title of some research project that might be published in a business journal, but what I want to talk about is simply some observations that have emerged in stark detail as I have practiced medicine for the last 30 years.

Neurology is a specialty that is obviously an area that most doctors and nurses struggled with in their training. This is not meant to be a derogatory statement, since I can easily recall that when I first tried to learn neuroanatomy I was rather convinced that there was too much to learn, and that it was all quite beyond my capabilities.

As you complete training in a field quite foreign to other health care workers, you become a kind of source of information that seems mysterious, and you become a font that people come to for enlightenment about various neurologic illnesses. If that weren't enough, I also did a fellowship in neuromuscular diseases, which can be a bit of black box for many neurologists, let alone those without some degree of comfort about neurologic diseases.

So now we finally get to the point suggested by the title. An individual person, let's say a nurse on a particular unit on a particular shift, wants to know some details about some condition. I can certainly expound on some subject, for example the various features of, expectations of, treatments for, a condition like Guillain-Barré syndrome, but this is a cul-de-sac conversation. It's not marked down somewhere, not entered in any notes, not passed on to other nurses, maybe not even well-assimilated by the nurse I'm talking to. And so it's like dumping my time into a hole, where it disappears.

Tomorrow, another nurse wants the same information. Do I deliver my time into another hole? The only practical thing for me is to find some spot in between, which I'm afraid probably comes across as being reticent to explain things, maybe withholding information, not being as explanatory as I can be. It might be easy enough to try the "Google is your friend" approach in some palatable way, but I know quite well that this will be the source of a lot of misinformation and noninformation for esoteric topics.

It's a major dilemma, and I don't think that most hospital organizations either understand it or have any investment in doing something about it.

Saturday, May 22, 2010

End of Life Decisions

These decisions are thankfully not an everyday experience, but still common for a neurologist to be involved in. Whereas there is a lot of intellectual angst about the topic, when you're at the bedside, it's mostly on a very personal level.

In many cases, you have a situation where someone was "perfectly Ok" one moment, then some disaster strikes -- a major stroke, cardiac arrest, or pulmonary embolus. Maybe the person came in the hospital for some routine procedure when disaster struck, either rapidly or in some sequential fashion, as one complication after another set in.

There is, of course, the rather straightforward concept of brain death, implying a total loss of all brain activity, in which case it doesn't matter how strenuously you try, you will not keep this person alive in any sense, since it tends to lead to circulatory collapse. When the blood vessels have no tone in the muscles of their walls, you simply cannot sustain a blood pressure even with medications or even stimulating the heart.

Mostly we are dealing with something far less than that, just a brain severely damaged in some patchy sort of way. So we try to assess, prognosticate what's ahead. A recent patient, a woman in her 40s, suddenly collapsed at home, EMS came, shocked the heart into a viable rhythm, she went to emergency cardiac catheterization where stents were placed, then to the hypothermia protocol, where patients are cooled for 24 hours, something shown to help protect the brain.

In her case, it wasn't enough. Twenty-four hours pass, then 48, 72 and beyond, and still only a very, very few signs of reactivity. Her EEG wasn't flat, but her overall condition indicated that there was severe, widespread damage, and especially involving deep brain structures. As I often explain to families, the brain is arranged something like a funnel, where everything coming in and going out passes through the neck of that funnel.

If the damage is only in this funnel neck, it might cause locked-in syndrome, in which a person might be quite conscious, yet simply unable to interact with anyone. There is a French film, The Butterfly and the Sarcophagus which is a true story about such a patient.

This woman's EEG did not suggest this, but lots of damage in various locations. So now it comes to the family to decide what we do. I do not, or try not to advocate any course of action, but mainly describe what I see, and make sure that they understand options. The easiest option for the short-term is to punt, just continuing to wait. But after many days pass, with no further improvement, we have to make decisions.

We can continue to maintain everything, ventilator support as needed, start tube feedings, and begin looking toward long-term care. The term persistent vegetative state comes into the conversation. It implies that the person is unlikely to become consciously aware of their surroundings, and I think it's important to keep a general commonsense notion of 'consciously aware', not some absolute suggestion that there is no reactivity to sounds, to voices, to stimuli. Generally, vegetative patients do not stay in a coma. Eventually they develop some kind of states that look like waking and others that look like sleeping, along with some minimal reactivity.

There are those who either on some religious grounds, or perhaps their own fears and anxieties, cling to any signs of life, interpret every movement, twitch, reflex, eye motion as signs that the person is conscious. But what kind of consciousness is this?

I think we can't help but introduce some personal perspectives at this point. Would I want to exist like this? Would I want this for anyone in my family? Long-term care has expenses, but this isn't about the expense, it's about my own sense of life worth living. Why would I want to cling to every last heart beat, every last breath inside a body chained to a bed with feedings, and no ability to interact with anyone? Not for me. But I also add that this time it's not my decision, and whatever you decide, you need to make sure you are comfortable with the decision, since it's one of the most important decisions you will ever make. Oddly enough, we mostly don't make this decision for ourself, living wills notwithstanding. It's going to be make by our family.

I also take care of ALS patients (Lou Gehrig's disease), and there reaches a time when, even though the brain is still Ok, you become a prisoner in your own body, unable to eat, unable to do the least thing for yourself. You never know what you will do until faced with the choice, but I don't think I could follow Stephen Hawking's example.

And so, when the decision came from this young woman's family, it was that they didn't see the future giving them back the woman, the sister that they knew, and knowing her felt comfortable that this is how she would see it too. So care was withdrawn, she was made comfortable, and we let her go.

Thursday, May 13, 2010

A bug in human software

This is my conclusion. Some years ago there was on ongoing mail discussion in one of the major medical journals (doesn't matter which one, since in the end it came to no great conclusions).

We all know about various circumstances that can trigger them, or at least it seems that way. We certainly see them arise in certain neurologic situations of posterior fossa or brainstem problems that by some mechanism get them going, and there are cases reported of hiccups lasting many years in an individual.

To me it can only make sense that they're a "bug" in the nervous system when you realize that they cannot have any possible physiologic purpose. Nothing good comes from them whatsoever. Mostly we can just be thankful that eventually there is something that resets itself to stop them.

Thursday, April 22, 2010

Pedophilia and the Catholic Church

I'd like to take a different approach that many or most seem to take, which seems to mostly be Pope-bashing, Priest-bashing, and sooner or later various legal actions which will be invariably labelled as "trying to send a message" but seem more like trying to make some money out of this.

From a medical-psychological point-of-view, there needs to be a realization that while this may not be epidemic in the clergy, but certainly at some level it seems to be an endemic problem. We might react by saying that pedophilia is a widespread societal problem, which I suppose is true enough, but we are dealing here with a segment of the population espousing the highest moral standards.

Maybe there is some cathartic effect of repentance, bashing pedophilic priests, paying out sums of money, but I see a number of questions that arise.

1. Do we understand how it is that some men choosing to enter the priesthood might have these kinds of issues? What is it about their backgrounds that may lead to this?

2. What is the culture of the seminary which, depending on ones perspective, either is unaware of these things, or perhaps fosters them in some way? We certainly have heard tales of sexual behaviors in seminaries -- is this widespread?

3. How can the modern Church reconcile these problems with the steadfast maintenance of the idea that priests must be unmarried and celibate? Is celibacy or the pretense of celibacy a root cause of the problem?

To me these are the far more important questions we should be asking the Vatican to answer.

Wednesday, March 24, 2010

Let me see if I've got this straight...

I recently bought a Dell computer, which came with Windows 7 pre-installed. I promptly replaced that with Linux, and then set up a virtual machine and installed Win7 from the disk I got. I'm not sure how, but my Win 7 has detected some anomaly, and now is telling me that I have a Win 7 that is "not genuine". Every time I start it up it wants me to connect to Microsoft to purchase a license for this pirated copy.

I also read recently that Dell is refusing to reimburse anyone for computers which came with Win7 pre-installed, since this came at "no charge".

Ok. I can accept this. I'd like to purchase 10 copies of Win7 at no charge, please.

Tuesday, March 23, 2010

A Call for Change

This might be construed as a nonmedical commentary, but it is and isn't at the same time. It's a call for a change in the fractured mindset we can so easily see in America right now. A call for a lowering, an elimination of the hate-filled language we continue to see and hear, espoused and encouraged by the various hate-mongerers out there.

We try to portray ourselves as a Christian nation which supposedly wishes to create a situation which follows the teachings of Jesus of Nazareth, who promoted the "turn the other cheek" mentality.

I do not see the Christian ideal evidenced by all the hate we see in the news on a daily basis. I don't see it in the opposition to some kind of universal health care --" yes, you may need health care, yes, you may not have insurance, but I will not help you get it, I will watch you die first."

This is not a healthy environment in which to raise our children. We cannot advocate hate, and acting on hate as a sensible way for us to live our lives. If we say that hate is Ok, then we say that it's Ok to spew hate at your doctor, your boss, your spouse, your neighbor -- where does it end?

We must begin to speak out, and speak out in unison, that all this hate-mongering, all this hate-tolerance is unhealthy, it's bad for our country, and no good will come of it.

Friday, March 12, 2010

Scribus in the Hospital - 3
over the top

It may have seemed that what I've already shown was as much as one could do, but you'd be wrong with that assumption.

Once we have access to something like Scribus, with all of its layout capabilities, you don't have to stop at lines, labels, barcodes, and text. Add images.

There are ways of doing all sorts of things. Behind the scenes, I have added a free program called Hoversnap to the mix, and now I can make screen captures of scan images, so I can add these to the chart.

I would quickly add that in the long run, these have no relevance. These chart pages get scanned into the EMR system, and as you can imagine are totally useless at that point, since they come out as they would running them through a fax machine. So why do them at all?

Education. In two directions. One is for the non-neurologists, who do not necessarily know what they're seeing on scans, and therefore don't generally bother to look at them, and admittedly the important pictures are typically a handful of hundreds. So I trim it down to the essence.

The other is for the nurses (and other non-physician staff). My note talks about what I see in the images, and the pictures show what I'm talking about. So everybody gets some education about brain scans and what they show. And people appreciate this – you know they do, because they go out of their way to tell you. Furthermore, this is round-the-clock teaching – even the overnight nurses get in on it.

As I said at the beginning, I am not advocating this, I am not suggesting this is what all doctors should do, it's just something I am doing, and I enjoy it and feel it's worth my time.

Tuesday, March 09, 2010

Scribus in the Hospital - 2

Here is what these notes look like. This, of course, is a bogus name and a more or less made-up history, although certainly neurologists hear this kind of story all the time.

The last post showed you the generic form used as a starting point, but here I have created a patient label. This was done in Scribus with a "script", a term used for a short program written in the Python programming language, which is able to interact with Scribus to carry out some operations, and do things like creating this rectangular-shaped label on top of the one you saw in my last post that said "Attach Sticker Here".

Rather than delete that other frame, I just create this one with an opaque white background.
The script prompts me for the bits that go in there, then makes the frame. I should add that the script automatically capitalizes the patient's name, and makes the font bold for the name on the label – if you can do it, why not?

After that, then I make the barcode for this patient's hospital number – Scribus has a plug-in to do this – then I just place and resize (it's 195 pts x 20 pts).

Something my actual template has that you didn't see in the last post is a frame all set up with "NEUROLOGY CONSULTATION" at the top, again, a frame with a white background. In this case, I want to hide the lines so we don't get visual interference and legibility problems. In Scribus, I'm using something called Story Editor, which is a simple text editor, simple as far as the text entry goes, but allows for assignment of various typographic features to the text. I know I talked about my narrative style in the last post, but as you can see, this is a bit truncated, with a lot of phrases instead of the complete sentences I would use in an office note, which is the only note there will be and therefore reads more like a letter.

So I've finished my note, now what? It just so happens that the various computers the doctors use are hooked up to network printers on the nursing station, so I just print right to them, and as luck would have it, most of the time they use paper with pre-punched holes at the top since they're used largely for printing out lab results, so I print my note, sign it, and it's in the chart.

Oh, what about orders? I've done a few which also include orders in the left column made with Scribus, but mostly I like to write these out by hand, it seems to save time – also, I've noticed that you may think you know everything you want to order, then as you're putting the sheet in the chart, you realize that you need to add something else, and then something else... Usually what I will also do is to write in the time on the order so I can compare the two columns. Almost invariably it takes no more than 10-15 minutes from when I start the progress note to when I write the order on the printed out page. I don't think that compares so unfavorably with how long it takes to handwrite a similar note, and certainly speaking for myself, is a major legibility improvement.

One thing that happened, and you won't be surprised I'm sure, is that nurses were rather quickly coming up all smiles and complimenting these notes. It never is a bad idea to bring a smile to a nurse's face.

I should mention at the end of this post that while I try to do this as much as I can, there are days when I just don't have the time for this. I'm not compelled to put this much into these notes, since I also dictate a note anyway, and for example, last Friday when I eventually had a total of 8 new consultations to see, plus all the followup visits and other tasks of the day, I did maybe 3 or 4 this way. Generally speaking, though, I'd say it's about 80-90% done with Scribus.

Sunday, March 07, 2010

Scribus in the Hospital

This is something I'm experimenting with lately. The idea was to be able to make my notes for the chart by typing them in. This raises a number of questions, like how much time does that take? Does this really work? Can you do it on some kind of regular/daily basis?

I'm certainly not trying to be an advocate of the concept or of how I do it. For many years in the office, I generally take few if any handwritten notes. I sit there with the patient, take their history, and type out my notes, then save them in the chart. I used to print them out and physically put them in the chart, but since we've had an EMR, they just get saved on the server. It's doable if, like me, you're a touch typist, and certainly leads to something anyone can read.

When I started it I wondered about how I would manage with the fact that word processor text entry is a linear process -- you keep appending what you've done, whereas if you're handwriting a note, you can skip around the page and go back and stick something up where it seems to fit better. But that wasn't such a big deal once I figured out a standard outline of sorts to use, and it isn't so hard to use arrow keys or whatever to skip up and down a bit. You can always reorganize later, if you want, but these are just working notes anyway.

The next step was doing all my own typing in the office. All of it. The official notes that go to referring docs, letters for this or that. It started out when we were having a bit of a backlog in typing, and it might take a couple of weeks for my transcriptions to come back. Meanwhile the patient calls, and I'm trying to remember what I said in my dictation, which I don't know until my typing gets done. Now that I do it myself, I finish all of it the day I see the patient, so it's in the mail and in the chart that same day. Let me add that my "style" if you will is a narrative style. I am not fond (putting it mildly) of these highly structured tabular/spreadsheet-like reports that are all too common from doctors' offices these days, where most things are in words and a few short phrases, and lots of medical lingo.

So when you do all this typing, you become pretty proficient at it. It may have been out of boredom, but I decided to experiment with hospital chart notes. While we have a LOT of the patients' information computerized, we still cling to paper charts, especially for the doctors handwritten notes. I dictate my consultations just like everyone else, but I've always written a fairly long note before dictating -- it helps me collect my thoughts for dictating as well as have something in the chart before the transcription gets done (actually usually within an hour or two of dictating most days).

For the heck of it I decided to create a progress note sheet, and did so with Scribus, so everything you see in that picture at the beginning of this post was created in Scribus, even the bar code, which by the way just denotes the type of page it is -- I gather that when these pages get scanned into the system the scanner uses the bar code to make sure each page gets to the right section in the chart.

In my next post, I'll take the next step, turning this generic page into the most legible doctor's note you'll ever see.

Friday, February 05, 2010

Warning! Warning!

An increasing source of irritation are the messages from some health insurance plan, or some mass pharmacy letting me know about their concerns about the fact that my patient, Mr./Mrs. X is on a medication that has been shown to have problems in the setting of some other medication, related to their age or some other issue.

Let's imagine a general intrusiveness in people's lives. You're outside mowing your lawn, and a car stops, a man comes out and wants to make sure that you are aware of all the risks that might entail mowing close to the road, running over stones or rocks, and especially the risks of refueling your lawn mower. And so you go about your day, with warnings by some concerned person about how you refuel your car, how you shop for poultry, whether you're wearing the right running shoe for the obvious pronation you show as you run.

Most of these I just look at, try to sift out the purpose of the message, then discard. The other day I felt that I needed to step up and defend my patient, who at the age of 61 was accused of being elderly, and therefore subject to risks that she would not have if she were "unelderly".
Maybe it was generated by someone in their 30s.

I wrote, "This patient is not elderly" and faxed it back to them.

Saturday, January 30, 2010

New Computer

After slowly watching my home-built, home-updated desktop getting slower and slower at various things (I think at least one of the hard drives is sick, and its age is denoted by the fact that its motherboard has USB 1.1 ports), I decided to just get a new one. I did look into getting the parts, motherboard, CPU, case, etc., etc., but after looking at prices of pre-built vs. doing that, it made no economic sense. This is, of course, a matter of being on the lookout for good buys.

I know that for many, HP is a popular choice, but I have been wanting to support Dell for their support of Linux (Ubuntu), not that I feel restricted to getting a Dell with Ubuntu already installed.

So a couple of weeks ago I got an email about one of their Vostro desktops, checked it out, looked at the deal ($312 off), compared that to a custom build, and bought it, with a few mods - upgrade to and E8400 Intel Core Duo, 3GB RAM, 320GB hard drive. It came with one of various versions of Windows 7 -- all 32-bit, interestingly enough, but this didn't matter so much to me (details below), so I just got the one that didn't cost me extra.

My aging desktop is a dual-boot Linux-WindowsXP machine. Dual boot machines give you some flexibility but actually are a pain in the butt. This rebooting into the other OS for something or other is aggravating. Also, because of Windows only being able to see vfat formatted drives, I would always have some vfat formatted partitions for sharing data without needing to reboot.

Now comes virtual machines, and more specifically VirtualBox, originally made by a German software company that was bought by Sun, and it's available for free. So now I could run Linux on a Windows machine or vice versa, and it's the vice versa I'm more interested in -- why? Because if I want to browse or check my email, Linux is by far safer. Everything else considered, this is the decision-maker. Also, Linux users are familiar with and expect multiple desktops, so I can leave my virtual machine up and running full size in one desktop, and flip over to another one in Linux any time.

So I received my Dell (Vostro 220s) yesterday, set it up, booted into Win7 once to make sure it worked, then shut it down and blew Win7 away to install 64-bit Fedora 12. In the past I wouldn't have had the courage to do this, but after doing some research, worst-case scenario #1 was that I would need to reinstall Win7, and it did come with a reinstall disk. Worst case #2 was that I would send it back to Dell for a "restocking fee."

So now this morning, I've installed VirtualBox, set up my Win7 virtual machine, installed Win7*, and I'm good. Well, almost there. The screenshot shows what I have now. My monitor is capable of a 1600x900 display, but Win7 could only offer 4:3 ratios, so what you see there is the biggest I could go and keep it all on the screen when I flip to full-screen mode in VB. My guess is the answer is on the drivers disk from Dell.

Update: no the answer is not on the Driver disks from Dell
Further update: The answer came from a command in VirtualBox. Since the VMs can only see what VB allows, I needed to create display parameters that the VM could see. You do this with VBoxManage:

VBoxManage setextradata WinXP_1 "CustomVideoMode1" "1600x900x32"

after which WinXP can find this display resolution. I made another one for Win7.

BTW, Fedora recognized my 1600x900 monitor and selected that all by itself. It also found my printer as soon as I hooked it up, and set it up -- no searching for a driver, no getting a driver disk. Fedora probably took longer to install, mainly because I typically install a lot of software (all free, of course), including both Gnome and KDE window managers (if you can, why not?)

So the final chapter will come when my Windows XP Pro 64-bit disk arrives in the mail. Why that "dinosaur"? One of the whole points of this purchase is that I need to be able to connect to the hospital and to my office from home (you probably thought this post had nothing to do with medicine). My hospital requires Windows XP and IE6 (yes the dreaded IE6) for connectivity. So that will be the other virtual machine I make on this computer, the one I'll probably use more often.

Soon I'll post about how I've begun using Scribus, my favorite desktop publishing software, in the hospital.

* Incidentally, I did nothing illegal. I looked at the license that came with my disk, and it says that I can install this on the hardware that I purchased with it, and furthermore, there is a specific clause that allows me to install using virtualization on the hardware I purchased.

Sunday, January 24, 2010

Dementia News

The January, 2010 issue of Archives of Neurology has some articles I find of interest.

MCI and Exercise

There were 2 articles on MCI (Mild Cognitive Impairment) and the effects of exercise. The first, from the Puget Sound VA, was a controlled trial of 33 men and women, testing aerobic exercise vs only stretching. Women were more likely to see benefit from this, especially with tests of executive function (more or less products of the frontal lobes).

The second article was a population-based study, in other words, taking a group of people with or without cognitive impairment, then seeing how they may differ, in this case in regard to exercise. Like some other studies, this one too showed that those with better cognition were more likely to carry out some form of moderate exercise on a regular basis. These kinds of studies always have questions about what is the cause of what -- are you more likely to avoid dementia by exercising, or more likely to exercise if you do not have dementia? One has to suspect a bit of both is true.

Does donepezil slow Alzheimer's progression?

Donepezil is the generic name for Aricept, widely used these days, not only in diagnosed Alzheimer's disease, but also by some for MCI, with the idea that it might forestall the development of Alzheimer's. This study used processed MRI images to follow the volume of the hippocampi (structures in the brain that have to do with memory formation) at a 2-year interval. No apparent effect of donepezil was seen, however.

Wednesday, January 20, 2010

This is an empty blog except for this notice. I decided to delete all content, and since I didn't save any of it, it is simply gone, unless Google has secretly kept some memory of it somewhere.