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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project
Thursday
Feb162006

TV Head

Maybe I have too much time on my hands, but I worry about how much TV my children watch. My wife and I try to restrict it, but on the occasions when we are both too tired and too busy to fight with them, they have amazed me with their voracious appetite for video input. They could watch from 7 am to 9 at night, every day, without complaint. Sometimes I wonder if they would forgo food for another round of “Thomas the Tank Engine” videos.

In the morning before I go to work, I will observe them sprawled out on the sofa, the steady stream of cool light entering their eyes and massaging the tips of their neurons, stimulating novel neuropathways never heard of when I was a toddler and our one black and white TV was only on a few hours a day. They sit there, almost motionless, and I wonder how that plasma screen is reshaping their little brains . . . .

My mind goes ahead forty years. My daughter is alone in a dark room. Over her eyes is a helmet with a visor that projects video images directly onto her retinas. She has a pair of the latest Virtugloves on her hands, the latest in virtual sensory perception with propriceptive enhancers. In those gloves she manipulates a $3 million pistol-grip joystick (inflation has been a problem in the last 40 years) molded precisely for her hand and no other.

She sees a black field of space. She is in a space ship flying though an endless cyber-cosmos. A small star appears ahead of her, and rapidly grows to become a huge green blob. She eases up on the joystick, searching the surface of a strange planet. Finally she spots what she is hunting for – a narrow crevasse in the surface. She pushes on the stick and glides in.

The inside of this planet is very different from the placid outside. There are electrical currents, like bolts of lightning, traveling everywhere. In a few places she sees these currents tangled up in vast storms. She is careful to avoid them – a single glancing contract and her mission may be over.

She accelerates, knowing she does not have much time, twenty minutes at the most. It took her ten minutes to get this far, so she will have to hurry. She accelerates her ship, rapidly and deftly dodging the currents of electricity that seem to be everywhere. She has never been inside this planet before, but she seems to have a familiarity with every one of those currents, every pathway.

She dives deeper. In the distance she sees what she was looking for, a volcano deep under the crust of this strange world. This volcano is very angry, spewing hot red magma for what seems like hundreds of miles. When the magma meets the electron streams, it throws their controlled flow into chaos, creating more electrical storms.

To get to the volcano, she must fly directly through one of the magma flows. There are only 2 minutes left, no time to hunt for an alternate approach. She thinks she knows enough about the electron streams to dodge them by memory. Through a hot mess of pulsating magma she flies, first darting up then down. She can see nothing; now she is flying on pure muscle memory. The magma clears, and she is right on top of the volcano. Her index finger moves to the trigger, and she delivers a volley of laser bullets into the gullet of the volcano. She waits. Too much ammo could cause surface damage, opening up the volcano rather than closing it.

The magma slows down to a trickle. Three more bullets, no more, no less, she decides. She is exactly right, and the flow stops completely.

Now she reverses her ship, rapidly weaving her way back out to the surface, almost exactly retracing her every move. This is the easy part. The computer has tracked her path exactly, so mostly she just follows its prompts, but on occasion she will make corrections because the virtual terrascape often shifts ever so slightly.

A moment later, she is again hovering over the surface of the green planet. The flight timer reads 18:54, not bad for an emergency procedure.

An overhead fluorescent light comes on. My daughter stands up, and flips her visor up. She blinks at the temporary harshness of the artificial light. The room she is in is empty, except for her chair and equipment. She strips off her gloves. Through a window facing her chair she can see a man lying anesthetized on a surgical table. One side of his skull has been removed, exposing his brain, and a huge robotic arm with a tiny probe on the end is moving away. A second arm supports the cut-away section of skull, and loads up a staple gun to fasten it back into place.

The door opens, and a young woman dressed in white scrubs steps through. “That was brilliant work, doctor,” she said. “You were able to cauterize that intracranial bleed without having to cut through a single major neuro tract.”

“Oh, don’t thank me, Deborah. Thank my dad,” she replies. “He is the one who let me watch all that TV when I was a baby.”

Tuesday
Feb142006

All the Confusion That's Fit to Print

This afternoon, Reuters news service is reporting that Harry Whittington, the man accidentally shot by Vice President Dick Cheney, has now suffered a heart attack. The story states that the attack occurred “when some of the birdshot migrated close to his heart.”

The AP reports it this way, ''Some of the birdshot appears to have moved and lodged into part of his heart in what we would say is a minor heart attack.''

I doubt that there is any malicious intent in these stories, or in the statements coming from the hospital in Corpus Christi that they are based on, but they are erroneous. A “heart attack,” or myocardial infarction, occurs when one of the arteries in the heart suddenly occludes, causing the death of cardiac tissue. This, clearly, is not what is happening.

A buckshot could only cause a myocardial infarction if it severed a coronary artery while passing through the body, which would mean death in minutes, or if it came to rest directly on top of a major coronary artery and occluded it, which is about as likely as a flipped coin landing on its edge and staying there as neither heads nor tails.

What may have happened is that the pellet lodged close to the heart, resulting in local irritation (called pericarditis), and that inflammation has aggravated an underlying heart problem, thus giving the patient symptoms. The problem with this theory is that it is me speculating. It is impossible to know unless someone involved issues a more accurate statement.

Why does it matter? It just makes me wonder: If I can pick up errors in medical reporting as often as I do, how many errors am I missing when I read topics I know nothing about?

Thursday
Feb092006

Two Trillion Ways to Leave Your Lover

IMG_0278.JPGThe White House has unfurled its brand-new $2.77 trillion budget, and I can’t help but feel a little disappointed. This ghastly amount of money is proof, as if we needed it, that we are indeed the richest country in the world. Let me see if I can get all those zeroes right: $2,770,000,000,000. Ten zeroes. Amazing.

But what amazes me most is that, with a budget of that astronomical sum, there is still posturing and moaning in Washington over the cost of the Hurricane Katrina cleanup. $2.7 trillion to spend and Congress is doing the “Let me see what I have in this empty pocket . . . sorry, nothing!” routine. That is, when they bother to stoop to the subject at all.

In his hour-long 2005 State of the Union address, President Bush devoted 151 words to the reconstruction of the Gulf Coast. He used up most of that paltry sum boasting that $85 billion has already been authorized. What he didn’t say was that most of that money is going to projects the government is required by law to pay for. For example: $1 billion will go to repair the I-10 span over Lake Pontchartrain. Great, but that road was federal property to start with. Money to fix your own structures does not constitute hurricane relief.

Also included in that figure is the billions (final figure not arrived at yet) paid to people like me for settlement of insurance claims. The national flood insurance program is funded by the U.S. Treasury, and so the White House adds these payments into its calculation of the “relief” package. This is about as fair as calling Social Security checks welfare. Those of us who had flood insurance paid premiums into the system for years (just as retirees have paid into the S.S. system). We signed the flood insurance contract and paid our money fair and square. The feds may not like it, but that money belongs to insurance policy holders. It is ridiculous for the federal government to call such insurance payments hurricane relief.

During the State of the Union speech, a television reporter remarked that “9/11 is seared on the President consciousness.” Well, Hurricane Katrina is seared into my consciousness. Just this week I talked to a patient and his wife whose 2 year-old son almost drowned in the storm. They were stranded at home because their one car broke down, lost everything they owned in the flood and are now living in a trailer in Mississippi. Both parents work, each driving 3 hours a day from Mississippi to New Orleans to work. These are good people, not the welfare addicts conservatives like to talk about, but they need help getting their lives back in order.

After 9/11, no one asked how much it would cost to put things back together. We spent all the money we needed to and then went to war in Afghanistan to make sure it didn’t happen again. Meanwhile, with Katrina, politicians and pundits started wringing their hands over the cost of recovery within days of the storm. Who is going to war for the Gulf Coast?

Last week, the President said he was opposed to passage of the Baker bill, a homeowner’s assistance program designed to rehabilitate decimated neighborhoods. The White House claims it is too expensive. It will cost about $30 billion. This comes from a government that spends $7.6 billion a day, year round. If Congress trimmed its overall budget by 2% and diverted the proceeds to the Gulf Coast, the Baker bill would be paid for 2 times over.

A month before Katrina hit, Louisiana passed its state budget, which was for $19 billion. The federal government spends more than that in 3 days. Thus, it should be no surprise to anyone that much of the financial heavy lifting has to come from Washington. Like every American citizen, Gulf South residents pay far more in federal taxes than state and local taxes. Not that our local governments are the very image of efficiency. But it is natural for anyone (such as myself) who has honestly paid thousands into the Federal Treasury to expect Uncle Sam to step up in a time of great need. On April 15 I am counted as a citizen, and charged dearly for it. What about the other 364 days?

Many people have expressed concerns about local political corruption. This would be funny if so many lives weren’t at stake. Washington chomps through $7.6 billion of your money a day, borrows $400 billion a year, and employs more people than the entire population of New Orleans and the Mississippi Gulf Coast put together and they are worried about how we spend money. With a $19 billion budget, Louisiana politicians couldn’t steal Washington quantities of money in their wildest dreams.

This is their excuse for doing nothing. The entire public health system in New Orleans is shut down, a system that served 250,000 patients a year, and as of today the feds have not put up a single penny to help revive it. Two medical schools could close, and hundreds of doctors and nurses in training wait in limbo, their education in jeopardy while Washington pauses over concerns about corruption and competency. They do not pause out of concern. They pause out of indifference.

It is not as if Louisiana and Mississippi would never pay America back. Once the economy down here is set back on its feet, it would begin to generate federal tax revenue again. In the long run, New Orleans is capable of creating enough wealth to at least significantly offset the cost of recovery. Louisiana and Mississippi are relatively poor, but they nonetheless offer employment opportunities for hundreds of thousands of Americans and are the source of a rich and interesting culture not found anywhere else on Earth.

America has always had a fondness for the new and a distaste for the old. But there is something unprecedented about throwing an entire city away. Yes, New Orleans is below sea level. Yes, the Gulf Coast is very vulnerable to hurricanes. But Louisiana is home to 40% of America’s salt water marsh. It has more alligators than Florida has and 353 species of birds. It produces the largest seafood catch in America after Alaska. To let all of that go and sink into the ocean given the extreme wealth and technology of this nation is a defeatist attitude I have never associated with America. We have thousands of troops who are dying to bring our political system to the Middle East. At the same time we are prepared to let a region of our homeland crumble and fall away from neglect. God bless America.

The numbers 9 and 6 explain the lack of urgency. 9 and 6 are the number of electoral votes of Louisiana and Mississippi, respectively. Two states that lack the clout of Florida or Pennsylvania in presidential elections and thus can be safely ignored for strategic purposes.

I am tired of hearing that there is no money to be had. $2.77 trillion and no one can find another $50 billion or so to make reconstruction really take off. We have found $240 billion so far to fund a war in Iraq. We are told this money is necessary to bring freedom to the Middle East. Who asks if this money is well spent? Why is it more important to have freedom in Iraq than to find permanent shelter for the 100,000 Americans who are still without a place to live?

I saw a patient last week, a 70 year-old man with diabetes and a history of stroke who is living in a tent in his own front yard without water or electricity. FEMA delivered a trailer a month ago, and it sits in the back yard behind his house unused because no one has bothered to hook it up its electricity. He is on the phone every day pleading with FEMA officials to come by and hook the power up so he can move in. (FEMA insists on doing its own utility hookups.) A FEMA trailer costs $15,000, and it sits in his yard, empty. That is your tax money, folks!

Nothing proves the wasteful indifference of Washington like the Mississippi River Gulf Outlet (MRGO). In 1965, this 76 mile-long shipping channel was dredged through some of the most pristine wetlands in America to give oceangoing vessels a more direct path to the Port of New Orleans. The MRGO costs $22 million a year to keep properly dredged for deepwater vessels, and this dredging process has been hugely destructive. The deep channel is very slow flowing, and thus tides from the Gulf daily carry saltwater inland into fresh water swamps. This process, called saltwater intrusion, has resulted in the complete erosion and loss of 27,000 acres of wetlands and the death of an additional 38,000 acres of bald cypress swamp. Over the 41 years of its operation, the channel itself has gradually eaten away at its own banks, widening from 650 feet at the time of its opening to over 2,000 feet today.

When Katrina hit, MRGO served as a huge funnel, channeling the hurricane’s 25 foot storm surge directly into my community. I lost my home because the MRGO retention levee that was supposed to protect me and the other 68,500 residents of St. Bernard Parish from rising water broke in 20 places.

MRGO was authorized and built by Congress. It was built against the objections of many residents of my old community, and the opposition increased as the years passed and the environmental damage of this channel continued to increase. In fact, in 1958, 7 years before MRGO opened, the St. Bernard Police Jury passed a resolution opposing its construction, arguing that the MRGO would destroy wetlands that serve to buffer St. Bernard from storm surges:

During the times of hurricane conditions the existence of the channel will be an enormous danger to the heavily populated areas of the parish.


But Congress continued to authorize MRGO maintenance despite the real danger it presented to the citizens of St. Bernard Parish. By 2005, MRGO was only being used by 226 ships a year, or less than one ship a day. Still it was kept in operation. Even after Katrina, despite the horrible damage it caused, Congress has still deferred the decision to close MRGO once and for all. The government is reluctant to close it now because no one wants to admit to the magnitude of the mistake that was made. And anyway, no one will lose his job for doing nothing. We only have 9 electoral votes, remember?

A lot of the damage caused by Hurricane Katrina was the fault of federal government neglect. MR GO helped render 68,500 Americans homeless. Outside of New Orleans, no one knows this.

It is not that I think New Orleanians should have no role in their recovery. Obviously we have to take the lead in reconstruction. But the Gulf South is America, and as someone who has lived there, I can testify that it is an America much more valuable than most people realize. It is an America that has suffered from neglect and the ignorance of citizens who have never really seen the place or understood what happened when Katrina hit. The same government that blames us for our problems has never owned up to its contribution to this terrible disaster.

So perhaps you can see why I find a $2.77 trillion budget hard to swallow. I have to pay taxes to support all that spending, even as the government does absolutely nothing to bring my old city back. But, hey, when it comes to the people in New Orleans, the federal government taketh and the federal government taketh away some more.

Two author's notes: First, the above photo was taken on Sept. 30 by me. The house is one block from my own. Second, I apologize for the length of this post, but I had a few things I needed to get off my chest.

Sunday
Feb052006

Good Moon Rising

In the transition from an urban medical practice to a rural one, I have found that some of my personal habits mark me as a city slicker. Like an ocean fish that does not notice that it breathes salt water until it is taken out of it, I find that I am now conscious of some things that were invisible to me in the city. My sleeping patterns, for example.

I have always been a late riser, and don’t need to be reminded that medicine is a poor fit for a nocturnal personality. I wish I had thought of that going in. When a person weighs career choices, the time the alarm clock goes off in the morning seems a most trivial factor. Ah, but I was fooled! Rolling out of bed at 4 am for a patient in the ER is a punishing task for someone who considers an 8 o’clock waking a burden. For me, nothing that happens before 11 am is free of the fog of sleep. When I shower in the morning I have to pay attention when I wash my hair, or I may in my morning stupor forget what I have done and wash it again. I have reason to believe that I may have washed it as many as 3 times on especially hazy mornings.

Late rising always struck me as a personal weakness, but it was not until I ensconced in McComb that I recognized it as a city habit. The electric light. The 24-hour grocery. The crowded street at midnight. Cities are always going, going, going. The surrounding bustle  ensures that a doctor doesn’t feel so strange working at night.

In New Orleans I always did hospital rounds after clinic. This meant sometimes starting in the hospital as late as 7 at night, and rounding until 10 or beyond. My latest time home: 2:30 am. Some argue that morning rounds are advantageous – they allow doctors to check on patients after the long night, and to write orders and plan tests for the coming day. If a patient is admitted to the hospital late at night, the morning rounders catch them first thing in the morning. Any poor sucker assigned to me and admitted at midnight might not see my face until the next evening. (Although, in my defense, if a patient was really sick I would trot over during my lunch break to lend them an eyeball.)

On the other hand, an early rounder misses afternoon admits, which wait until the next morning.  My afternooners waited only hours. And I swept the ER before going home at night, meaning only the really late admissions were waiting long. But more importantly, there is simply no doubt that I am faster and better at night. My morning-to-night mistake ratio is probably 3 to 1. Believe me, if I am your doctor, you want to see me at night.

In New Orleans I was not the only late rounder. When I finished rounds and went to my car at 10 o’clock, there were usually several other cars left in the doctor’s parking lot. Not always the same ones, but other ones, nonetheless.

Not in rural Mississippi. Here I get finished at 7 pm and nurses are saying, “Working late, huh?” In my previous life if I got home before 8 my wife would ask me if I had been fired. When I leave the hospital these days, I see one lonely car in the parking lot.

Such is the rural life. We are pretty well modernized here, with plumbing and all I mean, but there is still a culture left over from the days when the milk in the breakfast cereal came from Bessie in the barn. In farm culture everything has to be done in the daylight. When the sun goes down, the thresher is in the barn and the cows have been milked. Even though most people around here are no longer farmers, they have inherited the ethic of the early riser. Almost everything in town is closed after dark, except for the grocery store, a pharmacy, and thank heaven, my exercise club. But I have been up and down my street at midnight and seen lights off at every single house except my own. I feel like an eccentric. Even my wife has taken to turning in at 10:30.

In the city, night and day are just two phases of a continuum, and this is especially true in our fluorescent medical world. I would check on my patients in the ICU at Methodist at 11 pm and the nurses would talk to me as if it were the 10 am coffee break. To them, it was. And this made me feel almost normal, as if I were supposed in a bright room checking the setting on a ventilator while a window few feet away sealed me from a lightless world where crack and money moved in opposite directions, occasionally interrupted by the peal of a 9 millimeter. That was my world. Maybe I shouldn't have been comfortable with it, but I was.

I know the error of my ways. Why should people insist on scurrying about in artificially lighted rooms when there is 12 hours of perfectly good daylight? All the beasts in nature respond to the rhythms of day and night. A doctor is supposed to know the limits of the human machine. What can be accomplished by night that cannot be accomplished as well or better by day?

Well, a lot. On the occasion when I rounded in the AM, I competed with other doctors for charts. Patients were up, going to therapy, going to surgery, going to Xray, going, going, gone – no, not gone THAT way – just hard to find. I would waste precious time wandering around the hospital looking for them. At night, everyone was in bed. Everyone had just completed a day of tests, of therapy, of surgery, and they had stories to tell. Or they were too tired to tell stories, which was just as good for me, since that meant I got home 10 minutes earlier. All peace and quiet, and I had the computers, the staff, the patients, everything to myself.

The night is a little lonely, but when your job involves talking to 50 people a day, this can be a blessing.

As we get older, we tend to get up earlier. Perhaps this is hormones, or our biological clock, or fear that we have forgotten to take out the garbage, or the realization that our time in this world is running out and we are afraid we will miss something. Though instead of looking for something important not to miss, most of us turn on the TV.

For all of my adult life, I have resisted getting up early, but the tug of the old farmer's life may be unmooring me at long last. There is a reason to get back in sync with the world as I know it. As my children get older, they develop regular day-night cycles. If I want to see them awake, I have to be home. In the morning they will be busy getting ready for school, by mid-evening already asleep dreaming of their next day of fun and lessons. If I get home late I only get to see them asleep.

I have a patient here in Mississippi who, every night for the week that I attended him in the hospital, would look at his watch as I came in and say kiddingly, “You have a wife? Not for long if you are still working at 7 o’clock.”

I want to tell him that 7 is nothing compared to my past days. I don’t. I just finish up and hurry home.

A small town is about friends and family. It has to be, because rural life lacks the endless options of the big city. There is nothing to do after dark but be with each other. This is why every small town I have ever been to describes itself as “family-oriented.” It had better be, because “boring-oriented” is the only alternative, and it just doesn’t have that same ring.

The options may be limited, but then again, whether you live in the city or the country, any alternative to friends and family isn’t much comfort anyway. Country folk aren’t fools; they get their work done early so they can go home and cultivate their most important crop -- family life. I can stand to do a little cultivating myself.

Thursday
Feb022006

Furniture at Last!

Last Wednesday was a big night at our household. About 7 o'clock, there was a knock on our door, and behind it a very tired-looking delivery man who had come all the way from New Orleans. There it was. Furniture. It was a partial shipment, a sofa, a chair and ottoman, a TV stand, and a computer desk. More will come in a few weeks.

It was the first real furniture we have had since Hurricane Katrina. After the storm, we lived in a hotel for a week, my aunt's house in Baton Rouge for a month, and then my mother-in-law's home for two months before we bought our house in McComb, MS. Since then we have subsisted on a cheap futon that was our sofa by day and our children's bed by night, and on some surprisingly comfortable lawn chairs that we picked up at a department store in Metairie. My wife and I still sleep on the floor on an air mattress, as we have most days since August 29.

I am not looking for any sympathy -- this outcome is mostly our fault. After the hurricane, as we went around shopping for replacement furniture, my wife and I made two crucial decisions. First, we decided to buy all our new furniture in New Orleans. Second, we elected to get quality furniture. Since the storm washed everything away and we were starting from scratch, we decided to get the stuff we really wanted, and not to settle for whatever we could get. This complicated things, because by October every decent piece of furniture in southeastern Louisiana was sold out and on 10 weeks’ backorder. But we stuck to our guns. If we were going to replace everything we had, why buy cheap junk off the shelf and then have to replace it in a year or two? It seemed better to order exactly what we wanted, and then wait it out.

Furniture stores opened very early after Katrina. Within a month many homeowners were back in town, FEMA check in hand and ready to rebuild. Needless to say anyone who sold a product related to domestic life was doing great business. If it didn’t have mold it was good as gold. When we were shopping in October and November, it was a pleasure dealing with hardworking salespeople, many of whom had lost everything too, who had rushed back to the city to get their stores re-opened and to help returning evacuees get back on their feet.

At many of the places we went, construction crews were pulling up carpet and ripping out drywall in the showrooms while a few feet away salespeople closed the deals on bedroom sets for anxious people trying to restore order to their entropy-sodden lives.

And while this furious activity was going on, news outlets were telling America that New Orleans was an abandoned wasteland and that the people there were aimlessly wandering about waiting for government handouts.

Nothing changes a person’s appreciation for regular working people like a natural disaster. I remember checking out at a grocery store in early October, watching a man bag my groceries and thinking how glad I was that he came back to work. When no one is around to cut the grass, sweep the sidewalks, deliver the mail, or stock the dairy freezer, you begin to appreciate these things. Not just the heroes in the boats and helicopters that were on TV, but the regular people who do nothing more than show up for work every day and collectively make the world go round.

So how could we go to another city to buy furniture, when these salespeople, in ordinary times beneath anyone’s notice, were working so hard to bring our lives and their own back to normal? We ordered our furniture, and went home to wait the customary 8-12 weeks for it to arrive.

The sofa is great. The kids will be sleeping on it until their beds arrive. As for me, I’ll just keep pumping up that air mattress for a little while longer.