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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.

Tuesday
Jan172006

The Worst Gift Ever Given

I kept it in my right desk drawer. Frequently overlaid with misplaced papers, unwanted drug samples, and forlorn drug-rep paraphernalia was the worst gift I ever got. My desk and my office took on 8 feet of water after Hurricane Katrina, so I only have my memory of it; but my memory in this rare case is perfect: It was a 5-inch tall gray ceramic skull, a Halloween trinket, glazed to a high gloss. It had amber plastic orbits and a divot near the apex, right at the sagittal suture, for the insertion of a candle. It was, in a word, tacky. I kept it to remind me that I could never get a worse gift. My little  Yorick humored me.

As with any gift, its value was derived not simply from the value of the object itself but also from the circumstances of the giving, which I will now relate.

I had a patient, whom I will call Charley, that visited me from time to time for his diabetes. Charley would call my office to make an appointment for refills on his insulin almost every month, which tipped me off already of a scam in progress because I never failed to write him less than 3 refills for that medication. He would amble into the office, and when the door closed, the real reason for his visit would slowly emerge. Vicodin. The love of his life since his wife left him. Charley was very overweight and not well acquainted with bathtubs. Though he was always polite and respectful, it goes without saying that we did not always come to a mutual understanding about his pain needs.

Charley claimed disability from back pain, but, like many disabled patients in my old neighborhood, he sometimes worked side jobs to make ends meet. I did not necessarily hold this against him, since disability in Louisiana rarely pays more than $500 a month, a small sum that would scarcely cover my grocery bill, let alone his.

When Charley gave me the gift of the ceramic skull, he told me he got it for my kids, and that he stole it. Told me straight faced like he was supposed to do it. He had taken a job unloading trucks at the Dollar Store, a job he admitted he was paid "under the table" for. At the end of the work day he just slipped a couple of these fine items into the trunk of his car for gifts to family and friends.

Perhaps I should have been touched by his generosity. In a way I guess I was, but when I began to tally the value of the gift in my mind, the negatives ran so great in relation to its value that I clearly discerned that pound for pound, this was the crummiest gift I had ever gotten. First, it was a piece of junk -- it came from the Dollar Store, which pretty much told me what it was worth. Second, it was stolen. Third, it was stolen on the job by an employee who was working illegally (no taxes paid) and against the terms of his disability agreement, which requires that the recipient does not work. Fourth,  he was unloading trucks at this illicit job, which told me that he was less disabled than he was letting on. Fifth, he intended for me to pass this stolen gift on to my children. And last, and not at all least, I knew he was giving me that gift to butter me up for future Vicodin requests.

I wonder if a police officer was ever offered a 25 cent bribe? Or if an individual ever tried to claim a tax deduction on shoplifted clothing donated to the Salvation Army?

Needless to say, this choice bauble and I were not to be separated. It was my first non-drug rep bribe! So it sat in my drawer, and sat and sat, and from time to time I would dig it out and behold the new low in the world of pathetic gifts. I would laugh and put it back. It remained in its particle board sarcophagus until the flood waters of Katrina came and took it away. Alas, I miss poor Yorick! 

Friday
Jan132006

Book Review: The Known World

I have added to my book page a review of the last inhabitant of my nightstand: The Known World by Edward P. Jones. You can read my review here.

Thursday
Jan122006

The Bordelons: NPR's New Stars

National Public Radio had a luminous story this morning about the Bordelons, a family trying to rebuild in my old neighborhood, St. Bernard Parish. This was my first time hearing them, but apparently NPR has been following their story for quite some time now, and they seem to be very popular.

With good reason. The Bordelons reminded me, after much recent bad press about New Orleans, why I love the city so much. Despite losing everything in the hurricane, the Bordelons continue to be upbeat and happy. They waited months for a FEMA trailer, only to turn it over to relatives as soon as it arrived because the relatives had no place to live. They continue to live on the second floor of the house (the bottom floor is stripped to the studs because of flood water damage), with no electricity, and are simply happy with what little they have. There is no self-pity. Just an unshakable belief that as long as life goes on, there will always be an opportunity to pass a good time.*

And they sum New Orleans up. New Orleans and all South Louisiana have always had a certain devil-may-care attitude towards life, partially reflected in the well known Cajun phrase, "Laissez les bon temps rouler" ("Let the good times roll"). This attitude is very frustrating when issues of social reform come up, but is absolutely wonderful when times get tough. The Bordelons are not unique; they are typical of people I have known all my life.

It may not be possible for me to live in New Orleans all my life, but I certainly want to die there.

Note: In the interest of being picayune, I will point out that NPR makes an error in referring to the Bordelon's home as St. Bernard's. It is correctly called St. Bernard Parish.

*A Cajun phrase my grandfather used to use.

Wednesday
Jan112006

We Need a Rules Change: The Supreme Court Nominations

This week brings Senate hearings on yet another Supreme Court nomination. Each time, it seems to go according to the same partisan script. I will not expressing a political opinion on this issue, but here is a medical one: Supreme Court appointments should not be for life.

As distinguished as Chief Justice Rehnquist's career may have been (I wouldn't know, I'm not a lawyer), I was appalled at how it ended. Here was a man, the Chief Justice on arguably the most important court in the world, presiding over cases of national importance with active thyroid cancer and within weeks of his death. From what I know about end-stage cancer, there is no way this man could have been fit to make the decisions he was making. I put off major decisions when I have a bad head cold. Would you want a man a few weeks from death by cancer operating on you? Flying your jet plane? How about babysitting your newborn daughter?

This may seem harsh. Justice Rehnquist was, in his best days (the nineteen seventies!), truly an able and intelligent man. The secrecy of the Supreme Court being what it is, we may never know how much his skills eroded at the end. We do know that the man had a tracheostomy tube during his last term. We also know he refused to resign, even though he missed 44 oral arguments in his last year in office. And we know that the Bush inauguration was preceded by weeks of speculation about whether Rehnquist would be physically able to swear the president in. I do not know much about law, but swearing someone into office does not seem physically demanding to me.

This is not intended as a personal indictment of Rehnquist. Rehnquist may have been a staggering intellect, but he was human, just like the rest of us. And like the rest of us, he was afraid of death. Afraid that if he interrupted his gentle tread that he would wither away. Emily Dickinson, another dead person, said it well:

Because I could not stop for Death –

He kindly stopped for me –

We often think if we keep ourselves busy that the Inevitable will pass us by, but it never does.

Rehnquist was a Supreme Court Justice for 33 years. Ten years seems like a more appropriate term. Somewhere around a decade in the same job and the mind turns and the job becomes not a chapter but the whole novel. Like being a doctor. When you are a doctor for a little while it feels like a job, but the longer you are at it the more you start signing MD after your name on credit card receipts and raffle tickets. The job becomes you. And you start to think reflexively: as long as the job exists, I will exist. But it doesn’t work that way. The job will outlast you.

Once a person thinks a job is his forever he ceases to worry about his fitness for it. This may not be a big problem for elevator operators. For Supreme Court Justices, it is.

Doctors have to undergo recertification every 7 to 10 years, depending on the specialty. Though it is easy for me to get my dander up about having to reprove myself every decade or so, the lesson is that it is not about me. It is about the patient. I can argue that I have some rights, and perhaps I do, but not compared to my patients. If I am incompetent I have to go. The trouble with the Supreme Court is that there is not even a mechanism for re-evaluating fading judicial skills.

When the founding fathers ratified the Constitution, average life expectancy in the U.S. was about 35 years. This is deceiving, however, because there was a high infant mortality and a high death rate among pregnant women during delivery. Take these skewing factors out and for the average male who survives childhood (the typical early American voter), life expectancy was probably in the late 40s or early 50s. Elderly people were the exception, but not rare – Thomas Jefferson, 83, and John Adams, 91, were examples. Still, it is doubtful that any of the Framers thought 33 years in the Supreme Court would frequently happen. And yet, our last Chief Justice went 33 years, our current one, John Roberts, is 50 and could easily go that long. Sandra Day O’Connor hung it up after 25. John Paul Stevens is in his 31st year, and Antonin Scalia is in his 21th. Scalia, a relatively young 69, could roll on for another 15 years, if he follows Stevens’s example, and takes his medication like a good boy should.

The lifetime appointment was designed to insulate the Judicial Branch from the foibles of Congressional politics. Fine, but through the miracle of modern medicine, this strategy safeguarded against one foible and exposed another. Far be it for me, a doctor, to say that medical advances have allowed people to outlive their usefulness. But I will argue that it allows people to live well beyond their peaks. When I walk into the Supreme Court chamber, I want to see 9 peaks. That is not too much to ask.

Instead, what we get is people who have peaked and don’t have the good sense to admit it. The more your judgment slips the less likely you are to see that in yourself. Every drunk on the road thinks he is safe to drive.

Certainly we should accept an individual if he is the best available, even if he is not at his personal best. If we are trapped on a jet in a 1970s airline disaster movie, the two pilots are dead and the only experienced pilot on board is a 117 year-old World War I vet who flew air mail in the 1920s and now likes scotch too much, we take him. But with the number of lawyers we have in this country, I dare you to convince me that the very best one is 85 years old. If this is true, why not replace Rehnquist with another octogenarian?

A ten year term would help guarantee that our top court gets only the best. Every ten years, judges would be up for renewal. This would allow Congress to pick off the weaklings. This system works great for the Chairman of the Federal Reserve, and many would contend that that position is more important than any seat on the Supreme Court. The concern, I guess, is that with appointment renewals justices would be more easily influenced by public opinion. They would be more likely to bend to public pressure when they are up for re-election, so-to-speak. Okay, but that seems to me a fair price to pay to get people out of the court who have Parkinson tremors so bad that their signature looks like a seismic tracing. By our current system, a guy like that doesn’t get outed until God takes him. I love God as much as the next man, but sometimes His sense of humor is a little too arcane for politics.

This change might politicize the judical branch a bit. This is not all bad. Most judges, though they would never admit it, would rather go to their graves thinking they had been booted because they voted to overturn Roe v. Wade rather than because they had lost too many cerebral neurons. Let them think that. Sometimes we forget that one of the purposes of politics is to paper the ugly truth over. There is nothing wrong with allowing worthy public servants the dignity of political outrage instead of the public exposure of infirmity.

If you think I am ageist, consider this: a ten year term might open the door for older candidates. If I am in the White House, I do not consider nominating a 65 year-old for a lifetime appointment. Too many potential health problems, not enough good years on the bench. On the other hand, with ten year appointments, 65 doesn’t look so bad for a candidate in good health.

Being a Supreme Court Justice is either easy or hard. If it is hard (and we are told that it is), then we should have a keen interest in keeping people in there who are at their sharpest. If it is easy, so easy that an 83 year-old a with metastatic thyroid cancer can do it, then I still don’t see the fuss about eliminating lifetime appointments. Because if it is that easy, any nine people you round up off the street on a given Monday morning would be more than adequate.

Monday
Jan092006

Katrina #4: Cancel Mardi Gras?

Christmas and New Years' have passed, and now we are deep into January. For most New Orleanians, this means thoughts of Mardi Gras.

The Carnival season starts on Twelfth Night, the last day of Christmas, and runs until Mardi Gras, or Fat Tuesday, which is the day right before Ash Wednesday on the Catholic calendar. Because Ash Wednesday moves on the calendar, the Carnival season varies greatly in length, running from January 6 to the first week of February in years when Easter comes early, and to mid-March in years when it runs late. (I always remember that St. Patrick's day, March 17th, occurs during Lent when I try to remember how late in the winter Mardi Gras can be. For the sticklers, the actual late date for Mardi Gras Is March 9.)

Except maybe this year. With Katrina so recent, there has been discussion about calling Mardi Gras off. But I think less so in New Orleans than outside of it. Some of the complaints have come from New Orleans refugees In other cities, most notably Atlanta, who somewhat understandably want every effort made to pave the way for their return, sparing nothing for a party. The rest of the objections come from non-New Orleanians who misunderstand Carnival, making assumptions about it that lead to erroneous conclusions.

Mardi Gras is not exactly a religious celebration, but it is closely linked to the religious calendar. It is the day before Ash Wednesday, and 40 days before Easter. It was originally conceived as a big blow-out party before the faithful enter the 40 days of Lenten abstinence and prayer. Much as you might have a big steak dinner the day before starting an exercise and diet plan.

The Mardi Gras celebration in Louisiana is very old, and a strong tradition. In 1699 when the French explorers Iberville and Bienville came up the Mississippi River, they arrived at a place near modern Fort Jackson and named a small stream there Bayou Mardi Gras, commemorating their day of arrival. It was the beginning of a long series of celebrations.

Mardi Gras is not just a party, it is a day. It cannot be cancelled because, strictly speaking, it exists on the calendar whether celebrated or not. If we banned Christmas celebrations, December 25 would continue to roll around. Same with Mardi Gras: there is no stopping it.

There is also no stopping the celebration. Mardi Gras is not a planned event, like the Rose Bowl or the Macy's Thanksgiving Parade. It is spontaneous. If two Cajuns split a six pack over a pot of gumbo on Fat Tuesday, they are celebrating Mardi Gras. The New Orleans Mardi Gras is best known for its parades, its throws, and its bawdy French Quarter merriment, but that is just the surface of it. It is also comprised of endless balls and gatherings, fais-do-dos, and get-togethers that have nothing to do with floats or marching bands. These things will exist without the parades, no matter what.

Further, New Orleans is hardly the only home of the American Mardi Gras. It is celebrated in Lafayette, Houma, Thibodeaux, Baton Rouge, and as far east as Mobile, AL and Pensacola, FL. The Mobile parades are older than the ones in New Orleans.

The issue of whether New Orleans should celebrate Mardi Gras is really beside the point. Even if the city of New Orleans banned the parades there would still be parties. People would show up in the French Quarter dressed up, the walking clubs would amble on. Jefferson Parish and the West Bank, both right next door, have already announced plans to party on in places the city of New Orleans has no jurisdiction over. And if they did not, there would always be Lafayette, Houma, Mobile, Ville Platte, Grand Prairie, Eunice -- the list goes on and on. There are even displaced New Orleanians in San Antonio who have vowed to put on their annual Mardi Gras Indian celebration.

There are hundreds of Carnival Krewes (clubs) in New Orleans that will host a Mardi Gras ball, parade or not. The only thing the City of New Orleans can do is refuse to issue permits for the parades. This seems to me pointless, maybe even obstructionist. The truly great thing about Mardi Gras is that it is spontaneous. It is not, as some would believe, an innovation of the tourist industry. Quite the contrary, it is indisputable that New Orleans would have Mardi Gras even if no tourists showed up. It might be a bit smaller, but it would exist. Don't believe it? Go to Houma, or Covington, or Ville Platte, or any number of small Louisiana towns that celebrate Carnival beneath the tourist radar. They do it for themselves, just as New Orleans does.

So why would the issue of canceling Mardi Gras gain any traction at all? New Orleanians, people in all cities, is not always of one mind. Just as there are people who do not like the Christmas season, or hate football, or think that drinking alcohol is a moral downfall, there are some people even in New Orleans who do not like Mardi Gras. You can find them every year on ski slopes or in Disney World during Carnival, fleeing the city to escape the onslaught of the drunken tourist. I know a few people who leave New Orleans every Mardi Gras. These people do not hate New Orleans, or even Carnival, but it is not to their taste and they would rather not be a part of it. These are the people who are amplifying the sentiment, "Why have Mardi Gras after Katrina?" It is not that they are plotting the overthrow of this institution, or even that they begrudge anyone a party. But they are not party people themselves, and so the question, once raised, resonates with them. Why not take a year off? Just one year, that's all, and we'll go back to it.

The problem is, Mardi Gras can't be called off, because there is no one in charge of it. It is a decision of the masses. You can't make the majority stop doing what they dearly want to do. Not in a democracy, anyway.

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