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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

The Kool 100

I picked up the newspaper the other day and read the following:

Patients at risk for abdominal aortic aneurysm (AAA) will soon be eligible for ultrasound screening under the Medicare system. An at-risk patient is defined as a male over 65 who has smoked more than 100 cigarettes in a lifetime, or a woman with a family history of aneurysms . . .
A triple-A! I read on in horror, scarcely able to contain myself as I learned that the AAA kills 15,000 people a year in the United States. It is a silent killer, a ticking time-bomb. The aorta, the story explained, is the largest artery in the human body. In the abdomen, under the pressures and stresses of a lifetime, it may bulge outward, forming a pulsating egg that grows and grows until it finally and catastrophically bursts. I could be gardening, doing the laundry, cutting grass, or watching TV, when BAM, my aorta bursts, and, as Homer says, darkness is swirling before my eyes.


I had never heard of the AAA before, but the more I thought about it the more certain I was that I had one. I had to have that test. Even as I sat and read, the paper resting against by protuberant belly, I could see the newsprint bob up and down as my throbbing Triple-A ballooned.  There was not a moment to lose.

I made an appointment with my doctor the next day. The nurse showed me to the examination room, and I waited anxiously to make to plead my case for this lifesaving ultrasound.

A few minutes passed, and Dr. Hebert came in. He read my chart and my request. "So you are afraid you may have an aneurysm?" he asked.

How could I explain it to him? I have a AAA until proven otherwise, my mind screamed, but I said, calmly, "Doc, I don't know. But I have had these stomach pains, and I am worried . . ."

"I would be happy to order the test, Mr. Kent, but you know the Medicare rules. You read the article. I read it too because you left it under my windshield wiper in the hospital parking lot yesterday. You don't meet the criteria."

"I am 66 years old . . ."

"But you don't smoke. Oddly enough, this is the one time in life when there is a material advantage to smoking. Of course, if you want to pay for it yourself, you could get it for a few hundred dollars."

"Can't do it, Dr. Hebert." I was crushed, having blown all my money on lottery tickets. After choking back a sob, I finally said, "I'll figure something out."

I stumbled out of the office in a fog. At home, I fixed myself a cup of coffee, and lay on the sofa thinking. As I stared at my stomach, I swore I could see it pulsating, that evil AAA ripening like an August watermelon. How many minutes did I have left? Then I got an idea.

Without a word to my wife, I got into my car and drove over to the convenience store. Running up to the counter, I said to the clerk, "I need 100 cigarettes."

He made a funny face. "You mean you want a carton?"

"Whatever it takes to make 100 cigarettes. See, I gotta make criteria."

We figured it out. Twenty-five cigs a pack, so I needed 4 packs. I couldn't believe how much a pack cost! Each pack had a warning that said, "SMOKING IS HAZARDOUS TO YOUR HEALTH." But the Surgeon General certainly would approve under these extraordinary circumstances. These 100 smokes would save my life.

I took the cigarettes home, emptied the packs out and laid all 100 out on my kitchen table. My wife then walked in and asked what I was doing, though not as polite as all that.

"I am saving my life by qualifying for an ultrasound," I said.

"Not in my house!" she hollered, and I obligingly picked up all the cigarettes and went out to the yard.

Tobacco, of course, is the most addictive substance known to man. If I was to smoke 100 of them, I knew I had to make it as unpleasant an experience as possible to minimize my chance of getting hooked. To achieve this, I intended to smoke all 100 cigarettes in a one-hour period.

I lined them up side-by-side, and then picked up 5 and lit them. I stuck all 5 in my mouth. They were pointing in all directions, and with my fat head in the middle I looked something like a bagpipe. I inhaled. Presently I felt very dizzy, my heart beating faster and faster. I spat them out and lit up five more.

By the time I had gone through thirty I began to feel a horrific burning in my stomach. Along with it there was a buzzing sound in my ears. The bagpipe was revving up. As the stomach burning converted into intense nausea, I fell to my knees. I vomited over and over again, and then rolled over on my side, the whole world a haze.

My wife was standing over me. "What kind of fool are you," she said, and tried to pick me up by the collar. "It's bad enough that you are making yourself sick. You also set the lawn on fire."

She turned on the garden hose and snuffed out the blaze on the grass. Sick as I was, I made sure to gather the remaining cigarettes to my bosom so they would not get wet.

"I only have 55 to go," I murmured, and fumbled to find my matchbook. There was no going back now.

"Why don't you smoke them one at a time, instead of making yourself sick like a moron?" she said.

"I don't want to get addicted," I said, my heart palpitating. "If I make myself sick doing this, I won't want to smoke again." I grabbed 5 more cigarettes and stuffed them between my lips. The tips waggled up and down, and with my trembling fingers it was almost impossible to light them all with a single match.

I took a few more puffs, choked, and all 5 butts landed in the grass. I threw up again, and my wife doused the fallen cigarettes with another burst of water from her hose. When I vomited yet again, she hit me in the face with the water. I was on my hands and knees staring at the ground in near-defeat. A string of mucus ran from my nose down to the ground.

"Oh, you won't get addicted. If you ever pull this again I'll pound your head in with a frying pan."

How I did it, I will never know, but somehow I got through with all 100 cigarettes before everything went black.

The next thing I remember is waking up on the sofa. My wife had dragged me in somehow, and I found myself with a cold cloth on my forehead and a glass of water at arm's reach on the end table. After a few minutes, my wife came in. "Oh, you're awake," she said, and then launched into a tirade that I choose to block from my memory.

The next day I was in the doctor's office. I still looked rather wan, and Dr. Hebert was observing me suspiciously. "You smell like smoke," he said.

"I want that ultrasound test," I said. "I have smoked 100 cigarettes in my lifetime, so I qualify. If you don't believe it, you can ask my wife."

"Oh, I believe you," Dr. Hebert said. "I have already talked to your wife."

"Good. When can we get the test?"

"January 2007. Medicare is not starting the program for another 10 months, John. You will have to wait until then."

I thought I was going to faint. Deep in my abdomen I could feel that aorta, stretching, tearing, on the verge of explosion! Could I afford to wait another 10 months? I guess I had no choice. "Book it," I groaned, "on January 1st. At 12:01 am, if possible."

As I got up to leave, another thought passed through my mind.

"Doc, I just smoked 100 cigarettes yesterday. Think they would pay for a chest X-ray? I swear, I have been feeling a tumor in my chest ever since I woke up this morning."


The Smoking Gun

So I guess now we have it, the proof that President Bush was warned prior to Hurricane Katrina that New Orleans was at risk for levee breaks. Exhibit A: a video tape that shows Bush being briefed on the hurricane 48 hours prior to landfall. On the tape, National Hurricane Center Chief Max Mayfield clearly tells the President and his advisors that the strength of the New Orleans levees was a major concern. They knew, but did nothing about it.

The liberal press has taken up the standard. Bravely they accuse the White House of dishonesty, indifference, incompetence, and even outright lying.

I wish they would just shut up. The people of New Orleans have known since September 2 that the government let them down on all levels, and in every conceivable way. This news story tells us nothing new. It is nothing more than an attempt by Republican opponents to get cheap publicity over a great tragedy.

There is something awful about people who seek to profit from the suffering and humiliation of others. These critics don’t care about New Orleans any more than Bush did. They simply see this videotape as a great gotcha moment, and they will exploit it for all it is worth. Even as they speak, one can see in their eyes that they are forgetting the very people these mistakes have hurt and their criticism is intended to benefit. The human suffering in the aftermath of Katrina is not a political football, and it is shameful that so many people want to treat this situation as some kind of a game.

If opponents of President Bush really want to help the people of the Gulf Coast, they should be working to help rebuild instead of jockeying to make Republicans look bad. Bush’s critics have a lot to say about what went wrong, but when it comes to recovery plans they are absolutely silent. The people of the Gulf Coast don’t care if the President looks bad or not. We want our houses rebuilt.

If they are not going to help us with that, we would prefer that they just go away and leave us alone.

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The Mardi Gras Mambo

Picture 031.jpgPerhaps you have already seen it. The close-ups of drunken faces, the whooping and hollering, the tossing of the bead and the bearing of the breast. The crowded, raucous, filthy Rue de Bourbon, full of Mardi Gras revelers. Then the cut to the footage of decimated houses, ruined neighborhoods. Finally, the face of a blonde, always blonde, news correspondent, beautiful and ever loquacious, saying, "The drinking and the partying of Mardi Gras goes on, even as thousand suffer . . . "

Here is a word from someone who has seen at least 20 Carnivals: Bourbon Street is not Mardi Gras. For the hundreds of thousands of natives who attend Carnival every year, Mardi Gras is not a drunken, naked orgy. It is a family and cultural celebration.

The French Quarter is the smallest part of Mardi Gras. The parades, and the celebration, begin on Napoleon Avenue, 5 miles away, in a residential neighborhood, and move through the lovely oak-lined  St. Charles Avenue. St. Charles is the home of family Mardi Gras, and here you will find the streets crowded for miles with families, their children included, barbecuing, dancing, singing, and enjoying the holiday. Mardi Gras, for New Orleanians, is a celebration closer to Halloween or Christmas in its cultural importance than it has ever been to the foolishness seen on Bourbon Street.

Some people who have never been here, or even a few who have, have trouble believing this. These people are making the same error people make who think soap operas are real -- they are not looking hard enough, and are assuming what they can see is all that there is. New Orleans was the home to 1.3 million Americans before Katrina and just over 1 million now. If New Orleanians were the authors of the debauchery that goes on in the Quarter, we would all have died of AIDS or alcoholic cirrhosis years ago. We make our lives here, and our lives are just as family-oriented and spiritual as anywhere else. Mardi Gras is family-friendly and peaceful. If it were not, we would not have celebrated it for 150 years.

Picture 027.jpgMardi Gras is the fusion of the three great religions of Southeastern Louisiana -- Catholicism, music, and food. It would be an exaggeration to call it a religious holiday, but it certainly retains echoes of its original purpose as the big blowout before the austerity and prayerful fasting of Lent. In New Orleans, you will see the same faces going to church on Ash Wedneday, the day after Mardi Gras, as you saw on dancing on the streets the day before. The religion, music, and food are everywhere, and the three are never separated for long.

People in New Orleans take food and music very seriously. If you ever come to visit, you can test this theory. Stop any person on the street and ask where you can get the best gumbo in town. In the 20 minute lecture that follows, you will hear a litany of famous and unknown restaurants and dives, including Brennan's, Galatoire's, Clancy's, R&O's, Mandina's, the list will go on and on. This is a city devoted to the simple pleasures in life. It is not interested in excess. Excess requires too much work, and drains away the pleasures of the moment. New Orleanians live the the moment, enjoying each day for whatever delights it may yield. This may not always make life as productive as it can be, and sometimes as a credo it is short-sighted. But it is not destructive. An important side effect of this pleasure-of-the-day mentality is that it spurs people to keep things as they are so they can be enjoyed again and again. This attitude is incompatible with the tourists' desire to burn the candle at both ends, and thus to destroy the substance of living. Mardi Gras is a celebration of constancy, not of extremes.

Perhaps more than any other city in the United States, New Orleans has taken care to preserve its social structures and organizations. Sometimes this means time seems to pass us by, but that is the flavor of our town, and something that every tourist immediately senses, whether he goes to Bourbon Street or not. City life is centered around numerous neighborhoods -- Uptown, the Garden District, the Irish Channel, Treme, Mid-City, Carrollton, the Lower 9th Ward -- and each neighborhood is in turn organized around local watering holes, restaurants, and churches. Music, food, and Catholicism.

The Mardi Gras Krewes that so famously march down the streets of the city are nothing more than neighborhood social clubs gone public with their good will. Rex is an Uptown organization, Endymion originally hails from Mid-City. There is a Krewe of Mid-City and of Carrollton. Zulu, the largest African-American parade, is from Treme. Folks in the French Quarter (yes, the Quarter is a real neighborhood) host the Krewe the Vieux.  My old neighborhood of Chalmette birthed Gladiators, Aphrodite, and Shangri-La.

The histories of these Mardi Gras organizations erase any doubt that they are local, rather than tourist phenomema. Almost all of them run charitable funds. Thoth plans its route to pass near homes for the elderly and infirm -- it is sometimes known as the "Krewe of the Shut-ins." Many Krewes, especially Choctaw, Grela, Jason, and Sparta, sponsor children's causes as part of their mission.

It is this peculiar link between religion and fun that makes New Orleans go. Churches hold communities together, and are the social backbone, and Carnival arises from them. No faith and no community, no Mardi Gras. In the last few weeks there has been a great outpouring of grief over the decision of the Archdiocese of New Orleans to close St. Augustine Church in the old African-American neighborhood of Treme. Communities here die very, very hard, which is why the dislocation of Hurricane Katrina has been so difficult to bear.

So, when you watch the news reports and the ads for "Girls Gone Wild -- Post-Katrina Edition" remember that the faces you are seeing are the tourists, not the residents. The residents are the ones off to the side, laughing at the goofballs the tourist flights have brought into town. The residents have their own party, separate from the tourists, there in full view for anyone to see, but subtle enough that the hurried eyes of the media usually miss it.

Happy Mardi Gras, y'all.

For other takes on the "other" Mardi Gras, see the New Orleans Times-Picayune here, and Slate Magazine here


First Pellet

I have been reading here and there about President Bush's plan to turn over contracts at 6 U.S. ports (including the Port of New Orleans) to a company based in the United Arab Emirates.

As with most public issues, once you get below the superficial discussion on the airwaves, the matter appears less clear cut than the pundits would have us believe.

Yes, two of the 9/11 terrorists hailed from the UAE. And yes, the UAE was the site of some terrorist money-laundering prior to 9/11. But since 9/11 the UAE has been cooperating with U.S. intelligence, if the White House is to be believed. Dubai has also been allowing the U.S. Navy to use its port for its Persian Gulf operations. This is not a small thing, given the current climate in the Middle East.

The ports contract appears to have been a carrot offered to the UAE for its help. In this sense, the contract was a good political move. Building up trust and mutual support with Arab nations is a very important foreign policy goal, especially now.

The problem is that it was a poorly chosen carrot. Of all the contracts the US could have offered the UAE, a ports management contract is certainly one of the dumbest choices, considering America's current security concerns. Why not let Dubai sell hot dogs at Giants' stadium? Or put them in charge of a truck stop on the Jersey Turnpike. Anything but put them in charge of a port.

As a former resident of New Orleans, though, what offends the most is the way President Bush immediately went to the defense of the UAE when the controversy erupted. He as good as told his opponents that they were racist for opposing the contract. The only reason people are attacking the contract, he argued, is because the company is Arab-based.

I wish he exhibited such passion when he talks about the Gulf Coast. Here is a president who feels so strongly about prejudice against an Arab nation that he is willing to go to the mat for them. He has never, ever shown such determination to rebuild the Gulf Coast after Hurricane Katrina.

It is not as if Louisiana or Mississippi have not been loyal supporters. Both states went for Bush in 2000 and 2004, and both went for Bush, Sr. in 1988. And even more maddeningly, the Gulf Coast has almost as great an oil reserve as the UAE has (77 billion barrels vs. 91 billion barrels). We supply 15% of America's crude, which is more than the UAE supplies.

Any respect I ever had for George W is gone, all gone.

Second Pellet

I was dismayed to read that the Commonwealth of Virginia is trying to pass a law making it illegal for doctors to ask their patients about handguns in the home. This proposed law has been written as a response to recommendations by the American Academy of Pediatrics to ask about handguns as part of a routine review of patient safety in the home.

Critics of this policy complain that it is obtrusive and politicizes the doctor-patient relationship. It is tantamount, they say, to doctors discouraging private gun ownership.

Maybe so, but is threatening to revoke a doctor's license the solution? I have asked all kinds of private questions of my patients, such as: Do you have sex with men? Have you ever cheated on your wife? Do you use cocaine? How many abortions have you had? When you laugh do you pee on yourself? Asking about firearms cannot be any more intrusive than any of these questions.

It bothers me that this nonsense comes out of Virginia. I lived in Virginia for 11 years, and have strong feelings about the place. Virginia is the home of George Mason, the father of the Bill of Rights, not to mention George Washington, Thomas Jefferson, James Madison, and James Monroe. The House of Burgesses, founded almost 400 years ago, was the first democratically elected legislative body in the Western Hemisphere. With that pedigree, one would think that the Commonwealth would be more careful than to enact a law that so clearly runs counter to the spirit of the First Amendment.

Kevin, MD has further discussion about this topic here.


How I Spent Last Weekend

DSCN1433.JPGThey dogged me interminably. Those niggling bean counters, the ones in charge of the world and of my destiny. All I wanted was a license to practice medicine in Mississippi. They wanted a copy of my diploma, as if such a piece of paper qualifies as proof that I completed medical school, and more importantly, learned something in the process. I thought, naive me, that a valid license in another state, a verification letter from my residency program, a valid DEA certificate, and an active listing with two medical specialty boards would be proof enough. Hardly.

The problem: I left that piece of paper behind when I evacuated for Hurricane Katrina. My diploma was somewhere in what was left of my flooded home.

I tried to order a new copy from my medical school, but that would take 12 weeks. So, after explaining repeatedly that my diploma was lost, and after getting letters every single week for 2 months straight saying that I had to produce it, I gave up and decided that I would try to extricate the thing from my ruined home, come what may.

One fine Saturday morning, my wife and I set out for our old home in Chalmette, LA. We took with us the tools I knew we would need to prove unequivocally that I am a well-educated American Medical Graduate -- a hammer, a shovel, a set of screwdrivers, plumber's boots, and an ax.

The trip through New Orleans has changed significantly since the days right after the storm. The city is now well divided into the quick and the dead, the boundary between recovering communities and struggling ones snaking thought the city like the sharp line of dry gangrene on a withered limb. Those areas that have survived the storm have consolidated into spaces of vivacious activity, while those most heavily hit remain sagging and crushed, almost as they were in August.

Our neighborhood was showing some signs of life. A few of the houses were now gutted of flooded material and stood empty, stripped inside to the bare studs. The FEMA-supplied trailer, ubiquitous in recovering areas of the city, was rare but nonetheless present. This meant a few people were moving back in, and starting to rebuild. There was maybe one trailer on every block -- not many, but a start.

Our street was still blocked by a house that had been swept off its lot on the back street of our subdivision. It sits intact, slab and all, right in the middle of Bradbury Drive. Our new neighbors.

Before we went into our house we paused to look at the maple tree in our front yard. It was under 12 feet of saltwater for 9 days, and stood up to 140 mph winds. Most of its branches were stripped away, but there it stood, breathing green leaves in defiance of the surrounding devastation. The only living tree on our block, it is a symbol of nature's immortality if there ever was one.

Then to work. First, to get some light in the house, we pried the plywood we had used to board up our doors and windows before the storm off the front door and a back window. We moved in. To get the front door to open and close freely, I had to shovel away about 6 inches of swamp mud in our foyer.

Our door had a large hole in it near the lock, a calling card left by the National Guardsmen who broke the door down in the days after the storm. They were looking for dead bodies, and to let us know they found none they kindly left the number 0 spray-painted in hot orange on the front of our house.

My diploma, we knew, was in the utility room. In preparation for the storm, my wife took a number of important items and stored them there, some inside the clothes dryer and some wedged between the washing machine and the wall. She was thinking of wind damage rather than flooding, and the tiny utility room was the most secluded room in our house. Unfortunately, when the water rose the washer and dryer floated up and resettled against the door, wedging it closed. The water rose all the way to the ceiling, soaking it and causing it to collapse, which left a layer of insulation and sheet rock on top of everything. Getting the diploma out would not be easy, which was why I put it off for so long.

The door was immobile, so I went at it with the ax. In a few minutes it was in splinters and I was inside the room. Next, with a shovel I was able to clear away the sodden insulation and sheet rock and took a look around.

Under the washer I spotted a stack of what looked like picture frames. The first one I tried to pick up came apart in my hands. I recognized it as a commendation from the French government to my mother's great uncle for distinguished service in the French Army during World War I. Under that was my residency certificate. Also soaked, and falling to unreadable pieces as I tried to peel it up. And under that, there it was, my medical school diploma. Carefully I was able to separate it  from the muddy floor. I lifted it up, and my wife extended her hands to receive it. She quickly carried it off like an OB nurse whisking off an afterbirth.

In a sweep of the house we recovered a few dishes from the kitchen, and most of our wedding china, which was filthy but remarkably intact. Piece by piece we carried everything outside, and lined the items up on the driveway to dry.

Across the street, our old neighbor, Mr. Jim, was home. The 77 year-old Korean War veteran was slowly stripping moldy sheetrock from his walls and carrying the pieces out to the street. A huge pile of debris stood in front of his house. It looked like his flooded home had retched up its guts, the pile of rubble a mound of vomitus on the sidewalk. He had set up in an RV about a half a mile away and was living out of it, renting a small parking space next to an old shop that had power and, in the American entrepreneurial spirit, had converted its parking lot into a temporary trailer park. His wife sat in the front seat of his pickup, patiently watching us through the windshield. She had lung disease, and he didn't want her coming into the house to breathe the dust and mildew.

There was at least a ton of debris in front of Mr. Jim's house. He had moved every bit of it by himself.

Like the good neighbor he always was, Mr. Jim stopped to talk. He planned to strip out his home and then wait to see how things developed. If there was enough activity in the neighborhood, he would eventually sell or rebuild. Like all of us, he was waiting to see what would happen. None of us want to put money into our houses and then be the only person on a block of abandoned houses. So we all wait in community limbo, to see if a critical mass of citizens returns to make repairs worthwhile.

Mr. Jim had news about Mr. Brian, his 75 year-old next-door neighbor and the inhabitant of the house directly across the street from ours.

As he spoke, I remembered the last time I saw Mr. Brian. It was August 28, the morning before Katrina. We were packing up our car to leave town and Mr. Brian walked across the street to speak to my wife.

"I have never left for a storm before, but I'm leaving now," he had told her then. My wife had asked him if he thought the Mississippi River would overflow. "Oh, no," Mr. Brian had said. "The water is going to come from that way." He then pointed down the street in the direction of the levee facing the 40 Arpent canal, then 17 feet high but today only a nubbin.

Mr. Brian left his home that morning, and died during the evacuation. Mr. Jim said he heard it was pneumonia. The story Mr. Jim heard was that during the evacuation Mr. Bryan got sick with chest congestion and fever and that his family was unable to find him a hospital.

That would be ironic if true: He had lived 4 years across the street from a doctor (me) and then died because he couldn't get appropriate medical care.

As we stood there talking amid the ruins, a tourist bus cruised around the corner. I had heard that visitors to the city were taking tours of the disaster zone, but so far I had not seen it.  I took a certain grim pride in knowing that my neighborhood had made the National Registry of Devastated Places. Maybe we should apply for National Monument status.

The sun was hanging low; time to move on. We collected our now-dried stuff from the driveway. Back at my mother-in-law's house later that day, we had everything spread out in the grass again. In the cool January air, as the daylight failed us, we hosed down all the dishes to get the swamp mud off and then put them away in the garage.

Before I went to sleep that night, I had a vision. I saw my wife and I preparing a dinner at my new house, with FEMA director Michael Brown and Homeland Security Secretary Michael Chertoff the honored guests. We were serving them food on our wedding china, the plates that had soaked in the equivalent of sewer water for nine days. Naturally we hadn't bothered to wash them very well.

My tattered diploma came back to our new home in McComb in the back seat of our car. On Monday I made a photocopy of it, and impishly sent the faded image to the bean counters.