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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

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.


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.



Katrina #3: Some Financial Lessons

Hurricane Katrina is considered the worst natural disaster in U.S. history. Although the death toll, which now stands at about 1,200, is certainly significant, we are very lucky to say that most of our losses were financial. After all, compared to the Indian Ocean tsunami of 2004, which killed 250,000, or the Kashmir earthquake of 2005, which killed 75,000, we got off pretty easy.

But the financial effects are a different story. Probably close to 2 million people suffered significant financial loss from Katrina. I, for instance, lost my home and my medical practice . Every one of the 70,000 people in St. Bernard Parish, LA lost their homes too, as well as the 14,000 or so residents of the nearby (and better publicized) Lower 9th Ward of New Orleans. I learned a lot in my financial travails after the storm. In some ways, my story was different from most because I am a doctor. But many of the lessons I learned apply to just about anyone, and I would like to share some of them with you.

  1. Always keep a few hundred dollars in cash around. In an emergency, you may lose access to bank accounts. There may be regional problems with computers, so your credit cards could be worthless. But cash is accepted everywhere. Despite what American Express says, cash is the thing you should not leave home without.
  2. Keep enough money for 6 months of expenses in easily accessible accounts for emergencies. This was one of the financial goals my wife and I agreed on shortly after we got married, and it was a very good thing. The reserve cash took a lot of pressure off us, since we never had to worry about running out of food or not having a place to live. It was the best insurance plan we had.
  3. A good insurance company is worth its weight in gold. Our insurance carrier was State Farm. Though State Farm was not the cheapest insurance carrier available to us, we picked it because it had a good reputation for paying off claims and a sound financial record. Though I did not dwell on this issue, it turned out to be one of the best financial decisions I have ever made. Unlike other insurance companies (whom I will not name), State Farm rapidly paid on its claims and gave us no problems whatsover. It settled on our house and car for what I thought was a very fair price and in a short period of time. My claim was in by the end of September and we had our money by the early Novemeber. This freed us up financially to start looking for a new home. Despite what the commercials on TV say about saving money, a good insurance company is worth the price.
  4. Try to keep all of your insurance plans with one carrier. One of the problems many Katrina victims had was that they had fire and dwelling insurance with one carrier, flood with another, and car with a third. Besides the fact that this triples the paperwork, multiple carriers make final settlements more difficult. The dwelling carrier says the damage is from flood and the flood carrier says the damage is from wind. They play a game of passing responsibility back and forth, each refusing to pay until the other has paid. This has created serious problems for many on the Gulf Coast. We, however, had everything with one company. This meant that the total settlement would be the same dollar amount, regardless of how much was flood or how much was wind. The insurance company understood that, and so went rapidly towards finalizing the claim, since it was a no-win situation for them.
  5. Don’t save stuff for special occasions. I get pangs of regret every time I think of all the stuff we lost that we were saving for special occasions. We had unopened bottles of wine, fine china, silverware, crystal, and many other things that we never used because the time never seemed right. Now all that brand new stuff is gone, and we wish we had used it. Life is short, and you never know what will happen. I wish we had enjoyed that things we had more. Sometimes we forget when we break a plate or stain our best sofa with wine that at least we are getting use out of them. Try losing something that you never used at all.
  6. Keep all your financial and vital records together in a container that you can take with you easily. We got out with all our credit card numbers, our bank and tax records. And we took things I am now very thankful we have, like our birth certificates and Social Security cards, my medical license, and the deed to our house. The only thing I lost that I really need are my diplomas. Electronic records are the best. Anything you can put on a CD-ROM is easy to take in an emergency. I wish we had had everything on electronic record. That will be my future goal.
  7. Education is king. The one thing you can’t lose in a disaster is your skills. No matter what, if you have a solid education and good work skills you can always get back on your feet. The people who are suffering the most are the ones without education, who live paycheck to paycheck on minimum wages. For them, rebuilding is going to be very difficult, because they have no educational foundation to build a new career on. The best way to prepare for life’s worst events is to go to school. Of course I understand that, and I will make certain that my children do also.


Depression and the Importance of Doctor Follow-ups

A recent article in the American Journal of Psychiatry looks at depression and how it is treated. The study discussed in the article, the STAR-D trial, looked at the treatment of depression with the drug Celexa in 2,876 patients. The STAR-D trial found that Celexa is effective, which is no big surprise, but it also found that the patients who went back to the doctor regularly for medication adjustments (what the study called “measurement-based care procedures”) had more improvement that those who did not.

This helps to confirm what many doctors know from experience – that the first dose of an antidepressant seldom does the trick. Almost always, the medication has to be adjusted several times to arrive at the optimum dose.

It is important that people who seek treatment for depression do not give up. If the first dosage dose not work, the medicine may have to be adjusted. Or it may be necessary to try another medication.

It is my experience that patients who seek treatment for depression and anxiety often expect too much too soon from the medication. They think popping one pill will turn their lives around, and this is simply not the case. Antidepressives do work, and study after study has shown that, but making them work requires a little effort. If the medication does not seem to be working, or is working a little but not enough, it is vital that the patient discuss this with his doctor. With the proper re-evaluation, a good doctor can refine the treatment until the patient get the results he is looking for.


The Strange Case of Charles Cullen

Over the holidays, I stumbled upon a remarkable news story. A nurse in New Jersey, serving a life sentence for murdering 29 of his patients, has agreed to donate a kidney to an acquintance.

You can check out the story for more details, but I will outline the basics. The nurse, Charles Cullen, decided several years ago that he wanted to be New Jersey’s answer to Dr. Kevorkian. So he began killing older and weaker patients, people he thought were suffering and would die anyway. He did this by overdosing them on medication, typically insulin or digoxin.

In a brief review of Cullen's life, twothings stand out. First, Cullen is a deeply disturbed individual. He as attempted suicide on many occasions and has a documented history of spousal abuse and alcoholism. Divorce records indicate that he also has a history of animal abuse, and most psychologists regard animal abuse as a marker for severe mental distrubance.

Secondly, Cullen got away with his murders for years because again and again medical facilities hired him, unaware of his background. In fact, Cullen was dismissed from several hospitals and nursing homes under the suspicion of having harmed his patients. Although reporting laws have been strengthened since Cullen’s conviction in 2004, it remains remarkable how easily a healthcare professional can move from job to job despite a very poor work record, or even suspicion of malfeasance.

Which brings us to Cullen and the kidney. We usually think of organ donation as the most altruistic of actions – giving up a part or our own bodies and taking a health risk (surgery) to do it, all for the benefit of another. Here is a man who killed at least 29 people and yet wants to help save a man’s life.

Is Cullen just irrational? Or does he think he was doing a kindness by ending the lives of chronically ill people, and thus, the kidney donation is simply an extension of his desire to decrease suffering? One thing is for certain. If Cullen does have some sense of ethics he certainly has them out of order. It is not important simply to have values. A person must have the right priority of values. For instance, it may be ethical to be patriotic. But if a government asks a person to torture an innocent person because it is patriotic to do so, a moral person should at least pause. What is more important, patriotism or the right of an innocent person not to be tortured?

Values do not exist in a vacuum. They sometimes come into conflict (and this is often the case in medicine), and when they do, the people involved have to consider not just what their values are, but also which values take precidence in a given situation.

In the case of Mr. Cullen, perhaps he understood the value of not prolonging unnecessary suffering. But he missed the value of a patient’s right to live, even in suffering, if the patient wants to. It is a conflict of values that a balanced mind would not be likely to miss.

Aside from simply pointing out this very peculiar case, I would venture an observation. It is easy for us to see that Cullen, in his effort to relieve suffering, was doing the wrong thing. He, in his mentally ill state, stumbled over the conflict in values between relieving suffering and respecting a patient’s right to live. The fact that he would want to donate a kidney tells me that he really does have values, albeit very warped by his mental illness.

It is easy for us to see the faults in Cullen’s thinking. But there are tougher moral choices out there than the ones Cullen made. I wonder if our society is warped in its thinking, if we are making terrible moral choices but cannot see them, just as Cullen cannot see his. Our society once condoned slavery, and wife-beating, and lynching, because our ancestors stumbled over value conflicts our modern eyes now see as easily as we can see Cullen’s mistakes. There is no reason to think, having cast aside a few errors of the past, that we are now perfect, though it may be perfectly satisfying for us to be so kind to ourselves.