January 21st, 2006


Another Day of Basketball, Aneurysms and Budget Forecasting

Bruins face West Virginia at 12:45 at Pauley and are 1.5 point favorites. On CBS! They are a 3-point shooting team with a center who can step outside and sink 43% or so of his 3 pointers! Coach Howland has come up with a good defensive plan for each game. The Mountaineers are ranked #12 and the Bruins #18. Should be lovely in HD! At the same time, 1 PM, the Lady Bruins visit the Lady Trojans, so I will have to record one while watching the other. Choices!

On the medical front, good news and disappointments. A 79 year old man, who has been a patient for 13 years, was feeling weak and nauseated and had a change in his creatinine from 1.7 to 5.4, as measured by the assistant of a house call doctor with a bedside device. He was feeling too weak to come to the office and was availing himself of this house call service. To their credit, the abnormal value was called into the office and a nice message was written down for me, as though it were routine, by a new employee of the physician I share office space with. Mistake #1: Never trust an important message to the person who picks up a phone at the doctor's office! The message was left in a pile and I got to it Thursday at the end of office hours. I called the patient, spoke to his wife, found out that he was not urinating as often as normal, and knowing that he is a paraplegic, has a history of bladder stones, and didn't follow through on advice to see a vascular surgeon about an abdominal aortic aneurysm, I insisted that he needed to go to the emergency room and be admitted. Could it be acute renal failure due to the expanding aneurysm, or an obstruction? I phoned the ER, spoke to a nurse and relayed my concerns, and not wanting to take primary responsibility for the patient in the hospital, being the admitting physician, doing the admitting history and physical and the renal consultation for the same H&P fee, as well as handling first line calls, I asked that the patient be admitted to a hospitalist. Fine. Good insurance. He's there. I'm not. All the right heads-up, or so I thought. I even spoke to the hospitalist and told him the above. I didn't insist that he get a stat renal US. He looked at an elevated BNP, and a K+ of 5.7, and treated the minimal elevation of the K. The Creatinine was now 7.9. Self evident that first you rule out obstruction!

The next morning, at 8:30, while running from one dialysis unit to another, the nurse calls to inform me that the patient is putting out "much urine." Well, how much urine? "It's not recorded on the Intake and Output sheet." "Not much." Well what does the US show? "It's ordered for today." Well, get it stat and I'll be right there. (Nice to have a Porsche Turbo.)

On physical, no congestive heart failure. Smaller than expected left kidney, normal size right kidney. No obstruction. Aneurysm about the same size. BP good and not a lot of distress. So, we'll cautiously try a fluid challenge. A call today indicates that the creatinine is still in the 7's. The chart is with the patient who is getting a magnetic resonance arteriogram, with no iodine dye toxicity, so the vascular surgeon can see the extent of the aneurysm. As soon as he comes back, I'll examine him, determine the output and see if we can wait before dialyzing him. He may or may not allow me, just as he may or may not allow the vascular surgeon to repair the aneurysm. I know he's got the best surgeon available, that he's not obstructed, but I don't know about the renal arteries and the aorta. Dialysis will buy time. At least he's in the hospital! Interesting, to me anyway. No back pain, even in an acute dissection, which he probably doesn't have, because of the paraplegia.

And then there's Quicken! And a review of income tax, and no one wants to hear bad news. Anyway, on the basis of the pay, there has to be another reason for this stuff.... and there is, my Porsche, my employees, medical education in Hawaii, health insurance, and self-esteem. Still, my kind of medicine is only of historical interest, and the temptation grows all the time when I balance malpractice insurance and frustrations with the diminishing joys of practicing a profession that is increasingly being treated as a commodity. They don't get it, or I don't get it. Probably me. A good nurse practitioner armed with the right algorithm could do a better job for less money, and she would complain a whole lot less. I don't believe this for a moment! But, that's where we're headed. Doctors get paid for procedures, not for thinking or doing the right thing. That reward comes in heaven.... that place with the 72 virgins, I think. I don't know if that's a reward or a punishment.

Did you ever try to figure out how long your IRA will last and what life style sops you have to throw out and what family health factors encourage living in the now because the future is uncertain? None of this will buy my wife's health, and what really matters anyway? A wonderful wife, 7 kids, 9 grandchildren.... all that and the Porsche is back after a new alternator, a brake job, 2 new axles, etc, etc.... $4,900 worth of et ceteras! It's nice to work, have a job, a family and a Porsche. To try to understand it all, and to plan.

Oh, and of course I'm reading about Spitfires, and rereading old books! And hoping that old friends are well and happy, and that Democrts will put together a plan and send George into retirement. He doesn't feel he needs to obey the country's laws, and now he wants to recruit google to do his spying. And 2 of my sons are Republicans. Maybe, it's time to trade in the Porsche on an old Caddy with tail fins, learn to play bridge, and head for a condo in Florida. Not likely!
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    chipper chipper

While Waiting for the Magnetic Resonance Arteriogram, I'm....

listening to the Jim Lehrer New Hour on tape and waiting for the phone to ring. I've got to get to the hospital and back, see the patient, of course, and settle into the Bruin games!

I forgot to mention Lin, and the mysterious plan. I turn 70 on February 13th and Lin has told me that a surprise is coming. She was the woman who got me into a Spitfire! What could she possibly do? She's been working for a year! Holy Cow! I told her after the Spitfire to simply give up. She could never come close again. There is nothing more that I can conceive of doing when my Spitfire fantasy has already been fulfilled. I am not crazy enough to go farther or faster or more dangerously in an airplane, or in a sports car, any faster or more dangerously than I can already go in Torshia.... 571 HP, 527 foot pounds!

But she's got something going, and I know that a bunch of people have been invited to something, because while she was visiting Becky in Corte Madera, a deliciously printed envelope sent to a doctor friend, was returned as, "moved, no address." It was one of those over-sized envelopes, printed by calligraphy. You'd think it was a wedding or something really special. Despite all my complaining, I'm not retiring. Not yet. So what's going on, here.

She says it's something different. This from a woman who once tried to get Michael Chang to play tennis with me for my 55th (?) birthday and another surprise party.

I know that my kids are coming, including Laurie, from Nebraska, and she'll only be staying a short time. Lin is making noises as though she's going to be taking me to Canada for something. I don't believe that for a moment. She wants me to beg her to tell me what's going on, or ask for a hint, but I won't do that. I only know that I'm taking off from the 2nd to the 12th, and, as luck would have it, I resume work on the actual day, the 13th!

So, with good intentions, at least, I'll keep writing.
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    happy happy

Challenges.... the Sunflower Challenge!

My friend, Sannee, in Lake Havasu, AZ, recently mentioned that she was about to plant her sunflowers. I love sunflowers. They make me happy. I love them so much, that, by gosh, last year, my wife got me a Costco mini-greenhouse for my birthday! Well, I did a few things, but this year, with Sannee's stimulus, or threat, I immediately went out and popped some seeds in a peat cup and they're germinating. It's cold! California cold.... '40's at the lowest. The seeds are germinating. I wonder if I can get bigger peat pots so that I don't have to transplant until I transplant for good.

And why the hell can't we catch Osama? Too much time spent bringing democracy to Iraq! I caught the Frontline special on security in Iraq and the tension between the Army, Marines and the privatising of Security Efforts, Kellogg-Brown and logistics, and the Haliburton parent, and Chaney, of course. And that poor girl reporter in the hands of the terrorists!

I need to plant more sunflowers! Maybe watch the Bruins. Tired of waiting for the call. I'm going in to see waht the output is and make a decision about dialysis. And wandering if Howland will come up with a defensive scheme to stymnie the Mountaineers.
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    anxious anxious

Gansey and Mountaineers Come Off Big

It looked like a mismatch in the first half as the seniors and juniors pllayed with polish and deadly accuracy from 3 point range. West Virginia was as advertised, poised, mature, deadly sharpshooters, well-coached. The Bruin freshman and sophomores looked badly overmatched, playing at home, yet! Afflalo, the leading scorer was stifled, missing shots badly and playing with frustration. At one point, the Bruins were down by 20 points. But this team showed poise and determination, guts, and they ground down the advantage after the half to a mere 3 point deficit with 5 seconds to go. Then Gansey took the ball away from Farmar on a steal and hit freethrows to put the game away. It was a great comeback by a team with character, but a deserved win on the road for the Mountaineers.

Meanwhile the Lady Bruins fell short by 3 points at USC, missing too many giveaways right under the basket. The ladies are quite a sight, and play with enthusiasm. I had my eye on #1, Lenoir, from USC,
, Eshaya Murphy, a dynamo #14,
, and Allison Jaskowiak, #22

The pictures are from the USC site. Hope this works. Gansey is a really fine player, but the Lady Trojans are more photogenic.
This is Miss Lenoir, a 5'6" guard.
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    impressed impressed