SuperSize Me

I'm listening to "Don't Eat This Book" on tape. It's by the guy that did Super Size Me. Yes, the movie that was made a few years back. Yes, I never saw it. Yes, I know it's a good movie and that everyone and their mother has seen it. And yes, I will try to see it soon.

First off, Morgan Spurlock is hilarious. And the book is VERY interesting. I'm maybe a third of the way done and have already learned a lot about the "McCrack Shack" and the U.S. food industry. Scary stuff!! There were so many shocking facts that my eyebrows were permanently raised while listening to the tape. A couple that are still floating around in the head: McD's strawberry shake, which I dearly love, has 46 chemicals to recreate a "strawberry" taste. "Banana" flavoring is the same thing as some sort of jet engine fluid/chemical... EWWW!

Will keep you updated... For those who haven't read the book yet, go to your closest library. It's a must read.

A Sheep Amongst Wolves

Grand Rounds is up today, and there are lots of good reads.

Particularly riveting is a series of stories by different women bloggers about prior rapes. I marvel at their courage in being able to write about the experience. Too many of us have experiences like this but suffer in silence, not realizing that unfortunately, so many other share similar stories.

As you probably know, I'm currently working at the VA hospital, and for the most part, really enjoy the patients that come through. However, there was a recent incident that I've been trying to process. Nothing happened, but it brings up old fears, and having just read the aforementioned posts, I think I'll write about it here.

I like senior citizens. A lot. I have a wonderful relationship with my grandparents, especially my grandfather, and because of that, tend to see the elderly VA men as harmless, wise people that are to be respected for having lived to a ripe old age. I had heard from a co-worker that some of them were "lecherous old men," but had never really seen someone blatantly inappropriate. And although they are 80 to 90 year old men, I guess it's my fault for failing to remember that they are men first, before they are fathers and grandfathers, and they still have sexual urges. And perhaps the majority are not as "normal" as people who haven't been through the horrors of combat, and perhaps they cannot be blamed for being unable to control their thoughts, speech, and impulses. But even so, the physician-patient bond seems so sacred to me that the very thought that a patient would be sexually inappropriate just seems so alien. When I first meet a patient, I don't think "man," or "woman," but rather "new person," and I don't expect them to think "woman" before they think "doctor." So I was very unprepared for the almost 90 year old man who seemed appropriate enough during the visit, but as I got up to leave, started talking about how lonely his older brother was, how he lacked "female companionship," how he had tried to call an escort service and how he just wanted to feel up a woman. Saying so as he comes toward me with hands reaching toward my chest. Luckily I backed up quickly and got out of there with neither party harmed, but it was a chillingly close call that I would rather not relive again. And got me to thinking that, as a woman physician, being in the typical small, closed examining room with a male patient really has the potential for disaster. I've certainly had times when patients with psychiatric problems move closer and closer and block off my path to the door. What if this patient had been 40 instead of 90? What if he were bigger? What if he were crazy? Things might have turned out differently. And sadly, although I am now more aloof and guarded with male patients, I don't really know what anyone could do to prevent such a disaster from happening.

Farm Living

Check out Farmgirl's blog - she's a Northern California girl who, over ten years ago, picked up and moved onto a farm in the midwest. I just read a few of her entries (auction fever, sheep hugs, llama guard) and am hooked! Given a love of wide-open space, fresh air, and anything furry, I would love farm life. Well... maybe love the thought of farm life. Don't know how thrilled I would be about chopping wood or preparing meat or any of the many realities that come with living in the middle of nowhere.

****************************************************************

Just signed up for StatCounter. Now, we all know I'm a half-step (all right, perhaps 100 steps) behind the latest and greatest tech stuff, so this may be old news to everyone except me... StatCounter is really neat! It's this invisible counter that notes how many hits a page has gotten and gathers data about who has visited your site. (For the paranoid out there, you are right! There is a whole lot of data floating around about who your computer is and where you are logging in from.) It has a great map where you can see a "tack" for the people who have visited your site - as of now, there have been visitors from Europe, Canada, the U.S., Australia, and even as far away as Singapore and Malaysia. Welcome!

************************************************************************************

The picture is of a couple of gorgeous roses near work. There's a whole area full of them, with different but equally stunning colors, and I had to stop and get a few shots.

Thought of the Day

How can the environment hurt you, when the mind is still?
How can the environment help, when it is not?

Dark Matter, Dark Energy

Sounds like something from Star Wars, or perhaps Harry Potter. It's actually some theories astrophysicists are throwing around. Apparently, this is the composition of our universe:

5% normal matter, 25% dark matter, 70% dark energy

"Normal matter" consists of things that we can see. All these things give off energy at a certain wavelength of light that may or may not be able to be seen with the naked eye (ie visible light versus UV, infrared, radio waves).

In recent decades, researchers have become more and more convinced that there is a vast amount of material in the universe that does not give off any energy. This mysterious "dark matter" is thought to be common but invisible. Its presence is inferred because "normal matter" cannot account for all the gravity that exists. As in, if there weren't an explanation beyond what we can see, galaxies would fly apart rather than hold together.

If all this weren't mysterious enough, scientists invoke "dark energy," a force that is slight stronger than and goes against gravity, which is responsible for causing the universe to continue to expand slowly.

Interesting stuff. They may be right, they may be wrong - only time will tell. Science makes observations of the world around us, and scientists work to make sense of these observations. Hypotheses and theories of how things work evolve as our understanding of the world changes. Whether there are distinct entities of "dark matter" or "dark energy" is a matter of human interpretation of scientific data. These current theories may hold true for the next several hundred years, or may fall by the wayside, joining ether theory and other theories that have since been disproven. But it doesn't matter. What matters is that the investigative human spirit is a beautiful thing and that our universe --- is truly awe-inspiring.

What Not to Do...

Am probably one of the most code illiterate people around, but in case there are others like moi, here's a word of advice:

If you're thinking about switching around your template, SAVE your current template code. Or else face the wrath of the template gods as you frantically try to recreate all those great links and customized changes on your old template... DOH!

The little guy in the corner is a resident around the Grand Canyon lodge.

Would You Like Some Virus With That?

The FDA has approved a virus "spray" that will soon be added to your meat. It's a combination of six virus strains meant to kill a bacteria called Listeria monocytogenes, and it's going to be going on hot dogs, luncheon meats, chicken, etc.

The viruses are grown in the bacteria and purified out to make this spray.

According to CDC (Centers for Disease Control) data, 2500 people get "seriously ill" from Listeria every year, and of these 500 will die.

This raises a few scary points:

1) Virus spray may raise quite a few eyebrows, but the fact that this went through the FDA makes you wonder what other "food additives" are in our "food" that no one has heard about.

2) It can't be healthy to voluntarily eat viruses. I don't care if they are viruses that target bacteria (bacteriophages). With the latest information, there is no evidence that bacteriophages can harm us, but as a wise professor once said, 50% of what we learn in today's science and medicine is wrong - it's just that we have NO IDEA which 50%. From what we do know of viruses, they're tricky little things. A number of them infect humans and hide out for a long time (ie varicella/chicken pox virus, herpes simplex viruses, HIV, Epstein-Barr virus). Viruses are known to mutate (antigenic drift) and swap genetic material (antigenic shift), which is how different strains get more dangerous (think flu epidemics). As an example of how wrong we can be, for the longest time, scientists were adamant that humans couldn't get non-human strains of viruses, but then bird flu came along and proved that thought wrong. From a purely public health point of view, is it worth it for the sake of 500 lives to subject billions to something that may be harmful in the long run? If this virus were to mutate, it could be a problem that would affect the world and future generations. We just don't know enough to know how big of a problem this may turn into. Which suggests that #3, sadly, is alive and well.

3) Big business has BIG MONEY for lobbyists that can get things done. Intralytix, the company that produces this virus spray, stands to make a killing off of this "food additive."

Here's To A Long Life For All

UnitedHealth Group did a survey of 100 people between the age of 100 and 104 (young 'uns), and here are some of the results:

- 23 percent said faith was responsible for their long life
- other factors: genes, medical care, hard work, healthy diet, and "living a good, clean life"
- 61% said there was nothing they would have done more of in their lives
- 78% said there is nothing they would have done less
- 13% said they wished they had traveled more
- 9% said they wished they had worked less
- 6% said they wished they had spent more time with their families

- 30% considered raising a family as their most satisfying achievement while 20% valued mostly their careers (what about the other 50%??)

My take home message:

work less

travel more
worry less
trust more
and most of all
spend time with the people that really matter

Picture taken near Temple Square in Salt Lake City. A nice example of crepuscular rays.

Disclaimer: Have NO relationship whatsoever with Evercare or UnitedHealth. Just thought the results were interesting.

If You Have Something No One Else Has,

you may want to see your doctor. While this makes perfect sense, you'd be surprised at what people live with. In the last month I've seen two such examples. One was a person with a fist-sized hole in the middle of his chest, caused by a skin cancer that was never treated and had grown larger and larger over the years. The only person NOT concerned about the hole was the patient, who was in severe denial about the whole issue. I guess, in his defense, he had seen the lesion day after day, so maybe was less impressed by the whole thing, but good grief, man, you have a hole in your chest!

The other patient had a cauliflower-like cancer on the side of his face. Like, full-on cauliflower with a stalk and buds... Again, the patient was the least concerned about it and had postponed surgical removal time and time again. I'm sorry, but while there are some things that get better with time, a plant-like growth anywhere on the body will not go away by itself...

Moral of the story is, if you have something that no one else has, particularly if it is growing with time, or if it scares other people, don't mess around. PLEASE have it checked out by someone who might know what it is - in a timely fashion. It just might save your life.

Lichen, Lichen, Everywhere

Medicine has a lot of descriptive terms. Sometimes it's related to food - ex: "currant jelly" sputum seen in Klebsiella infection, anchovy-paste pus of an amoebic liver abscess, but sometimes, it's not. To a novice in dermatology, there seems to be an awful lot of reference to lichen. Lichen planus, lichen sclerosis et atrophicus, lichen simplex chronicus, lichen nitidus, lichen striatus, to name a few, which are all dermatologic diagnoses that look very different to the naked eye.

Whoever came up with these names obviously knew their lichens. For those of us who grew up in the city, lichen is about as greek as it gets. What in the world is this lichen thing, and why does it look so different?? So for those of you in the same boat, here's what I've learned:

Lichen is a cominbation of two organisms - a fungus and an algae. The latter produces food for the fungus via photoxynthesis, and the fungus provides the algae with minerals and water absorbed from the base they grow on (tree, soil, rock, etc). Most of the lichen's bulk is made up of fungus, and the shape of the lichen is usually determined by the fungal partner. Since they have little control over the amount of water in their environment, lichens are "poikilohydric," which means they can tolerate and survive through long periods with no water. As such, they can be found in more extreme environments where other plant forms may not be able to survive.

Lichen have different jobs as part of the environment. When they grow on soil, they assist help stabilize the sand and retain water. When they grow on rocks, some lichen contribute to the weathering of rocks to soil. They also serve as a food source for animals such as reindeer and butterflies.

So how come all these diagnoses look different but contain the name "lichen?" Turns out lichen differ greatly in what they look like and are classified into categories based on appearance: crustose (flat, paint-like), filamentose (hair-like), foliose (leafy), fruticose (branched), leprose (powdery), squamulose (scale-like), gelatinous. Who woulda thunk?

The Patient from Hell

This guy is probably the craziest person that I have seen outside a mental institution. Well, maybe not, but it sure seemed like it at the time. Clinic was running smoothly, everything was peachy, then I walk into a room with a complete psycho, part antisocial personality, part borderline, with a dash of ideas of grandiosity, who almost drove me up the wall. His whole M.O. was to try to pick a fight with everyone, and the kicker was that he didn't even have to be seen in our clinic. His dermatologic problem had already resolved but six months ago he made the last resident schedule him a follow-up visit. Here's a little taste of what happened:

Crazy pt: So I need three tubes of this each month and I four tubes of that and three of my other cream.
Me: Okay.
Crazy pt: Why are you saying "Okay?" Your generation says too much "okays"
Me: I'm just acknowledging what you said
Crazy pt: Well don't say okay.
Me: (Nods. Thinking to self, oooookay weirdo)
Crazy pt: Why aren't you saying anything? You can hear a pin drop in this room.
Me: I'm listening to you.
Crazy pt: Well, that's good, cause you should be listening to me. You're the doctor and I'm the patient.
Me: Sure.
Crazy pt: Why are you talking? I can put two sentences together, you know. (which happens to be his favorite line, as he used it on the medical student and the attending)
Me: I'm just trying to figure out why you're here and what I can do for you.
Crazy pt: I have this killer burning pain from the bottom of my feet all the way up to my thighs. Should I show you my legs?
Me: (Checking computer system - pt has chronic pain, seen in pain clinic and gets a ton of pain medications) The pain sounds pretty bad. Mr. Crazy, you were just in pain clinic last month. The pain specialists are experts at treating pain and I probably won't have much to add by looking at your legs. (his skin problem was NOT on the legs)
Crazy pt: What are you trying to say? That you're a doctor and you're refusing to look at an area I want you to look at?
Me: If you want me to look at your legs we can take a look at it. If you don't, we won't.

And so on. Yes, the patient did have a couple of horns, a trident, and maybe a hint of some fangs too. I'm pretty happy that at least externally I stayed calm through the whole painful scenario, but inside I was getting more and more agitated. Anyways, am a little less shaken now, but boy am I thankful I didn't end up in psychiatry... How do these people function in the world??!!!

Big Ol' Grump

VA patients, in general, are the nicest group of people. However, when they aren't, they can be some of the grumpiest, nastiest people you come across.

Had a patient today that was upset that he had to wait before being seen. Now, the way our clinics work, there's a general pool of patients, which means that they are not assigned a particular resident. The first resident done sees the next patient. And often, the rate limiting step (if I may borrow from oh so very distant chemistry classes) is the attending. There is one attending supervising several residents, so you hurry to see your patient and sit for a half hour waiting to present the case to the attending. And we, as the residents, never know if, when, and how long patients have been waiting. Which means that every time you step into a new room, there's a possible grumpy patient waiting for you. Most VA patients are extremely nice about waiting, and some are a little grumpy, but get over it when you apologize. Not Mr. Grumpy. Even after multiple apologies, he revelled in the scowl pasted on his face and hands across his chest. All his answers to questions were terse and would be somehow redirected to the fact that he had been kept waiting.

Me: Have you had any previous skin cancers?
Mr. X: What do you think?
Me: Okay, well let's take a look at the skin cancer that was biopsied last time. Where was the exact location?
Mr. X: How should I know? You're the doctor.
Me: (After finding the spot) Mr. X, there's a couple of things we could do today. We could do XYZ or ABC, both of which are equally effective at getting the rest of the cancer cells out.
Mr. X: (Silent, glaring.)
Me: Mr. X? Which would you prefer?
Mr. X: How should I know? I don't know how your systems work. Apparently an appointment for X time means you'll be seen at Y time.
Me: (Huge inward sigh...)

That was just part of it. He kept it up the ENTIRE visit. And interspersed it with threats of leaving. He was like a sulking five year old who didn't get what he wanted - except more wrinkly.

Now, I'm not saying he had no right to be angry. Anyone kept waiting would be upset. But we're all adults. Things often don't go as planned, but that doesn't give us an excuse to pout all day. And if pouting helped the situation, I would encourage him to pout more. But all it did was worsen his already foul mood and dampen the spirits of anyone who came in contact with him. Pouting couldn't change the fact that we were already late in seeing him, nor would it help us be more timely the next time we saw him. There's a fine line between feeling an emotion and allowing it to run amuck and negatively affect social interactions/relationships...

It's actually really sad to work with these patients. Patients like Mr. Grumpy and other "difficult" patients (ie borderline personality disorder) become victims caught in a vicious cycle of their own creation or perpetuation. They are not "nice" to others, so others stay away from, or become angry with them. Their perception of the world becomes one filled with angry people who either don't want anything to do with them or don't treat them well, which makes them even more surly/difficult to get along with... what's the solution? How can you help someone like that??

Sweet...

Today was great on two accounts:

Saw a patient today who had a forehead defect that I tried to close last week. There wasn't enough mobility of the skin, so we closed the two sides and left a circular defect in the middle to heal by second intention. He looked REALLY good. There was no bruising, the sutured areas looked great, and the central hole was healing nicely. After seeing him, I realized though, that what looks good to physicians may not be considered "looking good" to patients. A simple reason might be that the patient had untouched skin before he came to you, and left with (at the minimum) a linear incision. For us, having been there after the skin cancer was excised and left with a gaping hole to try to put back together, it's almost a miracle that the skin heals so nicely after being messed around with. But the patients never get to see that intermediate stage (ie big gaping hole on forehead) but rather see the end result (still a hole on the forehead) that is "worse" than what was there before... The other reason may be that we see so many incisions/scars that we see the whole range of "nice scar" to "ew... scar," and it's always a treat to see the nice ones. Whereas if you're the patient, your only scar might look ugly to you even if it would be the Miss Universe of scars...

Can you see the fungus??

The second thing awesome thing: I saw a patient's skin lesion today, thought "it must be XXX", knew WHERE to get the supplies to do a KOH preparation, did it, and looked under the microscope for fungus. Is that cool or what? Yeah, yeah, it might be boring to YOU, but compared to a few weeks ago, when the above sequence would have taken five times as long and involved getting answers from 3 people, it's AWESOME. I mean, it's the little things that count, right? Now I just have to work on seeing those darn fungi under the microscope...

All Things Furry

Now, I realize today was supposed to be on crepuscular rays. (Which are awesome and there will be a post/picture on that.) But today feels like an animal day. Similar to Keagirl, I'm a sucker for animals. If I'd known about the field of veterinary medicine, things might have been very different today... But no regrets - have an awesome job AND free time to enjoy all types of furry friends!

Check out this dude as he strolls right past - he's like hm, strange person pointing a box... what will we see next? This fun guy was at the Valley of the Temples Memorial Park beneath the Ko'olau mountain cliffs on O'ahu.

Nacreous and Noctilucent

No, this isn't Dermatology jargon (at least I hope not!) - these are two of the rarest (and most beautiful) cloud formations.

Did you know that clouds are water? Clouds form from rising air, which gets cooler the higher up it moves. Cool air in a lower atmospheric pressure can't hold as much water, so water condenses into cloud droplets. If the cloud moves higher, the cloud droplets will get together to form water droplets. Water droplets are too heavy to float, so will fall down as rain or snow.

Although there are many cloud types, there are several large categories. "Cirrus" clouds are wispy, "stratus" clouds are flat or layered, and "cumulus" clouds are puffy. (Fog is a cloud with its base on the ground.) Clouds are also named based on what layer of the atmosphere they are located in.

Nacreous clouds (aka Mother-of-Pearl clouds) are beautiful, rare clouds that form under strict conditions: temperatures lower than minus 80 degrees Celsius and only seen at sunrise or sunset.

Noctilucent clouds are clouds that shine at night and form in a very high (85km up) part of the atmosphere.

Stay tuned for... crepuscular rays :)

Dots 'n' Spots

Am pretty stoked that I'm actually able to recognize some things under the microscope. Part of our training includes the ability to diagnose skin disease based on tissue patterns under a microscope (pathology), and it's an entirely different beast than clinical medicine. Things are pink, purple, and blue, and shades of the above, and sizes range from small to smaller (see picture at right)... Am happy to report that I am now able to tell the difference between some of the little dots from other little dots, which is probably expected given that we are ONE MONTH into training (woohoo!)

Looking into a microscope, for those lucky souls who have never had to do it, is something else. You know how, at the doctor's office, they'll check your eyes with that light that they hold in their hand? And you know how it's uncomfortable to have that light shining in your eyeball for too long? Well, imagine sitting for an afternoon with a light shining into each eyeball - that, my friends, is what some people do for a living...

On the theme of pattern recognition, here's the picture of the day: You're right, it's water lilies, and from where else but the beautiful the island of O'ahu. Too bad dermatopathology isn't so easy... :)

Hawai'i

Thanks to an anonymous poster, I'm going to start putting pictures up. Remember the dilemma of trying to figure out what camera to get? Well, am happy to report that the choice was the Canon SD550 (elph series), which is a super compact digital with GREAT picture quality.

It's been a tough few days at work, so here's something that can relax us - close your eyes and think of Hawai'i...

Think Waikiki beach at sunset. Imagine the warm breeze, the sounds of the sea, the glorious, ever-changing colors of a setting sun... Mahalo nui lo for all the memories, Oahu!

Love the Veterans

I'm a huge fan of the elderly. Have always liked them, and really enjoy taking care of them. There's something about age that brings a certain wisdom and patience and an ability to slow down and accept the world. It never ceases to amaze that so many veterans can live through the horror of battle and still survive, even thrive, in old age. And although some are irreversibly affected by what they've been through, as a whole, they are one of the nicest, most grateful patient populations I've ever seen.