Category Archives: The Barbarous Craft


Colonoscopy: the live blog

My wife and sister have complained so much about this procedure that I have made a command decision: I’m going to enjoy this thing.

Stay tuned.

Either his head is that small, or my rectum is that huge

Either his head is that small, or my rectum is that huge

8:00 PM
The instructions said to take three Dulcolax (“dookies,” as we called them in residency) at 8:00 PM, two days prior to the procedure. They have a delightful candy coating, no doubt to encourage abuse. Yum!

8:15 PM
So far so good. I’m telling you, y’all are wimps.

9:40 PM
Nearly two hours into this, and I’m quite sure that I am still FOS. Color me underwhelmed. Meanwhile, I’ve been helping Jake with his housing application for UCLA. He didn’t want to bother with this, so I put him into the hall for brony vegans.

Thursday

1:30 PM
The dookies worked their magic at about 1:30 this morning. Kept me up for an hour, then I slept like a babe. Jake got his own ride to school this morning, so I didn’t have to face the specter of an unusually urgent commute. As for today, I’m on a clear liquid diet, and sadly I did not buy enough stuff to get me through the day. One can only drink so much chicken stock. Oddly enough, I’m not that hungry.

The real fun starts at 4:00, when I begin drinking the Miralax-Gatorade cocktail.

Oooh! Ancient popsicles! I’m in luck.

7:25 PM
I have created the finest green. So that’s what my bile looks like!

All of the Miralade is in and I’m feeling fine. More than anything else, I worry that the prep won’t be efficient enough and I’ll have to do this all over again. As much as I’m enjoying this, I would rather not do it again any time soon.

Friday
11:24 AM
And, done. The post-procedure crampiness (from gas) was the most unpleasant part of the whole thing. Otherwise, no big deal, and now my colon has a blue ribbon seal of approval. Or something like that.

D.

If dreams were based off what we watch most commonly, mine would be MUCH better than this.

So (in last night’s little adventure), this man comes to see me because he’s unhappy with the rhinoplasty my partner did for him. This is preposterous on the face of it, because my partner has twenty-five years of cosmetic surgery experience, and I’ve done, what, maybe twelve rhinoplasties in my entire career, ten of those during training? But whatever. The guy wants an opinion.

And, indeed, it’s a botched rhinoplasty, which is again preposterous because my partner does great work, but hey, this is a dream. This fellow has no tip support and the nasal dorsum has been over-reduced. It’s amazing that his nose hasn’t sunk two inches into his face. I’m shocked that all he wants is his money back (preposterousness #3 — this is the Kize — so you want your co-pay back? Sure!), but then he pulls out a ten-inch hunting knife, very shiny, and says he wants to see my partner.

Don't worry. I'm sure that must be fake blood.

Don't worry. I'm sure that must be fake blood.

I locate my partner in one of the other exam rooms and innocently (evilly?) tell him, “One of your patients has a question for you.” But he’s in a snit over something going down in his own room, and leaves in a huff. So, great. I have an angry patient in my room looking for sweet, bloody revenge, and my partner’s gone from the building.

When I get back, some young Vietnamese kid is delivering my patient an automatic rifle, but there seems to be some disagreement, everyone’s getting louder, and right then, close enough for me to get splashed with blood, my patient stabs the guy in the hand, screams, “Just give me the goddamn gun!” and grabs the rifle.

Clutching his bloody hand, the kid races over to the other side of the room, pulls out his cell phone (no doubt with a third hand), and starts screaming into it in Vietnamese. My patient, meanwhile, is loading a clip into his rifle. Thinking fast, the kid jumps onto a table, grabs a handful of window curtain, and when the rifle-fire shatters the picture window behind him, he swings out and down using the curtains as a tether.

Sadly for him, we’re several stories up, and he has to release the curtains to fall into the ocean below. (Yes. In Bakersfield.) He makes a splash, and I see him start to swim away, but then a nearby submarine fires two torpedoes his way.

I turn to my patient. “You want a refund? NO problem. But here, look at this diagram, I’d like to explain to you exactly what the trouble is . . .”

Moral of the story: Not all male rhinoplasty patients are nuts, but you have to wonder about the ones who come to their appointments with ten-inch-long hunting knives.

D.

Would you want to know?

Great Cowboy Junkies song from the 90s:

I just want to see what kills me. Well, would you? This morning, I learned of the existence of 23 and Me, a company that will do full genotyping of your spit sample for a cheap cheap $99. They’ll check your carrier status for 47 inherited conditions, and your genetic risk factors for 247 diseases. Genotyping can also reveal how you will respond (or fail to respond) to certain blood thinners, antidepressants, cholesterol-lowering meds, and so forth.

Do you want to know if you have a 60% chance of developing Parkinson’s disease? That you’re at risk of developing Lou Gehrig’s disease, coronary artery disease, cancer of the whatever? They’ve got all the bases covered. And if you think knowledge is power, 23 and Me is offering an awful lot of power for a relatively small sum of money.

I wonder, though, whether this knowledge might affect how I respond to future questionnaires for hospital privileges (Do you have any conditions which could affect your ability to perform your duties as a physician?) or health/life insurance. And if I learn something really scary, how do I keep it from dragging me down?

I think I want to do this. Of the other four docs who I was with today, only one of them was as excited as I was about the prospect of getting genotyped. The other three were of the No effing way persuasion.

I’m going to sleep on it.

D.

My most challenging patient

As any pediatrician will tell you, the scary thing about infants and toddlers is how fast they can go down the tubes. Humans are complex systems held in check by a variety of buffers and homeostatic feedback loops (there! four years of med school in 16 words), and the smaller the human, the more delicate those buffers and feedback loops. It doesn’t take much to go from eating-drinking-pooping to starving-dehydrated-feverish when you only weigh eight pounds.

How much worse, then, to weigh a fraction of a pound?

This week, our ferret Buehler (named by DCR in this contest, and pictured below — as a much younger weasel) went from eating-drinking-pooping to starving-dehydrated-feverish overnight. I noticed the problem in the morning, and by the time I got home in the afternoon, he looked moribund. We lost Buehler’s pal Harmonica last year, possibly because I underestimated how fast these little guys can plunge. And Harmonica only had an eye infection, whereas Buehler looked much, much worse.

I dithered on the question of taking him to the vet. He looked hopeless. He lay motionless in my arms, breathing fast, hot as a poker. I was able to get him to drink some water, but not much, and he wouldn’t take any food.

Read more: My most challenging patient

Voted onto the island

They like me. They really like me.

Here at California’s biggest and best HMO, physicians put in three years before they make partner. Partnership means a little more money and a lot more job security. Job security is, of course, worth far more than that little bit of extra money.

Some (like Karen) would say that there was never any doubt that I’d make partner, particularly since they keep showering me with leadership roles. I’m chief of my department, and as of June 1 looks like they’re gonna make me the Physician In Charge for our building. They jumped over a lot of docs with far more seniority than me for the latter job, which either means (A) the boss sees remarkable leadership qualities in me, or (B) I’m still naive enough to say ‘yes’ to an offer like that. It would have been odd (understatement) to make me chief and PIC, only to then dump me from the organization. But it’s the partners who vote people on or off the island, not the big boss, and it wouldn’t be inconceivable for a difference of opinion to exist.

As it was, the boss told me they had to delay the decision on me because the partners were slow to vote. But I think that has more to do with the I-never-read-my-damn-emails problem than with any reluctance to jump me in to the gang.

What can I do differently, now that I’ve made partner?

* Buy a saltwater aquarium. No one wants to buy a saltwater aquarium if he thinks he’s gonna have to find a new job and MOVE.

* Hang my partnership plaque up on the wall.

* Deduct things on my income taxes, apparently, and oh . . .

* Start paying income taxes quarterly, yay! because the organization will no longer take automatic deductions.

* Breathe a little easier. Except, this area of the country has the worst particulate smog of anywhere, so strike that last thought.

I think we’ll go to Santa Barbara next weekend to celebrate . . . it’s been about 20 years since we last went to the Palace Cafe.

D.

It’s on!

As I think I might have mentioned, one of the reasons I haven’t been around much (aside from the usual reasons of the family, the WiP, and career stuff) is my dad’s health, which has meant two trips to Vegas in the last six weeks or so.

One of the things I’ve noticed, both in myself and in my patients, is the subtlety of aging. Often, the patient doesn’t notice how old he is until something bad happens, and something bad can be as trivial as a cold or a pneumonia. In my dad’s case, it was pneumonia. His body tried very hard to kill him, but hey, this guy survived the entire American involvement in WWII, a little thing like pneumonia and a heart attack and kidney failure and severe anemia wasn’t going to slow HIM down. He spent 11 days in the hospital, during which a cardiothoracic surgeon told him there was no way on earth she would operate on him. No way, no how.

I took a disk with his angiogram back to Bako and showed it around. The consensus here was, “Your father needs a bypass. Make him get a second opinion.” And so I called a pal of mine who is a cardiothoracic surgeon at Scripps in San Diego. He was my chief when I was an intern, and I spent at least two months with the guy. When you’re an intern (or med student, for that matter), you grow to love your chiefs, the good ones anyway. The two I loved best both became cardiothoracic surgeons. I called Rich and he said, more or less, do it. And he gave me the name of a cardiothoracic surgeon who had done his fellowship at USC, and who was practicing in Vegas.

So my dad met with the guy today. My father had already decided to go through with this provided he had better than a fifty-fifty chance of surviving (hey, he’s a poker player. Old habits die hard). The surgeon told him there was only a 4 to 6% chance of failure (or as you folks call it, death). My dad’s going for it.

This is a good thing. My mother has a bit of dementia and depends on him heavily. Having him predecease her would be a disaster. (Is this a bad thing to say? Should I be more sentimental about this? Is our selfishness shining through? . . . Because my two sibs are all on the same page with this one: we do not want to see him predeceasing her.)

I told him tonight, “Don’t drop dead before this guy has a chance to save you, okay?” and he said, “Yeah, don’t worry, I won’t.”

Cuz that’s how we roll.

D.

That other Walnut

Lately, I’ve been using this new product in my facial recon work — pig basement membrane, which takes the place of an autogenous skin graft. The sales rep was in the OR today, and I guess he was trying to impress me, because he’d google me (I guess) and wanted to let me know how amazing I am.

“How did you do all those things?”

I wasn’t sure what “those things” were, but since I haven’t done much professionally except collect degrees, I said, “I dunno, I just stayed in school a long long time.”

“Yeah, but you must be brilliant. I mean, you graduated high school at 16, college at 19, you were an engineer –”

At which point I interrupted him. In retrospect, I should have let him go on, because now I’m curious what all else that other Walnut did. Was he an astronaut? Did he climb Kilimanjaro whilst fighting off a swarm of killer bees? Win a decathlon? Learn to bend spoons with his amazing mental powers?

I disabused him gently of his misconceptions. We hate losing our heroes.

***

Karen’s BD today . . . for which I made lamb tacos, homemade guacamole, and for dessert a Duomo Tiramisu. You can ignore the linked recipe and just focus on the picture, since that’s where I got the idea. I used my usual recipe, but decided to make it more kid-friendly so that Jake would eat it for a change. Instead of espresso, I soaked my pound cake in root beer. I did not use any alcohol in the zabaglione, but used some cherry juice instead. Then I split the zabaglione in half. Half of it I kept plain, and to the other half I added 4 ounces of German chocolate (melted). I then added one thingy of mascarpone cheese to each zabaglione sauce, then folded in the whipped cream.

After I had created multiple layers, I still had a fairly large volume at the center of my Duomo that was empty. (Yes, I’d used too large a bowl.) What could I do? If I left it empty, the whole thing would collapse when I inverted it. I really didn’t feel like going through the bother of making more filling and buying another pound cake. So instead, I bought a champagne cake, a small one, and stuffed that in the center. Thus achieving a dessert form of Turducken!

Good but rich. I’ll be shocked if we even manage to finish half of it. All three of us had some, and I think we only ate about 20% of the total.

***

Writing proceeds apace. I haven’t done a total word count lately but I suspect I’m something like 35K or 40K words into this. If so, this is feeling like a 100 to 120K story, which is just about right. So: epublish or not? I’d like to think I’d have the time to ship it out to agents, but who am I kidding.

D.

Enquiring minds want to know

Luke writes:

I just came across the boogers blog and I think it’s great. Is that you? Can I ask a related (and kind of gross) question here? For the last two weeks I’ve been sick with either a cold or a sinus infection and I’ve been producing copious amounts of mucus in my sinuses. A good portion of this mucus has ended up in my stomach. Am I conserving precious calories? Can my digestive tract reabsorb mucus and use it for energy or at least reuse it for mucus? Or does it just pass through? Youth wants to know and so far the internet won’t say but it seems like a question you might be able to answer.

Yes, that’s me. But I have a sneaking feeling that it’s a really, reeeeally old effort that I abandoned a long time ago, over at Blogger perhaps. Scary. I have blogs that I’ve forgotten about. I wonder if Bare Rump’s blog is still out there — you guys remember that?

But on to Luke’s question. I doubt there’s much caloric or nutritional value to mucus. Wikipedia defines mucus as a “viscous colloid containing antiseptic enzymes (such as lysozyme), immunoglobulins, inorganic salts, proteins such as lactoferrin, and glycoproteins known as mucins that are produced by goblet cells in the mucous membranes and submucosal glands.” Thus there’s some protein content and electrolytes and not much else of any value.

When that hits the stomach, your digestive enzymes will break it down and your gut will assimilate it like any other protein. The electrolytes will be reabsorbed and either used or excreted. And of course your body is extremely efficient at scavenging the mucus for its water content.

And now I wish I could find that boogers blog.

D.

Bits and pieces

I’m up to 23 tongue depressors. Still can’t open my mouth as wide as Karen (I’m betting she could fit at least 30 to 32 tongue depressors) but 23 is much better than 12, which is where I was stuck about one week ago. I’m thinking that this IMO (intermaxillary opening — doctor jargon that measures how wide you can open) is good enough for the dentist to put on that new crown. Hopefully, the new dental work won’t set me back another 10 tongue depressors.

***

Yesterday, I finished China Mieville’s Embassytown, which was a bit of a disappointment. With Kraken and The City & The City, I’d begun to feel as if Mieville could do no wrong. Perdido Street Station was a mixed success in my opinion, but then, it was one of his earlier works. I was really looking forward to Embassytown, which is Mieville’s stab at science fiction. Except it’s not. Not really. There’s an artificial-ness to the story, the sort of creeping falseness that happens when the idea or argument is central, and the characters and plot are secondary to it. In the case of Embassytown, I get the strong sense that he wants to engage us in an exploration of the fundamentals of semiotics. This sort of thing may be interesting, but it hardly makes for a great story. Let me put it this way . . . I have a linguistics friend from college who would absolutely lurve this book. Everyone else? Well . . .

Avice Benner Cho (and I’m sure the “ABC” of her name is intentional) is a colonist at a distant outpost, one of the fringe settlements of Homo diaspora. She grows up in Embassytown, a human (and other non-native sentient species) ghetto within the City, which is where the Hosts live, also known as the Ariekei. The Ariekei are mostly insect-like beings whose language is devoid of symbolic elements. When they say their word for “aircraft,” for example, their minds equate the word with the aircraft. It’s not so much that the sounds “aircraft” symbolize an actual aircraft; they might as well be that aircraft. The only way they can create similes is by having a concrete representation of the simile in their living experience. Thenceforward, they can refer to the memory of that simile and use it in conversation. In one of the book’s earliest scenes, Avice Benner Cho becomes one of their similes.

To a large degree, the success of such a story depends on whether you can accept that initial set-up: that a sentient being could exist for whom language lacks symbolic value. Red is not just a sound which we associate with a color, it is that color, and so on. Unfortunately, I was never able to make that leap.

There are, nevertheless, some cool aspects to this story. Without giving away too much, I’ll only say that Embassytown has about the most convincing “language as mind-altering substance” thread as any I’ve seen in a science fiction work of any media. Mieville sets up a language-based crisis which is convincing, and things go to hell in an equally convincing manner. Whether you’ll buy Avice Benner Cho’s solution to the crisis is another thing entirely.

You have to give the guy credit, though. He’s tackling some big questions here on the nature of language and how it shapes thought, and so I’m loath to criticize him for not hitting a home run on every point he tries to make. So many books these days are about nothing at all.

Which reminds me . . . did I forget to hype Sara Gran’s Claire DeWitt and the City of the Dead? Pure pleasure.

But now I need something new to read.

***

Gave a talk to the pediatricians today on tonsillitis, tonsillectomy, nasal and ear foreign bodies. I was competing with a talk in the other classroom — that one was on “the motivational interview” (basically, how to convince your patients to do something — quit smoking, exercise, lose weight, manage their diabetes more closely). Most of the docs went to that one, but I got the pediatricians and family practitioners, most of them, maybe 15 or so.

It went over well but I think they mostly wanted to share foreign body stories. Doctors love foreign body stories.

D.

Only sometimes . . .

do we resemble the esteemed Dr. Benway.

Ah, Burroughs, I love him. An essential member of the “if you could invite any three historical figures to dinner” club. (Let’s see . . . how about Burroughs, Ghandi, and Machiavelli?)

D.

Next page →