Mikey Gets Cut by Occam's Razor

A 62-year old woman with a past medical history significant for hypertenstion and rheumatoid arthritis came to the office for a follow-up visit two days after she had been diagnosed with acute angioedema in a local Emergency Department. She had been at Mohegan Sun on Saturday morning with her husband. She had a pastry for breakfast around 9AM. At 11AM her arthritis flared up, but she realized that she left her meds at home. She bummed some acetaminophen (generic) from her husband, who happened to carry some along with at least one other medication in the same pill box. 30 minutes later, the patient experienced the onset of severe sore throat and felt that her tongue was beginning to swell. She and her husband immediately drove to the ED. The ED noted that the patient takes Zestril (lisinopril) for her hypertension. They gave her Benadryl, prednisone, and instructed her to avoid taking the Zestril until she spoke with her family physician.

At the visit, the patient notes that her throat is still sore, and that her tongue is still mildly swollen. Physical exam is notable for mild glossitis and swelling of the right submandibular gland. There is no pharygneal erythema or swelling.

Breakdown of her medical history reveals that she has developed allergies to sulfa drugs and several anti-hypertensive medications, including generic lisinopril, which elicits cough from the patient. She is allergic to walnuts, and one of her brothers is allergic to Brazil nuts.

I do a Medline search looking at side effects of lisinopril, and it returns several articles associating angioedema with long-term use of ACE inhibitors. Proud of my evidence-based knowledge, I present my case to my preceptor, who listens with indifference or boredom, I can't tell which.

What caused the acute angioedema? Was it:
a) Zestril
b) the generic acetaminophen
c) some other medication out of her husband's pillbox
d) The Mystery Pastry

My preceptor decided that the most likely culprit was the Mystery Pastry. The patient has been taking Zestril for 5 years without incident. An anaphylactic reaction to the inert components of the acetaminophen pill is highly unlikely. We refer her to an allergist to screen for food allergies, and restart her Zestril because her blood pressure is elevated. There were no medications in her husband's pillbox that were associated with any of her allergies.

And just in case, we also write a prescription for an Epipen.

Moral of the story: The sexiest explanation (Zestril-induced angioedema) isn't necessarily the correct one. Occam's Razor - the simplest explanation is the most likely.

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Right now I'm listening to: This Beautiful Life, Big Bad Voodoo Daddy

The Law of Averages Hits Hard

I had another good week in Middletown. I made myself useful in both the hospital and the outpatient clinic. My presentations and progress notes were really good. Good feedback from the faculty. I learned a lot. I drove back to Boston Friday night. And...?

I'm less than 2 minutes from home when I'm in the middle of an intersection and another driver runs a red light. Time slows down. I brake, she brakes. I think we're going to make it out of this without incident. BAM! Oh, well. At least no one got hurt. We exchange info. Both cars drive away. I regret not calling the police to file a report.

I take my car to the mechanic and call the insurance company. The mechanics listen in on my conversation, look at each other, and one gestures. No police record, no witnesses. If the other driver decides to be less than honest, they say, then I'm in a little trouble. Such cynics.

I, on the other hand, choose to believe in my fellow human being and think all of this will go down smoothly. Already there's a silver lining. My rental car is demonstrating to me what life will be like when I'm rid of the aging heap seen above. Ahhhh...so this is what it's like to have power under the hood. Having more than 2.5 miles-per-gallon in the city feels REALLY niccccccce.

Detroit Rock City!

The Steelers are going to the Super Bowl¹!

¹ The Super Bowl is in Detroit this year, for those of you not following team sports on a regular basis and are confused by the disconnect between the title and the subject matter.

Be honest - this is how you saw me...isn't it?!

Dolphin Therapy

I'm trying to imagine the Grants Department of this study's institution trying to make this study look fundable. Dolphins?!?!

Compared with exposure to water in the natural setting, interaction with dolphins is beneficial for the treatment of mild to moderate depression, according to the results of a randomized trial reported in the Nov. 26 issue of the British Medical Journal.

"Disrupting the affiliation with nature and thus losing the biophilic equilibrium means to alter and damage our psychophysical health," write Christian Antonioli, MD, and Michael A. Reveley, MD, from the University of Leicester Medical School and Leicester General Hospital in the United Kingdom. "Numerous researchers have presented evidence showing the therapeutic value of nature and animals for sick and disabled people.... We chose the bottlenose dolphin, Tursiops truncatus, for the animal-facilitated therapy and mild to moderate depression as the illness to be treated."

This single-blind study took place in Honduras, with recruitment of outpatients in the United States and Honduras, using announcements on the Internet, radio, newspapers, and at hospitals.

Of the 30 patients randomized to the 2 treatment groups, 2 dropped out of the treatment group after the first week and 3 in the control group withdrew their consent after they had been randomized. For those who completed the study, the mean severity of depressive symptoms was more reduced in the treatment group than in the control group (Hamilton rating scale for depression, P = .002; Beck depression inventory, P = .006).

Okay. While I don't think any clinician would prescribe swimming with dolphins instead of, say, SSRI's, perhaps there's something about this whole 'getting back to nature' thing.

"The therapy was effective in alleviating symptoms of depression after two weeks of treatment," the authors write. "Animal-facilitated therapy with dolphins is an effective treatment for mild to moderate depression, which is based on a holistic approach, through interaction with animals in nature.... The echo location system, the aesthetic value, and the emotions raised by the interaction with dolphins may explain the mammals' healing properties."

Of course, every therapy has its limitations...

There were no adverse effects noted, but the authors mention the potential for accidental injuries, and they point out that water phobia and inability to swim represent limitations of the treatment.

So...take home point? Anyone suffering from the winter blues? Just put on your swim trunks and head to the beach. Bring something to lure them in closer to the shoreline - I hear dolphins prefer live bait.

Schadenfreude Revisited

A recent study found that men derive more pleasure from other people's misfortune. A quote from the article:

The scientists scanned the brains of 16 men and 16 women after the volunteers played a game with what they thought were other volunteers, but who in fact were actors. The actors either played the game fairly or obviously cheated.

During the brain scans, each volunteer watched as the hands of a "fair" player and a cheater received a mild electrical shock. When it came to the fair-player, both men's and women's brains showed activation in pain-related areas, indicating that they empathized with that player's pain.

But for the cheater, while the women's brains still showed a response, men's brains showed virtually no specific reaction. Also, in another brain area associated with feelings of reward, men's brains showed a greater average response to the cheater's shock than to the fair player's shock, while women's brains did not.

A questionnaire revealed that the men expressed a stronger desire than women did for revenge against the cheater. The more a man said he wanted revenge, the higher his jump in the brain's reward area when the cheater got a shock. No such correlation showed up in women.

Personally, I'm not satisfied with the methods here. I think we need to conduct our own experiment. Someone go get Matt. Someone else get me the Spanish Inquisition soft cushions, comfy chair, and the Iron Maiden. I'll go fetch some of the female members of Matt's former lab. I'll bet anything that I can show a nice response in the female reward center once I start in with my torture techniques.

Ooooohhh - I smell my first NIH grant coming.

Go B&G!

Midway

A couple of midpoints lately. First, I'm halfway through 3rd year!!! About a year ago, I couldn't have imagined that I would be at this point. Second, I'm halfway through the Family Medicine clerkship, which I'm really enjoying right now. I just had a meeting with the one of the faculty in Middletown, Connecticut for my mid-clerkship evaluation, which includes me filling out a self-assessment form to see if my perception of my performance jives with everyone else's.

I decided to change strategies this time around. Typically, third years students go into these evaluations with a modest assessment of their own abilities. This underestimation usually prompts encouragement from the evaluator "There there you're doing just fine, you're doing great," allowing the student to emerge from the meeting unscathed.

I've done pretty well during my time here in Connecticut, seeing patients independently, coming up with diagnoses and treatment plans, my H&P (History and Physical) writeups and my presentations are becoming more consistent, so I'm feeling a little more confident in my abilities. So...I wonder, instead, what would happen if I went in with a bit of an attitude:

Dr. Smith: So, Mike - how do you think your performance has been thus far?
Mikey: The questions is, "Do I have a God Complex?"
Dr. Smith: Well, actually, what I'm ask-
Mikey: Which makes me wonder whether you have any idea what it took for me to get this prestigious clerkship in Middletown, Connecticut to begin with.
Dr. Smith: ...I thought it was because you had a car.
Mikey: Or whether you have the vaguest clue as to how gifted someone has to be to make the drive from Boston to Middletown.
Dr. Smith: Well, I understand that New Englanders are bad drivers and all, but...
Mikey: I've survived five years in graduate school hell. I'm a card carrying blood donor of the American Red Cross. I won a coloring contest once in grade school, and I make a great apple pie.
So, I ask you, when the patient sees me walk into the examination room and they drop to their knees and pray to God that I prescribe antibiotics for a runny nose that they've had for 45 minutes, who do you think they're praying to? If you're looking for God, he was in Examination Room number 3, and he likes his ego to be stroked.

You ask me if I have a God Complex?

Dr. Smith: Well, actually, I -
Mikey: LET ME TELL YOU SOMETHING.

I Am God.

Dr. Smith: (stunned silence)

*******

Dr. Smith promised me that my evaluation would be unique compared to those he'd written for other med students. ROCK!!! My plan worked.

Taiwan: The Land of My Ancestors

Taiwan - It ain't just cheap toy knockoffs and brawling politicians anymore.

Now, Taiwan is supplying the world with....Green Pigs!

Finally.

Dollars and Sense

The issue of personal finance affecting the standard of medical care is forefront in my thoughts due to my experiences with a few patients this past week. During my Medicine clerkship this issue didn't come into play, as all patients had either insurance or qualified for free care in the hospital. Here in Middletown, Connecticut I'm seeing quite a few uninsured patients - whether these patients can afford the health care that their providers deem necessary becomes quite a barrier.

The first patient was a 55-year old woman who came in with severe epigastric abdominal pain - history and labs led to the conclusion that this was a classic presentation of gallstone pancreatitis. Ultrasound confirmed the presence of many small stones within her gallbladder. Standard medical care for a case like this is a cholecystectomy, preventing recurrence of further episodes. Upon presenting this information to her, the patient became visibly upset. She explained that she had only just finished paying off almost $1000 in dental bills, and it was clear that the cost of the procedure (in addition to several days in the hospital) was going to be difficult on her family's financial situation. We assured her that the hospital would her come up with a solution, but it feels like such an empty reassurance. I get upset with the cost of repairing my car - which is chump change to the cost of health care most of the time.

The issue arose again, this time when I was in the OB/GYN clinic observing a prenatal visit. Earlier in the pregnancy, an ultrasound of the fetus suggested a heart abnormality, but the report was inconclusive because the fetus was rotated at an angle that made it difficult to visualize. Echocardiogram was recommended, but the family declined at that time due to the cost of the test (this family had insurance which would not cover a fetal echo). A later ultrasound, this time at 30 weeks gestation, hinted that the abnormality might be transposition of the great vessels. (Briefly, in a normal heart the aorta leaves the left ventricle and the pulmonary artery leaves the right. In the aforementioned condition, these vessels are switched, a serious life-threatening congenital defect. Neonates essentially have to go right to the operating room to correct this abnormality if they're going to survive.) While management of this condition might not be changed with an earlier diagnosis, at least the family would have had more options at the time.

Perhaps I could conveniently ignore the issue during previous clerkships, but it weighs pretty heavily when economics plays such a prominent role in decision-making. It also makes me wish that I'd done a Masters of Public Health rather than the MD/PhD. So...Cathy, I'm looking at you to solve the economic problems in the health care industry. Have at it.

*******

What I'm listening to now: A Momentary Lapse of Reason, Pink Floyd