Breast-feeding Hormone Affects the Heart?

Could prolactin, the hormone responsible for lactation and uterine contraction after the birth of a child, have a sinister side?

Today researchers from Germany reported (subscription required) in the Journal of the American College of Cardiology that stopping lactation with bromocriptine, a direct inhibitor of prolactin, facilitated the resolution of peri-partum cardiomyopathy in two patients.

Peri-partum cardiomyopathy has been a heretofore poorly understood disease that causes a diffuse weakening of the heart in woman that develops within the last month of pregnancy or within five months immediately following pregnancy. It carries with it a high degree of mortality in women afflicted with the disease from heart failure or sudden death.

Today's report offers a unique insight as to a possible mechanism for the cardiomyopathy:

Prolactin exists in at least 2 biologically active forms with opposing effects. The physiological full-length 23 kDa prolactin promotes angiogenesis and protects endothelial cells whereas the cleaved 16 kDa derivate induces endothelial cell apoptosis and disrupts capillary structures. Recent data showed that oxidative stress promotes the postpartum generation of 16 kDa prolactin, which is causally related to PPCM. In turn, prolactin blockade with bromocriptine was successful in preventing onset of PPCM in mice and in patients at high risk for the disease.

Translating this: a shorter-than-normal piece of the prolcatin molecule is thought to lead to cell death and disrupts tiny blood vessels, possibly leading to the reduced heart function seen in peripartum cardiomyopathy (PPCM). Production of the specific form of dangerous prolactin (16 kDa) can be blocked with administration of bromocriptine in mice, so it was used in two cases in women and appeared to have beneficial effects, restoring heart muscle function in each of them.

The authors admit that the women were also receiving treatment with more conventional beta blocker and angiotensin converting enzyme inhibitors and these may have been responsible for the two patient's recovery, and that some patients recover despite any therapy. But the elucidation of the potential role of prolactin in the pathophysiology of this disease sheds light on a potentially exciting area to be evaluated in a prospective, multicenter trial.

-Wes

Reference: Denise Hilfiker-Kleiner, PhD, Gerd Peter Meyer, MD, Elisabeth Schieffer, MD, Britta Goldmann, MD, Edith Podewski, MD, Ingrid Struman, PhD, Philipp Fischer, MD and Helmut Drexler, MD. "Recovery From Postpartum Cardiomyopathy in 2 Patients by Blocking Prolactin Release With Bromocriptine," J Am Coll Cardiol, 2007; 50:2354-2355, doi:10.1016/j.jacc.2007.10.006

Image credit.

CT Scanning - The Doctor's Perspective

White Coat Rants challenges the lead authors of the recent New England Journal of Medicine article to walk in his shoes when deciding when to use a CT scan for diagnosis. He describes the "no-win" situation that ensnares physicians when fear-mongering pieces appear in our medical journals and are distributed at the speed of light to news agencies.

While risks with excessive radiation exposure are very real with CT scans (and rarely mentioned in promotional materials by the manufacturers), there are risks and benefits to every test or procedure we perform as physicians.

Kudos to White Coat Rants for keeping a sane perspective.

-Wes

h/t Kevin, MD

Online With Your Doctor

Julie Deardorff interviewed me about online doctor blogs for the Chicago Tribune and her piece appears today.

The article also encourages doctors getting their own '.md' top-level domain names (I never knew there was such a thing...). I guess it doesn't matter most people might thing I'm from Moldova.

Dermatologist Candice Thrash, MD's website and MedPage Today were mentioned as were physician blogs Jay Parkinson, MD, Kevin MD, Gruntdoc, Surgeonsblog, The Blog That Ate Manhattan, Dr. Deb, and Movin' Meat. Unfortunately, with the exception of Surgeonsblog, the links in the online article didn't work.

Hopefully, now they will.

-Wes

Addendum 3 Dec 2007 @ 1300: Ms. Deardorff was kind enough to re-post the article today on her blog, Julie's Health Club over at the Chicago Tribune's website, complete with links added.

Healthcare and SubPrime Mortgages

It has been very interesting to read the comments from the Wall Street Journal's economics blog about the subprime mortgage mess.

Why is it confusing that purchasing more house that we can afford with low "teaser" rates might come back to haunt us later when the rates reset? Why is it confusing to think that banks that lured gullible consumers by offering them subprime home loans might want to continue generating profits when the market turns?

So now, when the interest rates have reset, people with adjustable rate mortgages (ARMs) found they didn't have enough money to pay their loans(who knew?!!!?)! They default. The banks and financial institutions that created the ponsy scheme called ARMs suddenly lose their income stream. They lose billions. They run to the government before insolvency. "Help!" they cry. And now government now wants to "work with banks" to freeze "temporarily" interest rates on certain subprime home loans in the interest of assuring mortgage holders can still afford to pay their loans so the ponsy scheme can continue.

But despite the cost of the current subprime mortgage mess to our economy, it pales in comparison to the potential economic fallout of our current healthcare crisis. You see, government intervention on free markets occurred with healthcare before, too.

It started with Blue Cross - a health plan that originated in 1929 at Baylor University in Waco, TX that provided teachers 21 days of hospital care for $6 a year. The plan was extended to other employee groups in Dallas, and similar employer-sponsored health plans began to spread nationally. Employees began demanding the perk. Employers without these plans were at risk of losing employees to their competitors. And so the programs grew to be expected by employees. Upon retirement, though, retirees were threatened with the potential for no health insurance, so Medicare and Medicaid were formed - a government run "insurance program" signed into law in 1965 to assure the continued availability of healthcare at low cost to seniors. Remarkably affordable healthcare could then the obtained by many at very low cost (sound like ARMs?). So people felt entitled to healthcare, just like people felt entitled to a big 7000-square-foot house when money was cheap. The sky was the limit as to what they could spend. But unlike healthcare that was funded by an entity that could hide the cost-overruns by dipping into the endless money pool called the national debt, banks that supplied ARMs have no such safety net to write off their debts. They might go bankrupt. And so they now have run to the government for cover.

But if we can learn from anything, we should recall our experience with healthcare. Now, some relatively-short 42 years later, we see the effects of trying to make something appear cheaper than it really is: a $2 trillion dollar healthcare economy that has forgotten the very patient that it is supposed to benefit while preserving bureaucracy and corporate profits.

So go ahead, Mr. Bush. Have the government suck up the tab for the latest financial and banking debacle. Forty years from now, you'll be long gone. But our kids, just like with healthcare, well, they'll be left holding the bag.

-Wes

HIPAA, Guns, and Public Health

A while ago I was called to the Psych floor to see a patient with a cardiac arrhythmia. I thought I would check on the patient’s history via our fancy electronic medical record (EMR) before making the trek to an area rarely visited by this outsider, but I was surprised to see that I could not access charts electronically from outside the Psych ward. It seems there are some checks and balances installed in our EMR to avoid prying eyes. Although I was initially perturbed, I must admit I thought it was a smart move to limit access to psychiatric charts – especially since I might be up there as an inpatient myself given all the bureaucracy surrounding medicine these days.

But then this news appeared today about how the feds have miraculously increased their "Mental Defective File" database size to limit the sales of guns to goofy people. On first blush, I thought, “Thank God! I really don’t one of these crazy people with a gun.”

But then I looked into HOW the FBI expanded their database from 150,000 to over 400,000 people in the blink of an eye:

The vast majority of the individuals who were added to the FBI's list were identified by the state of California, which provided more than 200,000 names to the FBI in October, the Justice Department said. Ohio also provided more than 7,000 new names, and the number of states reporting mental health data to the FBI this year grew from 23 to 32, officials said.

So where did these states get these names from? Well it seems hospitals may have supplied the names:

A Virginia state court found (Seung Hui) Cho (remember, he caused the largest on-campus killing spree of anyone to date) to be dangerously mentally ill in 2005 and ordered him to receive outpatient treatment. But because Cho was not ordered into hospital treatment, the court's order was never provided to the FBI and incorporated in its database, which two gun dealers checked before selling Cho the 9mm Glock 19 and a Walther .22-caliber pistol used in the shootings.

The debate about this has been heated:

House Democrats reached an agreement earlier this year with the National Rifle Association on legislation meant to encourage states to submit timely background check data to the FBI, by offering monetary awards and threatening penalties.

"Our position has always been that those who have been adjudicated as mentally defective or a danger to themselves or to others or suicidal should not have access to firearms" and should be added to the FBI's list, said NRA spokesman Andrew Arulanandam.

The measure passed easily in the House, but it has stalled in the Senate due to a hold by Sen. Tom Coburn, R-Okla. He has said he opposes the legislation because its implementation would cost too much and because it lacks a mechanism to challenge inclusion on the list. He was joined by some veterans' groups, which argued that former soldiers might be denied gun-owning rights without due process.

Now, most of us assume such sensitive health records are protected in the interest of “privacy.” Isn’t that what we’ve been assured by HIPAA? So what’s the loophole that permits the feds access to sensitive hospital records to make their lists? What if I had an anxiety disorder or depression in my medical history requiring inpatient admission. Would I end up on the FBI’s “Mental Defective File?” Would I have any recourse to remove myself from that list if my condition improved? Who’s responsible for this information? If we take this a step further, what’s to stop the feds from forming another database in the interest of public health like, say, an “HIV Defective File” or other “Sexually-transmitted Disease Defective File?”

Probably nothing.

-Wes

Hospital Bill Padding Exposed

Hospital bill for compression stockings? $791.
Cost of the same pair on the internet? $12.

Hospital bill for oxygen mask? $2,225 to $6,675 a night.
Cost of the same oxygen mask at home? $250 a month.

Hospital bill to patient AFTER 1.5 million of catastrophic insurance coverage is exhausted? $1.2 million.

Final patient bill after the hospital's billing practices are investigated by the Wall Street Journal? $0.00.

Benefit of these investigations for healthcare reform?

Priceless.

-Wes

New Data on Driving With Defibrillators

Today's post on the above topic can be found over at MedPage Today.

-Wes

14:10 PM CST - Link fixed! Sorry.

A New Medical Subspecialty

First there was the internist - available day or night, inpatient or outpatient to care for their patients.

Then there was the hospitalist - available day or night, but only for inpatients.

And now it seems there comes the nocturnist - available only at night and only for inpatients.

I can't believe my eyes...

-Wes

The Deconstruction of Medicare Billing

The Happy Hospitalist demonstrates the mess, vividly.

I find it interesting that CMS wants to improve the quality of health care delivery by evaluating ever-expanding performance measures while ignoring the expense and inefficiencies their own billing morass.

-Wes

Photo credit.

The Collusion between Media and Hosptials

Today, the US News and World Report's Best Hospital issue list appears. Oh, boy! It makes for some great reading. Zzzzzzzzzz.

But what's funny is that the Big Boy winners are now in bed with US News and World Report - providing content for their issue about all kinds of diseases that they (alone, I'm sure) have mastered.

For instance, look at this page from their website. It lists tons of diseases. Now, click on one of the topics. And look at the top of the page, just to the right of the topic you picked. Who supplied the content "with" US News and World Report? Was it Cleveland Clinic? or Johns Hopkins? or Mayo?

Does anyone else find this conflict disturbing?

-Wes

Vice President Cheney Gets Atrial Fibrillation

Well, it was bound to happen.

Take a man with significant coronary artery disease, a prior history of more than enough cardiac bypass operations, a weakened heart muscle that requires an automatic defibrillator, and a prior deep venous thrombosis (blood clot) in his leg and what to you get? An almost inevitable likelihood that he will develop a heart rhythm disturbance, too.

It seems Vice President Dick Cheney has suffered another common complication of a weakened heart: atrial fibrillation (afib).

Atrial fibrillation, characterized by an irregular heart rhythm disturbance in the upper chambers of the heart (atria), becomes symptomatic in a variety of ways:

• It can made the lower chambers of the heart (ventricles) race too fast
• It can cause an uncomfortable irregularity of the heart rhythm that can be disturbing to the individual (called "palpitations")
• It can reduce the efficiency of the pumping action of the heart, making people feel more short of breath or perhaps develop a slight cough (as the above article suggests)
• Or, commonly, it can be completely silent and not cause any symptoms.

But by far and away the main concern with afib in someone like Mr. Cheney is its propensity to increase his risk of stroke. Fortunately for Mr. Cheney, however, this risk was minimized because he was probably taking warfarin (Coumadin®) for treatment of the earlier blood clot in his leg. More ominously, however, the presence of his persistent cough may have represented congestive heart failure (where fluid backs up into the lungs) caused by the reduced efficiency of his heart to pump blood in this rhythm.

Afib that occurs in someone who already has an automatic defibrillator presents additional therapeutic challenges. In defibrillator patients, if afib causes the heart to race too fast, the heart rate could exceed the rate limit in the defibrillator's pre-programmed settings that helps it separate normal from abnormal heart rates. If the lower chamber (ventricular) rate exceeds this limit, then the device might detect the rhythm as excessive, charge, and deliver a shock to attempt to correct the rhythm. If the shock encompasses the upper chambers sufficiently, it can restore the atrial fibrillation rhythm back to normal. If not, the lower chambers can be driven progressively faster by the upper chambers again, and additional shocks could occur. To prevent this, rate control medications (such as beta blockers) are an important therapeutic strategy.

So what usually happens next?

First, the White House really doesn't want or need this publicity. So the most logical step will be to convert Mr. Cheney's heart rhythm back to normal quickly. Provided he is on adequate anticoagulation, this could be performed right away, often using his defibrillator to restore his atrial rhythm to normal (an "internal" cardioversion) while sedated. If unsuccessful, a more conventional "external" cardioversion could be performed by applying a jolt of electricity across his chest to reset the heart rhythm - much like one hits "Alt-Ctrl-Del" on a PC to reboot it (sorry, I digress...) If these methods are objectionable to Mr. Cheney, pharmachologic cardioversion with a medication like ibutilide (Corvert®) could also be attempted. By restoring the rhythm back to normal quickly, Mr. Cheney loses his star power before the media and gets back to his business as Vice President. And as predicted, it's already been done.

Long-term, there will be a discussion if Mr. Cheney should remain on an anti-arrhythmic medication. This will most likely depend on the severity of symptoms he experienced with his afib. If the symptoms were deemed severe enough, he might placed on a medication to attempt to maintain normal atrial rhythm. The efficacy of these anti-arrhythmic medications are at best about 60% effective long-term at maintaining normal rhythm after one year. On the other hand, if his symptoms were minimal, then a rate-control medication (i.e., beta blocker) coupled with anticoagulation might be the better long-term option.

It would seem unlikely that Mr. Cheney would opt for primary catheter ablation of his atrial fibrillation right now, especially given the inherent risks to the procedure, but should the medicines prove ineffective at managing his symptoms, or if his atrial fibrillation rates prove difficult to control with medications alone, then catheter ablation might offer some effective therapeutic options.

No matter how you cut it, though, this rhythm disturbance is likely to be a recurrent problem for Mr. Cheney. Hopefully, its effects can be minimized with close management and follow-up.

-Wes

MedTees in the News Again

Pretty cool. Our health-related t-shirt website, MedTees.com, was in the Dallas Morning News on 6 November 2007, this time for our diabetic shirt line.

-Wes

More Direct-to-Consumer Insanity

Now it's Johnson and Johnson's turn: starting on Thanksgiving Day, coronary stent (specifically Cypher stent) advertisements began airing on television directly to "consumers," our patients, promoting the ability of stents to "prop up your life" that has been "narrowed" by coronary blockages. "Life wide open" is the tag line.

It's so catchy. As though our patients can go down to the corner store and pick one of these up for their heart. I guess J&J feels patients can discern when a drug-eluting stent is preferred over a bare metal stent, or better yet: when a stent is appropriate and when it is not. Why didn't their ad mention that other non-invasive options might be more appropriate before stenting in some circumstances?

Well, it's simple. The best medical care isn't important to J&J. What is important is that J&J sells more stents. To that end, what's really important to J&J is that patients ask their doctors why their life isn't "wide open" and full throttle yet. As if we don't have better things to discuss.

But I guess J&J figures our patients' wallets are wide open, given the cost of such advertising, especially in prime-time TV slots. This advertising, by the way, is in addition to an already re-worked website and other print media that has appeared in major newspapers.

And J&J seems to be taking a path that is in direct conflict with their own credo, their guiding mission statement, that has hung on their walls for over 60 years:

"We believe our first responsibility is to the doctors, nurses and patients, to mothers and fathers and all others who use our products and services. In meeting their needs everything we do must be of high quality. We must constantly strive to reduce our costs in order to maintain reasonable prices."

And where's the FDA who promised to monitor such advertising to our patient "consumers?"

Oh, I forgot - they're enjoying "monitoring" the commercials with a beer in their hand in front of the TV.

-Wes

Image credit.

NFL Rushes to Lose Image

Here I was, enjoying my Thanksgiving football, and on comes the NFL's compelling commercial promoting kids to "Play 60." Minutes, that is. It's a new campaign by the NFL to promote exercise in kids and reminds us that, according to their ad, 1 in 3 children are obese. 60 minutes of exercise per day will help, the ad claims. I suppose anything to get kids away from the TV makes sense. And they must be serious after spending $1.5 million for their "What Moves U" ad campaign, right?

But where does the ad direct the kids? To NFLRush.com, a cute kid-friendly website full of games and sound bites where our heavy-tushed youth can sit their butts down and be entertained and mesmerized by all kinds of cute games and football statistics that sound more like an NFL "get-'em while their young" ad campaign, rather than a bonafide health initiative:

"...the NFL has created NFLRUSH to provide young football fans with a refuge where they can celebrate their expanding interest in the game of football.

This site is filled with a great volume of up-to-the-minute statistics, data and information that will increase your child's understanding of the game of football, with connections to teams, player profiles that provide positive role models and inside information that will give your child a sense of mastery of the sport.

The site also delivers high-quality, football-themed, casual computer games and activities that are fun and often specifically educational, as well as contests that make the site even more exciting and vibrant for young football enthusiasts. We have tried to strike a balance between information and game play because we believe that an important part of growing up is just having fun."

But to partake, your child must register their name and e-mail, Mom and Dad. No doubt lots of NFL paraphernalia will be hawked in the future through direct-to-consumer advertising and reminders to come back and shop, er, play often.

Now while the message of getting off your butts is a good one, maybe they should rethink the credibility of their message by having their players lose weight and decreasing (rather than increasing) screen time in front of a computer as their way of "playing 60."

-Wes

The End of Delayed Gratification

Perhaps no greater stimulus for performing difficult tasks exists that are to become a person's vocation is that of delayed gratification. Successful lawyers, financial analysts and business people know this. But few are more a master of delayed gratification than a physician with their long, poorly-paid residencies - even more: surgeons.

The profession of surgery, after all, is a hands-on endeavor, involves countless hours at the patient's bedside and even more in the operating room to perfect the craft. The weeding process of individuals to find those with the "right stuff" to become a surgeon is remarkable: only the strong survive. Admittedly, that "worth" to some is just to have a nascissitic "bragging right" to calling themselves "surgeon" or the altruistic and admiral goal of being skilled at helping one's fellow man. But in the end to many, it is the hope that some day their efforts will pay off personally and financially. To this end delayed gratification, the hope that some day it will all be worth it, plays a significant role is helping an individual complete the training gauntlet.

But these times are difficult for anyone contemplating becoming a physician, let alone a surgeon. The commoditization of the profession, the ever-increasing regulatory environment, the decline of revenue, and the rise of liability - all serve to remove the carrot of delayed gratification dangling before the horse.

Josef Fischer, MD's excellent commentary appearing in the Journal of the American Medical Association last week illuminates the issues:

In the United States, approximately 1000 general surgeons complete their residency training each year. These surgeons have completed 4 years of medical school and 5 clinical years of residency, and during residency many also have spent 1 or 2 years in a research laboratory. Thus, these physicians enter the workforce between the ages of 33 and 35 and usually have $150 000 to $250 000 in educational debt. (editor's comment: some have suggested this number is MUCH higher) The training of surgeons has been stable since the early 1970s, and the number of general surgery residency training programs will not likely increase. Even if new medical schools were established the number of surgeons trained would not likely increase much, because many medical students have lost interest in pursuing a career in surgery.

In small urban or rural hospitals, which care for approximately 54 million patients, general surgeons care for emergencies and trauma and perform a variety of operations. They are essential to the provision of adequate health care and often are the most well-rounded surgical clinicians in the area. Therefore, training only 1000 general surgeons per year will not meet demands. Specialization also affects the general surgical workforce. Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice.

But the historical and future impacts of reimbursement for surgical services is articulated nicely by Dr. Fischer and spells the end of any hope of delayed gratification for surgeons:

In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians.10 Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day.11 In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

A recent Medicare Program review focused on concern about patients with chronic conditions and on compensating the physicians who care for them, not on the technical aspects of Current Procedural Terminology. Seventy-eight percent of Medicare beneficiaries have 1 chronic condition. By contrast, 63% of beneficiaries have 2 or more chronic illnesses; caring for such patients accounts for 96% of Centers for Medicare & Medicaid Services expenditures. It was proposed that patients with chronic disease were not receiving care because physicians were underpaid. The most frequently billed code in the physician fee schedule was revalued upward, and payment was increased by 37%. This year, the estimated $4 billion impact of the proposed changes in work RVUs resulting from the 5-year refinement will require that a budget neutrality adjustment be made.16 Fees for certain procedures, specifically for malignancies in women such as hysterectomy (–4.7%), partial mastectomy (–5%), and resection of ovarian carcinoma (–2.9%), decreased between 2006 and 2007.

In addition, the 90-day global period means that no additional payments will be made for any physician services that can be associated with the initial procedure, regardless of how much work the follow-up entails. Other physicians can see patients daily for the same illness or situation and can bill and collect each time.

No other profession or situation apart from medicine experiences denial of payment for services already performed. (ed: emphasis mine) At times, it seems that health insurance companies employ staff whose only goal appears to be to deny payment for services already performed.

These sequential decreases in reimbursement provide a substantial disincentive to enter these branches of surgery and may have profound future consequences. The self-designated specialties of internal medicine, medicine, and pediatrics have substantially increased members since 1985, while general surgery membership has remained level.

While I appreciate all of the new health care proposals to provide univeral health care (and certainly our system is broken), unless we address the shortages of physicians in general, we won't have professionals where the rubber meets the road: that is, physicians capable of performing the remarkable skills to which we and our health care system have become accustomed. Without them, the final policy enacted won't be worth the pile of paper upon which it is penned.

-Wes

Reference: Josef E. Fischer, MD. "The Impending Disappearance of the General Surgeon." JAMA. 2007;298(18):2191-2193.

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Things to Be Thankful For

I found this on our refrigerator:

I am thankful for the teenagers who are complaining about doing chores -- that means they are home and safe.

... for homework. It means we live in a country where education is valued and encouraged for all.

... for the taxes I pay; it means I have income.

... for the mess that I have to clean up after parties, because it means I am surrounded by friends.

... for the clothes that fit a little 'too snug' because it means I have enough to eat.

... for the lawn to mow, windows to wash and gutters to clean; it means I have a home.

... for the parking spot I found at the far end of the parking lot, because it means I am capable of walking and am blessed with transportation.

... for my huge heating bill, because it means I am warm.

... for the person behind me in church that sings off key, because it means I can hear.

... for the pile of laundry and ironing, because it means I have clothes to wear.

... for all the complaining I hear about the government; it means we have freedom of speech.

... for the alarm that goes off early in the morning because it means that I am alive!
Author unknown

For those leaving early to be with family or friends:

Happy Thanksgiving.

-Wes

Heretic

Though I was born and work in Illinois, my money's with the Blue Devils.

Fire Drill

It was a clinic day like any other - seeing too many patients in too little time. But remarkably, today I was on time, efficiently finishing with one patient and moving seemlessly to the next. It was poetry in motion - an accomplishment rarely achieved these days in the clinic.

I had just completed examining a patient and asked our nurse to assist with an EKG while I obtained headed outside to check on the next patient. The poor thing was disrobed when it happened.

Brrrrrring. Brrrrrrring. Brrrrrrrrrring. Brrrrrrrring.

What the...?

Brrrrrring. Brrrrrrring. Brrrrrrrrrring. Brrrrrrrring.

It was deafening.

I looked down the hall of the clinic and a sea of humanity slowly emptying into the halls. Disbelief surrounded us. The office manager looked perplexed and slightly anxious.

"I think it's the real thing," she whispered.

"Really? Damn. To think I was finally on time." She smiled and glaced toward the clinic exit as if to say, "You too, chump."

We checked each room. My patient was getting clothed again and shuffled out the door, somewhat excited at the prospect of finally adding some entertainment to her day.

"Isn't this exciting?" she exclaimed.

"Move along Ms. Jones," I said. Her Parkinsonian shuffle hastened toward the stairwell just outside our clinic. My eyes caught my colleague's gaze and they rolled upward, exasperated.

And then it dawned on me. A hoard of individuals were patiently waiting for the all-to-narrow stairwell to clear as an elderly man supported by a nurse and a doctor struggled to descend the stairs. The doctor held the man's armpit in one hand and his folded walker in the other. One slow step at a time. Step by painful step. My clinical acumen lept to action - no smell of smoke was detected. Patience. Patience. I looked behind me. Eyes glared. It was as if I was caught in Chicago's E2 niteclub disaster or decending the stairs from the World Trade Center before it collapsed. I tried to smile back. No one seemed amused. The pace was glacial. Finally after descending two floors, the old man touched down on the ground floor. People scurried past.

The fire department arrived, their flame-retardant jackets, fire-hoses and oxygen tanks in tow. They swam upstream to the sounding alarm location. Two seconds later: "All clear! Just a broken switch! Joe, call dispatch."

We shuffled back to clinic, this time taking the elevator and remembering.

No one said a word.

-Wes

Image credit.

deCodeJeans4Me.com

Dear Gullible Consumer,

Thank you for allowing me to introduce my new company, deCodeJeans4Me.com, where we promise to tell you if you’re at high risk of all kinds of scary diseases as well as determine your ancestral roots, by looking at your jeans. You see, we have a patented way to predict what diseases you might contract by merely having you send us a pair of your jeans from the privacy of your own home to our fancy multi-zillion dollar laboratory. We will run over a million tests to identify small imperfections in the color and contour of your jeans that we have been carefully correlated to your jean-etic risk factor for hundreds of ailments. Using fancy machines, our well-meaning staff will determine your Every Disease Known Score (EDKS) that no one else understands but us. And once we see what your EDKS looks like, we’ll tell you, based on the world’s literature, what your chances of getting a disease might be so you can be “empowered” and “network” with other like-minded suckers souls on our fancy web site. All it will take is for you to register your name, rank, serial number, number of children, address, pant size, height, weight, your e-mail address PLUS a mere $900 (we want to undercut our competitors) and we’ll send you a pre-addressed mailer in which to place your jeans.

By the way, the federal authorities think this is a great idea, too! We’ll be sure to save your jeans in our secure warehouse so the feds can examine them carefully with a court order, especially in times of National Security breeches.

So go ahead, sign up, and send us those jeans!

Yours in blue –

-Wes

P.S. Please send jeans only. Underwear present unique biohazards that we are not yet prepared to handle.

P.P.S.: Be sure to see our competitor's website, too, for an informative link to their video to see an example of how this is done!

Photo credit.

12:30 19 Nov 2007 CST: Addendum - Oh, no! Even more competition! (Glad I still have a cheaper price...).

Leisurely Physician Pastimes

At first it's faux poo, now it's rocket lauchers. What will ImpactEDNurse think of next?

-Wes