Maggie's Farm

Restless Leg Syndrome

Known as the most common disease nobody knows about, Restless Leg Syndrome (RLS) effects 6-9% of the population, to varying degrees. Typically producing a deep feeling of leg discomfort at night, relieved by motion, when it is severe RLS can interfere with sleep and cause daytime drowsiness. It also can cause significant discomfort, approaching pain, on long flights and train trips when movement is restricted. No-one dies from it, but it can be a real annoyance, and it is often mis-diagnosed or dismissed.

I myself have a mild case of it, and it makes me nuts on airplanes, mainly. I cannot sleep on planes and like to stand up next to the bulkheads. For the many who are bothered by RLS, there are effective treatments now if it bothers you enough. Neurologists tend to be the ones who would be familiar with the new treatments for this poorly-understood ailment. The latest information is available on Medscape.com, which I cannot link right now.

Abortion: One Doctor's View

I have participated in my share of D&Cs, many years ago, and maybe some elective ones that I cannot or do not want to recall. I am no politican, and no lawyer, but I can read the Constitution which is deliberately written in plain English so as to be understandable to the average farmer or country doctor like me, and I think it's fairly clear that the Federal Govt has no business getting into such matters - these seem like 10th Amendment matters, to be left either to the states or to the people - ie freedom. Wasn't the whole point of the Constitution to limit the power of the Feds so as not to recreate a distant tyranny like the one we had just driven away? As for the morality, it seems to me to pit two moral ideas against one-another: the value of human life vs. the value of personal freedom and self-determination. I tend towards the life end of that argument, and find the latter a bit new-age and narcissitic (there is no Commandment: Thou Shalt fully realize and fullfill thyself in a convenient and consequence-free manner), but things can get tough in real life and I am capable of sympathy. Anyway, overturning Roe v. Wade is not on my personal agenda, but it would not be a catastrophe, and would let the unfortunate, miserable battle be fought where it probably belongs, among the people, through politics. The Supreme Court is not the Sanhedrin.  In the end, though, if you don't use birth control and don't want a baby, as the Dylanologist would quote, "My advice is to not let the boys in." If you haven't figured it out yet, gals and ladies - boys have very little brains when it comes to a pretty girl and no court will ever be able to change that. It's called "biology." In the 70s they used to talk about "empowerment": control and master your own emotions and your own bodies, ladies, where the rubber meets the road, as it were. That is true empowerment - self-mastery.

Avian Flu

Bird Dog forwarded me a piece by Rick Moran about the spread of avian flu, and the possibility that China could be concealing its true impact, including human-to-human transmission, which would be something new for this virus. I agree with Rick - let's follow this scary story, and let's get some reporters off their duffs and into China to see what is really going on over there. The CDC reports that the virus is becoming more pathogenic to mammals, and that such viruses mutate faster than had been thought. Human-to-human transmission of a virus which is resistant to ordinary anti-virals, and which seems to have about a 50% mortality rate, would result in a modern-day plague. The key issue is whether it has mutated so as to permit inter-human transmission. I must admit I hate to contemplate that, especially having read The Black Death last month. (Photo is a nesting Common Tern, one of my favorite birds here in Narragansett Bay.)

Pain Control and the Law

It can be easy for modern folks to forget how recently medicine has been able to provide relief for serious pain. Yes, the ancient Greeks had aspirin - willow bark - but until narcotics, derived from the poppy, arrived, and ether, for surgical procedures, physicians could not offer much for pain, which may be the most common complaint of patients. A nice summary of the history of pain treatment here.

We distinquish chronic from acute pain. With acute pain, of course, we try to identify the cause and to fix it. For chronic pain, where we know the cause, for example, cancer, arthritis, back problems, and a vast variety of others, narcotics often end up being the only thing we have to offer. Sure, we send patients to pain clinics, neurologists, acupuncturists, etc., but narcotics are what we use when all else fails. They work, they are not evil, and they are a blessing to mankind. And yes, they are addictive or at least habit-forming, but with chronic pain or terminal cancer pain, you don't worry about that. Why would it matter?

What bothers me is when law-enforcement begins to worry about doctor prescribing, but I always figure it's a lot easier for them to go after docs than after drug dealers with 9 mm handguns, vast networks, street smarts, secrecy, etc. With docs, you just walk into their office with pharmacy records. Easy, but accomplishes nothing worthwhile. There may actually be MDs out there who prescribe narcotics in a criminal fashion, but they are so few as to be of no significance, while illegal drug-dealing is a billions-of-dollars business in the US. Not to excuse them, but it isn't exactly a major American crisis. All docs get pretty good, but never perfect, at discriminating drug-seekers from pain patients.

When, as is known to happen, patients with narcotics prescriptions sell or otherwise distribute their pills to others, it's not the doc's responsibility and it's not his doing. John Tierney in the NYT has an excellent piece on how legal intimidation can interfere with humane treatment of patients in pain, and his piece also shows how the "War on Drugs" has been totally ineffective. And when you read a case like this one featured in the current Time magazine, it breaks your heart. Any DA who thinks he's a hero for prosecuting a pain specialist is lower than whale poop. But it's much easier than going after the bad guys.

About twenty years ago, we went through one of these phases, when docs were fearful of making patients, even terminal patients, addicted. It was a silly medico-cultural fad, but it passed, and physicians resumed treating pain patients adequately. And the invention of the morphine pump has been, in recent years, a God-send. I would hate to see medicine forced back to the 1970s and 80s when docs were looking over their shoulders, worrying more about anything other than their patients' pain. And if you are a patient with pain, you will agree with that.

Spiritual Diseases

I like Dr. Bob, and I commend him for taking on a blog single-handedly, and for sticking with it. I doubt that he really knew that there was a writer in him, but the writer in him knew it, and out it came. As a Christian physician, Bob is able to see the spiritual dimensions of addictive and compulsive "diseases" in a way I find refreshing, and free of gobbledy-gook:

The paradox about 12-step programs–which have the only reliable track record for successful recovery from addiction–is that they emphasize the disease as the problem, and honesty, integrity, and personal responsibility as the solution. They do not excuse the behavior while admitting the disease, and this blend of honesty and humility, acceptance and tough love, works like nothing else. It is, as recovering alcoholics are quick to point out, a spiritual program: the Catch-22 of a body which craves alcohol without limit and a mind which denies the resulting problems cannot be solved any other means.

But as any recovering alcoholic will tell you, the problem is not the booze; it is not even the obsessive, irrational mindset which drives the drinking. Both these problems are symptoms of an underlying decay, one of spiritual dimensions, characterized at its core by extreme self-centeredness. The pursuit of happiness by feeding this monster creates not the promised joy but rather pain and emptiness. Alcohol hides that pain for a while, until the monster, growing ever stronger by its constant feeding, kills its host spiritually, emotionally, and often physically.

But addiction is hardly alone as a symptom of this dark core. The list of destructive behaviors arising from its belly is endless: obesity, sexual promiscuity, compulsive overwork, materialism, computer obsession, gambling, the pursuit of beauty over character, the lust for money and power. Some may be biologically-driven; some learned behaviors or dysfunctional coping. All seek to fill a hole with no bottom, providing the wrong salve for the pain, and more of the same when the salve makes the wound fester.

Read entire.

Living Wills

No-one enjoys anticipating their death, and plenty of folks seem to postpone dealing with it, but it is the grown-up thing to do. Having a Living Will is as important as having a will and, if you are young without kids, the Living Will is more important. Yes, your family and your doctor will probably decide to "let you go" if you are hopelessly damaged, but what if they aren't around? What if they are confused?

The CSM goes through what is involved.

The Illiterate Surgeon

In Africa - amazing and heart-breaking NYT audio-visual  story.

Diet and Breast Cancer

For all of the hype and pseudo-science and random blather about diet and cancer, we finally have a fact. The fact is that low-fat diets reduce recurrence of breast cancer. This is a big deal. Not that it prevents cancer, but reduces recurrence. I will strongly advise every breast cancer patient accordingly.

Piece in the NYT.

The Female Orgasm

Is it a vestigial occurrence, or is it evolutionarily adaptive? Everyone wants to know. Certainly not everything in the biological world is adaptive. Curious? Sure you are. Read here.

Medecins Sans Frontieres

Doctors without Borders. I admire this organization, I support it with money, and God bless the physicians who give their time. It is a high expression of the medical profession. In fact, I offered myself to them a few years ago, but could not be away for their minimum length of time committment, but I forget what it was. Several months. I could have given 1-2 months with a locum tenens, but that's all. The message is that these docs give a lot.

Interesting fact on their site: the media-sexy Marburg virus killed 200 - Malaria kills millions every year, but makes no headlines. Another interesting fact: MSF has treated 1000 in Haiti for gunshot wounds since December, mostly political disputes. Nice country.

Medical Dummies

I hadn't heard about the new medical dummies until I saw it in The New Yorker. I have to say that I think it's a wonderful thing, mainly for medical emergencies. There is nothing wrong with American medical education - best in the world - but the fact is that when you graduate, and it's your first night covering a NYC emergency room as an intern, you do see things you've never seen before, and you don't have time to think.

I'll never forget one night in my first month when I was the only medical intern on duty in the ER. I had 17 patients in there. One acute MI who coded and didn't make it, one respiratory failure who didn't make it, a rule-out MI who didn't have one (we didn't do the enzymes then), a bad asthmatic who finally did well, a total-body disintegration from a nursing home, a drunk with acute pancreatitis, a diabetic with an acute hyperglycemia who we got under control but later died of aspiration pneumonia, various gomers here and there trying to either die or to fall off their gurneys ("Gomers go to ground", remember House of God? Good book), an arrhythmia or two - can't remember, an upper GI bleed vomiting blood, and who knows what else.  With time to think, I could have taken care of any one of them fine. After a year of that, everything became routine.

In the ER, it's about rapid, accurate diagnosis. What is surgical, what is medical, and what can wait. Diagnosis is easy in books, tough in real life. Not only do I wish I had had a week to be challenged by one of these new dummies, I wouldn't even mind it now, even though it's been decades since I've done ER work. I've heard that aviation simulators can almost give pilots heart attacks, so I'm sure that a few hours with the dummy would be quite an adventure. Worth paying for.

Read the piece about medical simulation. Written with The New Yorker's usual craftsmanship.