Time for an FDA recall alert

Well, I suppose that with this sort of thing, you just have to try it out for a few years, and see what happens.

There has been a worldwide (of course) recall on the HeartMate II Left Ventricular Assist System, which have been in use since November of 2003. The failure rate has been deemed unacceptable. Apparently the leads that connect the pump to the controller wear down significantly enough to affect pump function. "The estimated probability of the need for pump replacement due to percutaneous lead damage is 1.3% at 12 months, 6.5% at 24 months and 11.4% at 36 months." (as per the FDA site) THAT is significant!!

Left ventricular assist devices are essentially used to buy time for "CHFers" (Congestive Heart Failure patients) who are awaiting transplant, or they may even be used indefinitely in patients who are not candidates for transplant.

(Not So) French Toast

Those of you that have looked at the recipes here before have probably realized: I am not much of a sweets person. I am much more of a savory eater, and therefore, a savory cook. So, I guess it should not come as too much of a surprise that this morning's breakfast was what is commonly known as a sweet food, turned not-so-sweet.

Best served with some grilled sausages (you can use veggie sausages, if you prefer), this makes for a really quick, simple breakfast. By the way, the way I prepared the sausages:

slice up an onion and let the slices cook in a pan over a low flame for a good 10 minutes or so in a small amount of olive oil
add a healthy splash of balsamic vinegar
add the sausages in slices and let that cook over a (really) low flame until the sausages are browned

On to the bread...

You need:
3 eggs
1C milk (I used 2%, but anything, including soy, would be fine)
bread (4-5 large slices or 9-10 small)
healthy pinch of salt
1t marjoram
1t sweet savory

(I used dried herbs, as my Aerogarden has not yet produced its crop. By all means, if you have fresh, use them... and feel free to play around with other herbs.)

You do:
1. In a rather shallow bowl, beat together eggs and milk. Add salt and herbs; beat some more.
2. Start heating up a skillet over a low-medium flame. I used a le Crueset grill, to make everything pretty, but any skillet will do. Don't forget to coat with olive oil or non-stick spray. Alternatively, you can bake these--see below.*
3. Throw the slices of bread into the mixture and let soak--at least 1 minute/side.
4. Once the bread is saturated, and the grill is hot, place the slices on the grill so that they do not touch one-another. Cook until browned on both sides.
5. If you have more than one batch, they will keep warm in an oven at 250F.

Voila--not so French, but very nice.

*Now, for baking:
1. Preheat an oven to 425F.
perform steps 1 and 3 above
2. Prepare a baking sheet with non-stick spray.
3. Place the bread slices on the sheet so that they do not touch one another, and place into the preheated oven for 6 minutes or so.
4. Flip the slices and place back into the oven for an additional 5-6 minutes.

That is all. Very simple, quick, and tasty.

Enjoy!

Never, not once. until yesteday

I am not proud. I am, in fact, rather ashamed. But the other emotions I feel are anger, distaste, and, quite frankly, dread.

I took the gentleman from this post to the OR last week... last Monday, to be exact. He was a mess. I have never seen anything like it. A grown man, mid-40s, strong (as far as looks--very muscular, fit), handsome, even... quivering uncontrollably at the sight of an IV needle. No joke. It took 5 of us to hold him down, after a lot of begging and bargaining, that is, to sssslide that little 20 into one of the hoses on his arm.

The surgery itself? I was so happy. I took off the distal phalanx routinely, looked at the middle phalanx--SOLID. No signs of infection. Surrounding skin? Healthy. Beautiful. The closure? I gotta tell you, I was so conscious of this man wanting to get back to work, I did not even allow a little dog ear. The whole surgery (minus starting the IV) went so smoothly, I was thrilled that he was coming for his first post op visit yesterday.

By the way, he called the day after surgery about some papers he needed to get filled out for work, but that was it. Smooth sailing. No calls about pain, nothing.

I explicitly ask all of my patients to leave their surgical dressing on until they see me at the first post-op visit. I tell them, reinforce it with their loved ones and write it in capital letters on the discharge papers. It is really, really rare that these orders are not followed. Seriously, my patients know I mean business.

So, I was almost confused when my friend came in with no dressing. Not even something he threw on at home, which some people try to fool me with. (Trust me, a surgeon ALWAYS knows their own dressing.) When I asked him what happened and when? He answered that the night of the surgery (!!!) the finger was itching him, so he took off the dressing so he could bite it (!). Then, over the past week, he remained with no dressing, going about his business (although he assured me he stayed in the house) changing his baby's diapers and the such, but NEVER ONCE WASHING HIS HAND!!!!

He complained (now, in my office, as he waved the swollen digit around) that the pain was tremendous. I asked him why he never called. I was calm, at first, when I reminded him that he called about his papers, but never mentioned any of this. My eyes were met with a blank stare.

I asked him to wash his hands now, in the office, with soap and water. As soon as he finished, he turned to me, "Why is there pus coming out?"

I looked in disbelief, at the same time realizing that it was the only explanation: he had a wound infection, which explained the tremendous pain and swelling. When he washed his hands, he dislodged some dirt and blood that was covering the wound, and now the pus was pouring out.

I told him that I would need to take out at least a few sutures and open the wound to let the pus drain. It was the only way to get rid of the pus and the pain. He started moaning and crying (crying, with tears streaming down his face). This is when the fiasco started. I called my medical assistant into the room. We are both small women. He is a tall, muscular, fit man. After wrestling with him for about 20 minutes, I asked my MA to call our administrator in. A man, pretty much the peace keeper, but not much larger than us. The amazing thing is that the whole problem was that this patient was truly, magnificently AFRAID. He was not aggressive to me or anyone else; he just would not allow me to do what I needed to. The whole procedure, on a cooperative patient, would take less than 1 minute. Really. Start to finish.

With this man, it took an hour and a half. Every five seconds, he was ready, and then he would freak out again. Taking out 3 sutures took 45 minutes. (I left the rest for another day.) He had on 5 layers of shirts, which he started taking off one by one. (I really kept thinking that he was going to be sitting in front of me nude.) He had on two hats (I am not joking). Once he finally let me do what I needed to do, it really did take exactly 2 seconds (scissors into wound, spread, done).

The thing that I find worst of all is my reaction. After the first 30 minutes of begging and cajoling, trying to mesmerize him into cooperating... I lost it. I really did. I was screaming at him. I have never done that. I feel awful. I was cursing, too. Not pretty, not professional. Really, really awful. I cannot stop thinking about it, replaying it in my brain. I cannot justify it. All I can say is that I really just wanted to do right for this man, and he would not let me. On top of that, I had patients piling up outside, so I felt pressured to get a move on. I even told him (and this I truly meant with all my heart) that if I had known that this was how things would go, I would have come in on my day off so I could spend as much time as necessary with him--even the whole day, if I had to. Unfortunately, that was not the case here.

The only good thing, well 2 good things: 1. When all was said and done and the dust settled, he thanked me. I mean, the man knows I really was trying to do good for him, NOT to hurt him. He understands he brought this on himself. 2. We called him today, and he said he is feeling much better with less pain. He is doing the wound care that I instructed him on.

No matter, I am seeing him again on Friday. He is one of the patients that I would move in with, if I could.

Really?

So, I went in to the office an hour early yesterday, thinking that that way, I could get some of the pile of paperwork done. As soon as I walked in, I noticed an X-ray hanging on the view box.

"Um, P, what's this?" I asked my medical assistant as I flipped on the switch and let the buzz of the old machine warm up. "Oh, Dr C dropped that off yesterday, for whenever you had a chance to look at it," she said nonchalantly.

The machine suddenly sprang to life, and I did a... more than a double-take, that's for sure, with my mouth agape, stammering. There, on the X-ray was an innocent little finger with more than 90% dorsal and 75% lateral dislocation at the proximal interphalangeal joint. I started firing questions at my innocent medical assistant. "When did this happen? Was anything done about it? Where's the kid, now?"

She knows me well. She knows that I was not angry, just very concerned about the patient. So, she quickly produced Dr C's extension and got her on the phone, so I could fire the same questions at her.

Dr C's answers were not comforting: "It happened yesterday, and the child came right to the office. Yes, of course I did something. I took an X-ray and wrapped it with an ACE."

"Did you reduce it?!"

"Reduce...? It looked less swollen and better, so I sent him home."

You've GOT to be kidding me. That is what I wanted to scream into the phone, but I kept my composure. I said, instead, "Did you get another film before sending him home to make SURE it was better?"

"No." Of course.

"OK, I'll take it from here. Thank you."

P called the child and mother, and they swiftly got into the office. We got another X-ray, and, as expected, still dislocated. So, I explained to them that since it was now more than 24 hours since the original injury, I was not sure if a reduction would be successful. I would attempt it, however, after a digital block. I told them all of the risks and warnings, including that if this did not work, then this fourteen year old boy was looking at surgery! (In my mind, I was thinking, "Damn, all because your stupid PCP wouldn't pull on your finger!!")

So, I numbed his finger and (with a little difficulty) reduced it (YAY!). I buddy taped him securely, and got another X-ray--still reduced (YAY). And, for good measure (he IS a 14 year old boy who likes to play sports), I put him in an ulnar gutter splint. (phew)

Here's the deal: Finger dislocations are REALLY easy to reduce, if they are gotten to in time. And they do really well, if they are gotten to in time and managed appropriately. Often, especially in kids, all you have to do is anesthetize the digit, give a pull and it pops back into place. (You always hear stories of people doing this on their own without anesthesia, but we are doctors. We have the goods. So, be nice, and numb them up.) Yes, sometimes you have to maneuver a little, but just look at the X-ray, and use common sense (AFTER distracting the joint). And always, always treat dislocations like fractures--meaning immobilization for the appropriate amount of time (buddy tape or splint, NOT just an ACE). Because they WILL dislocate again otherwise.

The problem comes when the dislocation is not treated, or treated and not immobilized. That's when things can result in a chronic dislocation. That can cause volar plate laxity, ligament laxity and disruption, and finally a hyperextension (Swan neck) deformity. That necessitates surgery. NOT pretty for a simple dislocation.

Needless to say, the pile of paperwork still awaits me.

Oh, and the man from the prior post (Lucky) is scheduled for amputation on Monday. Yes, there is osteomyelitis present. And, as expected, his first reaction was, "I need a drink," quickly followed by, "I need a cigaret," when I told him he cannot have a drink. I took my time explaining to him that both alcohol and cigarets slow healing. Since his primary goal is getting back to work ASAP, it is in his best interest that the post-operative healing takes place in the best environment possible. While he was in my office, he understood, but I hope he remembers when at home, too.

Lucky

We really are... many of us, at any rate. Here I am, complaining about my difficulties with starting a private practice, and yet... I am lucky. quite lucky, very lucky, I'd even venture. happy, healthy, with a tiny, but solid, family, a man who loves me, my cats (2), and a job... and both of my hands with all ten functional healthy fingers. That's it, really. Hands are so amazing, and so important. As a hand surgeon, you see it all. Most days, hands astound me, in surgery, in the office, on the street... and yet, sometimes, I just run on automatic. I think we all do, sometimes. Until it just hits you from time to time.

Yesterday, I saw a gentleman, mid-forties, completely candid recovering alcoholic, "I don't want to drink, doc, but it hurts so bad sometimes. I know a drink would make it better. But I can't. I gotta do better for my new baby."

"How old is your baby?"

"A month and a half--my first. I guess there was a reason I had to wait this long, and my wife, she's so good to me... So, when can I go back to work, doc? Because my wife, she's on maternity leave, and there's no one else..."

You see, this guy has a terrible, I mean really awful, poorly diagnosed and mistreated open wound of the right index finger (yes, he's right handed). Weeping, purulent, probably osteomyelitic, ongoing for more than a year. Did I mention that he was my last patient yesterday evening? Oh, and he works in dietary... in a hospital... and desperately wants to return to work.

Amongst the malingerers and bad attitudes, I just felt so much grief for this man.

And yes, we are lucky.

Silence...

I don't really know where to start. Is anyone still out there? Any of the five of you? I have been silent for so long. I thought that, by now, I would be up and running in my little 'enterprise.' ;) FAAAAAR from it.

Opening a private practice must be one of the most frustrating things in the world. Especially in this economic climate.

In order to get a business loan, you must be in business for at least two years. What if you need money to start that business? What if, like me, you are not independently wealthy? You can try lines of credit or business credit cards. Even those, with most banks, you have to already be in business to get. You can try "angel investors." However, most of these guys are currently interested in web-based, tech-y stuff. (Angel investors, by the way, got their name from the early 1900s, when wealthy businessmen would invest in Broadway shows. Now, most angels are far from multi-millionaires. They just find a company that they believe in and want to help. These people are very business-savvy and more often than not want to be on the board of directors or a partner of the company they support.) There are also physician funding companies on the internet. I will have more to say about these in the next few weeks, as I delve more deeply into them.

The whole setting up a corporation thing is another story entirely. Word to the wise: make sure the person that does this for you knows what they are doing!! The first guy I talked to was a business lawyer, who had never heard of a D.O. And he touted himself as a 'specialist' in professional corporations. "So, we don't have to set you up as a doctor, we could just do a regular corporation." This was after my explanation of, "I am a surgeon, a physician..." Which was then followed by, "OK, doooctooor." (very long, drawn out, not nice.) The next one is a family friend of a very close friend. Not good. This is the one that is actually working on my papers, but extremely slowly (molasses slow), and often with mistakes that I have to clean up. I have already paid him, and he is (finally) about two-thirds done, but it has been painful... and I have no idea when the other third will get finished.

These are major hold-ups. Hence, my silence.

And, I am in the meantime, keeping my "day job." Very busy. That was a joy, by the way, telling Mr. Big-Shot President of the company that I am opening a private practice. There I was, excited, like a little puppy, as what I do in my spare time does not affect Mr. BS Pres in any way, shape, or form. But, to be nice, I thought it only right that I put my plans "out there, in the open," so nothing has to be a secret. (Also, so if--rather when--insurance companies make mistakes and send checks to the wrong place, it won't be as big of an ordeal to retrieve the money.) The meeting ended in the most uncomfortable way: Mr. BS just repeating over and over again that I could not steal the group's patients, and me reassuring him that that was not my intention. He was so bothered, in fact, that he came to my office the next day to interrupt my patient hours and again reitterate that I was not to steal patients. This went on for another fifteen minutes.

Joyful.

Just a Few Words

Just explaining my silence here. I am in the midst of (ack!) starting a private practice (while keeping my "day job" with the group--it would be a little wacky to give up a steady income for something that is only a dream at this point). And I am overwhelmed. Hence, it leaves little time for posting anything here. Albeit, I do wish I had the time and energy, because, believe you me, I have the stories... just not the juice in my batteries. Soon, soon, I hope... thank you for being patient and understanding. I am assuming both of those. :)

There is NOTHING that I find more disturbing...

than a patient who does not have time for me. Access-a-ride, be damned.

So, there I was, clipping along my usual Tuesday patient marathon (trust me, 8A to 7P full of patients does not a happy surgeon make), when... "DrB, MsG wants to know when you will be seeing her. Her Access-a-Ride is coming soon, and she wants to know if she should reschedule," my medical assistant came into my office exactly as I pushed away from the EMR to get MsG. This automatically put me on edge. "Wait a minute," I said, "what time is her appointment?" "4:50," my assistant rolled her eyes. (She knows me too well, and could already see my blood starting to bubble.) I snapped my neck around to face the clock, "It's 5:02... twelve minutes past her appointment time. What's the problem?" Well, apparently, MsG had asked her transport service to pick her up at 5:16 (?huh?... why 16? and not, say 19? or 14, for that matter?) Well, I told my assistant to give the patient the choice (a grave error, this): stay and be seen--now--and the appointment would take roughly twenty minutes, or reschedule. "The patient will stay," my assistant soon told me. Three of the medical assistants in our 'area' (little office space in the medical center) knew of her predicament and promised to keep a look-out for her ride. They promised to make sure that the van did not leave without her.

So in she came. She was sitting in my office by 5:04PM. I acknowledged that I was running fourteen minutes behind schedule, and apologized. She, in turn, decided it was important for me to know that she had been waiting since 2PM. I (as nicely as I could muster at this point) explained to her that everybody has an appointment time, and I see patients according to the time of their appointment. It would not be fair for me to see patients out of turn. Frankly, I had been seeing patients nonstop (well, unless we count the seven minutes it took me to wolf down cold rice at 1:22PM) since 8AM, and there was no time at 2 for me to fit her in. I then quickly explained to her that I am happy to see her now, and would like to help her.

This is when the fun started. During my customary history taking, the patient was practically hanging out the window looking to see if her ride had come. I had to focus her attention back to me repeatedly, thereby wasting time (do you see the chasm here?). I called to the front to make sure that the medical assistants had not forgotten about MsG and her van--not only did they not forget, but the news had spread far and wide. More people were involved in making sure that the said van did not escape. It was not enough. That is when she started to look at her watch. But it was not a nonchalant, "Oh, let me just check the time here a second..." type of looking. NO! It was an all-out, "I need to get the f... out of here, and this damned surgeon is holding me up" kind of looking at the watch. Again, that strange dichotomy, that conflict, as I expressly told her that if she did not have time for me, we could easily reschedule her appointment. No, she said, "I'm here now..." as her voice trailed off. She was as far from here, now as possible.

I then started to examine her. She squealed even before I touched her, pushing my hands away. "Ma'am, I have to examine you. Please try to relax, as I cannot help you otherwise..." Once done, well, at least as far as she was concerned, she flew out of my office. She did not know what her treatment plan is, did not make a follow up appointment, and ran down the steps (cane waving in the air at her side) to an empty street to WAIT for the Access-a-Ride to come. (That was at 5:22PM.) I was so irritated (and busy), I did not wait to see when they finally got there to get her.

Her story? I honestly am not sure which is more disturbing--the above, or the below (what I am about to write). This lady, in her early seventies, had apparently been having trouble with her fingers (right ring and middle) for more than three years, "probably going on four," as she tells it. Her PCP attributed it to arthritis. The trouble? Locking of the fingers, so that she has to pull them, with pain, back into position. PEOPLE!! Holy moly, this is NOT arthritis (simply put, break-down of cartilage in a joint so that the bones rub against each other), it has nothing to do with arthritis. These are plain and simple trigger fingers, AKA flexor tenosynovitis or stenosing tenosynovitis.

(I have yet to master photo and drawing inserts here, so bear with me.)

Tendons are connections between the bones in the fingers and the muscles in the forearms (hence the reason that these patients will often have pain into the forearms). The flexor tendons are held in place with a pulley system (they are not like rubber bands, and therefore do not stretch, or give), of which the first annular pulley is the proximal-most in the palm. It also happens to be the tightest of the pulleys (in every person, in every finger--it is just the way we are made). When a patient has gout, or rheumatoid arthritis, or overuses a finger (always carrying heavy groceries, one on each finger), or falls on an outstretched finger, the flexor tendons will get inflamed. Once inflamed, they cannot pass fluidly past that first annular pulley. So, the person tries to bend the finger, the tendons bunch up distal to the pulley, and if the finger is forced to bend further, the tendons will clunk, or pop, under the pulley and get 'stuck,' or locked, now proximal to the pulley. So, the patient has to somehow maneuver the finger open.

If this is allowed to go on long enough, the tendons can actually get foreshortened, as the patient will eventually find it too painful to fully open and close the finger. That is, in effect, what had happened to this lady. She cannot straighten out her right ring finger at all. Not that I got a chance to explain this to her... (She also has a left middle trigger finger that has been ongoing for about 6 months.) So, what she needs is occupational therapy as optimization for surgery for the right hand, and an injection into the left.

Therapy for triggers should always include ultrasound with steroid ointment (NOT Biofreeze) and a home exercise program. This is a pet peeve of mine--for triggers, steroids, properly applied, work, Biofreeze does not.

Surgery consists of simply filleting open the first annular pulley. We have found that it is not necessary for motion of the tendon, or, for that matter, the finger. As long as the neurovascular bundles are protected, it is a fairly simple procedure (which gets hairy in fat hands). As for the injection, it is a steroid. The reason that steroids work (as an injection or an ointment--as in therapy) is that they are anti-inflammatory; they help to reduce edema around the tendon. In this way, the tendon can move in a supple manner past that A1 (first annular) pulley. The caveat is that there is a limit, as repeat injections can cause weakness, or even breakage of the tendons. I tell my patients no more than two injections per finger for your lifetime. Also be aware that in diabetics, the injection may make their sugars rise for a few days--better yet, don't just be aware, make your patients aware!!

You people have only an inkling of how much this lady upset me. I felt somehow abused. Maybe that sounds a little melodramatic, but... I did not even have a chance to go through a treatment plan with her.

Prove it

One of the hardest things, I think, in medical practice, is attempting to prove to a patient that you (as a specialist) are in the right, when, in fact another surgeon in your specialty has proven some other thing to said patient. (still with me?)

So, last Thursday, I was called, nay, paged, by the medical assistant of Dr X, who frantically told me that I have to do surgery on patient TB. I had to stifle a laugh and ask her to slow down, as I explained to her, "I never do surgery on a patient that I have never seen before. And, by the way, please explain to me, again, why, if Dr X has determined that TB needs surgery, she will not be performing it?" She took a breath, and, rather confused, affirmed that, "Of course, you should see the patient first. You see, the patient does not speak any English, he only speaks Spanish, and I have no idea how he got your name, but he did. And Dr X saw him yesterday and said that he needs surgery ASAP, but she cannot do it, as the hospitals that she goes to don't take his insurance."

For a myriad of reasons, I have a weakness for patients who are not fluent in English... whether it is the time that I spent in my fellowship in the South Bronx, or my own immigration into the States, but there you have it. So, I told the medical assistant to have the patient come to see me on Friday.

That is where the fun started. First off, Friday decided to be hell-day. I did not see that many patients (19 in all), but I felt like I saw about 50, and like each of them whipped me one-by-one. I did a few procedures, which added to the craziness. So I digress, back to TB:

My Spanish is mediocre, at best. It was learned on medical missions in Guatemala and in the aforementioned South Bronx. It has been slightly bettered recently, as I have been dating a Hispanic man, but still, it is not conversational. I was ready. We have several Spanish speaking people in our office, and I had alerted my ~favorite~ one that I would need her help. Alas, I got the man into the office, and he started speaking... perfect English. huh? I asked him where he got my name (as Dr X's medical assistant was in a quandary as to how that had happened), and he evenly stated, "Dr X provided me with your name, as the hospitals she goes to don't take my medical insurance." come again? (now I was wondering what language I spoke to that MA in...)

OK, fast forward to... the man had had a close run-in with his lawn mower. Apparently, he managed to stick not one, but BOTH of his middle fingers (and a tiny bit of his left index) into the blades while the motor was still going. "I didn't hear it," was his defense. No one else involved, just one man and his mower. ehem.

One really lucky man, I might add. Here is what he got: a left distal phalanx fracture (a tuft fracture), and a right mallet deformity. (Look here for dealing with mallets--Dr Bates gives a great tutorial.) The mallet was due to an avulsion fracture of the dorsal distal phalanx, but he also had some tissue loss (with ER repair/ coverage 2 days before I saw him) of the volar surface of the finger tip.

Problem was, that he had a tremendous amount of edema at the right finger. You see, fingertip injuries without bony involvement (which this, in effect, was), can often be treated very conservatively. They heal GORGEOUSLY--often with no scar. But, as soon as you start mucking with trying to tightly re-approximate skin to skin (remember: re-approximate, don't strangulate!!), you can cause enough edema for cell death. Cell death equals ischemia and, well, skin death. So, TB was looking at skin edges that didn't look so healthy, and a surgeon (moi) that did not want to touch him with a twelve foot pole. As far as I was concerned, surgery is not indicated! And he had so much edema, that if I did any sort of grafting, it would certainly fail. (This, by the way, was one of the surgeries for which Dr X had apparently booked TB. That, and something for the other middle finger... in other words, surgery on BOTH hands at the same time. YIKES!!)

Now, I was quite comfortable with my treatment plan (get the edema down, treat the mallet, treat any skin death as it happens--it usually sloughs off like a scab), but I had to convince the patient, his wife (who did not, in fact speak a lick of English), and his brother-in-law (whose grasp of English was somewhere between the two). So, how do you (I), a relatively young surgeon (at least 10 years junior to Dr X) who does not speak their native tongue (Dr X does) convince these people that I am in the right? By standing my ground, repeating myself as many times as necessary, explaining and re-explaining, going over the x-rays, and, above all, showing them that I care.

I still do not understand Dr X's approach. You might ask why I do not just pick up the phone and call. It may sound awful (to me it does), but there have been many affirmations that much of what Dr X does has to do with inflow of cash... and a bullshit excuse might just put me over the edge. I really do not, am not ready to, hear it. I mean, really, both hands... at the same time?! Only in extreme, extreme circumstances.

breathe...

Oh, I wanted to mention how honored I was to be mentioned in this month's edition of SurgeXperiences. Please make sure to take a look at the nicely written conglomerate as soon as you get a chance!

Flight lessons, and OFF...

Over the weekend, Sabado learned to fly... today, I regained my balcony.  Well, not entirely, but as much as I could, for the moment.  

You see, the little family will still come here; they still call this "home."  But, enough is enough.  Call me mean, self-serving, whatever, but when I saw Mommy nesting again (!?!?), I knew something had to be done.  And no, it doesn't make sense that she will lay more eggs this season.  For all I know, the nest is simply a comfy place in which to rest her little feathered butt. 

You see, I am a New Yorker, after all.  My balcony is all that I have.  If I had a house, with some other stretch of land to, well, stretch on, then it would be a different story.  But, I have gone enough beautiful evenings and days without the benefit of my wonderful balcony.  I have sacrificed dutifully.  And now that the little winged one can flitter at will, it is time.   

So, off I went and purchased my heavy-duty broom, and went out this evening in my mismatched tank top and running shorts (yay--they're again in use!), flip flops and gloves, and swept up what I could of the nest, poop, and feathers.  Don't worry, there is still much to do--I still need to Clorox (yes, a verb in this case) the place, but it's a start.  In the meantime, if I come down with bird flu, we all will know why, and will one of you then kindly contact R, as he does not read my blog.  ;)

By the way, as for Sabado, he is too damn cute for words.  He still is very discernible by his little left over yellow feathers on his head and the tips of his wings, and of course, he is still smaller than his parents.  He is also LAZY.  Whenever he sees his parents, he still runs after them, demanding to be fed.  I think the idea is that once they can fly, the little ones start to feed on their own.  The parents scamper off away from him every chance they get.  Oh, but then this weekend, I was starting to wonder if Sabado is a *girl,* because she is soooo clingy to her Daddy.  OK, OK, I know, I am projecting human emotions onto a bird.  But it's fun!

wait... WHAT?!

So, how is this voluntary, if it is mandatory?  Am I missing something here?  

Apparently, in the next three years, every adult in the Bronx, will be required to take an HIV test... voluntarily.  

Let me tell you a couple of things.  More than fifty (yes, 50) per cent of the Bronx is Hispanic (with the largest Dominican and Puerto Rican population in the United States).  In fact, there are many areas in the Bronx where not a lick of English is spoken.  People are not going to be interested in getting HIV tests.  They wait too long to get treatment for HIV for the same reason that they wait too long to get treatment for breast cancer, or any other such disease.  Trust me, I did my fellowship in the Bronx.  These people are not stupid, nor illiterate; they are simply IN DENIAL.  

These are the kind of people where instant gratification is in its exact meaning.  Mobile phones, bling, labels on clothes are much more valuable than the spots on their skin or their rotting teeth or that lump on the breast that now is eroding through their skin.  They do NOTHING until it hurts.  And, well, let's face it--HIV does not hurt, not until it is too late, same with breast carcinoma, or any other carcinoma.  

Now, let me tell you a more personal story:  When I was in my fourth year of surgical residency, there was a certain (ehem) gentleman in our SICU s/p trauma.  The trauma consisted of a 3 AM "But I was just on my way to church, and was jumped by some dudes" sort.  Now you are getting the picture.  So, now, this dude is vented in my SICU and I need to place a line and, sure enough... I stick myself.  We know NOTHING about his HIV status.  

I call my attending.  "No big deal (!), just talk to the wife (he had one), draw the test, and we'll get a result by the morning."  "Got it."  The wife was overly willing to help--very sweet.  I go to the bedside to draw blood, and my right arm is seized by a nurse.  "What are you doing?"  She growled at me.  I explained the situation to her.  I had a great rapport with all of the nurses, so I couldn't figure out what the problem was.  

Well, apparently, the New York City laws are such that ONLY the patient can say OK to an HIV test.  And this kind RN is just trying to protect the patient.  It doesn't matter that he is on a vent and on a drip--SEDATED--so that he doesn't rip all of his lines, etc out.  She is "just looking out for the patient's rights" she says to me with a sweet smile on her face.  

This actually went to the hospital's ethics committee, and they could do nothing.  The only consolation that I had was that we could draw a hep B titer, which came back fine.  And, in theory, if that is negative, well then, he shouldn't have HIV.  But, can you really deal with shouldn't when you have your WHOLE LIFE to live, your entire career ahead of you--in SURGERY, of all things?!  I ended up taking a full course of HIV meds, and being sick for 3 months.  When the "dude" finally came to, he took the test and (thank God, but also, of course) tested negative.  

New Territory

Sabado has discovered the neighbors' balcony.  Of course it was only a matter of time.  Our balconies are not completely separated--the divider does not go all the way to the "ground" or to the outer balustrade.  

So, off he went, around and over--walking, running, of course.  Still not flying.  :)  His wings are SO big, now... almost adult-size.  You would think that at any moment, during one of his little fits where he is squawking and running around fanning his wings, he would take flight, but... nope.  Not once, not yet.  Daddy still feeds him.  I am proud to say, also, that my balcony is definitely 'home' for him.  

And the felines love the show.  There are days, though, that I think they (the cats) really get it into their little heads that "Today is the day we get to go outside... to see the birdies up close."  Their little tails do the happy dance, and they won't stop mewing and meowing.  Alas, it is always a let-down.  It never turns out to be the day...

OK, OK, a little premature

my earlier post was.  

Mommy came back last evening.  Hip hip hooray!!  I admit that I was really worried for the little feathered family.

She was sopping wet (she made her reunion in the middle of a thunderstorm), but there she was.  She was so wet, in fact, that I almost did not recognize her, as she was a darker (wetter) shade of gray than usual.  

Last night, Saturday was freaked out with the thunderstorm.  He hid behind a table leg, as close to the building as possible.  

And today?  Well, Sabado has been in his nest all day.  It has been mostly a grey, overcast day.  I wonder if he is grounded?  I have not seen him sit in the nest in more than a week during the day.  He's usually out and about.  hmmm...

Sad to report...

but it looks as though Mommy has (possibly) fallen prey to the hawk.  Well, that is a supposition on my part.  

Here's what I know:  Daddy slept by himself last night in the corner of the balcony.  And today, I haven't seen Mommy at all.  It seems as though little Sabado (Saturday) and Daddy are on the lookout for Mommy.  They are sitting on the edge of the balcony looking out to the outside all morning.  She has not been here.  

And the super of my building told me earlier in the week that the hawk (which I saw a few weeks ago) was feasting on a pigeon just a week ago on the fourth floor balustrade.  Well, that was not Mommy, as she has only been missing since yesterday, but maybe it was time for another meal for Mr Hawk?  

I'll keep you updated, but things are looking pretty grim.  :(

Yikes-- Salmonella strikes again

News flash!  There has been a tomato recall.  

Considering that tomatoes are heavily consumed in the spring and summer months, this is a big deal.  Considering that this has (ehem) affected yours truly, this is an even bigger deal.  

I went to my friendly neighborhood grocery/ specialty store this morning and bought a bunch of stuff including, said, tomatoes.  I went about my day, having a tomato with lunch.  About two hours ago, it started... that uncomfortable feeling in the gut, dry mouth, running for the toilet.  ("What the h...?") 

And then, I checked my email, and found my U. S. FDA email.  I ran to the 'fridge, and checked my tomatoes against the list.  ALAS, mine were from Mexico---aaargh.  That explains it.  

So, I called that aforementioned neighborhood grocery/ specialty store to alert them.   "Yes, thank you, we have pulled all of our tomatoes already."  I told her that I bought some this morning, and they were from Mexico.  Her answer?  "You can bring them back for a full refund."  Well, what could she say?  She was not aware of my discomfort, and the fact that I had to stop my pilates (twice) to run to the bathroom.  

But, now you are aware, and maybe you have not yet eaten the tomatoes that you purchased this morning.  PLEASE check them against the list.  If you are not sure where your toms are from (as in, they are not clearly marked), call your store to find out.  Do not take a chance.  If you are young and healthy, it will likely be a nuisance; however, if you are immunocompromised in any way (elderly, ill, or very young), it could be very serious.  

Independence

I haven't had a chance to write while things happen, but that little squab is GROWING!! 

Last Friday, he was squawking so much, that I finally looked out of the window.  There he was, just outside of the nest, trying out his tiny little wings... Except, he does not really have feathers, yet.  Just a whole lotta fluff, so this resulted in him running around in a circle--clockwise, counter-clockwise, clockwise, coun... well, you get the idea.  I can only imagine that this was very frustrating, as he was making TONS of noise--squeaking and squawking the whole time.  It was darned cute to watch, though.  :)  I guess Mommy and Daddy thought so, too, as they were both there, watching the whole fiasco from two feet away.

That night, Saturday slept by himself.  Mommy and Daddy were on the balcony, huddled together in a corner about 10 feet away, but he was by himself in the nest.  

We went away for the weekend, but when we came back... he just really seems to have grown.  Yesterday, he was a few feet away from the nest.  But today?  Today, Saturday is all over the balcony!  And I got to watch him getting fed by Daddy.  THAT was amazing... and, I can only imagine, a little painful for Daddy.  I mean the little guy is digging into the mouth of Daddy with his beak to get all of the milk.  There was so much excitement during the feeding, that they were dancing together all over the balcony.  Once Saturday was done, he was chirping away, getting all fluffy, with Daddy patrolling.  And when he moved?  A nice big poop, after which he snuggled into the nest for a nap.  :)

A Break

from our feathered friends.  Surely you need one.  

So...  Papaya Quick Bread.  You see, I had that party, and I had planned on making lots of sangria.  Which I did, indeed, make, but I bought much more papaya.  (I made more than one type of sangria.  I've always been an over-achiever.)  So, I had to figure out what to do with all of the left over papaya.  Shakes (batidas) were somewhat uninspiring (although I STILL have some left to try my own creation).  So, I dug a little deeper.  I wasn't in the mood for a salsa, as that also meant that I would have to then make something to accompany the said salsa.  So, quick bread it was... kind of.  Except the recipes that I found had very little papaya and a lot of everything else.  I had to get creative, which also means that YOU get a new recipe!  I still would change things a little more next time around, but here is the recipe as I made it:  

You need:

3 eggs

1C sugar

3/4 C applesauce

1C shredded carrot

2 1/2 C smashed ripe papaya

1t salt

4C flour (I used 3C unbleached white and 1C whole wheat)

1T baking soda

1t cinnamon

1/2 t nutmeg

You do:

1.  Preheat the oven to 325F and coat either 2 regular-sized or 4 medium-sized loaves with oil, butter, or cooking spray.

2.  Mix together the eggs, sugar, and applesauce at slow speed for 1-2 minutes.

3.  Add in the carrots and papaya, mix 1-2 minutes.

4.  Add the flours, salt, spices and baking soda, and beat at medium for about 2 minutes.  Do not over-mix (just until blended), or your breads will fall flat and heavy.

5.  Pour into the loaf pans.  

6.  If you are using the regular-sized, bake 55-60 minutes; if the medium, bake about 40 minutes.  (You could do muffins baked about 18-20 minutes, too.)  All until a toothpick in the center comes out clean.

7.  Allow to cool in the pans for about 10 minutes before placing on cooling racks.

8.  Allow to cool on cooling racks completely before wrapping.

(If you don't have a standing mixer, do this:  Mix eggs, sugar, applesauce in a large bowl.  Mix completely.  Add the carrot and papaya to this.  Mix the dry ingredients (flours, salt, baking soda, spices) in a medium bowl.  Add the dry TO the wet ingredients and mix again.  This is where you DO NOT over-mix--just until blended.  Then go to step 5 above.)

Eat well  :)

Now, as I said, I will do differently next time:  I like carrots well enough, but cannot really figure out why they are here.  So, I would get rid of them altogether, and replace that cup with more papaya.  Also, although this is a good sweetness for me, I don't like very sweet things.  So I have a feeling that R (and the majority of you) would prefer more sugar.  (He'll try it tonight.)  In that case, either more sugar inside, or a caramelized topping would be good.  And, I don't know, those spices... I saw one recipe that called for a tablespoon (!!!) of cinnamon and a teaspoon of nutmeg (yes, for the same final quantity).  Even though I am using SOOO much less than that, it's still kind of overpowering.  I might just cut them out completely next time.  I guess we'll know more next time I overbuy for sangria!  :)

Well...

the hawk (a Red-Tailed Hawk, I later researched, who, by the way, looked like this) never came back... so far, I guess.  There is always tomorrow.  

The little one (Saturday) is growing.  Daddy leaves the nest more frequently, now.  I look out to just see Saturday (or the squab, as he is properly called) there; sometimes with dad hanging out on the balcony rail.  Finally, the days are getting a little warmer, too.  Interestingly, Mommy doesn't seem to have a problem staying on the nest all night long!

Both Mommy and Daddy make the cheesy milk that the squabs eat, until they are about a month old.  At that point, Daddy takes over with the food production, and general feeding.  

The squabs stay in the nest until they are six to eight weeks old.  (Oops, underestimated that one...)  Although they start flying at about 4 weeks.  (That should be fun!)  

While I am at it, I had mentioned the book, Extraordinary Pigeons in an earlier post.  Well, this guy, in Utah, actually breeds and sells pigeons of some of the varieties that are mentioned in the book.  So, if you think that they are exotic and not to be found, think again.  His photos are quite nice.  

Oh... My...G....!!!

Originally, I was going to write, today, a little eulogy... to the little life that was one of the pigeon chicks on the balcony. I honestly do not know what happened.

Whether he was ill, or hurt, but yesterday, I noticed that he was out of the nest...but within centimeters of it. Initially, he was active, and throughout the day, he stayed out... until the evening, when we went to check on him. (It has been a TERRIBLY cold May, and the nights are especially frigid.) By then, his breathing appeared agonal, and he would spread his weak little wings every 3-5 minutes. It was heart-breaking, especially with Mommy and his sibling just a few centimeters away. R suggested that we roll up a T-shirt to block out the wind around him for the night--'just in case.' So, I did.

First thing this morning, I checked on them. As expected--he was just a little heap of yellow and grey feathers. No breaths, no stretches. As R said, "animals act on instinct," there must have been something wrong. I added, "because of course Mommy and Daddy were strong enough to bring baby back into the nest if he had simply wandered out..."

So, as I said, I was ~originally~ going to write about that, but, um, now we have bigger fish to fry. I came home this afternoon. Took a step towards the balcony, and looked straight into the eyes of a... HAWK. I kid you not. I am not talking about a Peregrine Falcon

No siree. This was a real, in-the-flesh (and feathers) hawk. Holy crap. My stomach fell. I really felt like I was looking into the eyes of a predator. He was HUGE--just under 2 feet tall. I opened the window to scare him, but he wasn't scared. He actually stared right back at me, and, on top of it, I briefly entertained the idea of, "What if he flew into the apartment after me?!" Of course, of course, my luck was that the battery in the camera was DEAD--as a doornail, dead. Next, I looked at the nest, both babies (live and ~gulp~ not) there, with no parents in sight (yeah, I guess that makes sense...). So, I yelled at him, and wildly flapped my arms around. At that point, he finally lazily turned tail and flew away. The felines, of course, slept through the whole thing.

Now, of course, I keep looking back at the balcony--to see if HE comes back, but also because now I'm (again) freaked that the parents won't come back. And now, I wonder if he was who originally hurt the other little one, or who Daddy was fighting with a couple of days ago--remember?

Not much is going to get done today, I fear. I am on the look-out.

Cookbooks... and gardens... et al

Completely a self-absorbed, me, all about me, kind of post.  

I desperately want this cookbook!  I adore Jamie Oliver's style, and I have one of his cookbooks.  Since I now also have my little AeroGarden (where the --2 kinds of-- basil, by the way, threatens to take over the kitchen on a daily basis), I really, really want this book.  

By the way, the thyme is not far behind.  The mint, dill, and *finally,* the chives are just fine, thank you, but the parsley, oh, the parsley.  Well, let's just say that, to their credit, if you have something that is failing in your AeroGrow, the kind people will replace that pod.  Sadly, I just realized that!  A FULL four weeks into growth--yikes.  Now, I cannot raise the lamps, and I have to keep cutting back all the herbs... Let's just say it hurts, just a little.  Of course it's just grand that the herbs grow without soil, but I do love outdoor gardens, too.  Oh, well, we New Yorkers make do.  Next, I think, will be the Japanese herbs... but that is many, many months away... by then, I may change my mind to the chiles and tomatoes, or, who knows, there are so many choices...  (OK, I know, I've completely derailed this... I have to change the title.  There, that's better.)

As an aside, considering the girl-cat's panache for anything green or flowery, I am simply AMAZED that she has not yet discovered the herbs!!  :) 

To finalize the haphazardness of my thoughts, and in case anyone is wondering:  The pigeons did just fine for the party this weekend.  The balcony remained blocked off, and the guests did not even complain, too much.  Mommy stayed on the chicks throughout, keeping them warm.  (It has been quite a cold May!)  

Speaking of that, Daddy got into a bit of a scuffle today.  I don't know exactly what happened, but I heard all sorts of pigeon noises at one point.  When I looked out, I saw a pigeon that looked ~almost~ like Daddy chasing another pigeon away.  I then realized that it WAS Daddy, and that the ~almost~ was because he had been pecked at!  Now, he has some loose white feathers high on his chest.  Once the intruder was gone, he went back and settled on the wriggling, peeping little yellow chicks in the nest.  And all was right with the world, again.  :)

Ok, so I guess the post wasn't all about me, after all...

OOPS!!

There is a new FDA recall--this one is again a big deal in the medical world.  Apparently, Medicis realized they accidently mislabeled a bottle of azathioprine--an immunosuppressant--with minocycline--an antibiotic!!  Then, it went out with the lot of antibiotics, of course.  So, now they are recalling the minocycline, which they brand as Solodyn.  (They brand azathioprine as Azasan.)

Here is their own recall page.

If you may have taken the implied medication, please contact your physician immediately.  

Right on Time

18 days I read, and 18 days it was--We have pigeon babies--chicks!!  One was born Friday, the other Saturday--both exactly 18 days from the days their respective eggs were laid.  So, R decided we should call them "Friday" and "Saturday."  I know, very imaginative, but, really, what DO you call pigeons, anyway?  

So, now they will stay in the nest for roughly a month.  Learning the pigeon ways, tricks of the trade, and all.  And then, well, off they go, I suppose.  That's when I get my balcony back.  

For now, they are TINY, and very weak.  They literally cannot hold their little heads up, and their eyes are humungous!  In puppies and kittens, the paws are huge, in pigeons--eyes!  

Mom and dad still take turns keeping them warm--these little ones cannot regulate their body temperature, yet.  They have to be kept together--the siblings, that is--or they get lonely.  They don't mind letting  you know, either.  They'll make lots of noise until their brother or sister is next to them.  Both parents make milk to feed them.  Lots of teamwork!  :)  

Everything is as it should be.  

Oh, I should also let you know that there is a great book, called Extraordinary Pigeons.   It's quite amazing, and will change the way you think of these birds. 

More about pigeons...

Did you know that pigeons weigh less than a pound?! That's pretty amazing, but I suppose it should be intuitive, in a sense. I mean, they do have to be airborne, and considering that they reach speeds of 50, yes, FIFTY, miles/hour, they should be light. They just look bigger, I guess.

Did you also know that they seem to be the only (?) bird with such amazing color variation? I mean look at them--it seems that no two are alike. Some are all grey, all white (doves, after all, are pigeons with another name), all brown, some with white-, or black-tipped wings, some spotted, some banded (or striped) some with iridescent greens, reds, or blues around their necks, or on their proud bellies. They really are amazing.

Our couple is gorgeous. Never mind that the daddy is quite skittish. He got ridiculously frightened as I tried to open the window yesterday. (End result--window didn't get opened, and he returned to nest within 2 minutes.) Back to colors: the female is just -gentle- there is really no other word for her color or manner. She is beautiful, pale grey, with a few spots. She is quite small, too. She walks slowly on small grey feet, but is proud and determined. Daddy is much larger, probably twice her size. He looks more like a 'typical' pigeon in some respects--he is a darker grey, with a pale belly and darker yet tips to the wings. His distinguishing feature --and maybe why she fell for him? :) --are the iridescent green and red patches around his neck. I already wrote of his propensity to run. Oh, and he has red feet. They both have very clear eyes.

303 species, right in all of our backyards, and they seem to be the birds that we know the least about. So, Cornell University, in Ithaca, NY, is doing a program to try to change that. It's quite interesting. Please take a look--maybe you'd like to become a pigeon watcher, and help out. :)

We're having babies!

I suppose I need to clarify...not us, per se, but our dwellers. :)

About 10 days ago, R and I went out on the balcony for the first time in, well, a LONG time (the winter has been COLD) to enjoy the first warmth of spring. I immediately noticed a bunch of twigs in the corner, behind a chair. "What the ...?" Did our neighbors sweep trash under the divider?

I looked over--it didn't make sense. As usual, there was NOTHING on our neighbors' balcony--not a table, a plant, nothing. And the twigs were in kind of a neat little pile...

Well, I guess it was another thing we'd have to clean up before the first party of the year. *sigh* The same day, I put Mandy, the mandarin tree, back out on the balcony, so she, too, could enjoy the sunshine and warmth.

Then, we were busy again, or as always... no more balcony.

On Monday, I went out to water Mandy. I was startled to see a pigeon waddle slowly, almost sleepily, out from the corner, behind the chair! I looked, and THERE, on top of the twigs, was a beautiful, perfect little EGG!! It's a nest! (Wow, living in Manhattan for 7 years does something to some of our instincts...)

I froze; I almost started crying. I tried to tell her that it was OK, that I wouldn't hurt her, but she kept moving away, still slow. I went inside quietly and quickly ran to the computer to look up everything possible on pigeons and their eggs--just in case I scared her so badly that R and I would be raising a new chick. And I called R in emergency.

Contrary to popular belief, they do not carry diseases, and they are actually not dirty. They mate for life--bet you didn't know THAT! Their incubation period is 18 days, and the little eggs have to be kept at 97-102F (like human body temp, I told R--you know, we had to be prepared...), and they usually come in pairs.

These last three facts gave me so much anxiety I could barely go through the day. You see, we have a party planned for the 17th, and I scared mommy away, and I only saw ONE, solitary egg.

Most importantly, Mommy pigeon had to come back, so I was looking out the window constantly. This was fruitless, as the nest is exactly UNDER the window, and there is a ledge, so unless she sticks her tail or head out, or adjusts, I am unlikely to see her. But, FINALLY, the next morning, I awoke R, "She came back!!"

#2, there should be siblings. So, last evening, R and I quietly went out to look. Mommy was there, and she wasn't terribly scared of us. She left the nest, but only went about 3 1/2 feet away, to the edge of the balcony, where she stayed, while we looked, from about 5 feet in the other direction, at our trophies--TWO little eggs. YAY!!

Now, the last thing, the party. We have decided to go ahead and have it. The chicks should pip (break out of their shells) by then. We will block off that area of the balcony, and we figure our friends are good people. They will probably like to see our little friends, and we have faith that they will go unharmed. That is, of course, if they are even still there! (I have a feeling they will be.)

Something else really cool: Mommy sits on the eggs to keep them warm from late afternoon through the night until mid-morning, at which point Daddy takes over and does the day shift.

I will keep you posted. I may even try to take some photos. I just don't want to scare them too much. :)

Of Carrots and Love...

I believe this story deserves some sort of honorable mention.  

Husband and wife argue.  During the argument, the man chucks a carrot (?! I guess it was the closest thing to him.  Wait, I got it, now, he was EATING the carrot during the argument.) across the kitchen--about 20 feet--, which happens to hit the woman squarely in the EYE, of all things.  

This results in one ruptured eyeball, then a glass eye, and (apparently) life happily ever-after.  They are still together!!  (It's been close to two years, people.)

ehem, I just realized that in my previous post, I used 'carrot' as a euphemism.  Please forgive, and there is no correlation...

What Motivates Us?

Is it money? prestige? recognition? helping others? a means to an end? retirement? some carrot, to be sure. But sometimes it is quite difficult to define that "carrot." Assuredly, it is different for each individual.

R and I talk about this quite a lot. Neither of us being our own boss, working in large companies, answering to supervisors, and their supervisors, can often be tiring... not to mention, frustrating... especially since we are both outspoken and intelligent; we know what we want. The problem is, we sometimes can see problems arising leagues ahead while others are concerned about what is just in front of their noses.

Case in point, at our most recent all docs meeting, our chief spoke of his dream of making our (physicians!!) group a franchise like McDonald's: a franchise that can deliver 'quality, low cost food in a clean environment... as a unique (medical) experience.' I have nothing against McDonald's, but I see SO MUCH wrong with this statement. Yet, it was as if I was the only one that heard it, out of 300+ docs. No one reacted. The rest of the time (more than 2 hours) was spent in various shouting matches regarding paid vacations.

For me, I don't mind so much the knowledge that I will always have to answer to my patients. That's a given. That part is easy. I care about them, and they know it. Answering to 'the others' is a challenge, especially since they often are, quite honestly, less educated, unionized, 'untouchable,' so to speak; and the ones that are well-educated seem to be caught up in... I don't know? numbers? cash-flow? statistics? so much that they are also seemingly untouchable, unreachable.

Some people, it seems, are happy, content to be followers. Others are, well, simply put--NOT. They need to be leaders, their own person, so to speak. I think R and I fall into that category. So, this is what we strive for. Yup... definitely need to get going on that private practice.

Maybe, for us, the carrot is just the knowledge that we answer to ourselves...

Easy Bread

I know, it's been a while. Not quite what I promised. Work (and life) has been, well, busy. So, I decided to give you this, for now, as a friend asked if I could email this recipe, and I thought this might be... not easier, but more fun, somehow. So, here it is:

This recipe will make two nice-sized, loaves. It is quite easy, and therapeutic, to make.

You need:

3/4 oz active dry yeast (3 packages) or 1oz fresh yeast
2T honey
2C warm water (or a little more, as needed)
7-8C flour (I use a combination of about 6 cups all-purpose unbleached, and the rest whole wheat. But if I have almond, or other, flour, I'll throw that in to equal the 8C) I mentioned, before, the experimentation...
2T salt
a little extra flour for dusting, etc.

You do:

1. Dissolve the yeast and honey in 1C of the water. Do not make the mistake I made the first time I did this (as the other times I've made bread, it was without honey). Let me tell you, the yeast LOVES the honey, and will grow, grOW, GROW quickly. So, do NOT walk away, do not make coffee, have breakfast, kiss your love on the cheek... move on... to measuring for step 2.
2. Measure out the flour and salt on a large surface (or in a large bowl) into a big pile. Make a well in the center.
3. Pour the yeast mix into the well. Work (with your hand) out from the center to mix the dry flour/salt into the yeast. Pour in the rest of the water to bring in all of the flour. Adjust the quantity of flour as needed to make a moist dough.
4. Knead for about 5 minutes. Use extra flour as necessary. The dough will become elastic and stick together (to itself) and less and less to your hands.
(You can do #2,3, and 4 in an electric mixer. My KitchenAid Artisan set at #2 setting with the dough hook attachment was amazing. Then, I pulled out the dough and couldn't resist kneading a bit more-it's fun, after all!)
5. Form the dough into a ball (of sorts) and place in a lightly greased bowl. You can score the top with a sharp knife, and cover the bowl with plastic wrap to speed the process. Leave to rise to about double-this takes about 45-90 minutes depending on the temperature of the surroundings.
6. Now, punch down the dough, and divide in two.
7. Shape and leave to rise again to double. (If you plan on filling the bread, this is where you'd do that.) If you leave the bread as-is, in loaves, it is best to score the tops again. This is also the best time to preheat your oven-for basic bread, 425F is the temp.
8. Bake for 20-25 minutes. You can tell it is done when you tap the bottom, and the bread sounds "hollow." (This makes perfect sense the first time you hear the sound.)
9. As hard as it is, leave the bread on a cooling rack for about 1 hour before slicing or eating.

At #7, you can roll the bread out, fill with meats, spices, and/or olives, raisins... pesto (home-made, of course)... olive tapenade (ditto)... herbs and olive oil... nuts and dried fruits... the possibilities are endless, really. Then, roll back up, and leave as is, or cut (with a very sharp knife) into 2cm slices and place side by side in a pan to rise for the remainder of step 7. If you do the latter, your baking time will be reduced to about 20-22 minutes. Your cooling time is also reduced (about 30 minutes)-BONUS!!

Eat well... :)

Listeria in Pennsylvania Milk

Well, the (written) boards were last weekend, so I can breathe a little now.  Maybe, I'll even be a little more present here.  :)

First thing that I need to let you know about, though, is another FDA recall--this one is specific to Pennsylvania, but quite frightening, so please be aware.  If you buy milk from these farms, then please make sure to check when you purchased the products, as they may be tainted with the unfriendly bacteria, Listeria monocytogenes.  

If there is a chance that you may have been exposed, or have reason to believe that you are ill as a result of Listeriosis, please contact your physician immediately for care.  

More, and Final, Updates on the Cantaloupes

The FDA has finally put together this list, as the recall is continuously expanding.  So, if you are a concerned consumer, then please check back to that link, specifically.  It will have the most up-to-date info on the melons and bugs, as well as what is being done about them.  

Oh, and that will be the last that I will say on this topic.  :)

Cantaloupe Recall Update

Apparently, the recall is continuing and branching out.  These cantaloupes were sold mainly on the East Coast, but may have been distributed out.  There is a common sticker of "Mike's Melons."  (The sad fact is that the recall states that the sticker 'may have fallen off.')

Further, and you knew this was coming, there are now some recalls of fruit mixes that may have included the aforementioned melon.

The infecting organism remains Salmonella;  please look at my prior blog for information on this bug.  

Cantaloupe Recall

Apparently, there has been a cantaloupe recall, as this fruit is contaminated with Salmonella.  

Please note that the link covers ALL Salmonella infections, although, obviously, the one of concern, is nontyphoidal.  This usually presents as a diarrheal illness, often with fever and general malaise.  In the young and elderly, it can become much more serious.  Please see your physician, if you recently consumed the product and are experiencing any of these symptoms.  

The cantaloupe was sold in the U.S., as well as in Canada.  Please make sure to check what you are buying.  

Continued Heparin Recall

So, maybe for now, (since I have so little time) I'll just do little blurbs here and there about FDA recalls. 

It appears that the heparin recall has not yet ended. Please be aware, and check this out. Wait, there's more--look here, too, for Baxter's information on their continued recall.

Spelt Bread Recall

Not able to write much these days.  A little here and there, but this is very important:

Here is another FDA recall.  This one is for humans, and is on Spelt Bread from the Food for Life Baking Co.  If you know anyone with celiac disease (patients, family, friends), please pass this on, as it may seriously affect their health.  

Yogurt

I just realized that I promised cooking here, and, well, there's none, so far.  So, for now, something simple.  Something I have been making A LOT of, lately... and we have loved it.  Home made yogurt.  It tastes so pure and clean.  So much better than store-bought, I think.  And very easy to make. 

You will quickly learn that I don't like to follow recipes much, I tend to change them often, and substitute what's in the 'fridge at the last minute.  So, when I originally read about this, it asked (I think) for whole or 2% milk.  All I had at the time was 1%, so that is what I used then, and pretty much have been using... although there was one time that, on a whim, I threw in a cup of cream...

you need:

1qt milk (whatever percentage is available)

2T yogurt starter or store bought yogurt  (Yogurt starter can be gotten at any health food store.  As for the store-bought yogurt, it should be plain yogurt--no flavors, not even vanilla.)

you do:

Place milk in saucepan and heat over low heat until bubbles form at edges and steam rises from the middle.  Do not allow to boil.  Transfer to large bowl.  Allow to cool to 110-115F on a cooking thermometer.  Don't have one?  Nor do I--just get it to a temperature where you can stand to keep your index finger in the milk for 20 seconds.  

Place the starter or yogurt in a small bowl, and add a few tablespoons of the warm milk.  Stir well, and return to the rest of the warm milk a small portion at a time, stirring well with each addition.  

Cover with a heavy towel and keep in a warm place at least 6 hours, or overnight.  My kitchen tends to be cold in the winter, so I preheat my oven to 200F, turn it off and place my mixture in the oven for the allotted time.  

Now, cover with plastic wrap, and place the yogurt in the 'fridge for at least 8 hours before serving.  I like a very thick yogurt, so I strain it through a cheesecloth in a fine sieve suspended in a bowl for another 6 hours or so.

Yes, it takes a long time--about a whole day, but it is not at all work-intensive.  And the reward is well worth it!!  Now, you can eat your yogurt as-is, mix with marmalades, fresh fruits and cinnamon, place in crepes (mine is VERY thick), the possibilities are endless.  

Eat well  :)

I guess there was another one...

he could use.  So, did ya hear about the woman who sat on her boyfriend's toilet for so long, she got stuck to it?  Even to a surgeon, it's a little nauseating.  

I tried to find the corresponding medical info, but I'm sure it was pretty straightforward--debride and resect, for now.  I would probably place a wound VAC, and finish off with a nice flap.  I doubt you have to do anything fancy like tissue expanders.  The skin here is pretty stretchy.  Then again, I am kind of assuming that, to get stuck, she probably has some to give in the first place.  

It really is mind boggling.  She was there FOR TWO YEARS!!  I suppose there was another toilet in the house, or he would have been more adamant about getting her out.  But can you imagine it?  Eating, sleeping, LIVING on a toilet for TWO YEARS?!  I guess she's not working... don't let me get started on that.  She's in her 30s, 'nuf said.  And the fact that he entertained the idea... "Come out, honey."  The reply?:  "No, not today, maybe tomorrow."  (Because I'm stuck, you moron...No, really, I'm STUCK!!  But it's OK, I'll just hang out here.  The shower curtain's kinda purty...)  Really, it's very sad.  Maybe that's why it's so nauseating.  two years...

Carpal Tunnel Syndrome

So, maybe now that a local newspaper has talked about it, my patients are more likely to believe me.  It still amazes me how many patients walk into my office and start the conversation with, "I have carpal tunnel syndrome, and I use the computer at work.  So, I need you to write a letter saying that this is work related."  

Some are more willing than others to listen.  Some initially get angry at me, "But my PCP told me..."  (My apologies to the PCPs that are well educated on the cause and effect relationships of CTS.)  The truth is that we still know very little about this syndrome.  We know that heredity is a big factor, as is hypothyroidism; we know that retired and disabled people are often just as likely to get it as anyone else.  We have recently found that people that are manual laborers--bakers, custodians, construction workers--are more likely to get it, and there are multitudes of computer programmers and the such that have no signs of carpal tunnel problems.  So no, just because you sit at a computer all day long does not mean that that is why you have carpal tunnel problems.

I spend MUCH time with each patient, explaining anatomy, pathology and their treatment options; trust me, they are thankful for that.  Unfortunately, there are still many physicians that are also poorly educated about this common problem.  I get so many referrals for "hand numbness" that is straight out of the text book, and it is obvious that the referring doc hasn't a clue.  These patients should stop by their friendly neurologist first for a baseline EMG, then come to me for treatment.  It's OK, we end up ushering them along, eventually, but sometimes they feel like a pinball--being pinged between different doctors.  

how 'bout patients like this?

Crazy day today, and not the worst I've had, by far, but... Seeing patients from 8-7:30 straight through, does not a happy surgeon make. 28 of them, to be exact, no breaks. And then the phone calls. Ugh. So, you finally get a chance to breathe... and reflect. 2 patients stand out. Although, my medical assistant is always amazed that I seem to have a knack for remembering everybody, and I do. There are some that just strike a chord.

Mrs.___, who came with her husband; she has DEBILITATING median and ulnar neuropathy--bilaterally, although it's worse in the right. I know I can get her better with surgery. Wanna know why she's refusing? Not because she's scared of surgery, or because her neighbor or church friend told her a friend of a friend's aunt's sister had a bad outcome... But because she thinks that if she gets better, her kids will start using her for their chores and babysitting again. She's convinced that that's why they want her better.  The fact that she is pleasantly confused, 70, and quite forgetful doesn't make things any better.  I wanted to put my arms around her and hug her, or maybe just cry. I couldn't decide, so I just looked at her and blinked. Her husband sat next to her and comforted her, "No, baby, that's not it, I'll help you. We want you better because we don't want you in pain..." And ya know, it's hard to say...

And then there are the ones that just, well, surprise you.  I did surgery (CTR) on a (retired) physician last week.  She called today, frantic, that her hand was swollen and she had a blue thumb.  OK, "please come right in."  Yup, the thumb was blue, alright, as in BLACK AND BLUE, and the hand WAS swollen, because she immediately affirmed that she had not been elevating it, as per my instructions.  I changed the splint, as I would have done, anyway, at her scheduled appointment on Friday.  Disposition:  please elevate the hand as instructed, and wait for the bruise to resolve, keep your appointment in 2 weeks.  

You can eat extra pineapple, if you like...

They just sometimes catch you off guard, is all.  And I have to say that working for 'the group' doesn't make things any easier.  If I was making my own hours, my own money, well, I think it would just make me happier.  All in good time, I suppose.

Cat Vitamins

I wasn't going to write any more right now, really.  But then, this came across my email:  "The Hartz Mountain Corporation Recalls Vitamin Care for Cats Because of Possible Health Risks."  Please check this out,  if there is a chance that your furry ones would be affected.  We have to help those who cannot help themselves.  

 http://www.fda.gov/oc/po/firmrecalls/hartz03_08.html

beginnings.

I have wanted to be a surgeon since I was knee-high to a tadpole.  When I was very small (maybe a year or two), my great uncle, from Australia, gave me a stuffed koala.  I still have it; it has a place on my vanity.  

I performed 'surgery' on it from the moment my parents allowed something remotely sharp in my chubby little hands.  There are slashes across the belly (I can hear the rant of one of my former attendings, "Horses have bellies, humans have abdomens!"  Well, Dr.___, this is a KOALA!!), and I had chopped off all of the claws (why?!).  I also had a doll (the chosen one), who came down with multiple imaginary ailments, of which I would repeatedly cure her.  My poor cats were also my experiments--don't worry, not surgically, of course, but--I would constantly check their noses to see if they were the proper temperature.  If they were the slightest bit warm, they were immediately subject to tea bag compresses and warm tea to drink.  The poor things were very tolerant, and I was smart enough, I suppose, to realize that a few sips of human tea to a cat, meant the world to me.  When I was in first grade, one of our teachers asked us to draw ourselves as 'What we would be when we grew up.'  There I was, by a patient's hospital bed, in scrubs, a white coat... I think I even had a mask on!  

Sure, I had little forays... I love to draw, so I seriously considered architecture.  I looked into schools.  But, the human body proved too fascinating to me.  One of my college professors suggested (much to the complete and utter horror of my parents) that I had "it" to be the next F.H. Netter.  An amazing compliment, to be sure, which left my parents speechless--literally, they wouldn't speak to me for days, nay, weeks.  I entertained a double major--BS in biology with a BA in fine arts, but settled on the aforementioned BS with a minor in fine arts/drawing... and, in the end, I found my way back to my original passion.  Medicine, in the true art form of caring for people, not just drawing them, and their ailments, and later:  surgery, in my true, and original calling.

(For those wondering, even with the above excerpts, it is much easier for me to care for humans than animals.  Humans can tell you (usually) more easily what's wrong... ditto for peds.  Note that I am NOT a pediatric surgeon.  Further, I have a hard time dealing with the parents of said patients.)

Less than 1 month to the boards...

and I decided to start a blog.  One of my oldest friends has always said that I don't know how to survive without pressure.  If it's not there, I create it.  That's not entirely true, but there are some things that I organize better when I have more to organize.  So, here we are.  

From perusing other's blogs, and looking at frequency of writings, I don't know if I'll be able to keep up... but I'll try.  Baby steps, at first, I suppose.  I guess I have to look around, see what all of these buttons mean.  That will take a little time.  Then, up, up, and away... or so I think.  

Oh, yes, and that private practice should be underway soon, as well... A few things on my plate.  :)  More to write about that way.  Well, I wanted to jot down SOMETHING here.  A little tidbit instead of an empty page.  

While I'm at it, was anyone else taken by surprise with the time change today?!?!  We did a quadruple take before one of us said, "Wait a minute, was there a time change?" while blinking at the time on the computer screen.  Someone stole an hour--terrible!