Tuesday, January 30, 2007

Katrina Story, Chapter 5: Witness to the Storm

Maryland may have been a border state in the Civil War (or rather, as some here call it, the "War Between the States"). Nevertheless, it wasn't close enough to Mississippi, which was where we needed to be. My wife called a friend in Atlanta to see if she had any contacts or ideas. Incredibly, she in turn had just been on the phone with a friend of hers in Birmingham who wanted to do something, anything to help after Katrina. This friend-of-a-friend, our soon-to-be-rescuer, wanted to host our whole family for as long as we needed. We were taken aback; they already were a family of 6, and they were willing to host a family of 5, complete with 2-month old baby, asking nothing in return?

Were they for real? After Katrina, across this great country, they and others just like them answered, again and again, a resounding YES.

We made preparations to leave on the weekend, not even 1 week after the storm had changed our lives. Our family and friends in Maryland surprised us with a bag of Target gift cards. At first I refused the accept the gift; others needed this more than we did. We had savings, we had insurance, we would be okay. My wife persuaded me to reluctantly take the bag, which was a smart move: the cards were spent within two weeks, just on basics, and toys for the kids. And the insurance would soon fail us, while the savings would dwindle down all too quickly. Even those who thought themselves well-off had to swallow pride and accept, if not even ask for help. A pediatrician I know has said that at first after a disaster, people will give and give even when it's not needed or appropriate; only later, when you start realizing what you need, the donations will dry up.

Before leaving Maryland, we finally heard the good news for which we had been praying: the family that had stayed in our house was alive and safe.

Days later, they told us their story. Through Sunday night, the wind howled and the rain came down. At times they heard a rattling and a whistling, sounding like a nearby freight train (the tracks ran a block from our house); this was no train, but rather the wind rushing through the attic. Sometime in the morning, the wind started to ease. Then one of their sons looked out the front window and saw the water coming in. Our front yard had flooded before, during severe rains, but now the water was surging in and steadily rising. The floor of the house was about 3 feet off the ground, and soon the water was coming up through the floorboards. They tried to keep Oscar the dog in his cage on a table in the living room, but he was having none of that, so they let him out, whereupon he made straight for the couch. But the water--thick, brackish, brown, carrying debris and who knows what from the sewer pipes--continued to rise, and now the couch was floating around the room, with Oscar riding it. The family climbed up onto the kitchen counters, not knowing how high the water would reach, and Oscar followed.

Finally, the surge peaked at 3 feet inside the house (or about 6 feet off the ground), before receding. A brown muck covered every surface below the water line. The teenage daughter insisted on keeping part of the front hall clean, and was meticulous--even militant--about removing dirt as it was tracked in. This sounded ridiculous at first--with all of this debris and muck, she's worrying about cleaning the floor?--but gradually began to make perfect sense: she was fighting to hold onto a few square feet of cleanliness, of normalcy.

Yet normalcy was a relative term. Power, telephones, cell phones, water, sewage were all gone. The rains were also gone, and would not return for days, but the Mississippi sun was bringing a fierce heat. The meager stockpiles of water we had collectively stored in the house were quickly used, and the father walked about 2 miles up to the main road to get more from the distribution center. Food was running out as well, the house was smelling oppressively of mold, the children were having nightmares, and it would be weeks before the situation would change substantially. Their own house was even less of an option: it had flooded to the ceiling and was now partially collapsed. (Perhaps it was another instance of fate that they had stayed in our house after all.) By Thursday, the family decided they had to try to leave. Their car had flooded out and now was ruined. Somehow they contacted a relative who lent them a rickety van, and they moved out to his place in Wiggins, about 45 minutes to the north-east, a town with relatively minor damage. Like we had done a few days ago, they were now pondering their next move; remarkably, they would soon end up near Birmingham as well.

As for Oscar, he was in the care of a neighbor 2 doors down, sharing digs with her two canine companions. He was also safe, and purportedly waiting patiently to be rescued. All told, though Katrina had brought death with destruction, no one we knew personally had perished.

Friday, January 26, 2007

Resistance: Fall of Man

Right after the stomach bug made its way through the household (as described in The Circle of Bleccccccch), my wife came down with lower abdominal pain, suspicious for a UTI.

(It's okay, I've received the necessary clearance to discuss this with you.)

So I brought home a urine dipstick from the office, confirmed (+) leukocytes, and wrote her a prescription for ciprofloxacin for 3 days.

Five days later, she was having back pain. Seems like the UTI bug fought the cipro and won, and was now moving on to the kidneys.

I consulted my Sanford Guide, wrote a new prescription for bigger, badder Levaquin x 7d, and soon enough, we were good again.

Last night, as the Levaquin started clearing her system, the back pain returned.

We called her OB-GYN, who recommended a repeat urinalysis, this time with culture, as well as a renal ultrasound.

(I suppose we could talk about the ethics of treating family members, but I think my treatment to this point was very standard-of-care. One of the unwritten perks of marrying a primary care physician is easy access to treatment and prescriptions, at least for (apparently) straightforward issues.)

The renal ultrasound was normal. (Levaquin: $25. Renal ultrasound: $694. Peace of mind: priceless.)

Meanwhile, the OB-GYN heard from her partner, who had been talking with a local urologist, who described the exact same thing in 3 other patients recently. UTIs that failed to respond to cipro, followed by Levaquin, finally cured with Augmentin.

The Sanford Guide notes "increasing resistance of E. coli to both TMP-SMX [aka Bactrim] & FQs [fluoroquinolones such as cipro and Levaquin] a concern." We should know in a couple of days exactly what the bug is, and its antibiotic sensitivities, but we are seeing the evolution of antibiotic resistance in almost real-time. The standard, first-line antibiotics are no longer working, and we have to resort to stronger and/or more unusual treatments.

In a similar manner, skin infections such as boils and abscesses used to be treated with Augmentin or first-generation cephalosporins such as Keflex or Duricef. The bug that commonly causes these infections is known as staphylococcus aureus, or staph aureus, or staph. Within the past 3-4 years a particularly hardy variety of staph has emerged, known as MRSA (methicillin-resistant staph aureus). It laughs at Augmentin. It eats Keflex for breakfast. Pediatricians are now being advised to use Bactrim as the new first-line therapy against MRSA, and there are only about 3 or 4 other antibiotics total that have any effect. In some parts of the country, about 20% of the staph is now MRSA. In other places, it is 50%.

I don't get a bacterial culture of every skin infection that I see. However, I can say this: in my area of South Mississippi, over the past two years, every single abscess culture has been MRSA. 100%. Without exception.

And people wonder why I am stingy with my antibiotics.

Wednesday, January 24, 2007


I really should have posted this yesterday, but I have my office staff as my witnesses. I gave 5:1 odds that Bush doesn't mention Katrina or New Orleans in his State of the Union address, and 10:1 that he doesn't mention the Mississippi Gulf Coast. And I was right on both counts.

I realize that this week I seem to have gone from "Just Practicing" to "The Katrina Blog." I promise I will get back to more medicine-related stuff soon. But you must realize that:
(1) For those of us here in the Katrina Disaster Zone, this is really all-encompassing. It affects truly every aspect of life here, every minute of the day, everywhere you go. I'll stop writing about Katrina when things are back to normal. That should be in about another 10 years or so.
(2)...Or it might be never. Katrina has been a life-changing event, not only for the residents here, but for our entire country. Disaster response and recovery has become a prime issue for people everywhere, but we obviously still have a lot to learn. In fact, even though citizens have taken many lessons to heart, I'm not sure our government has learned any lessons yet, and seems doomed to repeat them when (and not IF) the next disaster strikes.
(3) Don't ask us to "get over it." We haven't asked New Yorkers to "get over" 9/11. 9/11 changed America's entire mindset and priorities--as it should have. 9/11 was a man-made disaster with profound repercussions. Yet Katrina, a natural disaster affecting far many more people, has already faded into memory, as Bush's speech last night illustrates so well.
(4) Finally, things are not chugging along smoothly down here, despite what y'all might think. I'd refer you to this enlightening article at Gulf Coast News.

And besides, it's my blog, so I can write what I want. Ideally its focus is on the intersection between Katrina and health care, but it's going to veer back and forth at times. Hopefully, wherever it goes, it will continue to hold your interest. And I promise that there's lots more of Katrina Story to tell.

Tuesday, January 23, 2007

Katrina Story, Chapter 4: A Failure to Communicate

The very first news out of Bay St. Louis came Tuesday night, when the ticker at the bottom of the screen on CNN announced that Hancock Medical Center was asking all available personnel to report in.

Wednesday morning I tried calling the hospital, but phone lines were out of service, as they would be for the few weeks or more. The Mississippi Emergency Management Agency had no information, nor did the Mississippi Department of Health. I managed to eventually reach a regional commander for FEMA, who said he had heard the announcement. He gave me the main number to the hospital.

I told him that number was of no help. Perhaps he had a satellite phone number, or he could coordinate a special patch-through. No, he said, and his own satellite phone was given to someone else earlier today; he also had no communication to the coast.

In retrospect, this was probably the first sign of things to come. And so, for the time being, Hancock Medical Center would have to survive without me.

Other than the CNN news ticker, there was no news whatsoever from town, which was more than a little disconcerting. Where were the news crews? Was the devastation so profound that no one could make it through? But what about helicopter footage? Or was it that no one cared about lil' ol' Hancock County, when Gulfport/Biloxi was a more recognizable name, not to mention the emerging crisis in New Orleans around the levees and the Superdome? A most grisly thought occurred: perhaps there were bodies strewn everywhere and the footage would be too shocking.

Finally, on Wednesday night, Anderson Cooper was on the beach in Bay St. Louis. For the first time, we had a glimpse into the destruction. Survivors talked about a monstrous storm surge and hanging on to tree limbs to survive as their homes and storefronts washed away. Every modern convenience was gone--electricity, phones, water, sewer. The camera crew showed stragglers gathering at the remains of the Bay St. Louis bridge, where some had found a strange little zone of cell phone coverage. We wanted to both cry and cheer when Cooper, in his now famous broadcasts, asked Michael Brown and the country where FEMA was. Why were our citizens going without basic food and water? If Cooper could get a CNN satellite truck down onto the beach in Hancock County, why couldn't any government agency do the same? For that matter, if Cooper had a satellite hookup to the outside world, why were FEMA, MEMA, and the MS DoH seemingly unable to duplicate the feat?

We called the Red Cross to see if they had any word about the family that had stayed in our house. Again, no news, but they would try to alert the search and rescue teams. We searched online bulletin boards, but the postings were too numerous and unorganized. We tried not to dwell on nightmarish visions of the entire family of six drowning in our home.

My office nurse, who was in Bay St. Louis for the storm, has commented that in some ways, it was easier to be a survivor in town than an evacuee on the outside. She knew that she was alright, whereas her family had no idea what had happened; all they could do was wait, and worry.

Eventually, later in the week, we received the first precious gems of communication from friends. Our office billing manager was safe in Louisiana with her two kids, having evacuated beforehand. Her boyfriend was my friend the Waveland cop. Despite rumors that the entire police force had perished, she found out he (and the others) had indeed survived, and she was going to drive to Oklahoma to meet him at his father's place at the end of the week. Apparently the Waveland police department building flooded to the second floor, and the officers climbed out a window and survived only by holding on to a scraggly tree. (*) She also mentioned that her sister had stopped by my office and reported, miraculously, that the waiting room looked largely untouched. Meanwhile, our office nurse--who had also left for Louisiana--had returned to Gulfport but now couldn't get out, since there was no gasoline. Her apartment off the beach was entirely, completely gone.

As anxious as we had been to flee the coast to the safety of family, we were now agitating to return to assess the situation first-hand. As a doctor, I also wanted to go back to help my patients and lend my skills. I called the Red Cross to see if a local team might be going down soon, but the training session was still a week away. I thought about just finding my way down to the coast, but I started to worry about being stopped by the National Guard because I didn't have the right clearance. When I contacted the Mississippi Department of Health, they informed me they would soon be collecting names and credentials of doctors wanting to help, but this was more for out-of-state volunteers; as a local, they didn't know what to make of my situation, and could offer no advice. Clearly this was not a situation they had ever prepared for, they were making it up as they went, and it showed.

The more I though about how to get down to the coast, the more my wife became concerned. In a pivotal conversation, she said: you are not just a doctor. You are a father and husband. Right now, we need you more than the hospital does. We may have lost our home and belongings, but we are not going to risk losing each other.

And so, by the end of the week, a plan had emerged: we would find a "staging ground" closer to the coast, from which we could drive in and out (possibly even commute, if close enough) yet still be safe and surrounded by basic amenities.

(*) This incident is detailed in Douglas Brinkley's masterful book, The Great Deluge. I wouldn't be surprised if it makes it onto film or TV someday. Or you can read more here.

Monday, January 22, 2007

A small indignation

A parent called this morning asking to have her 7-year old daughter seen for a cough. My receptionist offered her 11:00am today, to which the parent replied, "well, I can't wait that long. I'll just take her to the ER."
The parent called back 10 minutes later asking for the 11:00am appointment.

In my office we do our best to get sick patients seen on the same day. We'll sometimes double-book or tell people to come in at 4:00pm--"You may have to wait, but you will be seen." Children who sound really sick are asked to come in right away and squeezed into the schedule.

I have no patience for parents that think a same-day appointment is unacceptable.

First, two hours might get you seen in the ED. If they're busy, it might not. So we get you in for an appointment before the ED--a walk-in facility--could even see you. (Aside from the fact that the most demanding parents tend to have children with relatively minor problems which don't even warrant being seen in an ED.)
Second, try this with any other specialty. Call up your internist and ask for an appointment today. I'd suggest you could use a stopwatch to see how long they laugh before they compose themselves and ask you, "are you serious? Our first available appointment is in 1 week."
Third, try this with any other profession. Call up your auto mechanic. I dare you to throw a hissy fit if they can't squeeze in your timing-belt replacement in the next 2 hours. See if your hairdresser will bend over backwards to get you in for a perm in the next 20 minutes.

I understand we are dealing with sick children, and anxious parents. But we pediatricians seem to get the least respect and the most outlandish demands, for reasons that tend to have little to do with the acuity of illness and more with the convenience of parents. ("I can't make it at 3pm, I have an appointment. If you can't accomodate me at the time I want, I'll just find someone else who can.")

One of these days, in a world without HIPAA privacy regulations, I'm tempted to ask one of these demanding parents: here is a list of the patients already scheduled this morning. You're welcome to call them, ask if they would give up their spot for you, and call us back when you find someone willing to do that.

There's no upbeat ending or silver lining to this post, just something I had to gripe about.

Friday, January 19, 2007

Katrina Story, Chapter 3: On the Road

(With apologies to Jack Kerouac)
Sunday afternoon: the van and family are headed east to Florida as Katrina starts making its presence felt. Our policeman friend tells us that I-10 is already at a crawl, so we take Highway 90 along the beach. A quick lesson in the geography of the Mississippi coast: if you drive from west to east, you will go through Waveland, Bay St. Louis, Pass Christian, Long Beach, Gulfport, Biloxi, Ocean Springs, and Pascagoula, before crossing into Alabama and the outskirts of Mobile. We make good progress from Waveland to Ocean Springs until traffic on Highway 90 also slows to 5 mph. By 4:30--2 hours after leaving--we're only in Pascagoula, a long way from Florida. At this rate we will be riding out the storm in our car.

In the parking lot of a freshly boarded shopping center, we consider options, and decide to change our destination to Maryland, where our family is. My wife's uncle will host us when we arrive in a couple of days. My wife grabs the atlas and starts plotting side roads going north and east.

As we travel down country backroads, we're accompanied by many other drivers with the same idea. We pass through small Mississippi towns that probably have never seen this much traffic since...well, ever. At a particularly confusing intersection, we even pass by one of my patients.

The hour gets late, the boys are tired, and we finally reconnect with the interstate north of Mobile. L. tries calling every hotel in Montgomery (how did people manage before cell phones?) and finally reaches one with a vacant room. We arrive well past the boys' bedtimes and collapse into fitful but welcome sleep.

At roughly 6:30am my pager goes off. The security service on my office is notifying me that the office alarm was tripped and the police have been called to investigate. This has happened a few times before, so I'm not very concerned (though I do wonder a little if an audacious looter has taken advantage of the situation). Then I realize: the power is still on in Waveland. Communications are still working. Our town must have made it through the night okay.

(We later surmise that the power failed shortly after that page.)

So once again we turn on The Weather Channel, just in time to see Katrina over the southeastern Louisiana coast. The eye will soon cross the outlet of the Mississippi and make a repeat landfall somewhere near the Louisiana-Mississippi border. But after that, it will continue north-northeast, and Montgomery is too close for comfort--and we have many miles to go before Maryland. On the tv, reporters are in New Orleans showing footage of an empty French Quarter, and Jim Cantore is in Biloxi with strong winds coming off the beach, but on the whole, it looks like typical hurricane footage everyone's seen before. Winds thrashing palm trees, trash cans blowing by, driving rain; the worst is yet to come, we're concerned, but so far, so good. Anyway, gotta keep moving.

We leave Montgomery at 9:30 am, putting the portable DVD player to good use. The endless stream of Barney and Wiggles satisfies the boys--the things parents endure for the good of their children. As a respite from the kid stuff we listen to the radio up front, trying to catch some news from Waveland.

Gradually over the course of the day, the mood starts to change. Whether from the frantic evacuation, the stress of travel with small children, the single-minded goal of reaching Maryland, the lack of any communication from home, or the unfolding realization that what was happening on the Gulf Coast was becoming an event of unprecedented national and historical importance--and that our town was Ground Zero--we start to become less complacent, more concerned and agitated. We make it as far as North Carolina (it may have been Kannapolis, just past Charlotte--it's hard to remember now), settle in another hotel, but this one appears to be a temporary home to a lot of college students (maybe a local football game?). I remember thinking an irrational disgust that they could just carry on with the usual smoking, drinking, conversation, and laughter when our lives were now permanently disrupted. I almost wanted the hotel to be somber and respectful on this day of national significance, much like on 9/11. But the college kids were having none of it, with some of them throwing bemused looks at us, as if to say, "what's up with you?" Of course, it may have also been just my self-centered imagination, since I was unable to concentrate on anything beyond my immediate family and possessions in our minivan. It wasn't a completely unreasonable mindset, since this might be all that I had left in the world.

The next day, Tuesday August 30, we finally reach Maryland, spending the first night at my wife's father's house (we would go to her uncle's the next day). We were safe, with family. Now we could start to take stock of our situation and figure out: what next?

Score: NY Times 3, Katrina Recovery 0

The NY Times scored a trifecta blast this week against the administration's so-called recovery and rebuilding since Katrina.

First, on Wednesday Jan. 17, in the Business section: a column discussing "What $1.2 Trillion Can Buy." The $1.2 trillion in question being, of course, the cost of the war in Iraq--so far, with more expenditures undoubtedly planned. (Actually, as the article explains, direct appropriations have been a mere $700 billion, with indirect costs making up the rest--the author, David Leonhardt, arrives at the $1.2 trillion as "the actual money that Americans would have been able to spend in the absence of a war.") Congress has spent a total of $100 billion on Hurricane Katrina. Even if you account for spectacular amounts of diversion, fraud, and waste (as has been the case ever since August 29), just think what even another $100 billion could do to finally get this recovery moving. There is a snide but apropos bumper sticker making the rounds here: it says, simply enough, "SCREW IRAQ, REBUILD THE GULF COAST."

Second is today's lead Editorial entitled, "Nowhere to Turn for Shelter." In a dead-on analysis, the Times holds the Bush administration to task for the shameful inaction on housing on the Gulf Coast. To quote: "...The response to the drowning of New Orleans has been a failure on every level...There has been no concrete action plan for reconstruction--only a patchwork of programs marked by dithering, bickering and bureaucratic finger-pointing throughout. The federal response was, after great delay, largely to cut a check and let overmatched local officials try to sort it out...The time is long past to turn from planning to action. And those in need of shelter today cannot take comfort in housing that won't be ready for another two years...That New Orleans remains a shattered city is a sad monument to impotence for the most powerful country in the world. Our grand plans were never laid, our brightest minds were never assembled, our nation's muscle and ingenuity were never brought to bear in any concerted way to overcome the crisis of the Gulf." (my italics)

Lastly is a Letter to the Editor also published today, strikingly forceful in its poetic elegance in tying together the above two thoughts. The letter reads, in its entirety:
Sometimes, I go to sleep and dream that I live in another America. One where we sent 140,000 able-bodied men and women, and one trillion dollars--to rebuild New Orleans.

Thursday, January 18, 2007

A doctor watches American Idol

I've been trading posts with Dr. Mary Johnson about American Idol, and I confess it's one of my guilty pleasures. Actually, once the season gets going it's not so guilty, since it is a showcase for some genuine talent and great performances (not in the PBS vein), and it's fairly family-friendly too. But the early "audition round" shows have been more of a freaks-and-geeks spectacle, bordering on mean-spirited. Last night's show in Seattle was fairly over-the-top even by Idol standards, and host Ryan Seacrest remarked as much. Unfortunately, it also offered a chance for my inner evil doctor--um, Dr. Evil?--to emerge and make off-the-cuff assessments.
That very tall woman, 6'4" (6'7" in heels), with a really nice voice...disqualified from the Air Force due to a heart condition...long spindly fingers...almost certainly Marfan's.
The guy at the end..."Big Red"...odd affect and speech...schizotypal personality disorder?
The dark-haired guy with delusions of N'Sync grandeur, who Simon thought looked like a lemur...well, ya got me there.

Oh, great. Now I feel doubly guilty about watching the show.

Tuesday, January 16, 2007

Katrina Story, Chapter 2: Preparations

By the morning of Saturday, August 27, it was becoming clear that Waveland, Mississippi would have a hard time avoiding being hit by Hurricane Katrina. The predictions still carried a lot of unknowns: the exact where and when of landfall, windspeed and hurricane strength, lowest central pressure. At the local hospital, the administration asked doctors to discharge patients and get out of town in anticipation of closing the facility. I had one newborn in the nursery; I asked the parents, where will you go? The mother worked for the city of Picayune, about an hour north-west; she planned to take the baby to the city's command bunker. Normally I don't advocate exposing newborns to large groups of people in cramped, confined spaces, but I figured the baby would be as safe there as any place.

Sunday morning, my wife and I woke at 7am; she went to the computer, I went to the TV. Latest storm track and forecast revealed Katrina was now a full Category Five, on a near-perfect track for Waveland by tomorrow morning. Meanwhile, the satellite picture on The Weather Channel showed a massive cyclone filling nearly the whole of the Gulf of Mexico.

It was time to leave.

For those fortunate enough never to have evacuated for a hurricane, it is not an easy process. It takes planning, effort, and a lot of time--even more when you have a dog and 3 small children (our youngest was now all of 2 months old). We called family and let them know our plans (go east to Florida, vacation for a few days, then come back). Then we dragged out the suitcases and starting packing clothes, toiletries, and diapers, enough to last for about 6 days. We filled shopping bags with food and drink for the road. I grabbed the essential electronics: cell phones, chargers, portable DVD player, all of the kid's DVDs and CDs. My wife packed away toys, books, blankets, and pillows, and photo albums while I organized the essential documents: birth certificates, passports, insurance papers, medical credentials, copies of diplomas and licenses.

Then I went to my office.

My practice uses an electronic medical record. All patient information is stored on a server in the office, my receptionist and biller each use a desktop computer, and my nurse and I go room-to-room with tablet PCs. We are the medical practice of the 21st century, a paperless office.

Normally the tablet PC needs to be on the office network to access the patient data. But the computer program we use has a very special feature, one I had used just a few times prior. The tablet can be placed into "disconnected mode," where the data is downloaded onto the tablet itself. The tablet then becomes the computer system for the practice, until it's later re-synchronized with the server.

I set the tablet into the disconnected mode, grabbed a backup data tape from the server, disconnected the computers, placed them up on desks, and packed up some practice essentials: stethoscope, pocket reference, otoscope and ophthalmoscope. Time was running out, and I left most of the rest; if the office flooded, the majority of equipment was off the ground and should be safe. If the roof caved in or blew off, everything would be lost anyway. Leaving my practice to fate, I headed back home.

Our friendly neighborhood handyman was screwing plywood over the windows, making the house very dark, if more secure. Meanwhile, a change in plans had occurred regarding our dog, Oscar. We had every intention of taking him with us--until a family with which we were close decided, against all attempts at persuasion, to stay through the coming storm. If the family was that determined to ride out the hurricane, we convinced them to at least stay in our house, which was on higher ground (and, due to its older age, probably more solid) than theirs. They in turn volunteered to care for Oscar and keep him safe until we returned.

It was to be a fateful set of decisions on everyone's part.

The van was completely packed, it was now 2:30pm, and the skies were turning grey. Just before leaving, a good friend stopped by. He was a part-time officer for the Waveland police department, and he was required to be on-duty for Katrina. He assured us he would check on our house--and our family-friends--while we were gone. And so we drove out to Highway 90 and started east.
About a half-hour later, we pulled to the side of the road off the beach in Gulfport, to allow my wife to nurse the baby. I stepped out of the van and was pelted with rain blowing sideways as the wind whipped around. From the satellite pictures I had checked just before we left, I knew these were the first outer bands, even though landfall was still projected to be 18 hours away.

This was going to be a monster of a storm.

Monday, January 15, 2007

Expect the unexpected

Remember the girl with Hepatitis A?
It's not Hepatitis A.

She seems to be getting steadily better, but after consultation with 2 specialists, and many tests, we still don't have a definite diagnosis. It's probably a viral hepatitis, just from an "unknown" virus. So the treatment and course remain the same, though the community as a whole gets spared.

This is what medicine is often about. This is why I like House, M.D.
No, I don't know why House and his lackeys do all the procedures themselves. And no, I don' t know if those lackeys are residents, fellows, or just visiting professors. But at least the writers get the process of medicine right. Problem leads to hypothesis leads to testing and/or treatment. Evaluate results. Rework hypothesis, start over again.
Granted, on the TV show, the patients usually have an inexorable decline towards death, with numerous evolving complications; patients don't just spontaneously start getting better again. But that's what makes it a television drama. It wouldn't be satisfying TV to end an episode with the docs escorting the patient out the door, followed by just sitting around with no good answer as to what just happened in the last 58 minutes, taking consolation in the fact that at least the patient is better.

Despite what patients may think, medicine is often without satisfying, definite answers. Learning to deal with that uncertainty is part of the art of medicine.

I also like House because the characters are compelling and very well-acted, and I have fun trying to guess the diagnosis. But I won't get to watch it for three weeks: American Idol starts tomorrow night!

Saturday, January 13, 2007

Oh Will The Saints Go Marching In

Normally I'm not a big supporter of professional athletics. I just don't care for immature, self-important boys being paid millions of dollars to go play games--nor the attendant revolving of the universe that follows around them. I'm not saying professional sports don't have some benefits; they can inspire children to exercise, even pursue dreams, and the true "good-guy" athletes can accomplish great things (raise money for foundations, create awareness of issues, even--*gasp*--be credible role models--as a native Baltimorean/Baltimoron I'm thinking of Cal Ripken, Jr as a shining example). A team can also create a groundswell of civic pride, particularly when they reach the playoffs. The New Orleans Saints have never been a powerhouse team; in fact, they've only won one playoff game in their entire history. Yet, somehow, this season has been one of their best ever, and they are now even contenders. So, in light of the suffering of our brothers and sisters in the Crescent City, it would be a Great Thing if this was finally the Saints' year to shine. Playoff game is tonight against the Philadelphia Eagles, 8pm EST/7pm CST, on Fox. Maybe I'll even watch.


Thursday, January 11, 2007

Katrina Story, Chapter 1: Prologue

By popular request, I will tell my Katrina story. At one point I thought about writing a book about the whole damn thing, but I figure by the time I did that, the whole world will have had enough about Katrina and won't want to hear anymore. Maybe that's not quite true, since some of you out there still have interest. I expect this to be rather long, but a journey of a thousand words starts with a single step, or something like that. So, without further ado, here we go...

There's a morbid joke on the Mississippi Gulf Coast that Hurricane Camille killed more people in 2005 than it did in 1969.

When Camille plowed through the Gulf Coast in August 1969, everyone thought they had witnessed just about the worst fury that Mother Nature could throw. Camille made landfall as a deadly Category Five, one of only three to strike the United States in the last 155 years. Top winds reached over 190 mph, and some have estimated gusts as high as 210 mph. The NOAA ranked Camille as the second most intense US storm on record, the top prize going to an unnamed monster commonly called the "Labor Day Hurricane" that hit the Florida Keys in 1935.

Camille defined a generation on the Coast. People remember the apartment complex in Pass Christian, MS, where people supposedly partied through the storm until they drowned. Others recall the complete devastation afterwards, with entire city blocks leveled. Many Civil War era mansions in Pass Christian and Long Beach miraculously survived, a testament to their solid construction. What was destroyed was eventually rebuilt, and by the 1990s, the Coast underwent a commercial boom, thanks in large part to the new and opulent casinos such as the Beau Rivage and the Grand. Gulfport and Biloxi had gone from sleepy backwater beach towns to tourist destinations.

Further east, the towns of Bay St. Louis and Waveland were doing well enough for themselves, if not quite as popular as the larger cities to their west. According to the 2000 census, Waveland had nearly 6700 residents, with another 8200 in Bay St. Louis. Casino Magic brought jobs, revenue, and famous jazz clarinet player Pete Fountain to the county. NASA's Stennis Space Center complex, site of rocket engine development and testing ever since the Saturn V took America to the moon, also hosted aerospace corporations and military and government agencies. New Orleans residents tired of the bustle of the city retired to Waveland, one of the last beachfront communities in the country where even ordinary Joes could own beachfront property. The surrounding Hancock County, Mississippi was one of the fastest-growing counties in the state.

Thanks to that growth, the area needed another pediatrician. My family and I travelled to Bay St. Louis in October 2003 and immediately fell in love with the area. We moved down January 1, 2004 and opened my pediatric practice about 6 weeks later.

Living anywhere on the Gulf or Atlantic Coasts--from the southern tip of Texas, around to Key West, up to the rocky beaches of New England--means hurricanes are always a possibility from June to November. In mid-September 2004, Hurricane Ivan was approaching the Mississippi and Alabama coasts, with Waveland and Bay St. Louis on the western edge of the National Hurricane Center's predicted landfall. We decided it best to leave town; however, not having friends or family anywhere nearby, we drove west until we found a vacant hotel room. Unfortunately, much of New Orleans also had the same plan.

We drove 17 hours to Dallas, Texas. Me, my wife, our 2 boys, and 2 dogs were exhausted, but we were safe. My wife wanted to make the trip a mini-vacation, but I was anxious to return to our home and my work. And when we did return, we found 2 large tree limbs down in our yard. The house was untouched, our town was largely untouched, and life had continued uninterrupted. Ivan had made a last-minute turn to the east, which was very unfortunate for eastern Alabama and Pensacola, FL, but it meant only a tropical storm in Hancock County, MS.

And so, on Friday August 26, 2005, when the National Hurricane Center was showing a large hurricane crossing Florida and entering the Gulf of Mexico, we felt little urgency. We knew that it was still too early to make an accurate landfall prediction, and besides: even if it did hit our town, the area had already weathered one of the worst storms in recorded history. Our neighbor, an Emergency Room physician who endured Betsy in New Orleans in 1965, and then Camille in Waveland, offered this prognosis: "I probably wouldn't stay through the storm, but I think we'll be okay."

To be continued...

Monday, January 8, 2007

The Circle of Bleccccch

The stomach bug that B and J had last week made its way through me (Friday night/Saturday), then my wife (Saturday night/Sunday). E has been fighting it on and off all week but yesterday Mr. Mom (uh, that would be me) didn't hydrate him enough during the day and he became worse; so Dr. & Mrs. Scott both stayed up all night pushing Pedialyte through a medicine syringe. True oral rehydration therapy in action, and it saved us from a trip to the ER for an IV. But now I'm at home trying to catch up on sleep before I see patients.

Well, not at this very instant. Though I would love to be able to blog in my sleep. It would be a great way to get all these thoughts out of my head.

In the meantime, thank you all for welcoming me to the blogosphere, and I hope not to disappoint. Too much.

Friday, January 5, 2007

Doo, doo, doo, looking out my back door

Looking out my back door, I see:
  • 3 occupied houses
  • 8 empty property slabs
  • 1 abandoned, empty house
  • 1 house under construction
  • 5 FEMA trailers
  • 1 abandoned car, and
  • 1 empty lot
The empty lot is right in back of our house, and it has become a small swamp after all these rains. "Swamp" meaning about 3 inches of standing water with nowhere to go except into the southwest corner of our backyard.

The view hasn't changed much in the past 6 months we've been in this house, other than the house under construction.
This is what it means to live in Katrina-land. Everywhere you go is a constant reminder of the destruction and loss.
This is not a healthy way to live, or to raise children.

Thursday, January 4, 2007

Thank you!

A hearty thanks to Flea for his shout-out today welcoming me to the blogosphere. Lately he's been running a great series on vaccine-preventable diseases. And he's also nominated for the 2006 Medical Weblog Awards (I've yet to check out all of the nominees, but I can assure you he's in good company). Of course, you probably already knew this since there is a good chance you came across my blog via his.
Speaking of vaccine-preventable diseases, yesterday I saw a child with what is most likely Hepatitis A. If it is, that's good, because it's a self-limited virus that just runs its course--for her. Her family and preschool face a different situation, with vaccine and immune globulin shots all around.
HepA is widespread in the west and southwest, but relatively rare here. In fact, I think this is the first case I've seen in seven years. I talked to a Pedi Gastroenterologist in New Orleans who confirmed he hasn't seen much either.
Just last year the immunization schedule was updated, recommending Hepatitis A shots for all kids 12-24 months. Prior to that, it had been just for children in high-risk areas. This is one of those indirect vaccination strategies, since infants and toddlers usually don't get sick or have severe symptoms, but the older kids and adults are the ones that end up suffering (and even face a risk of fulminant liver failure). The toddlers share and spread the disease, so you vaccinate them to protect the older folks. I can't comment on the public health costs and benefits of universal vaccination in term of dollars and cents, but I think it's fair to say that this one case is probably going to cause a lot of worry and work for a lot of people around here.

Wednesday, January 3, 2007

A medical practice is/is not a small business

I love practicing medicine, which is good, because it's how I pay the bills. My patients often seem to forget that I charge for my services because I need to make a living, but I also need to pay my staff, pay for vaccines, pay for rent and utilities and office supplies and table paper and toilet paper and malpractice insurance and other insurance and what not. Just like any other small business, right? Post-Katrina, FEMA and the SBA have said so. Medical practices received no special treatment. So I try and pursue grants, loans, and other assistance to rebuild my practice. But my revenue is solely and entirely dependent on me seeing patients. So if I'm out of the office (say, for a meeting), I'm not making money.
That's not special, you say. Same as any other professional in a service field--lawyers, plumbers, electricians.
Yes, but an electrician sets his rate, gives you a bill, and you pay.
In healthcare, the insurer sets the reimbursement and pays what they feel is appropriate. This is like walking into Circuit City, seeing a TV for $1000, and saying, "no, I'll give you $700 for it. Thanks!" In theory, the insurer gets to take a cut off the doctor's standard prices in exchange for steering patients to the provider, enabling prompt and worry-free payment. In practice, it's done this way because doctors usually have no choice.
So unlike any other business in town after Katrina, I cannot increase my revenue by increasing charges, because it won't make any difference. I can charge Medicaid $65 for an office visit, or $650, and they still pay me $50.48. But I still have to pay an extra $2 for my $6 roast beef po' boy (mmm...roast beef po' boy). I still have to pay when Merck raises prices on its vaccines. In short, trapped. The only way to make more money is to see more patients.

And there's the final catch: there was an initial surge in population here after Katrina as everyone started coming back, and the contractors and workers started flooding into town. But now the population growth has slowed. Why? Housing. Here in Waveland MS about 90% of the houses were damaged or destroyed. As a result, people aren't coming to the area because there's no place to live. Few houses are on the market; the houses that are, are overpriced (simple market economics, supply and demand), squeezing out poorer working-class families. You can buy an overpriced empty lot, but you'll have to wait about 6-12 months before you can hire a contractor to even start construction.
So the doctors can't raise fees, can't see more patients, still have to pay the bills, and--oh yeah--try to recover all of the losses and expenses related from the storm and the loss of practice. (I'll try to post on that at a later date.)

Why does all this matter? So if I can't make it, shouldn't I just leave town?
First is the personal, community aspect. I feel a commitment to my patients. I want to be there for them when I'm most needed, and see them (and me) through this recovery.
Second: well, doctors are all rich anyway. Shouldn't I just sell off one of my 3 Lamborghinis, or my vacation home in the Bahamas? Actually, pediatricians are generally not rich. Most middle class 2-income families earn what I make--without the associated student loans, and with a good many years headstart on saving for retirement. I realize I'm doing better than many others, but I certainly don't have the resources to weather this for much longer. As is, I've taken out a $40,000 home equity loan and $60,000 SBA loan to cover post-storm and restarting expenses. That's $100,000 in new debt. OUCH. At least the SBA loan can be paid back over 30 years--just like my Stafford loan from med school.
Third, and most importantly, if I leave, who will see my patients? This is not a rhetorical question. There are two other pediatricians in town (one is now employed by the local hospital, the other works for a community health center). They could probably cover things, and patients could also see other pediatricians further away. But then what? A town without good medical care won't be very enticing to new families, or new businesses. And the recovery stalls out and the community never rebuilds.
Is that okay for little old Waveland, MS? How about New Orleans, LA? How about the next city hit by a major disaster?
I'm not even bringing in the moral arguments, that health care is a necessary community service and should be maintained for the good of the community. Or that doctors such as me are being not rewarded, but penalized, for staying on after Katrina. (Every week I get a flier for "Lucrative position! Starting income $200,000!" or something similar. Yet I'm still here????) Just on an economic basis, physicians face inherent difficulties unique to healthcare. We can't respond like other businesses can, yet we're expected to anyway. No special treatment, despite special circumstances.
So what to do? More to come.

You know, that Elvis dude

B and J are at the breakfast table the other day.
B starts humming a song.
B: "Do you know that song, J?"
J: "Um, no. What is it?"
B: "It was on American Idol last year."
J: "Oh, yeah, I know that song."
B: "Yeah, it was sung by Taylor Hicks. Except he didn't write it. It was a song by some guy named Elvis."