Forbidden Medical Abbreviations

Social drinkers, problem drinkers, and high-functioning alcoholics

I know nothing about anything other than AA.  And I know next to nothing about AA.  So psychiatrists, doctors, med students with a clue, people who have ever had a drink in their lives, whoever – please explain.

Yesterday I finished reading Drinking: A Love Story.  The author said that reading A Drinking Life by Pete Hamill was a major factor in her sobriety, so I bought and read that book last night.

I just finished the last chapter, and am sitting in bed with the cat, thinking about it.

Both authors talk about how muddled the line is between a “problem drinker” and an “alcoholic” – and both had convinced themselves that because they were achieving and maintaining successful careers, they couldn’t possibly be the latter – even though they knew they drank more than most people.

Both authors define themselves as “high-functioning alcoholics” and admit it’s a troubling category.

I agree, it’s troubling.  The DSM doesn’t currently recognize “alcoholism” as being a thing – just Alcohol Dependence and Alcohol Abuse, which is – to put it mildly – completely confusing.  Alcoholism itself doesn’t fit neatly into either category.

But alcoholism, at least, can be shoved into one of those umbrellas – as long as you acknowledge that the patient has genuine social or work problems as a result of their alcohol abuse.

But high-functioning alcoholics don’t.  So what do you call that?  They’re still dependent on the alcohol, and that’s still extraordinarily dangerous.

So how do you draw the line between being a social drinker, a problem drinker, and a high-functioning alcoholic?  

Here’s why I think that’s an important question, and not just a word game:  All of the psychiatrists I’ve talked to about this have said that recovery doesn’t necessarily mean abstinence. Abstinence isn’t even included in the new SAMHSA definition of recovery.

I’m guessing that has more to do with methadone treatment for heroin addiction than it has to do with alcoholics eventually drinking moderately – but the possibility is there.  Moderation Management seems to have been accepted as a legitimate form of cognitive-behavioral therapy, albeit one that doesn’t seem to work in the most severe alcohol abusers.

Is alcoholism so ingrained in genetics and environment that an alcoholic should never have had their 1st drink to begin with?  Or is there a straight line of progression in alcoholism, from “social drinker” to “problem drinker”?  Is “high-functioning alcoholic” a step along the way, or an end-point alternative to true alcoholism for some people?

And if it is a straight line of progression, is it possible to intervene with a Moderation strategy before they hit the alcoholic state?

If so, shouldn’t this be the sort of thing we’re billing to problem drinkers?  ”If you keep on the way you are, you may have to go into AA and never drink again.  Sound scary as hell?  Maybe you should learn strategies to cut back now to avoid it, then.  Here’s a pamphlet, here’s a website, here’s a Moderation hotline.”

Seems like it’d be easier to get someone to agree to that then to agree to abstinence.  But would that just inevitably be a speed bump on their way to complete abstinence or death?

The founder of Moderation Management ended up joining AA, relapsing, and killing two people in a drunk driving accident.

Where’s the line, and – in light of the above example – is it worth finding?

Why are Heberden and Bouchard’s nodes named after 2 different people?

(In osteoarthritis, enlarged DIP joints (knuckles closest to the end of your fingers) are called “Heberden’s nodes” and enlarged PIP joints (knuckles you use to knock on doors) are called “Bouchard’s nodes”.  And yes, I really am going to complain about it.)

Medicine is moving away from most eponyms, since they’re generally undeserved and were also inevitably given to some sketchy doctors who didn’t deserve to be immortalized (case in point: Wegener’s granulomatosis.  He was, it turns out, a nazi.

So that led to a 50-year-long awkward moment in medicine.  A moment which has only been extended by trying to rename the disease “granulomatosis with polyangiitis”).

To be fair, some people will try to tell you that, actually, medicine is moving away from eponyms because they’re “so difficult to memorize” – a viewpoint that’s, at best, pretty damned optimistic.  (Fun game:  Go find a physician, resident, or M4 and ask if they think organic chemistry was helpful.  Then, after they finish laughing, ask them if they’d be in favor of dropping it as a pre-med requirement.

… Yeah.  Spoiler alert: they’re not for it.  Neither am I. “Medical education” is practically synonymous with “Sure, some of it’s inefficient, but if my generation had to do it anyway, so do you.”   People who say that “medicine eats its young” aren’t kidding.)

Heberden’s and Bouchard’s nodes seem even sillier than most other eponyms.  Getting credit for seeing some weird manifestation of a disease, I understand.  Getting credit for some weird “you can only see this part of the anatomy if you cut a person open and squint at them sideways” piece of organ anatomy, I understand.

But getting credit for the fancy notion that sometimes when your knuckles are inflamed, they’re enlarged?  That’s ridiculous.  You may as well call a sore throat “Heberden’s throat”.  In either case, regardless of how fancy the pathogenesis is, I’m pretty sure people already knew the symptom was directly related to the disease.

So I looked it up.  Heberden was a fancy London physician from a good family, who wrote a chapter on arthritis in the medical book that was most in vogue at the time.  So they gave him the DIP-joint-is-inflamed eponym.  Okay, fine.

But nearly one hundred years later, the PIP -joint-is-inflamed symptom was – it appears – randomly assigned “Bouchard” as an eponym.  Bouchard was a French pathologist who studied under Charcot and doubtless did a lot of interesting things, but none of them seem to be related to arthritis.  I guess medicine felt like he was such a stand-up guy he deserved an orphan eponym?

If that’s a legitimate action to take when confronted with an awesome pathologist and an unnamed disease, Wegener’s Granulomatosis should just be renamed Goljan’s Granulomatosis.  TWO BIRDS. ONE STONE.

Goljan is a champion arm-wrestler. Hand over the eponym and no one gets hurt.

Bouchard’s nodes are less common than Heberden’s nodes, so maybe we should give Heberden a pass on not noticing that the swelling sometimes happened on the PIP joints. But I’m honestly not convinced that Heberden didn’t notice the “Bouchard’s nodes”.

You know what I think?  I think he was just like, “meh, it’s exactly the same thing in a location just centimeters away, no need to write about these nodes like they’re any different.  It’s not like they’re going to give it someone else’s name.”

Well, the joke’s on you, Heberden.

Joke’s on you.

The Science of Babies

Tonight’s Netflix suggestion:  ”The Science of Babies”!

6:50pm:  Fantastic. I had no idea this existed. With a title like “The Science of Babies”, I expect a 3 year neonatalogy fellowship condensed down to 30 minutes. Do not disappoint me, Netflix.

6:51  WILL SOMEONE PLEASE PICK UP THIS POOR CHILD.

"Babies: They come into this world alone."

6:55:  … No?  No one?  We’re still narrating things over a lonely baby?

Correction!  A lonely, CRYING baby.

7:00:  ”A human will likely take over 6 million breaths in a lifetime.  But the first is by far the most difficult – AND DANGEROUS.”  Shit is getting real.

7:05:  ”Two thirds of baby deaths occur in the first month – a rate not equaled again until the 7th decade of life.”  Poor babies!

7:07:  ”A newborn’s vision is cloudy, and therefore limited to about 12 inches.”  POOR BABIES.

7:10:  ”Babies know intuitively to hold their breath under water.”  Poor ba- wait, what?

And then there was a bunch of stuff about neurons and synaptogenesis and synaptic pruning, which is all well and good, except facebook.  (Don’t worry, I periodically checked back into the Netflix tab to see if anyone ever picked up the crying theater baby.)

7:30:  (They didn’t.)

I don’t think I got a neonatology fellowship out of this, so in that sense, the documentary was a disappointment.  However, a counterpoint:

Vowels!

… I think the counterpoint wins.

Anatomy: Take Two

After college anatomy, med school anatomy, and several patients with knee problems, I have finally sat down and learned my knee anatomy – but only because I knew I’d have to teach it to the first years tonight.

And in retrospect, I don’t know what was so damned hard about it.

It’s like doing your laundry.  You put it off for weeks, thinking it’s “too much work”, and then you do it and you’re like, “Oh, wait, no – I’m just lazy.”  (… No?  Just me?)

I suspect it seemed too hard because 1) all the initials make it seem like there’s more ligaments than there really are, 2) no one ever shows any simplified diagrams before jumping right to the 100% anatomically accurate stuff and 3) people teaching the knee tend to forget how confusing it looks at first.

Professor:  Just like the ACL, MCL, and LCL – the action of the PCL obviously makes sense.  Any questions?
Me:  Yes.  But only about the stuff that “obviously makes sense”… because I’m an idiot.

But to be fair, I used to teach MCAT classes and I did the exact same thing.  That’s just what happens when you have to cover 3.5 hours of material in 3 hours – you inevitably assume you know which parts are easy for your students, and if you get it wrong, you feel like a total jerk.

Me:  Look at how clear that passage was, especially when there’s so many difficult ones on the test!  This is exactly why you NEED to triage the verbal section.
Students: … *panicked expressions*
Me:  <– in all of test-taking history, never once actually “triaged” a verbal section.
Me:  <– what a jerk.

While we’re on the subject of anatomy, here’s a slide that was actually included in the 1st year’s foot lecture.

I like how nicely it sums up absolutely everything you need to know about med school lectures.

Happy International Brainstem Day!

Last night I studied neuroanatomy until I started feeling a strange fondness for it.  (“Aw, look – the spinal trigeminal tract again!  Bless its heart, it just keeps going out of its way.“)

Then I woke up surrounded by flashcards and with the vague sense that I may have studied myself into some alternate universe where neuroanatomy makes sense, because I still feel like it’s fascinating.

It’s like there’s a magical switch that gets flipped 3/4 of the way through memorization – a switch that makes you realize how everything acts in relation to everything else.  This must be what drugs feel like.  

(Did I finally lose it?  I don’t know.*  Possibly.  DARE to keep kids off neuroanatomy.)

But as long as I feel this optimistic, I’ve decided to declare today to be International Brainstem Day.  Maybe that’ll keep me in the right frame of mind to dedicate today to all the neuroanatomy lectures I’ve been avoiding.

(Actually, I was originally going to only suggest that someone official should declare this holiday.  But then the internet told me that yesterday was Wrinkled Raincoat Day**, and I decided I have to have at least as much power as that person did.)

(Let’s face it – the founder of Wrinkled Raincoat Day was probably a frustrated fashion school student posting on their fashion school blog, and then some “Weird Holidays” website put it on their calendar and legitimized it through the magic of google.)

I bought you a new holiday, and it's AWESOME.

…  Speaking of being legitimized through the magic of google:  just in case some holiday-cataloguing website owner does come across this page, I’d like to assure you that this is Totally A Thing.  I didn’t make it up at all.  It’s heavily observed in Metropolis.  We have.. traditions, and everything.

For example, traditional gifts given on International Brainstem Day: Coffee, unsentimental cards, and sympathetic looks.

Traditional International Brainstem Day activities:  Memorizing the brainstem.

*  Yes.  The answer is “Yes”.

**Plus, according to the same website, today is apparently National Student Day, which is practically International Brainstem Day already, right?.

Memorizing Cyp450 Inducers & Inhibitors

One of my favorite new apps on my Android phone is made by Pendragon Entertainment: USMLE Pharmacology.  Definitely recommend it – while I was setting it up yesterday, it asked me about cytochrome p450 inhibitors and inducers so many times that I accidentally learned them.

(I know, right?  Technology!)

It seems like the first step was being able to recognize that a drug is a cytochrome p450 something.  The commonly tested ones, at least on that app, were these:  Erythromycin, quinidine, rifampin, isoniazid, griseofulvin, cimetidine, carbamazepine, phenytoin, and phenobarbital.

And that’s basically the hard part, because I realized the names themselves are simply divided into “quick” names (inducers) and “slow” names (inhibitors).

Of course, you don’t need pictures to recognize that QUICKidine, GRIZZLYofulvin, CARbamazepine, RifAMPin, and PHENPHEN (Phenytoin & Phenobarbital) are “fast” names.

No, I don’t know where the grizzly bear got the illegal drugs. I suspect his dealer was in the car, and the mosquito’s all “Dude, Phenphen isn’t legal. LET ME TAKE CARE OF THAT FOR YOU.”

Similarly, no one should need a poorly-drawn picture to recognize that ICEoniazid, ERRORythromicin, and CEMENTidine are “slow” names.

Why is there a block of cement in the middle of the ice rink? I don’t know. Maybe someone just hates that poor robot.

But then, where would be the fun in that?

Ig Nobel Prize Winners in Medicine

I love everything about the Ig Nobel Prize Awards.  Their motto is “Achievements that make people laugh, then think” – which is sort of the best thing ever, right?

So I’m going to give a run-down of all the past winners, broken up into completely arbitrary categories of my own sleep-deprived choosing.
 

I Would’ve Loved to be at That IRB Meeting

2006:  ”Termination of Intractable Hiccups by Digital Rectal Massage” (A strangely popular concept.)

2005:  The invention of Neuticles: Fake Testicles for Neutered Dogs.

2002:  ”Scrotal Asymmetry in Man and in Ancient Sculpture“

2001: “Injuries Due To Falling Coconuts” (Published in The Journal of Trauma!  Which is apparently a thing!)

1999:  ”Collecting, cataloging, and contemplating” the different types of containers patients use for urine samples.  (Out of 164 samples, the best is definitely the roll-on deodorant.)

1995: ”The Effects of Unilateral Forced Nostril Breathing on Cognition“
 

I Would Totally Read That Study

2007:  The side-effects of swallowing swords. (For example, the gag reflex is a problem.)

2004:  The Effect of Country Music on Suicide.  (Money quote:  ”The greater the airtime devoted to country music, the greater the white suicide rate.”)

2000: “Magnetic Resonance Imaging of Male and Female Genitals During Coitus and Female Sexual Arousal.”  (What?  And you wouldn’t?  C’mon, it’s an MRI.)
 

Useful Info with Funny Titles

2010: Symptoms of asthma can be alleviated by riding on rollercoasters.

2008:  Expensive placebos work better than inexpensive placebos

2003:  The hippocampi of London taxi drivers are more highly developed.  (I have been to London, and I am not surprised by this.)

1998:  The Man who Pricked His Finger and Smelt Putrid for Five Years.

1997:  Listening to Muzak stimulates your immune system

1993:  ”Acute Management of the Zipper-Entrapped Penis“

 

That’s Dedication

2009:  Donald Unger, an allergist/immunologist, won the Medicine prize for personally investigating the claim that knuckle-cracking causes arthritis by cracking the knuckles of only one hand, daily, for six decades.
 
And finally:

Nice Try

1996: Presented to tobacco company scientists for “their unshakeable discovery, as revealed in sworn testimony to the U.S. Congress, that nicotine is not addictive.”
 

Prescription: Take with grain of salt

Directions for my dicloxacillin Rx:  ”Take one tablet by mouth every 6 hours 1 hour before a meal or 2 hours after a meal for 14 days.“

According to my time-consuming math, this means I’m supposed to have only two meals a day (unless I schedule “dinner” for 4am) and each time I only have a 3 hour window to eat.

Also, I have to get up after only 6 hours of sleep to take a pill, but then can’t eat breakfast for an hour.

… For 2 weeks.

You cannot tell me people do this successfully.

No wonder patients have trouble taking prescriptions as directed.  Especially if they’re prescribed more than one with this particular “we-must-provide-100%-ideal-pharmacokinetics-or-so-help-us-god” militant brand of directions.

I may have a passing grade in pharmacology, but these pills are smarter than me.  So I’m sure I’ll eventually ignore the finer details of the directions – which is sad, since I’m a person with tons of free time, supposed higher education, and alleged common sense.

You know, for all the buzz about the alleged ‘convenience’ of prescribing a penicillinase-resistant penicillin in oral form (and I hope you correctly assume that by “all the buzz” I mean “that one comic in Clinical Micro Made Ridiculously Simple”), I’d rather just cart around an IV.

Typical Sunday night, really.

Boyfriend is currently studying for Step 2, while I’m studying for “oh god, I’m going to be an M3 in 6 months”.  So sometimes we quiz each other.

Boyfriend:  Okay. There’s a woman in her 60s – a smoker with a history of COPD and diabetes mellitus who presents to you in the middle of a current stroke.  She frequently travels on long, crowded bus rides.  What’s the most likely etiology of the stroke?
Me:  … Hmm.  Any medications?
Boyfriend:  Estrogen pills, albuterol, and metformin.
Me:  *am stumped* Well, what are her stroke symptoms?
Boyfriend:  Doesn’t matter.

Me:  Well, why does she travel on buses so much?
Boyfriend:  Uh, she’s volunteering at a nursing home in another city, 4 hours away.
Me:  What kind of buses are they?
Boyfriend: … they are buses.
Me:  Who else rides these buses?  Any homeless people?
Boyfriend:  … No.  They’re, uh, extremely fancy buses for rich people.
Me:  Does she have cats?
Boyfriend:  No.  She has never touched a cat in her life.  Or a litter box.
Me:  … What about sushi?
Boyfriend:  No.  She’s never even seen a fish.  Or eaten raw meat of any kind.  Or touched a rabbit, or a pigeon, or traveled outside of the country -

Me:  Ah, but what about-
Boyfriend:  Or Florida.  Nowhere sub-tropical.
Me:  Damn.  Well, what were the lung and heart exams like?
Boyfriend:  Lungs were surprisingly clear, though there was a mild diastolic murmur in the heart.
Me: AHA.  Can I get a chest x-ray?  And a brain CT without contrast?
Boyfriend:  CT comes back normal.  CXR shows clear lungs, slightly hyperinflated, and some mild cardiomegaly.
Me:  Aha!  Cardiac… stuff.  So.
Boyfriend:  So.
Me:  So… any claudication?
Boyfriend:  You don’t know.  She can’t tell you.  She’s currently stroking out.

Me:  See, it does matter what her stroke symptoms are!  I didn’t know she couldn’t talk.
Boyfriend:  Okay, fine – we’ll say she had a PCA stroke.  So she only has ocular deficits and can still talk to you.  And her thighs are red and swollen, which she’s unhappy about.
Me:  INFECTION.  I demand a CBC.
Boyfriend:  It’s normal.
Me:  Damn.  Thyroid?  Crepitus?
Boyfriend:  Healthy.  And no crepitus.  I promise she doesn’t have necrotizing fasciitis.
Me:  Well then, what the -
Boyfriend:  Soooo.. the thigh symptoms are..?
Me:  Oh.  OH! So she had a DVT!  A DVT that embolized to her brain!  But why did she have a clot to throw in the first place?
Boyfriend: …
Me: – you know, I still think that TB might have something to do with it.  I don’t know how, but the buses were “crowded”…
Boyfriend: … But how can a DVT embolize to the brain?
Me:  Because she has a patent foramen ovale, just like 25% of the population.
Boyfriend:  HIGH FIVE!  See, you know your stuff!

Me:  Oh. Wait, that was – that was it?  That’s the answer? But… why did she throw a clot?
Boyfriend:  … because smoking, estrogen, and long travel are all risk factors for DVT.
Me:   Damnit! I thought it had something to do with the bus exhaust fumes.
Boyfriend:  Yeah, it didn’t.

Me:  But the good news is, in two years, I’m gonna rock Step 2.
Boyfriend:  … Just so you know, on Step 2 you only get 72 seconds per question.