"Why don't we do it in our sleeves?"

I feel an enormous amount of compassion for the sick people in my exam room. But my fountain of understanding abruptly runs dry when some infectious chucklehead lets loose an unrestrained cough or sneeze as we sit together in that tiny space.

So please, one and all, as we pass through this scary, fluish time in close quarters, check out this video . Give your family, your co-workers, and your doctor a break!

Cytokine storm and the H1N1 swine flu virus

At a time when the flu season should be winding down in North America and Mexico, scary reports are emerging from our Southern neighbor of a new swine flu variant whose victims are primarily young. Not only does this influenza A strain appear to be a previously unknown combination of bird, swine, and human genetic material, but the course of fatal illness caused by this bad actor seems to be marked by a 'cytokine storm' that leads to grave lung damage in those affected.

Well shoot, who wants to be in the eye of a cytokine storm? Cytokines are worthy molecules that various body immune cells make in response to an infectious invasion. This is generally a good thing insofar as these various chemicals amplify the body's attack on unwanted intruders. As is true of so many physiological functions, however, a little is good but a lot is destructive.

At the heart of the stormy matter are macrophages ('first responder' white cells activated by damaged cells or foreign invaders such as bacteria or viruses) and CD8+T-lymphocytes (circulating white cells that leap into killer mode the moment they get a whiff of flu viral proteins nearby). These white knights in cell membrane clothing produce a whole host of cytokines--including Tumor Necrosis Factor (TNF)-alpha, Interferon (IFN)-gamma, IFN-alpha/beta, Interleukin (IL)-6, IL-1, MIP-1 (Macrophage Inflammatory Protein), MIG (Monokine Induced by IFN-gamma), IP-10 (Interferon-gamma-Inducible Protein), and MCP-1 (Monocyte Chemoattractant Protein) to name a few. H5N1 influenza (bird flu) happens to be a particularly strong inducer of this cytokine over-production due to the virulence and enthusiasm with which it enters human tissues. Whether or not swine flu and this newest swine version causes this kind of cytokine mess is still not known.

So the human lung and too many cytokines is way too much of a good thing, causing swelling, hemorrhage, and tissue death which are, ironically, more a result of the body's defense mode than a primary flu-generated injury. Scientists theorize that young people may have a more robust cytokine response and less H1N1 immunity from previous exposure compared with older populations.

As of today, 8 cases have been reported in the US from California and Mexico that have been identified as the swinish H1N1 flu but mild and self-limited illnesses in those affected. Remember, increasing evidence suggests that robust body levels of vitamin D are flu-protective, so this might be a good time to get your blood tested for vitamin D and step up your supplements under advisement with your physician.

For up-dated information on the H1N1 flu, see Triple Reassortment Swine Influenza, H1N1 flu shots, Why should I get a flu shot?, and What's a Phase 6 Pandemic?

These glasses have got to go!

I've just returned from a round trip drive to the East coast. Don't ask why, just know that the last time I did that journey, I was 19, and it's quite a different matter to sit in a car that long that far nearly 4 decades later.

We were equipped with snacks, books on tape, and my favorite pair of sunglasses. When I tried them on at the sporting goods store, I was impressed with their style and comfort. I wore them for six months before I noticed that they had skulls embossed on the ear pieces--perhaps some sort of extreme sports insignia? Actually my son brought the look to my attention.

Well I can live with the skull thing, but I discovered during hours of driving into the late afternoon Kansas sun, these shades simply don't fit. The beskulled left ear piece digs painfully into my very own skull just above and behind my ear. So what misery to pick--squinting into the sun (wrinkles! cataracts! an inability to see the road!) or incessant fiddling with the way glasses meet head?

On top of that, my left shoulder began hurting terribly. I'm picturing my aging, degenerating neck sinking into my torso, pinching a nerve on its way to the bucket seat, and I add massaging the shoulder to sunglass fussing to my general in-car fidgets. After ripping the stupid things off when the sun went behind a cloud, I discovered that my shoulder pain resolved within minutes.

I've always told my patients that muscle tension in the neck can easily cause a headache. Apparently pounding plastic into the temporalis muscle on the side of the head can reverse the pain flow down the neck to the shoulder.

Bilateral shingles

I wished recently for a consult with Dr. House (in the form of Hugh Laurie with the patience of Mother Theresa). My patient felt awful for a week or so. She was having palpitations, her chest hurt terribly with any position change--say with settling back into bed--or with deep breathing, and the skin on the back of her neck hurt terribly. Her appetite was down, she had no pain with swallowing nor acid reflux, and generally felt unwell due to her newly diagnosed rheumatoid arthritis and Crohn's disease.

Her blood pressure was low and her pulse was up, no fever, her chest wall was not painful to touch, her lungs were clear, and her abdomen wasn't tender. Any movement of her torso caused her to cry out in pain. Her blood count and lab work were normal except for an expected elevation in her sedimentation rate (a non-specific measure of inflammation or infection in the body) due to her arthritis and colitis. A chest x-ray was clear, her thoracic spine films looked good, and the EKG showed no evidence of heart troubles.

Yikes, what on earth? Perhaps yeast in her esophagus? Yet she had no trouble swallowing food. Costochondritis (inflammation where the ribs meet the sternum)? No pain on pressing those joints. Acid gastritis? Her pain was positional and not affected a bit by eating. Heart pain? Nope, the pain was totally atypical. Pre-shingles nerve pain? Maybe in the neck, but not on both sides, and what did that have to do with her chest pain.

Two days later she broke out in shingles--on both sides of her head behind and on her ears. So much for conventional wisdom that shingles only affects one side. In fact, 4% of patients break out on both sides of their bodies. Meanwhile, she researched the side effects of Asacol (a medication used to decrease the inflammation of colitis) and found chest pain on the list. She quit the medication, and, within a day, her pain was gone.

So who needs House when patients use the Internet? I regret that I didn't start her right away on one of the drugs that work against shingles (Valtrex, Famvir, or acyclovir). House would've done that.

Meat-related mortality

I just finished a liverwurst sandwich (delicious with dijon mustard and sliced purple onion); it was 'to die for' but not exactly my definition of health food. Imagine my dismay when to die for took on a more literal meaning as I opened the March 23rd issue of The Archives of Internal Medicine to this headline news: "Meat intake and mortality: a prospective study of over half a million people."(1)

So what do 500,000 meat eaters have to teach us about the guilty pleasure of a liverwurst sandwich? Namely that the consumption of red meat and processed meats (and liverwurst, while not red, is oddly pink in a processed, not-found-in-nature sort of way) is associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.

In other words, too much meat and you're so much dead meat. My sandwich sits like a guilty lump in my stomach. An accompanying editorial goes on to indict me further: "Far too few clinicians speak out on topics such as this. What the public hears is the side of the profession that is preaching vegetarian diets and not the side of the profession that is discussing moderation as a healthy option." So I'm telling you now, the very occasional processed meat treat may be good for your soul, but mostly you should emulate my favorite dinner--which I had last night--namely a bowl of Bear Naked Granola.

And just to further fuel my discomfort with meat, I have just ordered "Dying for a Hamburger: Modern Meat Processing and the Epidemic of Alzheimer's Disease" wherein the authors make a case that Alzheimer's Disease is spreading like an infectious disease which, per them, is carried in cow meat meals contaminated by prions, the proteinaceous particles associated with mad cow disease. Lovely. I'll let you know if this sounds cutting edge or lunatic fringe.
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1) Arch Into Med. 2009 Mar 23;169(6):562-71.

Flector patch

Looking for the anti-inflammatory relief of Advil or Aleve without the stomach distress? If you're injured and hurting, check out Flector Patch for a brand new alternative in pain control

How gross is this ad?

Actual advertisement on London bus--does this stud muffin do Pap tests?
(from copyranter.blogspot.com)

Fatty liver disease

"As the nation gets heavier, our livers will get fatter."
---Chin Hee Kim, MD

Nonalcoholic fatty liver disease (NAFLD) is the most common form of liver disease AND it affects 20-30% of the US population per Drs. Kim and Younossi writing in the Cleveland Clinic Journal of Medicine(1). NAFLD can range from no big deal fat in liver through inflammation and liver cell damage (nonalcoholic steatohepatosis or NASH) to cirrhosis, liver cancer, or liver failure.

The standard, automated laboratory blood profile includes a panel of liver enzymes. These transaminases(2) which are involved in the production of amino acids are part of the biochemical equipment within liver cells. They are normally present in the bloodstream in small amounts, but disruption of liver cells causes their blood levels to rise. A case of hepatitis skyrockets transaminase levels into the 1,000s and beyond, but even very low level elevations found on lab screening are worthy of follow-up because they may indicate an ongoing, asymptomatic inflammatory liver process that can ultimately lead to cirrhosis and liver failure.

Often, elevated liver enzymes or liver function tests (LFTs) in overweight persons demonstrating signs of metabolic troubles (fat concentrated around the waistline, elevated blood pressure, elevated triglycerides, low HDL, or high blood sugar) are the first sign of NAFLD. This fatty liver business is usually asymptomatic and only noted on lab testing. In order to chase down the cause of abnormal LFTs, we next order tests to check for chronic hepatitis B or C infections, auto-immune liver disease, or metabolic diseases such as abnormally stored copper or iron in the liver. An ultrasound of the liver is fairly accurate in assessing the presence of fat in the liver.

Liver biopsy is the best way to determine if the fatty liver troubles are benign or carry a risk of progression from nonalcoholic steatohepatosis to scarring and permanent liver damage or failure. Once diagnosed, the best approach to treating fatty livers is the same strategy that improves overall health in overweight persons on the road to diabetes or heart disease. These include weight loss (including use of bariatric or gastric bypass procedures), trials of various drugs that promote insulin sensitivity such as metformin, Actos, or Avandia or drugs that lower triglycerides and raise HDL levels such as statins and gemfibrozil. Fatty livers are more sensitive to damage from regular alcohol intake.

If you tend to pack the pounds around your waistline, be sure to ask your doctor to test your liver enzymes.
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1) Kim, HK and Younossi, ZM. Nonalcoholic fatty liver disease: A manifestation of the metabolic syndrome. Cleveland Clinic Journal of Medicine. October, 2008, Vol 75, pp 721-728.
2) Aspartate transaminase (AST) and alanine transaminase (ALT) levels generally range up to 40 or so. In mild NAFLD, AST <> ALT.

Cures for the red face?

And who wants a red face? I had a new patient in yesterday who specifically complained of a red nose, and indeed, the tip of her nose was red with tiny enlarged blood vessels visible on its surface (but only seen by me with reading glasses assist!).

Thanks again to TheDermBlog.com (and I highly recommend this site to you), I am able to bring you a little more info on the subject. One of the most common causes of a red face is rosacea, an inflammatory skin condition that often causes red cheeks and nose (and occasionally eyes), that gets redder yet with alcohol consumption, and responds to topical antibiotics like Metrogel. Sun damage also permanently dilates the superficial blood vessels in our skin, particularly visible in those with Type I sun-sensitive skin (as in fair, easily burned, often in red heads and persons of Northern European ancestry). Dr. Benabio notes on his blog that laser treatment can take away those enlarged capillaries at the skin surface.

I also see persons with acne succumb, as did I, to overscrub syndrome, using washcloths and various exfoliants in a vain attempt (in both senses of the word vain) to liberate the pores from pus and oil. I have been following Dr. Benabio's advice to wash the face less often, but it still goes against my basic impulse to scrub early, scrub often and dab with astringent in between.

He recommends anti-inflammatory, anti-redness skin products for the those who carry the red badge of sun damage/acne/rosacea front and center on their face. In particular, he mentioned Aveeno calming lotions with the herb feverfew. Aveeno apparently has gone to some trouble along with a host of phytochemists to remove the pesky parthenolide component of feverfew (which sensitizes the skin i.e. makes it redder) leaving behind its beneficial anti-inflammatory components. In particular, the parthenolide-depleted feverfew inhibits 5-lipoxygenase, a pro-inflammatory molecule that is the target of a new anti-arthritis medication working its way through clinical trials. Maybe feverfew should join the A-list of herbals that we smear on and swallow (it's supposedly good for migraine prevention as well) along with vitamin C and green tea.

Well, of all my skin troubles, redness is not one. Testimonials for Aveeno (and Eucerin) anti-redness creams abound on the internet. Let me know if you try it and like it!

Vitamin A supplements and cancer risk

A little is essential, a lot, apparently, is too much of a good thing.

Enamored with the potential of anti-oxidants in fruits and vegetables in cancer prevention, scientists theorized that concentrating these worthy phytonutrients in supplement form might be even better yet. Several studies through the years designed to test this theory on vitamin A derivatives such as carotene (that substance which imparts the orange color to carrots, sweet potatoes, melons, etc.) have been abruptly halted when smokers enrolled in the trials who took the real deal beta-carotene preparations developed lung cancer at a significantly higher rate than those on placebos.

University of North Carolina researchers took another tact and arrived at the same conclusion. They examined data from 77,000 Americans over 10 years--correlating use of dietary supplements with subsequent cancer diagnoses. Note that these subjects were not assigned to a certain vitamin or placebo but rather self-reported their use of over-the-counter vitamin pills.

Not only did beta-carotene again prove problematic in a cancer-causing sort of way for the smokers in the study group, but retinol and lutein demonstrated a potent total dose-related association with lung cancer risk. The longer a person took these supplements, the greater their risk compared with those smokers who did not use them--53% for retinol and 102% for lutein!

Lutein, of course, is recommended to help prevent macular degeneration, an age-related eye condition that can result in significant vision loss. The researchers did not comment on the conflicting reasons to take or pass up lutein, but perhaps persons who smoke should pass up the lutein.

Vitamin D and URIs

When all around the wind doth blow,
And coughing drowns the parson's saw,
And birds sit brooding in the snow,
And Marion's nose looks red and raw.
---William Shakespeare

Denver weather includes some wind, no snow, and no brooding birds sighted in our bushes. Lots of patients coughing in the waiting room, however, drowning in their own secretions, their throats, noses, and eyes red and raw. Colorado scientists, revisiting data from the Third National Health and Nutrition Examination Survey, conclude, as have others before them, that a lack of vitamin D is at the heart of these viral matters(1).

They conducted a 'probability survey' based on six years of results looking for an association between a person's vitamin D levels and a recent personal history of an upper respiratory tract infection. Indeed, those persons with puny little D levels (<10 ng/ml) were nearly twice as likely to have had a recent viral URI as those with robust amounts of D on board (30 ng/ml or more).

To give you a notion of what's common here in sunny Colorado, I don't see one person in ten whose D levels break the 30 nanogram level. In many patients who claim to take at least 400 units of D per day in their multi-vitamin pills, levels hover in the low teens.

No one has time for a viral URI. If you don't want the problem, check and see if you have D problem; get your D level checked.
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( 1) Arch Intern Med. 2009;169:384-390.

Winter vomiting disease

Lovely, huh? WVD is the UK name for the 1-2 day intestinal crud whose hallmark is...vomiting! And I can personally attest that it's a toilet-hugging disaster--been there hugged that all yesterday afternoon.

As noted in The Rocky Mountain News recently, WVD--caused by the norovirus (and rather picturesquely as the 'small round structured virus' or SRSV)--is currently epidemic here in Colorado. Here's what Brit SRSV expert Professor Steve Field had to say:

Generally you do not need to go and see your doctor.

Because, dear patients of mine, if you go and see your doctor with it, as about 10 of you did last week, she will get it too. That said, I finally got my son to call my doctor--the lovely and talented internist Adele Sykes--to rush over ASAP (leaving her Valentine's Day dinner party to do so) with a phenergan shot to put me out of my misery. Now I know why all of you who are her patients love her so--she was a veritable angel of mercy in a red sweater with a red band about her more or less reddish hair, and she certainly saved my sorry self from hours more of misery.

Maybe, then, we should have those of you who peel yourself off the bathroom floor to visit us with WVD sneak in the back door where a gowned and glove assistant will shoot you up too. And if you're too sick to travel, know that this too shall pass provided you don't pass out and break your head open.

How would you have handled this one?

My long-time patient has struggled with alcohol abuse in the last two years. She's been in and out of rehab plus had several hospitalizations with serious illnesses indirectly linked to her addiction. Now she's back to work and looking the best I've seen her in ages. She came in alone yesterday regarding a mild skin ailment--her daughter usually accompanies her-- and walked slowly and a little unsteadily into the exam room due to a 'minor ankle sprain'.

After our pleasant visit, I gave her a hug and realized she smelled of alcohol.

Screening for post-partum depression

For those of us who have abruptly run out of estrogen--before a period, after delivering a child or miscarrying, and entering menopause--it is no news that sudden declines in this hormone can precipitate anxiety and depression. Pediatricians at the University of Colorado have devised a quick and easy 3 question screen to identify women at risk for significant post-partum mood disorders.

Women are instructed to answer 'most of the time,' 'some of the time,' 'not very often,' and 'never' to the following statements:

1. I have blamed myself unnecessarily when things went wrong.
2. I have felt scared or panicky for not very good reason.
3. I have been anxious or worried for not very good reason.

Dr. Stephen Stahl has pointed out a phenomenon he calls 'kindling' with respect to hormone-related mood swings, namely that a history of responding to hormone changes in a sad or anxious sort of way makes it more likely that a woman will have a similar response to such episodes in the future. I think this 3 question tool would be useful in identifying women having a rough go of it mood-wise through the other biggest hormonal challenge of a woman's life, namely menopause.

Pyridium (phenazopyridine)

Chances are good that this specimen will look familiar to those of you who have been treated for a urinary tract infection known as cystitis. While waiting for the antibiotics to start to work killing the unwanted bacteria invading your bladder, your doctor may have given you Pyridium, an analgesic that soothes the burning pain and spasms of the infection and turns your pee the color of orange Kool-Aid in the process.

A case report in the Mayo Clinic's journal last year(1) is a good reminder that even that which seems innocuous-- a drug taken for a day or two to jump start recovery from a bladder infection-- can have serious side effects. This little old lady with a history of recurrent urinary tract infections (a problem common both to little old and not-so-little, not-so-old ladies) complained her urine was orange and her hands were blue. No problem with the orange urine, we see that of course all the time with the initial use of Pyridium. But what was up with the alarming discoloration of her hands and her ear lobes?

The satisfying pink color of our palms derives from the oxygenated blood carried in the arteries within. Hemoglobin combined with oxygen or oxyhemoglobin imparts that familiar red hue to arterial blood. In order to grab an oxygen molecule, the iron in hemoglobin must be in its reduced or ferrous state with a free electron which can bind to a free electron hanging off the oxygen we absorb through our lungs. When iron is oxidized into its ferric state, a lack of a free electron means no oxygen-binding resulting in methemoglobin which is brown and causes a dusky discoloration to skin. In a normal healthy state, enzymes act to reduce methemoglobin back to oxyhemoglobin.

What's all this got to do with seeking a little relief from a bad bladder day? While a little relief, i.e. a day or two of Pyridium is a good thing, ongoing use of the drug--in this case ten days--is a bad thing. Pyridium and other drugs that diminish the activity of reductase enzymes can result in methemoglobin production. A little abnormal hemoglobin makes your digits blue, a lot makes you seize, fall into a coma, and die.

I've not seen a case of this in all the years I've prescribed this analgesic for UTIs. But this is a good reminder that some folks, on receiving a prescription of thirty Pyridium with the instructions to take it three times daily as needed for bladder pain will do just that, take the entire prescription rather than quitting its use when the bladder no longer pains.
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(1) Singh NK et al. Elderly Woman With Orange Urine and Purple Hands. MayoClinProc. July 2008;83(7):744.

Sleep deprivation and susceptibility to colds

What a sorry parade I've had through my office the last month. Not only were these poor souls coughing their brains out (and sharing their respiratory droplets with me!), they had: company coming, an upcoming trip to London, an important work presentation, a parent in the hospital, an enormous party to host, and finals to study for (and take). There's never a good time to be sick, but somehow we often seem to be sick when we can least afford to take to our beds. So here's interesting medical news from Carnegie Mellon University in Pittsburgh.

Psychologists there polled 153 healthy subjects over 14 consecutive days about how long they slept and how rested they felt. And then--get this--they quarantined off this group who quite clearly were paid for this study, inoculated their noses with infected droplets from other people's noses (!) and checked out who fell ill and who did not.

Participants reporting less than 7 hours of sleep were nearly 3 times as likely to get sick than their 8+ hours-of-sleep colleagues. And those with less than 92% sleep efficiency meaning that they actually slept less than 92% of the time that they were in bed were over 5 times more likely to succumb to the germs in the donated mucous.

So ah-hah! That explains it--you stay up late cleaning house for company, finishing your work before your trip, fretting over your ailing parent, studying for exams, you walk through the supermarket and the bag boy sneezes on you, and poof! done deal! you're sick. So get some sleep and I will too in case you can't sleep, get sick, come to my office, and cough on me.

Caffeine-induced hallucinations

Psychologists at Durham University in the UK polled students there about their caffeine intake as it related to hearing voices, seeing things or people that weren't there, or the predisposition to out-of-body experiences. Turns out, the more coffee (or tea) you quaff, the more likely you are to have paranormal encounters.


Study author Dr. Simon Jones allowed, however, that these result might simply indicate that "People who tend to see or hear things may just be more naturally prone to drink a lot of coffee."

Do you see dead people at Starbucks? If you're the sort--and I certainly am-- who enjoys other people's surveys, log-on to Caffeine Questionnaire . The researchers are still collecting data on close encounters of the caffeinated kind.

"Shampoo your hair, not your body"

It's dry skin city here in Denver year-round but especially in winter when the air is cold as well. As a result, I see any number of patients with bizarre skin rashes that look icky and infectious but are the result, rather, of too much hot water and not enough moisturizer.

This skin care tip comes from Dr. Jeffrey Benabio's The Dermatology Blog. He notes that shampoo is specifically designed to remove oils from your hair and will do the same to your skin. Rather than lather yourself like an Irish Spring commercial with rich shampoo bubbles (or soap bubbles for that matter), check out his other tips on this post and the rest of his blog.

Fidgeting and weight loss

I got a pedometer that actually works this holiday season. I discovered not only do I get well over half of my recommended 10,000 steps in a 90 minute Jazzercise workout (did that yesterday), but also that I don't sit still very long. This reminded me of a study I wrote about some time ago, so I thought I'd share it with you that you might consider the health benefits of racing around looking for your keys etc. as you consider your New Year's Resolution List (1. Fidget more, 2. Run upstairs to answer the phone instead of putting the handset on the table next to your recliner, etc.).

Consider inclinometers and triaxial accelerometers. Gizmos found in the instrument panel of a fighter jet that were sewn for this study into the high-tech underwear encasing the more or less active behinds of twenty Minnesotans. While all of the subjects were self-proclaimed 'couch potatoes,' half were lean and half were mildly obese. Dr. James Levine and colleagues then recorded 25 million underwear-generated data points on posture and movement from each subject over ten days. The Mayo Clinic investigators believe the results may explain why some persons tend to put on the pounds more easily than others.

Healthy adults gain weight when energy in (food) exceeds energy out (daily activity). While energy expenditure occurs during exercise, a large part of our daily calorie output is Non-Exercise Activity Thermogenesis or NEAT. Dr. Levine defines NEAT as "physical activities other than volitional exercise, such as the activities of daily living, fidgeting, spontaneous muscle contraction, and maintaining posture when not recumbent." The more you twitch, squirm, and generally fussbudget through your daily activities, the more calories you burn in this unexpected way. The researchers discovered that their obese volunteers were seated daily for 164 minutes more than were lean participants. In fact, if the heavier group had demonstrated the same NEAT behavior as their skinnier colleagues, they would've burned off an extra 350 calories per day or the equivalent of 7 pounds per year.

The Mayo endocrinologists had previously conducted research on the effects of overeating on NEAT. They stuffed an extra 1000 calories/day over 8 weeks into sixteen normal weight volunteers. During the two month feeding extravaganza, the subjects increased their energy output in subtle but significant ways, burning the majority of the extra calories as NEAT. Based on these studies, the researchers theorize that while obese individuals may "have a biologically determined posture allocation" (genetically inclined to hit the recliner), perhaps they can be taught to consciously overcome their torpid destiny with increased body busyness as part of a weight loss program.

"Studied calm"

I'm still reading Jerome Groopman's book "How Doctors Think", and I still highly recommend it to you. Not only does he illuminate the processes--some good, some ill-considered--that doctors use to arrive at clinical decisions, he recommends various participation strategies to patients that they should use to keep their doctor on an objective path to a diagnosis.

Dr. Harrison Alter is an ER physician that Groopman interviewed for this book. Alter notes that the emergency room atmosphere can be hectic and chaotic, and he personally works on fostering "studied calm, consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed [into a hasty decision]. "

Well, you don't have to practice in an ER these days to feel pressed for time. I too have to make a conscious decision to slow down and forget the schedule, settling into my chair and focusing on the patient and what she's saying. Sometimes, this take-a-deep-breath-and-listen attitude pays off big-time.

I was running nearly 15 minutes late when I called Ms. V in from the waiting room. She's a 70-something dynamo, raising her teen-aged granddaughter and taking care of her ailing spouse. The previous morning, she'd had nothing to eat in preparation for a glucose tolerance test. After two hours at the lab where she drank the hyper-sugary Glucola and had hourly blood draws, she headed home, lightheaded and nauseous. Once there, she proceeded to begin cleaning the kitchen, leaning into those counters with her usual elbow grease. Moments later, she dropped to the floor, hitting her head and not really coming to until the paramedics arrived. While she was cleared for home at the ER, the doc there urged her to follow-up with me.

Ah, that is so you, I said to Mrs. V, cleaning up in lieu of relaxing over a late breakfast. On the other hand, I thought, it is so not you to faint. Groopman warns against making clinical judgments based on what we know or expect about a patient. I checked her goose egg of a lump on her head, took her blood pressure, then asked "So anything else going on?"

Well, she said, she'd been having episodic shoulder pain, did I think perhaps she had strained a muscle? And she'd nearly fainted in the Sears parking lot the week before. Ms. V has hypertension, high cholesterol, pre-diabetes, and her EKG at my office looked vaguely abnormal. I sent her directly to the hospital for admission to the cardiology service, and the following morning they put a stent into her nearly obstructed main coronary.

Here's to studied calm.