March 19, 2009
BehindTheMedspeak: Sausage Toe
I must've been playing hooky the day they covered this ailment in med school 'cause I'd never heard of it until I read Sandra G. Boodman's alarming March 3, 2009 Washington Post Health section front page story about one Karen K. Abrams (above), whose sausage toe — misdiagnosed as a hammertoe — caused her over a year of misery, resulting in serious medical problems requiring hospitalization and medical bills totaling $60,000.
Once the complication train leaves the station, there's no end to the capacity of the baggage car.
Here's the article.
Four Podiatrists, One Painful Little Toe
When Karen K. Abrams told her foot doctor the result of a second opinion she'd obtained about the surgery he had been recommending for months, he erupted.
"That's the most ridiculous thing I ever heard!" the podiatrist told her, dismissing a specialist's recommendation that she undergo an MRI of her increasingly enlarged and painful toe before any operation. "I told you, you need surgery!"
Cowed and unnerved, Abrams slunk out of the office and immediately booked the operation to correct what the podiatrist had diagnosed as a hammertoe, a crooked joint that was causing painful swelling.
A clinical psychologist with a busy practice and three children, Abrams, then 47, had been reluctant to undergo hammertoe surgery, which seemed overly aggressive.
But three months later, in July 2006, Abrams was forced to consent to a different operation, one she'd never imagined. The painful digit many doctors seemed to regard as trivial had become a serious problem, landing her in the hospital with medical bills that totaled $60,000.
"It was a very frightening experience," recalled Abrams, who is called Kay and lives in Montgomery County. For a long time, she said, "everyone seemed to think, well, it was just a little toe."
An avid walker, Abrams first noticed the problem in February 2005, when she developed a painful corn on the top of what podiatrists refer to as the "left fifth toe." A foot doctor at a sports medicine clinic near her home took an X-ray and, finding nothing broken, gave her a cortisone shot to ease the pain. The doctor advised her to avoid wearing narrow, tight shoes.
"I never wear them," Abrams said, but "that became their mantra. Every podiatrist I saw told me the same thing."
A few months later, when the pain, sharper but still intermittent, hadn't gone away, Abrams consulted a second podiatrist. He told her the problem was caused by a hammertoe and recommended surgery.
Taken aback by the proposed treatment, Abrams's internist referred her to a third foot doctor, who had a thriving practice and a good reputation. Podiatrist No. 3 agreed with Podiatrist No. 2. Because both baby toes appeared crooked, the third doctor said he could operate on the pair.
The timing couldn't have been worse, but there seemed to be no rush. Abrams was about to accompany her 80-year-old father on what she called "the trip of a lifetime" to Vienna and Brussels, where he had grown up. She bought a pair of fleece-lined clogs and padding for her toe, and hoped for the best. To treat periodic flare-ups, she tried smoothing down the corn with a pumice stone.
By March 2006, her toe was clearly worse: It was more swollen and hurt constantly, even in the clogs. Abrams went back to Podiatrist No. 3, who reiterated his recommendation of hammertoe surgery.
When she told a friend about her upcoming surgery, he suggested that Abrams consult his son, Washington podiatrist M. Joel Morse, for another opinion. "He's not one of those guys who jumps to surgery," Abrams remembers being told.
After examining Abrams, Morse thought her primary problem was not a hammertoe but a "sausage toe," a term podiatrists use to describe swelling often due to injury or infection. He asked Abrams if she had injured her toe; she didn't remember doing so. Morse suggested she undergo an MRI to check for an abscess or other problem before any surgery.
When Podiatrist No. 3 erupted, mocking Morse's recommendation, Abrams scheduled surgery for June, after her son's high school graduation. But by Memorial Day weekend, her toe had gotten dramatically worse. It felt hot and was so painful she could not stand the pressure of even a bedsheet.
"I just wanted to chop it off, it hurt so much," Abrams recalled. A cardiologist friend dropped by, took one look at her toe and told her it was infected and required urgent treatment. In a panic, she reached Morse, who told her to report to Sibley Memorial Hospital the next morning, without eating breakfast in case she needed surgery.
"I had no idea what I was about to face," she said. Within hours she underwent an MRI and a procedure that opened the toe to look for an abscess. Afterward several grim-faced doctors filed into her room and told her to forget about any hammertoe operation. She had osteomyelitis, an infection that was eating away at the bone in her toe.
There were two treatment options: several weeks of intravenous antibiotics to see if the infection would clear up, or amputation.
Osteomyelitis, which affects about two of every 10,000 people, is typically caused by bacteria, often staphylococcus, according to the Cleveland Clinic. It can result from an injury, such as a fracture in which a bone pierces the skin. Sometimes a long-standing infection can penetrate to the surface of the bone. Untreated, osteomyelitis can become chronic and lead to the death of the affected bone. A 2000 article by British physicians in Diabetic Medicine found that sausage toe is a reliable indicator of underlying osteomyelitis.
The infection is more common among people with diabetes, those on kidney dialysis, intravenous drug users, the elderly and patients with weakened immune systems. Abrams fit none of those categories.
Shocked by the news, Abrams chose to try to save her toe. Doctors implanted an intravenous line in her chest through which she would receive antibiotics; after two days, they sent her home.
She remembers the next five weeks as awful. Unable to eat because the antibiotics made her nauseated, she developed an allergy to two of the drugs and had to be rushed back to the hospital twice. Worst of all, the medicines didn't seem to be working.
What she wasn't told at the time was that doctors had become concerned that she might have MRSA, methicillin-resistant staphylococcus aureus, the flesh-eating bacteria. While recuperating at home, Abrams called her internist. The physician told her she needed to have the toe amputated and referred her to a prominent orthopedic surgeon in Baltimore who specializes in foot problems. "Come back tomorrow and we can take the toe off," the orthopod told her. "You can live without it, and the antibiotics are doing nothing for you."
Abrams said she burst into tears, then called Morse for a second opinion. "He said, 'You're making the right decision,' " she recalled.
The next morning she was given a local anesthetic and wheeled into an operating room at Baltimore's Mercy Medical Center, where her baby toe was amputated.
Abrams said she still wonders whether it could have been saved. Self-conscious about her missing toe at first, she later developed a shoe obsession. "For a while I couldn't stop buying shoes," she recalled.
Although it is clear what was wrong with her toe, the cause of the osteomyelitis remains a mystery.
To Morse, Abrams is "a very unfortunate case. Had [the MRI] been ordered earlier, she might not have lost her toe."
Abrams said it took her a long time to get over her fear that any injury might conceal a smoldering infection. She remains grateful to Morse, who, she said, "was the first doctor who really listened and was thoughtful."
These days when something goes wrong, she does more research and is less easily intimidated. Her attitude toward doctors has also changed.
"In your gut if you feel dismissed," she said, "keep looking."
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6cm x 6cm (2.36" x 2.36") PVC sign.
Amusingly enough, made in China.
Co-ed Naked Hiking — Switzerland's new national sport?
Not me, that's for sure — at least until I read John Tagliabue's March 16, 2009 New York Times article about the current kerfuffle concerning clothesless hiking in the Swiss Alps.
In Thin Air of the Alps, Swiss Secrecy is Vanishing
The Swiss like their secrecy, particularly in banking. At other times, they are more open. Take hiking.
In recent years, it has become fashionable for a growing number of Swiss and some foreigners to wander in the Alps clad in little more than hiking shoes and sun screen. Last summer, the number of nude hikers increased to such an extent that the hills often seemed alive with the sound of everything but the swish of trousers.
In September, the police in this mountainous town detained a young hiker, whose friends will identify him only as Peter, wandering with nothing on but hiking boots and a knapsack. But they had to release him, because in Switzerland there is no law against hiking in the nude. The experience alarmed the city fathers of Appenzell, pop. 5,600, who worried that the town might become a Mecca for the unclad. Like most remote mountain regions, this is a conservative area.
For centuries the farmers here lived off their famed Appenzeller cheese and a bitter liqueur that most, except fervent admirers, say tastes like cough medicine gone bad. Not until 1990 did Appenzell grant women the right to vote, decades after other regions of Switzerland.
Suppose families with children were out hiking and encountered a group of nude hikers, officials asked. Moreover, the name of Appenzell was popping up with troublesome frequency in the blogs and chat rooms of nude hiking enthusiasts.
“We’re not in Canada, where you can hike for hours in vast forests,” said Markus Dörig, 49, spokesman for the local government, a look of exasperation on his face. “Here you meet other hikers every few minutes. It was bothersome.”
Konrad Hepenstrick says he almost never meets people who are bothered. “You greet them, and they greet you, though in winter, of course, many ask, ‘Aren’t you cold?’” he said, picking at a lunch of coarse, spicy Appenzeller sausage in a restaurant high on the slopes over the town. Unseasonable snow showers clouded the view of the surrounding peaks, thwarting plans for a nude hike with this reporter.
Mr. Hepenstrick, 54, is an architect who loves to hike in the altogether. In winter, he said, he has hiked for hours in temperatures well below freezing, though he does concede the need for a hat and gloves. He has hiked in the nude for about 30 years, he said, and has crisscrossed the hills and mountains around Appenzell, as well as in France, Germany, Italy and even the Appalachians.
His companion, a schoolteacher, also hikes, though she will not do so au naturel, he said. So why does he take off his clothes? “There’s not much to discuss,” he said. “It’s freedom. First, freedom in your head; then, freedom of the body.”
With some Swiss legal experts arguing that banning nudity in public would be unconstitutional, the government has been hamstrung in responding to the hikers. It has drafted legislation that, if enacted, would outlaw “abusive behavior that offends against custom and decency,” but it seems likely to be challenged. Daniel Kettiger, a legal expert, published a six-page paper last month titled, predictably enough, “The Bare Facts: On the Criminal Prosecution of Nude Hiking,” pointing out that in 1991 Switzerland struck a law from its books that banned nudity in public.
“Simply being naked without any sexual connotation is no longer illegal,” Mr. Kettiger said by telephone, adding, “at the time there was a wave of nudism.” Was he himself a hiker? “Yes, but never nude,” he replied. “First there is the danger of sunburn, and then there are ticks all over the place in the Alps, which carry Boreliosa,” or Lyme disease.
The Appenzeller justice minister, Melchior Looser, is sure he can frame a law that will force the naked to cover up. “I think the measure will work the way we have fashioned it,” said Mr. Looser, 63, noting that offenders would be fined the equivalent of $170.
He would like to have the law in place by springtime, when hikers again take to the hills. But he concedes that it must be approved by the grand assembly of the people, a gathering of all citizens of voting age once a year on the town’s main square, which is scheduled to convene April 26. Passage is by no means assured.
Hans Eggimann believes it will be enacted. “I hike around the house naked, but outside I put my pants on,” said Mr. Eggimann, 57, a large man who sells more than 60 types of cheese in his shop in the town center.
Others are not so sure. “Many Appenzellers I know say it doesn’t bother them,” said Alessandra Maselli, who works in a dry goods store not far from Mr. Eggimann’s cheese emporium. “I’d say it’s about half and half, with a slight majority for the law,” she said.
Over in the Bücherladen bookstore, Caroline Habazin, 46, said the controversy gave everyone a good laugh at the town Carnival parade last month. One float featured a male and a female hiker in flesh-colored tights, their arm and leg muscles and their rear ends stuffed up steroid-style with filling, though the man’s private parts were mostly covered by fake grape leaves. “I think it’s only a pretty small group,” she said.
Her colleague, Edith Sklorz, 48, said why anyone would want to hike nude was puzzling to her, though her husband felt differently. “I can understand swimming nude,” she said, “but not hiking.”
What offended her equally though, was the government’s choice of responding to the hikers with a law. Recently, the neighboring town of Gossau passed a measure banning spitting in public, she said, threatening offenders with a $50 fine; and now a law to ban nude hikers. “For every tiny thing, there’s a law,” she said.
Ursula Heller has been selling apparel for hikers and trekkers for five years in her shop just off the town’s main square. A threat to her business from nude hikers? She laughed deeply. She and her husband are avid hikers, she said, but she is against nudity.
“If you want to get undressed,” she said, “you can always wear shorts or a bikini.”
How low can you go?
"55-oz. glass mug is dishwasher-safe."
Like it says on the website: "Please drink responsibly."
bookofjoe live on Twitter (I lied)
You may recall that just four days ago (this past Sunday) I said that once I reached a critical mass of 1,000 followers I'd consider updating my Twitter page (my last Tweet when I wrote those words had been on November 26, 2006).
Then yesterday longtime reader Stephen Bové emailed me that I should consider leveraging bookofjoe using Twitter, like most of the big-time sites are doing.
So I passed the suggestion on to the Prince of Pixels — techmaster Phillip Winn — who within an hour or so had me up and running on Twitter, such that each time a post appears on bookofjoe, a direct link appears as a Tweet on my Twitter page (top).
The key to it all, for me, is that I don't have to do anything other than what I ordinarily do, yet now bookofjoe appears via an additional channel.
As I've mentioned before (and will no doubt will again), quoting Kinky Friedman, "I'm in search of a lifestyle that does not require my presence."
bookofjoe via automatic Twitterfeed passes the test nicely.
Note that at this moment — 11:34 a.m. on Thursday, March 19, 2009 — I have 74 followers on Twitter.
We'll see what happens.
ME + YOU = us
I love this T-shirt by Nancy Wu.
Maybe if enough people let her know they want one, she'll sell them.
Can't hurt to ask: email@example.com
'Dead Man': 'The best movie I've ever seen' — Ashlee Vance
I'll find out soon enough if that's true.
But who the heck is Ashlee Vance and why should we care what he has to say?
I thought you'd never ask.
I've been seeing his byline in the New York Times in recent months over stories that were consistently interesting and unexpected, so I had my crack research team go deep and see what they could find out.
The second sentence of the first paragraph on the website: "It's the opening for the best movie I've ever seen — 'Dead Man.'"
Besides being opinionated about films, he's also quite definitive about books, writing that "My book is the best such work on Silicon Valley to date. I mean that."
He concluded, "I want your help in a big way, but I'm only going to chuck up the good stuff."
I should take a lesson, what?
Anyhow, I'm sure he'd like to hear from you — why else would he put his email (firstname.lastname@example.org) on his site?
Tell him I sent you, he appears to be the sort of person who's easily amused.
So maybe you've only got one cooking utensil and it's a frying pan, not a pot.
What if you want some steamed asparagus?
Well, now you're in luck.
Just place this aluminum basket on top of your water-filled 10" skillet and you've got a large, flat steamer for vegetables, fish, seafood and more.
1.25"H x 11.25"Ø basket has an 8.75"Ø bottom.
$10 (asparagus and skillet not included).