Mystery

Yesterday M was in. She sees me for her back pain, her "sciatica" and her neuropathy. I have done a somewhat nice job of getting her out of a lot of pain. I give her epidurals now almost every three months. I gave her one and it helped for about six months. She also had gotten some Botox injections in the back. Those were very helpful also. But there were some problems that developed. She got pain that didn't seem to fit with everything and I had her go for an MRI, which showed knee problems. I sent her to an Orthopedic doctor, who drained her knee with some help. Then she got severe swelling in the ankle, so he sent her to an arthritis doctor, who tested her for "autoimmune diseases". She had some positive antibodies, but he didn't think she had a real autoimmune problem. She developed bone infarctions (where the bones die from lack of blood flow). She was sent to a blood doctor, who said she has B12 deficiency and is treating that. She has developed severe osteoporosis as well. She was sent to a university expert in bone disease and immune disase, and they didn't really even evaluate her there. They couldn't find all of her records. So basically, none of us really know what's wrong with her. I'll put her on one of the neurology discussion groups, but I doubt that's going to help much. She doesn't really have much of a neurology problem. I'm stopping her Topamax, because that can cause osteoporosis, although not bone infarcts or these other problems. I'm sending her to an endocrinologist next week. She is a mystery.
Sometimes we never really figure it out. This may happen with M. The endocrine person I'm sending her to is extremely smart. He's very thorough and will likely do a systematic careful approach. I need to do that this weekend also. You look up each symptom and generate a long list of possible causes ("differential diagnosis") and see if any of it seems to fit: the larger your list, the higher the chance of getting the answer. the problem is it's still a "chance". Most diagnoses occur quickly by pattern recognition. It's like when we look at someone's face and know who it is. "How did you know who that is?" You can't explain it based on the details of their nose and mouth and skin. In fact, that's almost harder to do.
When we don't know what's wrong it's often just because there's so much that we don't know. there are diseases that exist which we haven't even named and described yet. There are also disease that aren't one disease, they're two or three diseases that are happening at the same time. While we're all trying to find some kind of an answer, we don't have much treatment, so M is in pain and can't really walk very well. She is, on the whole, getting worse. I know that she's frustrated and getting depressed (What else can you expect?) Even if it isn't neurology, you can't just pass it off to another person to figure it out. If they don't get the answer it's still your patient who is suffering. Most of the time when I get a second opinion it's not because I expect that someone else is going to figure out something I missed or got wrong. They almost never do. It's usually so the patient has some reassurance that they went to the "bigshots". Generally, if I can't figure out, others can't either. There's no despair, no giving up. You just keep on going. People don't think that Dori (the blue fish in the movie Finding Nemo) is really that smart. But she is. She says "Just keep swimming; just keep swimming.." That's really a great idea. You just keep swimming.

Errors

Yesterday there were mistakes. These are very tricky things. I saw a patient from Vocational Rehab. She was young, in the early twenties. She was injured when a heavy box of CDs fell onto her head in March. That's six months ago. Ever since then, she has pretty severe pain in the neck on the right side. She was treated with physical therapy, pain medications, and muscle relaxants. She isn't getting any better. I reviewed what the physical therapy people did with her. She is not on any at-home exercise program. She wasn't sent to me for her neck pain. She was sent over by Dr. L, a semi-retired excellent Neurosurgeon, who wanted nerve testing done to make sure there wasn't any nerve injury. She doesn't have normal neck range of motion. She can't bend or twist the neck properly. It isn't the same on the two sides. The left side moves normal, but the right side has limited motion. This indicates that the muslces don't stretch out normally, they're too tight. That problem has a very simple solution: stretch the muscles. Muscle stretching takes a long time with very consistent effort. The yoga people are very limber, and their range of motion increases with constant stretching. But that hasn't been tried yet. So I told her to do it. If she does it every day, twice a day, then she's going to be better in about three months. It's ridiculous that she hasn't had that done. It's upsetting, but that happens. I'm glad I got to see her, though. It's not because I like to see people make mistakes; not because I want to think I'm smarter than that other person: because now she'll probably (finally) get better.
I saw an eighteen year old who gets shakey. She feels just not right, and at various times in school she starts to shake. She shakes inside which is the most disturbing. It is variable in intensity. Now this girl is quite strikingly thin. Her bones aren't showing. She's just REALLY thin. I think most people would think that she's too thin, although I didn't figure out her BMI (Body Mass Index), the real way to tell if she's truly "underweight". So I asked her about her exercise habits, but she laughed at me (She doesn't like exercise). So I asked her about her eating. She doesn't really eat. She has a piece of toast for breakfast, and then she has a tuna sandwich after school. She has some candy. She says she only drinks water in the day time, but her mother thinks she takes a lot of coke and tea. She only takes those with dinner. I don't know, really. I want to believe that she's only taking the caffeine with dinner. You never can really tell. Anyway, not eating any food makes you shake. Eating nothing and then having candy makes you shake more. But no one told her to eat. Instead they checked her blood. She faints when her blood is taken. She told the people who drew her blood. People who faint with blood draws need to be lying down so they don't faint. But they didn't lay her down. So she fainted, and then had a seizure. Seizures that occur from fainting are called "syncopal seizures". They are a well known thing. They are one of the "provoked seizures". That is, seizures that are a normal reaction of the brain to a certain stress (like fainting). The reason she had that is that when she fainted, the chair that she was in held her up. If she had fallen down, then she wouldn't have had a seizure (she probably wouldn't have even fainted if she was laying down.) The proper treatment for THAT is to not draw her blood sitting up, making her not faint, and eliminating the seizures. Instead, she was given an MRI of the brain and an EEG which were both interpreted as abnormal and indicating seizures from epilepsy. Epilepsy is two or more UNPROVOKED seizures. That's the definition. So she can't have that diagnosis, no matter what the tests say. I had a great professor who told me "If there's any way possible you should always ignore test results from tests that shouldn't have been ordered. Never order a test that isn't crucial." Well, I should ignore the tests (MRI and EEG), especially if they have some subjective component to them (which these do). So she was placed on Depakote which is a fairly dangerous anti-epilepsy (and definitely NOT anti-syncopal seizure) medication. Luckily, that hasn't made her sick yet. I told her to stop that. The girl just needs to eat some food. Actually, she is a little high strung and she needs to relax a little bit too.
We all make mistakes, so it's going to happen. I have a fabulous patient who had surgery with an excellent neurosurgeon in town. He forgot to put the patient back on his coumadin right after surgery, so he had a stroke. That was a mistake. Our mistakes cause physical harm to people. I've made them. There are different causes. Some people just aren't very good at what they do. There's so many reasons for that. Some of them don't have the aptitude, and some of them have become totally "burned out". Some of them don't care enough, or don't try hard enough. Some are depressed, or they're ill and they don't know it.
Some people are good at what they do, but sometimes they make mistakes. Some of those are going to harm the patients. We miss simple things. We miss details. We go too fast and don't see things. We get tired. We do really stupid things because we refuse to go home with a migraine, or we took a medicine that made us goofy. We get emotional and believe patients when we shouldn't or don't when we should, or don't listen. I think it's us and how we are. We aren't really here a lot. We aren't focused on this very moment with this very person and this very person. We're distracted with all the things that are "stressing us out". We're thinking of another thing when we're with someone. We're carrying too many plates. Life isn't simple. So we should slow down. We should just take a breath. Maybe we should blog. Most importantly, we have to always try to find a way to let go of the past and forgive our mistakes. If it's possible, we should try to forgive the mistakes of the other people too.

Yesterday

It's a good thing to just review the day. Yesterday: F. came in. She is on dialysis from renal failure, had a stroke and has a fairly severe and painful nerve injury from her fistula surgery (the site where they do the dialysis). She just go over a terrible infection. P is a new patient. She is fainting, but no one really knows why. She has had every test in the world. She's very anxious, and can't be left alone. T came. Another new patient. She has developed very severe every day disabling migraines. It's getting to the point where she can't work. P - another new patient. She fell and fractured her head from tripping on a hurricane panel floor brace. She is very much off balance and can barely walk. She has diabetes. I ordered some tests. I think she has a spinal cord problem. L: He's amazing. It's a pleasure to see him. He's had Parkinson's for about five years and looks totally normal. His golf score hasn't changed a bit. This is very rare. D- has Alzheimer's. His wife is starting to get burned out, which most of them do. He is depressed. I added some anti-depressants. I changed his Exelon to the new patch, because he has chronic diarrhea (likely from the medicine). E: Neuropathy. He's doing well. F: She is just fantastic. I see her only once a year now. She's been a patient about six or seven years. She had severe neuropathy pain, but it is totally controlled now. She has a great outlook and is happy. Her happiness helps control her disease. S: He is in severe constant pain. He's had a neck fusion at every level with rods. He has a severe daily headache that's uncontrollable. I changed his medicines. He gets Botox in three weeks. It gives him no headaches for about a month then wears off. M: a new patient. She has severe migraines. She was nearly crying so I think she's depressed, even though she takes Paxil. She is young, and has urinary incontinence. J: She just had back surgery. I'm not sure if it helped. She's in severe pain, which she's had for a couple of years. She is allergic to just about everything. D: He has seizures, but they are well controlled. They think he has "memory loss". I just tested him, and the thinking is still good. D: She had severe neuropathy "CIDP". I have treated her with immune suppression for two years. She is great right now, and I think she's in remission. I'm planning to see her one more time, then she'll be done with me. It's going to be sad to see her go, but it's always nice to "cure" someone. L: He got chemotherapy that caused extremely severe nerve damage. He can barely walk and is in severe constant pain. I increased his Oxycontin, and changed his Keppra. I've been seeing him for a few months. He's definitely better, but still very far from "good". Three patients didn't come - either they cancelled or just didn't show. My technician decided she wasn't coming in because she didn't have money for gas. That's odd, because she just bought a new couch. I'm not sure that's a good reason to not come to work.
That was yesterday. Yesterday was a good day. You battle against disease. It's all about gaining a few inches here and there on the front. If there are one or two "good" patients that's what makes the day feel like there's success. With the others, there's just hope, sweat, creativity, hanging in there, and inches.

Words

It is the nature of neurology to see things that are difficult to diagnose. We commonly see people who seem to have problems that no one can explain. One of my colleagues said to me that if he didn't know what was going on, then it was Neurology. I had a GI doctor consult me for evaluation of a patient who had stomach pain. He couldn't explain why there was stomach pain, so he called me. (I think it was what we call "stress".) Sometimes I diagnose the problem but I've become very comfortable not knowing what's wrong with patients. I've decided that even when I think I know what's going on, I should wonder if I really know. One of the most common mistakes that physicians make is having the wrong diagnosis but failing to question the first diagnosis and come up with a new one. The diagnoses that I make which others (sometimes many others) have not seen are almost all due to language. We don't get a good history. Actually, it isn't really that the doctors fail to get a good history. It's different. It's that doctors fail to properly translate. The patients speak English (for the most part). The physicians think in Medicine. Many times, the languages just don't translate well. For example, there is "weakness". When people say "weakness" it means nothing at all. That particular word means "ZXCDL". What is that? That's nothing. They may as well not have said anything at all. It's the same thing with the words "dizziness" and "numbness". These are common words. You would think that common words like these have a meaning that we all understand. I don't understand these words at all. Neither, I think, do most doctors. Some of them think that they know what these words mean. I see them get wrong diagnoses because they think that they understand these words but they don't. Most physicians think that "weakness" implies loss of muscular power, which would be indicated by the maximum amount of force that a muscle or group of muscles or all muscles can exert against resistance. Patients often think weakness means lack of ability to do what they were previously able to do. This may be due to what we call "exercise intolerance" or easy fatiguablitiy. It is sometimes due to lack of coordination, inability to walk, generalized lack of initiative, or shortness of breath. It may be due to many other things as well. I have twice now fixed "weakness" by treating the sleep apnea that hadn't been diagnosed. So in my mind it meant "sleepiness". In the patient's mind it meant "weakness". It's a communication problem.
Even when we listen to each other very carefully, we don't hear what we say to each other properly. We don't understand each other. We think that we know what we've said, but what the other person hears isn't what we intended them to hear. We live in different worlds with different languages. Every person walks around with their own language. This makes life challenging. This creates conflicts between people. It creates great difficulty with others. When we don't understand someone, we should realize that we don't understand them. This way, we can still have compassion for them. When we don't understand our patients too many of us think that their problems aren't real. We think that they're making it up too much. I very rarely think that patients have psychogenic illness. In fact, I think I'm very bad with that diagnosis. I don't think that many people come to doctors because they enjoy it as entertainment. I think they've found something wrong in their body. We just don't understand them. It seems to me most of us don't even understand our own husbands, wives, children, siblings and parents. We don't understand our friends and co-workers. The "closeness" we feel with some of the people some of the time is directly related to our ability to "connect" which comes from the ability to communicate, to understand each other. When simple words like "weakness" are so hard to understand it's no wonder that we find it hard to get along.

NGESI

These days I'm seeing a lot of patients who are feeling as though they aren't good enough. My wife and I had invented a word called NGESI. Often our language fails to describe reality. So we need a new word. Its derivation is from "Not Good Enough Soul Injury". It is a fairly serious condition. We saw this as a developmental issue which results in a pervasive personality issue. People with NGESI suffer in childhood with degradation that impairs the development of proper self-image. They see themselves as inadequate in all of their interpersonal relationships. They filter reality with a bias towards their own imperfections. The concept has helped with my understanding of people.
Now there is a new nuance. Perhaps it's a NGESI variant. There are several different types of multiple sclerosis. They have a different clinical course and a different presentation. Then, there is transverse myelitis. This involves demyelination that occurs in the spinal cord. But it happens only once. So it's seen as entirely different from MS in which there are multiple demyelination events over time and are not limited to spinal cord but involve brain as well. Still, they share the similarity of being demyelination events. So they're the same but they're different.
I'm seeing people who likely didn't have a childhood onset NGESI that came from upbringing that involved creating poor self esteem (it's usually the result of the childhood abuse-neglect complex). They are developing "late-onset NGESI". Perhaps it is "LONGESI". I'm not sure. These people were doing reasonably well. But the disease that they developed has changed them. They are uncomfortable with being "an ill person". They see themselves as inadequate, because "ill people" are not "good people." Of course, "good" isn't really the same as "healthy". It isn't the potentially synonomous nature of the two concepts that generates the loss of self-esteem, though. It's the essence of our judgements.
In our world it is acceptable practice to judge ourselves and others. We work hard to prove that we are better than this person or that one. We talk about how that person isn't really such a "good" person. We create criteria that determine who is and who isn't "good". Our religions tell us that some people are good. They tell us what determines this.
Yesterday, a colleague told me about his experience working at a Catholic hospital. They had a contract with a very large insurer who required abortion services (it was state mandated) that the hospital couldn't turn down. Turning it down would mean fiscal insolvency. So they agreed to sub-contract with a group at another facility to perform their abortion requests, and they were to pay them directly. This way, they could pay another person to perform the abortions, and it absolved them of any wrong-doing. So they created a distinction between performing an abortion (makes you a bad person) and paying someone else to perform an abortion (makes them a bad person). There are also those who know that people who don't accept Christ as their God are going to hell. That's because they believe you can't be "good" unless you meet this criteria.
There is the western secular world that belives (pretty much, with a few nuances) that those who are wealthy are "better" than those who are "poor". There are advertisers who claim that if you use their products you are "better" than if you don't. It's not that they sell good products anymore. It isn't even that they're selling something that will make you happy. It's actually become that their product is necessary if you want to be a good person. So, conversly, if you don't have that product, you aren't a good person.
This has, for most of us, become a way of life. It is even a "purpose" or a meaning for life. People are dedicated to being "a good person". They work very hard to figure out what that is, and how to be that. They have developed a very complicated set of rules and behaviors that apply. So becoming ill can affect this. It does so by changing our abilities. "Good people" are largely the result of their abilities and performances. There are some other criteria, of course. But our productivity and our capability determine a great deal (for most of us) of our "goodness" as people. If we lose this, we lose our value and our "goodness". This is the nature of the late onset NGESI.
It's a very dangerous, very pervasive delusion that some people are better than some other people. It isn't a reality. People are all people. I've yet to meet a perfect person. The imperfections in people are all about the same. People are wonderful things, though. Everyone of them has a wonderful nature about them. They are just as wonderful as dogs. Some say that's not the case. But I think they are. I think we're a good species.
We don't spend a great deal of our time creating criteria for a "good cat" and a "bad cat". When cats are imperfect, we see that it is their nature. Cats sometimes scratch things. They just don't know that a furniture leg is not good for scratching. It's their nature. Dogs bark. That's their nature. When they awaken us at 2:00 am to bark at a threatening fly, it isn't that they're a "bad dog". (I have heard people tell their dog that it's a bad dog, though. I think they're mistaken, of course.) We can't tell the difference between a good dog and a bad dog. We can't tell the difference between a good cat and a bad cat. We can't tell a good anything from a bad anything: spider, ant, butterfly, cat or dog.
Mice are like people. We can tell the difference between the good ones and the bad ones. When you buy mice to feed your pet snake, it's a bad mouse. When you buy a mouse as a pet for your child, it's a good mouse. A homeless mouse (or wild mouse) that wanders into the home accidentally (no doubt looking for food due to hunger that came about from our destruction of its environment) it's a bad mouse. So we can tell good mice from bad mice. And we can also tell good people from bad people.
Anyway, it turns out that when people are ill, they are bad people. They may have been good people before. That doesn't matter once they are sick, though. Then they are bad people.
Sometimes these crazy rules can upset me. Then, I remember that they were made up by these imperfect people. It's their nature to come up with all sorts of delusions. Sometimes, their delusions can come back to harm them. So they suffer with NGESI. Even so, they're all good mice.

Chronic Pain

Yesterday was injection day. I do all of the injections in one day, primarily due to Botox. If you have left over botox from one vial, you can use it for the next patient. At $500 per vial it seems a shame to waste the left over from one patient. So it was chronic pain day. Injections can help alleviate some of that for a while. But many of us suffer with pain that seems to be permanent. It's not a question of eliminating it. It's a matter of living with it. But living with pain is hard. It seems so strange. We think that there should be a diagnosis that causes the pain with a treatment for that diagnosis. But it isn't like that. There are several stumbling blocks. Some people have pain that is chronic and severe without a very clear cause. Others have a good diagnosis but the treatments aren't very effective. I see so many people who just have pain every day. Most of them just have it all of the time. It's tiring. They tend to develop depression. All we do together is try to reduce it. They try to cope with it. There are articles written about how people do better if they are told that they will have to live with pain. I'm not convinced that helps very much. Some people find solace in knowing that others are "much worse off". Others believe that even this type of suffering has a purpose. It might help to know that everything possible has been tried. Some of us can accept it. Some of us are broken in spirit by it. Narcotic medications help some people. They hurt some people as well. It's a very confusing entity, chronic pain. There isn't very much that I know about it generally because it seems to me that every individual with chronic pain is very different. Stress makes pain worse. That's true for everyone. But stress makes everything worse. Anti-stress is not an easy thing. But there's one thing that I think is true. People need each other. So if we can just "be there" it helps. I don't really do a lot for many people in a medical sense. This is especially true with the chronic pain syndromes. But the patients know that I'm there. They know that I listen. They have a sense that "I'm there". And that's helpful. With a lot of friends and family, they are abandoned. That's because we don't like seeing pain. We don't feel comfortable when someone we care about has pain and there's nothing that we can do. This is also true for many physicians. It's a deep need that we have. We have to help to fix the pain; we have to DO something. But the patients pretty much know that whatever we do, it won't do much. So the doing isn't really doing anything. That's why the doing nothing is actually what does the most. We do nothing, we're just being there. That's what helps. It helps because it decreases the loneliness that comes with the pain. Pain isolates us. I don't mean that we don't have to try everything that there is that might actually decrease the pain. We do that, of course. But it doesn't seem to be as powerful as the not-doing. It's very strange.

Daily Death and Rebirth

A brain is a very interesting fluid and static structure. It is not a computer. It changes on a constant basis. But it's not a software change. There is a simultaneous software and hardware change. It changes chemically and structurally on the basis of our experiences. That's what makes it so fascinating.
When we learn something, we know it. We never knew it before. It may be something that we remember forever. That means our brain has changed forever. We don't have the same brain that we had before that moment. This happens over and over again throughout the day. At the end of the day, we have a very different brain than we had at the beginning of the day. This may be subtle. Even if it is, after a year or a decade the changes are profound. So mentally we have a physically and chemically different brain than we once had.
Our brain isn't the only thing that is changing. If we breath in some of the oxygen that goes into our lungs is absorbed. It is attached to our blood. It then is brought into some tissue - perhaps a liver or a muscle. Here, the oxygen is deposited and may become a part of that cell. When we exhale, carbon dioxide is released. Some of that carbon used to be a part of a cell in our body. The urine and the feces also eliminate compounds that were at one time integral pieces of our body. They made up a part of a cell's membrane or other organelle. So if we could monitor the molecules in our body, we would notice that each day (actually each breath) they were changing. Although you may perceive that your body is the same body that you once had, it isn't. It would be like a car that we took every single piece off of and replaced. It's not really the same car anymore.
We are attached to the notion that we are the same person we've always been. But this isn't real. We are constantly different. The one that we were yesterday is dead. Today we are someone else. We are reborn every morning. We are a new person.
Sometimes, this can be very dramatic. In a moment, when we have a stroke, we are very profoundly different. We have completely died. A new person is born. This is very hard for our loved ones. They are attached to thinking that we are (or should be) the person that we were yesterday.
It's a good idea to meet everyone that we know as a new person every day. We tend to treat people the way we think they are, which is actually the way that they were before. But they've changed now. So we need to treat them differently. It's very bothersome this way. That's because we don't know anyone since they're different this minute than they were last minute.
In medicine, this is critical. Every time a patient comes in, they may have changed their diagnosis. People want to know, based on their disease, what their future holds. But I tell them that any statement that I make regarding their health is only valid until the time they walk out of the office. Bodies and health change very quickly, without warning.
People say to me that they had a stress test and everything was fine. Therefore, they shouldn't have had a heart attack one week later. But it's not like that. That heart attack can come suddenly without warning. We might not be able to see it coming.
When there is a new illness in our family we have to confront this reality. We have to look very deeply at our loved one. We have to meet them for the first time and acknowledge that the person we knew yesterday is gone. And we have to realize that we are also a new person. We have to start all over again. In a way, this is painful. Everything that we've done, that we've created and worked for is gone. But in another way it is also pretty exciting. People get bored with relationships. That's because they fail to see that every relationship is reborn every moment and every day.

Computer Medicine

Computer medicine is certainly the destruction of quality care. It is most unfortunate that we have become entirely dependent on the computer to function. I need to create some reports today, but the computer won't let me access my flash card due to computer PMS. I need to access my medications database which I use multiple times per day to look up things (usually drug-drug interactions since everyone who comes here is on ten or more medications) but I can't. The web site doesn't like some of my cookies. The tech support there wants me to delete all of my cookies, which I obviously don't want to do. I do have a "tech man". He is quite good at what he does, but he can't seem to fix my computer, it is in a state of permanent breaking. He patches up one hole and another one pops up right away. Things are getting worse. There is a powerful move for us to all get "EMR". That is short hand for electronic medical records. It is an undisputed fact among the powerful (the "payors") that EMRs improve quality of care. The research that has been done shows that this is not true at all. There is no evidence to support that claim. What it does do, is it allows more access to medical activity that can be more quickly and easily assessed. It will help insurance companies to gain data on economic activity, but little else. There are computerized models that can assess "quality" based on guidelines. More and more power is being conceded to computerized methodology of assessing compliance with guidelines. But there is a very serious problem with this. Research on guidelines shows that they are not appropriate for MANY or even most patients. They have not been evaluated in the setting of multiple medical issues. We know that we should use beta blockers in heart failure since they decrease death. So that is a guideline. However, beta blockers can be very dangerous for diabetics with neuropathy since they cause fainting and broken hips and head trauma. So when I take them off their beta blockers in an attempt to balance risks and benefits, the computers find out that I am performing "poor quality" medicine. Research on this topic does not in any way support that idea, because no one has done research on how we should treat diabetic neuropathy patients who also have heart failure and present with dizziness that is due to "orthostasis". Since hip fractures have a 30% death rate, it is very possible that these people will actually have an INCREASE in their death rate if we treat them with a beta blocker. We just have no idea. So if we have no idea, and what we do know is that the patient is complaining of dizziness with risk of falling and passing out with the medication he or she is in certain danger from a medication with an unknown benefit. There is really no way to dispute this. However, the computer knows that this is bad quality. Meanwhile, I can't open the documents on my flash card. We can cosider putting the computer outside and driving over it with the Suburban (I'm not anti-environment. I have to have a Suburban due to a very large family). However, there is the blogging benefit. I can blog which seems to help with patient care. It lets me think about how taking care of the patients fits in to the universe. Also, I can get the patient notes at home. This is invaluable. If the terrorists or the hurricanes destroy my office, I have almost all of the patient chart information in the laptop. So you have to love them. But it's an awful state of affairs. It's love-hate.