Yikes... been so busy that I have been unable to finish entries
from over a month ago! Oh well...
Sad story... My department chief came up to me the other day
and told me that "this has never happen in the last twenty
years," but "payroll called me and said that you have
too many hours, and they can't pay you for all them." LOL...
Thursday, October 31: Case of the Month
Patient presented to the ER in Supra-Ventricular Tachycardia
(SVT) at 240. Problematic since he was hypotensive, diaphoretic,
and unable to give a medical history secondary to what appeared
to an old craniotomy scar. Attempted adenosine 12mg IVP without
effect, did some etomidate 10mg, and then cardioverted biphasic
at 120 (I don't believe in 50 Joule cardioverts...especially
when the patient looks bad, and I might have to give succinylcholine
and intubate the patient--there's no time to play around with
multiple cardioverts). Converted the patient to Sinus Tach...
Whew... first time that I have ever shocked an unstable narrow-complex
tachycardia. Had my heart racing for a few seconds as well when
the patient had the complication of myoclonus after etomidate
administration. Etiology... multiple pulmonary emboli and hypoxia...
Great social case...
Taught a 6 year old girl to wave a finger at Mom and say "na
na na na na" whenever she saw mom, who is a diabetic, eat
cookies, crackers, chips, candy, or cola. What better a diet
plan than the social pressure of your 6 year old daughter?
Thursday, October 26: Chief Complaints of the Month
This is what the patient wrote down on triage paper as to the
reason for their visit to the ER...
"bit in litf lign" Translation: Bite on the left
"I thank I'm pregyec" Yikes... not really the patient
you want to get pregnant if they can't even spell "pregnant,"
let alone "think."
"ungrowing toenail" LOL... That was pretty funny...
a little different that an "ingrown toenail"
Favorite statement of the month:
A lady with an ankle sprain, who I informed that I was going
home and that she was being discharged as well, replied with
a "Don't leave, I've got chicken wings!"
...just about died laughing with that one. You can probably
guess the secondary diagnosis...
Wednesday, October 25: Freakonomics and Incentives
interesting book on bizarre topics that you tend not to think
about. Econ and public policy are my favorite topics which I
like to talk about, so reading this book was an imperative.
I particularly liked the analysis of cheating sumo wrestlers...
maybe on one hand because the "sport" just seems so
lame, especially when the majority of the training consists
of eating endless amounts of white rice.
One of the things that I found most fascinating was the analysis
of crime rates. I found it very interesting that another author,
Malcolm Gladwell, had written about the same phenomena in The
Tipping Point, and had come to completely different conclusions.
While I have not read that book, the attributed claim for the
decline in crime rates in NY city was "innovative policing"
strategies... I had long known that best correlation with crime
rates was the male population between the ages of 18 and 25,
so the idea that Roe v. Wade had more influence on crime than
looking at broken windows made a lot more sense. On an aside,
Gladwell wrote probably one of the most fascinating articles
that I have ever read entitled "John
Rock's Error." I think I've read this article five
times... An interesting intersection of modern lifestyle, politics,
religion, and biology...
In my opinion, more books like this need to be written, or
at least discussed in the media... Issues like why there is
a disincentive for poor people to work based on the structure
of AFDC, WIC, Medicaid, and Social Security/Disability. Why
increased spending on poverty does virtually nothing to change
social economic status. Why smaller classroom sizes have only
small effects on student performance. Why Head Start still exists
when has never been shown to produce long-lasting results. Why
car pool lanes actually increase pollution, traffic, and car
accidents. Why no-fault car insurance is still not the law...
The true point of this book is thinking about topics in terms
of incentives and outcomes. Trying to provide welfare/social
programs are fine ideas, but the way in which they are designed
creates an incentive to try and abuse the system. Eisenhower
once wrote about such entities as the military industrial complex,
and in my opinion the new MIC is the social security/welfare/disability
system... I can't count how many times people come into the
ER trying to manipulate the system. As an example, out of all
car accidents, 95% of the people who show up to the ER are the
ones with minor injuries (ie. nothing objective that I can find)
and are the ones who were rear-ended. What about the people
who caused the accident? They never show up. Why? Because the
legal system pays more if you see a doctor. Now I'm not saying
that the person who caused the accident should not pay, I would
simply argue that the use of limited resources (the use of the
medical system and the use of the legal system) and the siphoning
off of money to lawyers creates a whole system of fraudulent
claims. Interesting in that if you slip and fall at a grocery
store, there are pre-arranged guidelines/money that the store
is willing to pay you just to leave and not sue... Extending
this out to a national level, an interesting question arises,
to which I have mentioned before in the past... How is the US
going to compete with foreign competitors when we have such
I'm on a ridiculous rampage with excessive work... Over the
last 5 months I have been averaging about 25 shifts/month. At
this rate I will be very comfortable in about 3-4 years and
hopefully buy a nice house when the market comes down. It still
does not make sense for me to buy a house right now since the
estimated depreciation on housing is about 4-7% for 2007, and
according to the UCLA Anderson School of Business, housing prices
will be flat for the next 5 years (if you believe any housing
"study" these days; talk of the "bubble"
started in late 2002, and much to my chagrin, I believed what
I heard). Of course, a mortgage has a benefit as well since
I can write off the interest... I just need to find the right
amount so that I just edge up to the AMT. Anyway, the downside
to excessive work... physically tired. The one upside, I have
come to the realization that mentally I don't tire out... I
only get physically tired... Maybe I just need to hit the gym
This is an interesting article since it reflects the differing
perceptions between the different generations. On one hand the
"old guard" that believes in discipline and hard work
versus the "new guard" of medical doctors that believes
in regulations and seems less likely to want to work hard. Maybe
its just me, but I find my profession to be an honorable one
that I am fortune to have... That said, I have no problem doing
As a point of note, the people who I noticed get "harassed"
during medical school were the ones who deserved it. There was
always a groups of students who failed to make it to work on
time, did not do a complete history or physical exam, did not
follow up on studies, some who even lied to attendings... Now
what would you as a patient like to have a doctor who was "harassed"
and potentially learned their lesson, or one who was never "harassed"
and allow to do sloppy work and let things slide?
The problem with the med school system was that there were
rarely sufficient remedies for bad behavior.. In fact, I know
one med student who took 8 years to graduate
from med school!?!?!?!? In my opinion, he should have never
been allowed the honor.
Sunday, September 24: Dominos beginning to Fall
Cataclysmic news for the health care industry in LA. MLK which
appears to have lost CMS (Centers for Medicare and Medicaid
Services) accreditation. Which correlates to a loss of about
220 million in funding. Looks like the LA county supervisors
will get their wish (although they will never admit to it).
I can hear the sounds of padlocks coming soon...
This is actually some really bad news... especially since I
work at two hospitals that are relatively close and will get
some spillover. The problem: the typical "King Patient"
is a medical nightmare. Chronic problems, low access to health
care (no health insurance), language and knowledge barriers,
diagnoses, and self neglect. When I was in residency we
called this patient the "crumper"--the person that
reaches your front door alive and living on a razor's edge and
despite all best efforts goes down to ground permanently.
Already hospitals are at a breaking point with not enough nurses,
not enough hospital beds, and excessive paper work mandated
by the ten different regulatory boards monitoring health care.
I still find it a little funny that the regulations (and the
legal system) have made health care so distorted such that I
typically spend probably four times as much time with the chart
than with the patient. This usually means that I only have about
5 minutes to get a history, do a physical exam, and establish
a diagnosis or a working differential. Unfortunately, I would
guess that most people would not understand the implications
of such a change.
I think my biggest gripe about healthcare in general is that
it seems to me (especially in the patient population that I
treat) that the perceptions of healthcare is that responsibility
lies with the physician. A typical quote that I hear: "Dr.
X still can't get my blood pressure right." Meanwhile,
the patient is not compliant with meds, nor monitoring their
blood pressure, and still feeding themselves as if to prepare
for hibernation. I would simply state that patient's often times
do not sound "incentivized" to take care of themselves.
Instead, the perception in LA is that if there is a medical
problem (at least for ER patients), it is the doctor's fault.
Maybe its the entitlement mentality at work, who knows?
Wednesday, September 13: Cases of the Week
Back by popular demand!!! Yep--one person requested that I
write more about interesting cases. So here they are...
Awful olfaction: Yep a good old case of the
nec fasc.. (necrotizing
fasciitis, AKA the "flesh-eating bacteria") Probably the
worst case that I have seen, and we were all shocked that the
patient was still alive! Some diseases have a distinct smell
to them such as DKA (Diabetic KetoAcidosis)--which has a subtle
fruity ketone smell--and for some odd reason I can't detect.
I had one attending during residency who was so sensitive to
the smell that when she walked into the emergency department,
in ten seconds, she would say "who's in DKA?" She
would then look around the room and in another ten seconds identify
the patient simply on appearance with an index finger extended
and pointing at the culprit. It was pretty amazing one time
in that the resident who was taking care of the patient didn't
even know the ultimate diagnosis. However, unlike the aromatic
smells of ketones, nec fasc has the unbelievably nasty smell
that travels. In this case you could smell it about 50 feet
away... the good thing about cases like this, is all you have
to do is recognize the smell and then you know the patient needs
antibiotics that cover anaerobes (the MICU antibiotics: Metronidazole,
Imipenum--aka "liquid Jesus," Clindamycin,
Cefoxitin, Cefotetan, and
Unasyn--or any other synthetic extended spectrum
penicillin with an inhibitor) in addition to coverage for the
Group A Strep (i.e. penicillin G 4 million units) and then call
V-Tach: Had my first true case of stable ventricular
tachycardia of a likely ventricular origin (I'm guessing here
since I don't know what the electrophysiologic studies ultimately
showed, but its highly presumptive based on the history of past
myocardial infarction). Now typically this is a bad phenomena--I've
seen one patient crash from this in 5 minutes, but he was experiencing
"unstable" V-tach with crushing chest pain--memorable
patient from residency who I will never forget--secondary to
crack cocaine (I think I wrote about this patient before in
the past since his memorable last words were "What the
fuck was that!"). V-tach tends to be a "wastebasket
diagnosis" since it is made simply by looking at the EKG
and it doesn't state the underlying etiology. My last patient
with V-tach, I loaded on amiodarone and the patient had a step
down decrease in rate that eventually slowed to an atrial fibrillation
with a rate-dependent bundle brach block. Technically the treatment
algorithm is for V-tach, but the diagnosis was the atrial fib
with aberrancy. Anyway, my recent patient presented with tachycardia
at a rate of 190. Patient had no chest pain so I started a load
of amiodarone 150 mg over 10 minutes. The amiodarone finished
without changing the rhythm, but the rate decreased to about
160. I loaded the patient with another 150 of amiodarone and
still no change. Next in line is cardioversion...and I opt to
talk it over with the cardiologist on the phone...and at the
exact time that I tell him that I had just finished the second
loading dose of amiodarone, and the heart rate was still 150's,
my nurse calls out that the patient went back to normal sinus
rhythm at 72! I then state to the cardiologist, "well it
looks like the patient just converted, so thanks for the call
back" to which he replied "okay sounds good."
lol ...what timing huh?
Crash Airway: I'll finish this entry later...can
never seem to finish what I am writing!!!
Monday, September 11: Observation
Bush was out on the campaign trail this weekend and amazingly
said something that 1) used proper grammar and 2) made some
Basically he stated that we (the US) have to be right 100%
of the time, whereas "they" (the terrorists) have
to be right only once. Obviously its something that everyone
knows, and maybe its needs to be said, but the real interesting
thing about this statement is how true it is for the medical
profession! A great analogy: Doctors have to be right 100% of
the time and lawyers only need to be right once! Ha...
Hence, and albeit with some artistic licence, lawyers must
therefore be terrorists! (or maybe just the med-mal lawyers)
Sunday, September 3: Impressed
This is one interesting
story... a test fire of a missile interceptor was successful
in shooting down an "incoming" missile fired from
The interceptor carried a refrigerator-sized “kill
vehicle” that locked on to the approaching mock enemy
missile and flew into the 4-foot-long warhead at 18,000 mph.
Lehner said both disintegrated more than 100 miles above the
Earth and a few hundred miles west of Vandenberg. The interceptor’s
flight lasted 13 minutes.
I must admit that that is unbelievably awesome... two "small"
objects hitting each other at 18,000 mph... To put that in perspective,
the US is about (according to Yahoo maps) 3,000 miles from Boston
to LA. The speed at which these two things hit each other basically
was fast enough to transverse the US in 10 minutes!
I really enjoyed reading he next paragraph in the article on
"The U.S. move “clearly shows that it is the U.S.
which is increasing tensions on the Korean Peninsula and threatening
war against our country,” the North’s Committee
for the Peaceful Reunification of the Fatherland said in a
I laugh... this is the country that had to do its missile test
firings on the Fourth of July...
Monday, August 28: Missing the Forest
Sometimes I feel like I only see trees. But maybe that's the
only thing I can see when I opt to put my nose to grindstone
so much. I'm not saying that I regret working hard, there are
definite benefits to getting established, and, in my opinion,
its tougher to accelerate work/saving later in life. On the
flip side I could benefit from taking it a little slower and
I did a little reflecting the other day... I think I am the
prototypical male who tends to focus on one task and tries to
complete it before starting another. Kind of odd, since I can
manage an ER pretty damn well. And that is an environment when
the shit can hit the fan and disrupt everything. (Arghh, I already
used three metaphors...can I sound more trite?) Balance in my
life has always been one of my biggest struggles--and its something
that I need to get better at.
Thursday, August 24: Wabi-Sabi
roughly translated means "beauty in the imperfect and incomplete."
While everyone struggles with the aesthetic and the acceptance
of transience such as what is the right balance in life between
esoteric things like work and play, one must not be so concerned
with this trendy little spot in Venice. From a aesthetic perspective
there wasn't much that delighted the eyes with its somewhat
prosthetic expansion in the rear. Maybe it was artificial imperfection
intentionally designed? Probably a meaningless observation since
the real interest in any japanese restaurant is the sushi bar
with its low counters and minimalistic appearance to display
the real intrigue. Either way, it was a warm environment and
even though it was filled with the yuppie crowd that seems so
fake it felt like it was off of the beaten path and a deviation
from some of the uninspiring things in LA.
The sushi menu looked the same as virtually every other sushi
place in the world... "California roll" even flashed
across my eyes and my initial guttural response was slight nausea.
I was always impressed by the places that served no fake sushi,
even though I was always memorized by western creations like
dynamite and the dragon roll even though I know its not real
sushi. Anyway, my experiences at Sushi Wasabi in Tustin, and
Sasabune (prior to it moving over to Wilshire) enlightened me
to the really interesting sushi exploration.
The real intrigue of the menu obviously did not appear to reside
with the sushi. Instead, ordering from the small plate menu
was the fascinating part. To my utter surprise and elation were
a few things that I have never tried before and just absolutely
loved. The shishito
peppers provided a seemingly endless supply of crispy heat.
The mushroom wantons perfectly fried in a luscious sauce. And
finally, the best on the menu, the black cod was unbelievably
good... buttery like a barely cooked chilean sea bass--this,
in and of itself, reason for another visit in a few months to
experience again this transitory treat. The Wabi-Sabi, as I
discovered here, was that good things in life come and go, and
the nostalgia of good eats is only inspiration to do it again.
1635 Abbot Kinney Blvd.
Venice, CA 90291
August 22: I love this stuff...
I'm a huge fan of the UFC... Next up: Sobral versus Liddell.
Opinion: I think this fight will go the way of Liddell, even
though he hasn't been fighting as much as Sobral. The first
fight was pretty good when Liddell kicked Sobral in the face...
Anyways, Sobral's got one of the best ground games, and Liddell
throws some of the best bombs. My impression on how the fight
will turn out: Liddell will keep the match standing up since
he has great ability to keep distance and defend against the
Great picture of Sobral doing an arm bar. His opponent is tapping
Monday, August 21: Satriani!!!
Video of Satriani
in "Always with me, Always with you." Love this song... In fact
it was my "first" song. :)
Here is another video by Satriani: WAR! One of my favorites.
And a pretty good live version too.
August 18: Catch-up
Arghhh... what a week. I think I went way to hard. Sometimes
I question if even know how to take it easy. I know... stupid
question. Having averaged 5-6 days of work per week in addition
to excessive weight lifting and running, really put me into
a tailspin. Did a 4 mile run a few days ago, and then followed
that up by an hour in the gym. Today I am just unbelievably
tired... I think I must be dehydrated since my weight fluctuated
by 6 pounds in 3 days. Also point to self--not a good idea to
have a Trader
Joe's Vintage Ale afterwards (but oh so good). Oh well,
its nothing that a little excess water and whey protein can't
Finally decided on some tires for the beemer. Such a confusing
subject since there are so many different tires with different
performance ratings, wear ratings (UTQG), opinions, and huge
variations in price points. Here is a graph on the
max performance tires from Tirerack. Seems to me that the
Goodyear F1 DS-G3 are the best tire for the money (and they
have a great UTQG rating of 280). Also, Car and Driver stated
that it is the number one tire in their tests (article
here)... even beating out the Michelin PS2. Not only that,
they are about 300 dollars less than the Michelins!!! I think
the unidirectional tread probably will reduce tram-lining as
well which is a problem with low profile tires. Total damage:
$950!?!?!?! ugh. Oh well, got 33K out of my first set of tires.
Maybe that means I hit the apex of turns pretty good?
Interesting cases for the week:
Myocardial Infarction: Professional athlete in his mid 30's
presented with a heart attack! Yikes, makes me want to cut out
(by far the best Cuban food that I have ever tried--and yes,
oh so greasy. As for recommendations: the Lechon Asado and the
Famoso Pollo Versailles). Best part about the case: after receiving
thrombolytics I asked him his pain level to which he replied
2 out of 10. I then asked him what it was beforehand, to which
he replied "2". LOL... No male comes to the ER for
2/10 pain! Especially a professional athlete who is used to
getting hurt. Anyways, after some cajoling he acquiesced and
admitted that it was about a 7/10 prior to coming in...
fracture: Reduced one of these puppies the other day. I
love doing reductions with the finger traps. Basically the Galeazzi
fracture involves the distal radius being fractured and the
disruption of the distal radius--ulnar junction (or the DRUJ).
The fracture is unstable and needs surgery, but emergent reduction
of most dislocations are handled in the emergency room. Because
so much structure is disrupted, the reduction is quite easy,
and is stabilized fairly well with the reverse sugar-tong splint
while the patient is still in the finger traps and there is
sufficient traction to reduce the DRUJ. :) (if you take the
patient out of traction then the reduction falls apart)
Found down: Lots of those good ER stories found with the phrase
"found down." In my experience its typically not a
good sign... Patient presented with an altered level of consciousness
(ALOC) and was oriented only to name. Reportedly, the patient
was not seen for three days, and was found on the ground after
the paramedics were called and they broke through the front
door. Anyway, CT of the brain showed an intraparenchymal bleed
about 5 cm in diameter (another good reason why not to stop
your hypertensive medications). After the CT, the patient started
to have a focal seizure which progressed to a generalized tonic-clonic
and then went into status epilepticus, eventually requiring
ativan, phenytoin, and diprivan to stop the seizures! First
time I have seen an ICH/IPH go into status epilepticus. Eventually
diagnoses: IPH with shift, ALOC, status epilepticus, respiratory
failure (intubation), rhabdomyolysis, renal failure, hypernatremia
(sodium of 155--normal sodium is 140 meaning the patient was
about 7-10 liters dehydrated), pneumonia, and of course, the
thing that started it all, hypertension...
typhi: A kid that I admitted the other day grew out this
stuff... Further proof that LA is a third world nation. :) The
typical vector for this bug, fleas from Rats!!! Yikes!
Thursday, August 10: Update
Maurice Clarett back in the news
again. Wow... this guy is out of control. check out the AK-47...
Great quote: "attempts to subdue him with a Taser proved
ineffective because he was wearing a bullet-proof vest."
Wednesday, August 9: Men not working, entitlement,
the Phillips curve, immigration, and job exportation
Men not working: Excellent series on men
not working the the New York Times. I've always been fascinated
by these social-economic phenomena such as the marriage gap,
education gap, and of course this "men
not working" which is the reversal of the gender gap. To
some extent, this is a scary topic. I'd like to think that people
have at least some motivation to improve themselves, or to have
a greater goal such as possibly raising a family. When you read
this article and find people who are taking out second mortgages
out on their homes to "buy time" before they become
eligible for social security is amazing--amazingly stupid.
Entitlement: I'd have to argue that the idea
of not working at all since you believe that you are more valuable
than the rate that you should get is a dangerous concept. In
my opinion, entitlement thinking is destructive and creates
a victim mentality. Unfortunately, I think that "entitlement"
is highly prevalent in our society. I would argue that if you
took the society of today, and transplanted them into the Great
Depression, the US would simply dissolve away. Okay, maybe a
little too much hyperbole, but it is nonetheless probably an
accurate reflection of the differences in culture that evolved
over time. Maybe to some this is progress, as evidenced by a
to the editor where one person (who is writing a book on
the topic) writes:
Your article is well reported and useful. But why should
we classify as “missing” a laid-off steelworker
who writes novels and plays piano at home rather than take
a low-wage job? Couldn't’t we also classify him as present
and accounted for?
Contemporary America still uses a neurotic measure for success:
how committed a man is to serving his employer, earning the
highest possible salary and exhausting himself by midlife.
What about another standard, rejuvenating himself with family
intimacy and exploration of his own gifts?
I laugh... such a superficial analysis and this guy is writing
a book? Like "rejuvenating himself with family intimacy
and exploration of his own gifts" is exclusive of supporting
himself. What is the next book? The value of leeching off of
the welfare system when you are fully capable of working yourself?
Other lines like "how committed a man is to serving his
employer," are great examples of the change in work ethic.
Instead of thinking of it as "serving his employer"
how about calling it "work to make money"? And how
about arguing that one must "[earn] the highest possible
salary [by] exhausting himself in midlife"? For one, I
don't think that the person they are talking about here is exhausting
himself sitting on the porch. Maybe lines like this prove the
point that anyone can write a book...
However, that response was much better than the next lady writing
"The surest way to help these men (and women) is to
pass anti-age job discrimination legislation." Huh???
One of the interesting thing about this article is the graphic
on the left hand side of the page that charts the number of
not working men over the different decades. Men appeared to
work hard in the 50's and 60's, there was a small change in
the 70's and up into the 80's, 90's once the women's liberation
movement went into full swing. But now, in 2000 and even substantially
more in 2004, men seem to have fallen out of the work force.
It seems to me that just by looking at the graph, over 15% of
men aged 30-55 are not working and maybe not even looking for
Phillips Curve: Economically, and politically
to some extent, the unemployment rate has been low, which is
one of the few reason why the fed was raising rates. But it
now appears that this is a very deceptive statistic. Basically,
this is the relationship between interest rates and unemployment
(which for some reason I seem to talk about a lot) known as
curve. Still a theoretical curve which describes the inverse
relationship between unemployment and inflation. The interesting
thing about the calculation of the unemployment rate, however,
is that it is the number of people who are out of work and who
are looking for work, not those who have stopped looking for
work, as in what seems to be referenced in the article. Therefore
they are classified as "missing."
Immigration: Politically, both parties have
taken a different approach with the cited "low" unemployment
rate. Democrats on one hand say the Bush is doing a horrible
job on the economy, such as issues with job exportation, deterioration
of real wages, yet the measurement of the GDP continues to be
strong and unemployment "low." (we will have to wait
until the full effect of the oil cost have trickled into the
economy) Republicans on the other hand, tend to claim that illegal
immigration is pushing people out of work or taking "american
jobs", yet the unemployment rate is "low" so it seems
that that argument is not completely true. Obviously, both parties
are using the same datum and spinning it both ways, with the
truth probably located in the middle. The GDP remains strong,
yet the "low" unemployment may not necessarily be
low because the way in which the unemployment rate is calculated.
Ultimately, common sense wins this argument: The unemployment
rate is not low (unless the graph on the article is wrong) and
excessive immigration (in blue collar jobs) results in depression
of wages to the extent that people who used to work in those
traditional areas now state that they don't want to work for
Job exportation: On another note, reading
this article probably explains, in small part, why some manufacturing
companies are exporting jobs to other countries. In reality,
there is little way in which the US worker with the entitlement
mentality can compete with foreign competition. While overall,
I think Americans tend to be one of the hardest working developed
economies, there are definitely things that we could do better
to retain these jobs--develop some gratitude for the ability
to work (some people leave their own nations and cultures to
work here), decrease the cost of doing business (reform of legal
liability, and supply-side changes to health insurance policy),
and remove some of the incentives and disincentives to stay
unemployed (welfare reform--always a politically dangerous topic,
but really the people in this article could be working if they