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Thursday, November 9: Catch up

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 case.

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 leg.

"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

Freakonomics... 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... etc.

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 inefficiencies?

Anyway... I think I'm getting way off track... Next book: Naked Economics

Thursday, October 19: Recovering...

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 harder....

Interesting article in the last month on med school: U.S. Medical Students Endure Daily Harassment

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 the work.

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, dual 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 surgery. Dispo'd.

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 sense!!! Wow.

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 Alaska.

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 "Pyongyang reacts."

"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 statement Saturday."

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 relaxing.

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

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.

Wabi-Sabi
1635 Abbot Kinney Blvd.
Venice, CA 90291
(310) 314-2229

Tuesday, 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 take down.

Great picture of Sobral doing an arm bar. His opponent is tapping out...

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.

Friday, 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 cure..

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 the Versailles (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...

Galeazzi 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...

Rickettsia 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." LOL

ESPN describes Clarett as a "spectacular flameout."

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 letter 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?

Terry Lee

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 in:

"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 work! Yikes!

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 the Phillips 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 depressed wages.

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 wanted).

 

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