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Thursday, April 29: Beer Floats

The Kuru has advanced to a whole new level... Yesterday I had a little bit of the sweet tooth and decided to throw in some "dulce de leche" Breyer's Ice Cream into a San Miguel Dark Lager... ahhh the taste of nuts, soy, and sweet caramel... Call me crazy, but it was actually pretty good. It didn't go together as well when I tried it with the Guinness Extra Bitter Stout even though the Guinness Extra Bitter Stout Ice Cream (an Emeril recipe) is actually pretty damn awesome.

I recommend pouring a warm dark beer into a glass and mixing it a little bit to get some carbonation out. Next add a little ice cream and mix to remove more carbonation. If you don't, the foam from the ice cream mixed with the beer with make a HUGE head...

...and yes, its better than a root beer float ...especially if you have Kuru.

Kuru is a spongiform encephalopathy similar to Mad Cow disease. Kuru was spread by the endocannibalistic funeral practices of the Fore. Family members were ritualistically cooked and eaten following their death, with the closest female relatives and children usually consuming the brain, which was the most infectious organ. (from eMedicine)

Thursday, April 29: Overwhelmed

Ugh ...I've got way too much going on. Its crunch time with only 60 some odd days left in residency and I still have yet to come up with a research project. My first project was shot down by the ultra-conservative IRB (Institutional Review Board) which I unfortunately wasted about 80 hours of work. I'm actually still pissed off about it since my original project would have been approved at every other institution on the planet.

Also, I still have yet to figure out where I will be living next year...buy a house? Accept full time at one of my moonlighting hospitals? Still need to figure out if I need disability insurance. Prep for the oral boards in Chicago for November. Establish myself as a corporation.

Recently however, I think that I will do a Locum Tenum in Hawaii and live there for a few months... Ugh...so many decisions so little time. I think that I will slow down a little on the moonlighting a bit more...try to figure some of these things out...

Monday, April 25: Ha!!! ...still got it...

So I was fooling around on a game of chess today...did the Four Pawns attack... an overly ambitious attack that usually catches amateurs by surprise...but is otherwise a pretty crappy opening (in my opinion)... Anyways I screwed up and went down a rook but then came back with a queen pin, a minor sacrifice, a discovered check, and then a forced mate with his King trapped in the corner! I laugh...

Damn I'm nerdy... :) Oh well, at least I don't have Fragile X Syndrome like Alywn...

Here are the moves (I'm white):

1. d2-d4 g7-g6
2. e2-e4 f8-g7
3. f2-f4 d7-d6
4. g1-f3 b7-b6
5. c2-c4 c8-b7
6. b1-c3 g8-f6
7. c1-e3 o-o
8. f1-d3 c7-c5
9. d4-d5 b8-a6
10. a2-a3 a6-c7
11. b2-b4 f6-g4
12. d1-d2 g4xe3
13. d2xe3 g7xc3+
14. e1-f2 c3xa1
15. h1xa1 e7-e6
16. h2-h4 e6xd5
17. c4xd5 d8-f6
18. a1-h1 h7-h5
19. d3-c4 f6-b2+
20. f2-g3 a8-e8
21. e3-d3 a7-a6
22. b4xc5 b6xc5
23. h1-b1 b2-f6
24. b1xb7 f6-d8
25. e4-e5 d8-d7
26. e5-e6 f7xe6
27. d3xg6+ g8-h8
28. g6xh5+ h8-g8
29. h5-g6+ g8-h8
30. g6-h6+ h8-g8
31. d5xe6 d7-e7
32. b7xc7 e7xc7
33. e6-e7+ f8-f7
34. h6-g6+ g8-h8
35. g6-h6+ f7-h7
36. h6-f8+ e8xf8
37. e7xf8++

Saturday, April 23: The Da Vinci Code

After seven years of only reading medical textbooks and literature, I finally put them down and picked up a book for entertainment. And what better a book to pick up than the Da Vinci Code!

Yeah, so I'm on page 40...which took me about an hour and a half! Oh my God... I must be the slowest reader ever. Granted I've been only reading information-intensive medical related stuff and I've probably conditioned myself to read slowly and try to understand everything prior to moving on. Otherwise there is no point if you have to read everything more than once... If I only believed that myself. Some of the medical stuff has taken up to 4 reads to fully understand and compare to other disease processes to make accurate diagnoses.

I knew I was in trouble when after reading the first page, I stopped and asked myself... "okay, what is going on." Ahhh, how lame can I get... Not only that. I think I have the inability to sit still for very long. Some people might think that that is a symptom of ADHD, but I don't have any problem concentrating for long periods of times ...which, I must admit, sometime is too strong and I neglect other things that are going on. For some odd reason, after finishing a chapter I'm up at the refrig grabbing another Old Rasputin Russian Imperial Stout... I feel like Barney from the Simpsons. j/k

Anyways, I'm doing my last night shift tonight in a stretch of night shifts...28 days with some moonlighting interspersed, albeit a little on the decreased side. I am so sick of nights... I need more sleep now that I am hitting the gym a little harder. Anybody want to prescribe me some roids???

Thursday, April 21: Words of Encouragement

...a response to my April 15th entry:

Yes there are interesting women in LA. However, after the age of 30, women are like parking places at the mall during christmas season, all the good ones are taken and the rest are handicap.

Thanks for the help...

Saturday, April 16: Doppelbock

I salivate... just had the Celebrator Doppelbock. Very odd... I used to not like beer that much. In college I drank mostly Jack Daniel's and Blackberry Brandy. In med school, I was pretty poor, and when we went to the pool hall I'd order double Kamikazis...at a fricking $8 bucks a pop. Needless to say, I was forced to start drinking beer ...albeit the yellow brand...the kind I don't like. Too bitter for me, its a good thing that I found the dark ales and then the more complex beer like the doppelbocks...

Next conquest: Find some beers from the Kuhnhenn Brewing Company... I want to try the Kuhnhenn Raspberry Eisbock...ahh that sounds so good. Also that Fourth Dementia sounds good as well... "falling deep into dementia"

Saturday, April 16: Zone 3

So this guy drives up in the ER with a gun shot wound to zone 3 in the neck ...almost a theoretical wound being that the zone is so small. (above the angle of the jaw yet lower than the temporal bone and anterior to the sternocleidomastoid muscle) So he is completely with it and his only complaint is that he can't breath well. ...Amazing since this is where the external and internal carotid arteries and veins live, not to mention some important nerves.

He refuses to lie down on his back (he's on his stomach) so we can even take a look at the wound and assess his airway. We try to move his tattooed body into onto his back but he fights us since he has difficulty breathing. As we are struggling to place him on his back, he tells us to "fuck off" and then he flashes his gang signs!!! Oh, how funny things can be in the ER. We really needed to know which gang you belong to...

Turns out that this is not an uncommon event. A coworker of mine, Dr. Geirahn, was treating patients in the pediatric department when he got flashed gang signs from a two year old kid! The mom then yells out "I told you not to do that! Oh! I'm going to kill him!" ...referring to the father who had been teaching the gang signs to the kid. Ha! I laugh...

Anyways, the extent of Gang Banger #1's injuries: only airway and hypopharynx ...the bullet ended up lodging in the the submandibular space of the mouth. No spinal cord, no vascular, and no nerve injury...he will live to gang bang another day and possibly rob you at gunpoint. :)

Friday, April 15: Are there any women left in LA with some ovaries?

I think the next time I go out on a date with a woman and find out that she is either vegetarian, is lactose intolerant, doesn't drink beer and orders another fricking green tea, I'm going to scream. The last potential candidate that I went out on a date with said that she didn't eat spicy food, drink alcohol, or eat raw fish... Next, I find out she has virtually no hobbies, interests or sports with the exception of shopping...how dull can you get??? Good looks only can get you so far ...are there any interesting women left in LA?

Friday, April 15: Semi-Interesting Case of the Day

A middle aged male with a history of alcohol binges presented in Atrial Flutter...rate 145 and stable vital signs and symptoms. The patient's QRS was narrow so I gave him some adenosine and make the diagnosis...even though it was readily apparent on the rhythm strip (adenosine is one of those really interesting drugs since all it does is stop the heart for about 5 to 10 seconds). I next give him diltiazem 20 mg IV push. heart rate slows to the 110s, but jumps up to 145 in about 10 minutes. I repeat the dilt dose at 25 IV push and give him some dilt 60 mg PO. Also I figure out that he is going to be a tough one to control so I start a digoxin load. Heart rate drops to about 100 but is again right back up there at 145 in a few minutes. I start a dilt drip at 10 mg/hr and throw in another dose of the digoxin. I hand him off to the internal medicine doctor... "Atrial Flutter--difficult to control."

Internal medicine calls the cardiologist down to see the patient. The cardiologist proceeds to start a THIRD AV nodal blocking drug ...metoprolol. Heart rate comes down to 90s but then is up into the 130 in a few minutes. Next he gives ibutilide and another dose of metoprolol waits for 10 minutes without a chemical conversion. Hah! the last time I saw ibutilide used was in med school... :) Anyways, nothing works on this guy, so we give him some versed and morphine and zap his chest at, believe it or not, 120 joules biphasic. ...back in sinus at a heart rate now at 40... :) Ran the full gambit on this guy...

Wednesday, April 13: Lambic

I went running yesterday, but instead of heading north along the beach like I normally do, I headed south. After years of being a slave to the grindstone, I finally feel like I have little more control. And running south seemed to me like I could change some things in my life ...however lame that may sound. Living with purpose is tough, and constantly challenging yourself to do things differently or to look at life's issues and really analyze why you do things the way you do is difficult. I'm not the most introspective person...

I woke up this morning to make an omelet breakfast, had some orange juice, and an avocado as a side with kosher salt sprinkled on top. My muscles were sore...too much stress and too little exercise and sleep in the last few weeks. It was a nice change of pace.

Anyways, I am totally enthralled with the Lambic style naturally wild top-fermented beers. Turns out the brewers make their brew and leave the stuff out in the open ...yeast in the air eventually ferment the wort prior to placing it in a cask with a fruit where a secondary fermentation process occurs over a few years. This stuff is just awesome ...I would drink it every day for the rest of my life if I could afford it. I got the peche, kriek, and the framboise styles yesterday... Eventually, I think I will start buying this by the case. :)

Varieties that I got... (this stuff is expensive)

Lindeman's Framboise Lambic
750 ml
$10
Lindeman's Peche Lambic
750 ml
$10
Framboise Boon
355 ml
$9
Kriek Boon
355 ml
$8
Melbourne Bros. Apricot
355 ml
$5

...Interesting article of the week: Wages Lagging Behind Prices

Tuesday, April 12: Random

Best Program Ever!
Windows XP is full of problems and the more you use it the worse it gets. Have no fear ...Registry Mechanic is here. Ran this program and it fixed about 150 registry errors ...errors that Norton Systemswork didn't even find. Now three programs that I was having problems with work perfectly.

Peak Oil Question:
The problem with oil is two fold. Obviously it is a resource that is in limited supply and the world will eventually run out of it. Sure we may have it for another hundred years, and therefore some argue that it won't really affect us or the next generation. The problem that we are facing right now happens to be a supply-demand problem. Peak-oil actually refers to the maximal rate at which the crude can be pumped out of the ground. In the past few years, OPEC has been able to increase the rate of production to match demand and keep prices low. When demand starts to exceed supply the price will rapidly increase since oil happens to be demand-inelastic. Because of the inelasticity of demand for gasoline, it is likely that the price for a gallon of gas will go up to 4 dollars a gallon and even higher in the coming years. The impact that this will have is very significant since every product and service has the cost of energy somewhere in its production and distribution. Essentially its a cost-push inflationary pressure which will make the trade deficit greater and the greenback weaker.

Framboise Lambic:
Wow! this is one of the most flavorful beers that I have ever had...in fact this has rapidly become one of my favor drinks after only one try. This happens to a raspberry malt beer from Belgium ...I'm heading over to Mauries today to get some more!!!.






Monday, April 11: Shift...

Somehow, I totally screwed up this weekend. I accidentally put a moonlighting shift in between two of my normal shifts (in a three shift night stretch). Basically I did almost 50 hours of work with about 10 hours of sleep in between ( a scheduling snafu on my part). Not that big of a deal ...prior to the regulation of med school and residency work hours, I had three months where I put in about 110 hours a week for a month. ...So I'm used to squeezing the adrenals, but a few months went too far and probably made me a little less interested in pursuing medical carpentry (i.e. ortho...I love the surgeries but couldn't stand wearing all the garb). Now the weird thing is that I just came off of work and I'm only slightly tired... I don't know what it is, but whenever I see the sun out I find it almost impossible to sleep...

On a different note, I will have to admit that there definitely is a component of stress to the job, and I feel like I've probably stressed myself too much lately because I often don't know when to say "stop." On one hand, its good because I learn about my limitations, but on the other hand I know its not the healthiest thing to do.

Today is actually the day where we shift responsibilities. The first year resident moves to the critical area in the emergency room, the second year runs the whole show, and the third years just make sure nothing really bad happens. Yeah, if only it was that simple... Being the supervising resident is brutal, ...managing up to 20 patients at a time, supervising two interns and a few second years, making sure everything gets done, getting interrupted incessantly and asked questions all the time is just nuts. Its an odd sensation to have three people asking you questions at the same time. I will enjoy the peace and serenity... ...serenity now! :)

Friday, April 8: Taxes Done

Woohoo ...taxes done and my HSA is set up (I owe more money--awesome). This will be the last year that I will be able to contribute to a Roth. :( Also been very lazy with the financial stuff...need to set up my independent contractor status because I need some write-offs!!!

Thursday, April 7: Peak Oil

...Speaking of gas, I was actually entertained a few weeks ago when the concept of peak-oil happened to find its way onto Alias.

Needless to say, this is a very scary subject and it appears that we are heading to some extent in that direction. I have a difficult time trying to remain optimistic for the future when it appears that the cost of oil will likely double in the next two years (according to a few analysts). And with medicare, medicaid, social security going bankrupt in due time, I can't imagine a future that is better to live in than the one we have now.

My only wish would be that society and governments face these facts and start doing something about it. Unfortunately, I think most people and politicians only live in the now and don't really plan for the future.

If you don't know what I am talking about, do a google search on "peak-oil"... Its a chilling read.

Side note: ...okay... so I drive a car that get about 25 miles a gallon, but even if I never used another drop of gas from here on out, it wouldn't change anything at all. The answers to these problems are global...

MSN articles: Can the U.S. stop using oil by 2050? Why gas prices will keep on rising

Thursday, April 7: Woohoo! The beemer is back in business...

...yeah, maybe I should write about something other than my car, but lately things seem like they haven't been going that well....

Anyways, BMW replaced my whole clutch...the pressure plate, the throw-out bearing, and of course the clutch. They didn't say if the clutch was just glazed from to heavy of usage or there was some defect in it... All I know is that I should be able to abuse an organic disk pretty damn heavily without it developing problems. I guess the next time that I'm in the mountains, I probably shouldn't be at 3500 to 6000 rpms for the entire drive down the hill... :) Either way, I'm happy that there is no annoying squeaking noise and I no longer have to drive around in a crappy base-model automatic 325i loaner car...the thing felt like I was driving a Honda...

Side Note: Prior to dropping it off, I launched the car a few times... Feathered the clutch in at about 2500 rpms and that thing shot off the line... :) I think I would run into trouble with a more powerful car... That or the cost of gas would just get too much...

Sunday, April 3: Reasonable Doubt Argument???

One of my favorite political analyses pertains to that of nature versus nurture. Back in the early nineties, conservatives argued that there were biological reasons that women should not be in the military, claiming that they didn't have the right temperament (read this as the inclination to go out and kill people) ...basically arguing that it was not in a woman's nature to kill (which I happen to agree). But when it came to homosexuality, conservatives would argue that this was a choice based of the environment in which a person was raised (which I disagree). Liberals, of course, said the opposite. Women didn't go into the military like their male counterparts because society "conditioned" them into being passive since they were given dolls to play with instead of fake guns (the premise for which I obviously disagree). Likewise, homosexuals were born homosexual (which I agree) and didn't become homosexual because Johnny was given a doll to play with. So for different issues, the nature vs. nurture argument was bent for whatever political stance the pundits on the left or the right decided to take.

Well, its seems to be happening again... Of course now its with the Schiavo case. Some conservative argued the case for life based on "reasonable doubt." Huh?!?!? Out of all the legal crap they decide to chose, they pick the one the one term that they have been lambasting forever. I, of course, agree that the standard of "reasonable doubt" has been incorrectly interpreted and I'd argue that probably 70% of the population doesn't even have the CAPACITY (yes, you read that correctly ...capacity and not capabiltiy...okay, maybe I don't have too much faith in people) to even understand what it means...(go read my blog from the archives section). Sure it is nice to attack on principle, but don't attack on a principle to which you yourself would argue is a flawed one. It makes an interesting point...but the absolutist view of the world is pretty damn narrow.

Of course, its easy to understand the logic... There is obviously a spectrum of capacity, ranging from normal intelligence to mental retardation to dementia to persistent vegetative states to fricking comas. But if the "reasonable doubt" argument applies to this in the way that conservatives (in this instance or defense lawyers in all instances) have implied it, then nobody should ever die. My patient the other day with two bullets though the brain that crossed the midline (each of which individually carries a mortality rate of 99.99%) conceivably has a "reasonable doubt" that he is not dead... i.e. like a 1 out of a hundred million chance. So should I really spend millions of dollars to keep his heart and lungs working while he descends into DIC and insipidus? I don't think so...

How about the other end of the argument? ...maybe it is more reasonable the Schiavo only felt pain? This actually sounds more plausible to me than her having a personality... Anyways, somebody please remove "reasonable doubt" from our vocabulary....only the simple minded spew such nonsense...

Saturday, April 2: Diagnosis of the Week

Ovarian Torsion: a twisting of the vascular pedicle that interrupts blood flow to the ovary. Eventually leads to necrosis of the ovary and possible infertility.

The patient was actually seen the day before and was sent home. ...return visits are always a warning sign. Anyways, this patient had the perfect story. Intermittent abdominal pain lasting 30 minutes with nausea interspersed with pain free intervals. No Ultrasound needed here. Told the ob/gyn doc and he said it was a good story....he took her to the operating room and called me back..."completely torsed." Woohoo!

Side note: Favorite Diagnosis about 2 months ago: Serum Sickness


Saturday, April 2: Things I learned last night

Two bullets can go through the SAME hole in the head and take completely different paths. I was pretty impressed that DIC (disseminated intravascular coagulation) occurred so rapidly.

Don't smoke crystal and the rock at the same time. ...incessantly yelling "Nacho" only lands you in hard restraints.

Squirrels. Damned Squirrels... Overrun by them again!!! Seems like the heat brings them out of the woodwork ...you almost wish it was winter.


Tuesday, March 29: Frayed Ends of Sanity

Somehow I have developed a knack for trying to do to much... I was so fatigued yesterday, too much running, gym, work, and not enough sleep. Fortunately, I've got the day off today and I'm just going to sit on my balcony in the sun and relax... Maybe I'll go buy a book ...haven't read a fiction book in ages... My body needs a vacation from my brain. :)

Struggle within
Triggered again
Now the candle burns at both ends


Friday, March 25: Trach and PEG

I worked my final Neurosurgical ICU last night. I felt like I had to get one last moonlighting shift in before the service was taken over by the anesthesia department. That being the case, I'm glad that I will never have to be on call again, but I also feel conflicted because it was a great experience that really solidified my understanding and management of neurosurgical patients, better enabling me to manage neuro patients who present to the emergency room in their whacked out conditions.

Unfortunately, the gentleman in the second room still happened to be there from when I last saw him a few months ago. A young man with a wife and children got in a pretty bad car accident and sustained a severe brain injury with what appears to be secondary anoxia from apnea as well. I felt horrible when I explained to the family when he initially came in that this was most likely not a reversible event. The only thing that still works on him is that damn brain stem. And his only medical issue has been trying to get him out of the hospital...no facilities to send him to since LA is overwhelmed with expensive long-term vent dependent patients. I'm sure we have spent about a million dollars on him to keep his heart, lungs and kidneys working...

The guy in the second room reminds me of the Schiavo case ...a horrible case in itself. there are many similarities. The family says he tracks with his eyes, and responds to noises, etc... Anyways, being that I am a "blogger", and the "blogs" have been going wild with commentary on this case, I feel like I should throw in my two cents as well.

In my opinion, the ability to think, understand and interact is what makes a human a human being. Without the frontal lobe, there is no personality, there is no interaction, there is no person. The movement of eyes to loud noises is a brainstem function. Even the withdrawal of pain is a primitive brainstem function with its interpretation being in the cortex.

As a society, I don't think that we promote humanity by simply doing everything to keep people alive. Quite the contrary, as doctors we sometimes take humanity away by some of the horrible things that we do...like keeping some people alive who should otherwise die.

The worst case that I saw was that of an end-stage multiple sclerosis patient in Detroit. This old lady was essentially quadriplegic, couldn't talk, couldn't swallow, and probably only felt pain--but had no ability to prevent it or tell others to do something about it. The only thing that indicated to us that she was in pain was the grimace on her face. She was admitted from her nursing home for sepsis secondary to pressure ulcers. This lady unfortunately had a family who received and cashed her social security check on a monthly basis. The family wanted everything done to keep her alive to keep those checks coming in the mail, yet never once came into the hospital to visit her. Fortunately, the infection was overwhelming and she took the opportunity to end her own suffering, despite our retarded efforts demanded by the fucking family to keep her alive. Sorry again for the profanity...but I felt like calling the social security administration to suspend the payments. Maybe then the family would do the right thing and let her go peacefully instead of inflicting more pain on her.

Not only is this issue about what is right and wrong... the other question about the Schiavo case centers around who is paying for this? Is it society's burden to keep a brainstem alive at the cost of about 100-200K per year? Couldn't we be spending this money on "the children." (I hate that line. Seems like every political issue now centers around that stupid tag line). But in all seriousness, living wills, power of attorney, and other legal mumbo jumbo set aside, there is no point.

Sure a distinction needs to be made with mental retardation patients since there needs to be some protection there. But we're not talking about mental retardation, we're talking about persistent vegetative states ...a condition where this is no meaningful interaction with other people or the environment. And if a persistent vegetative state has been diagnosed, I don't really care what the power of attorney, living will or whatever says ...there is no person there anymore. Its time to let go...

Side Note: If I ever am diagnosed as being in a persistent vegetative state, for God's sake, remove the tubes, yank the IVs, and pull the cord. Throw in a hefty dose of the barbiturates, let my brainstem get high, and for heaven's sake, throw in some benzos for good measure....and hell give me the rocuronium.

Wednesday, March 23: Arrgggh!

One of the best parts of snowboarding a few weeks ago was the drive in the mountains in the Performance Package 330i BMW. Lowered and with a stiffer suspension, this thing was a blast to drive. Dropping it into second and pulling through the turn at 60 was just nuts (I love engine drag...tach hit about 6K). I could feel the subtle adjustment in the back end as it slid out and corrected thrust angle. What an amazing machine!

Unfortunately, a day later I noted a squeak in the clutch when the car was not warmed up. Clutch feel otherwise is normal, but I wonder if I burnt that organic disk up. I actually did more reading and found out that the PP 330i does have a lighter-weight flywheel so that may account from some of the squeak. In addition, turns out that I burnt off 1 1/2 quarts of synthetic 5W-30! Either way its going into the shop...its a performance machine and there is no reason to have a squeaking clutch with so few miles on it... Oh well, can't wait until I see the bill for replacing the tires...at this rate I better do a little more moonlighting.

Also, I'm still trying to figure out the optimal front tire pressure. The car was shipped with a 32 psi in the front and a 34 psi in the back as far as I can tell. At these pressures, I had three episodes of push understeer...one with Dynamic Stability Control off and two even with it on! At 26 psi, there was actually a little oversteer...so maybe I'll drop it down to 30...


Monday, March 21: Beer Analysis

Beer Analysis
Rating
Samuel Smith Imperial Stout Russian Imperial Stout--Rich tasting smooth beer. Excellent. Already one of the top rated beers...Need I say more?
5
Bert Grant's Imperial Stout Russian Imperial Stout--pending
p
Samuel Smith Taddy Porter English Porter--Very good...but I think I liked the Original Flag Porter was better. ...of course, the Taddy comes in a 550 mL bottle instead of the normal 355...which helps drown out those daemons. :)
4
Samuel Smith Oatmeal Stout Oatmeal Stout--Hmmm, I know I drank this one...but I was already pretty buzzed...so I don't remember it that much. I've had this one before and I know its a great beer. I'm discovering that I love malt and oatmeal flavors....
4.5
Young's Oatmeal Stout Oatmeal Stout--Arrrghh ...I feel like Barney on the Simpson's by now. Very rich taste. Can't figure out which one is better the Sam Smith or the Young's...
4.5
Young's Double Chocolate Stout Milk/Sweet Stout--Ahh...so good tastes like chocolate. An old favorite with a rich deep flavor. I don't think I can decide which one is better..the Mackeson or the Young's...
5
Stone Brewing Old Guardian American Barley Wine--Okay...the last in my Barley Wine Style beers...this one was not that bad. Very strong and not as smooth as stout, but not overtly bitter like the Talon or the Sierra Nevada. I liked it and I'll give it a 3 even though I won't be getting it again... especially since its 4 bucks a bottle.
3
Stone Brewing Arrogant Bastard Ale American Strong Ale--pending
p
Paulaner Hefe-weizen Hefe Weizen--This was a nice hefe. Smooth and easy drinking. In my opinion could use a little more wheat taste. Even though you are not supposed to put a lemon in a hefe, I think that it would make it a little nicer.
3.5
Schneider and Sohn Schneider Weisse Hefe Weizen--Very good. Better than the Paulaner. The German Hefe-weizen have a more of a stronger aftertaste. I think I like the Redhook and the Pyramid better.
4
Aventinus Weizen Eisbock Eisbock--If one word described this one...its "strong." This one had the highest alcohol content of all the beers that I got...12%. Basically, an eisbock is a dark beer that is frozen and then has some ice removed so it is a concentrated beer. This eisbock was not as rich as a oatmeal or a milk stout or a Chimay, but it was dark and had a powerful and unique flavor ...definitely not as smooth. This is a good potent beer and probably a nice beer to have once in a while, but its not a regular drinker.
3
Mackeson Triple XXX Stout Milk/Sweet Stout--Now this beer caught my attention. Very sweet and full of flavor and extremely smooth. Almost like a chocolate stout. In my opinion, this would make an excellent desert beer. I'll definitely be getting this one in the future. Excellent price as well at Trader Joe's.
5
Sierra Nevada Bigfoot Ale American Barley Wine--UGH!!! Nasty Beer. I could not finish it. Supposively, this is a beer that needs to be aged prior to drinking to get rid of some of the rancid bitterness--Mine had a 2005 label on it. But am I really going to buy these and leave them somewhere for a year??? Come on... This was the first barley wine that I have tried. I hope the rest are not similar because they will be going down the drain if that is the case.
1
Grant's Mandarin Hefeweizen

Hefe Weizen--This Hefe had a fake orange taste to it that overpowered the rest of the beer. Drinkable, but just not that interesting since there was no balance. I'll stick to my Pyramid Apricot Ale for my wheat based beer with an interesting brew.

2
Celebrator Double Bock Beer Doppelbock--Probably the best beer out of the whole bunch (number 21 of the highest rated beers from beeradvocate)... It better be since it was $3.50 for one 12 oz beer. But cost aside, this one was smooth, rich, complex and powerful. Puts yellow beers to shame... If it was more affordable, I'd probably get some more, but I think the the Spaten is an excellent choice as well.
5
Spaten Optimator Doppelbock--Wow! This was one of the first beers that I tried in my beer tasting. Initially after my first sip, I was shocked...this was one potent beer. Very complex in flavor. After getting over the initial shock, the rest of the beer was an adventure...each sip was different, rich, and flavorful. The Doppelbock is definitely an interesting beer.
5
Talon Barley Wine American Barley Wine--Yikes! After trying the Sierra Nevada Bigfoot Barley Wine Style Ale and disliking it so much, I had to figure out if the Sierra Nevada was just an aberration, or the taste was bad throughout this category. Unfortunately, I happened to hate this beer too. I don't know why...but maybe because I am what is called a "super taster" (basically, a person who has has a taste sensation for bitter foods, with the hallmark food being brussel spouts...uck!). Again, this was one bitter beer that was difficult to drink. I think I would prefer a Jack Daniel's or some shots of tequila over this. ...so far 0/2 in the Barley Wine class. ...any body want the rest?
1
Guinness Pub Draught Irish Dry Stout--I thought that Guinness was synonymous with good beer, or the beer that people who had discerning tastes would drink. How wrong could I be. This was one of the most watery beers that was not labeled "light" that I have ever tried. Will avoid this one in the future. Note this is not the normal Guinness. ie, the Extra Bitter Stout.
2
Theakston Old Peculier Old Ale--Interesting beer... Its like a newcastle on steroids. Changes from malt in the beginning to hops in the end. Not overpowering on either side. In my opinion, needs to be a little more salty. Otherwise its a good beer, but I think there are better examples within this style such as the Original Flag Porter.
3.5
Murphy's Pub Draught Irish Dry Stout--Now the Widget is a cool invention, but it doesn't make up for the lack of flavor in a beer. This one was better than the Guinness Draught but still was a little weak. I'll avoid Irish Dry Stouts in the future...not my cup of tea.
2.5
Black Toad Dark Ale American Porter--Had a little too much burnt malt flavor. It had the consistency of a Newcastle, but, in my opinion, not as good.
2
Mendocino Black Hawk Stout American Stout--This one is a good, solid beer. Good flavor with a full and rich taste. Not as complex or powerful as some of the others but I have found to the Stout calls of beers (with the exception of the Irish Dry Stout) to be a uniformly good choice.
3.5
Original Flag Porter English Porter--Very refreshing. Nice clean crisp taste. Has a vinegar/worcestershire flavor to it. Low alcohol at 5% and a bit light on the taste, but it still had a nice character to it. I guzzled this one is seconds....maybe I was really thirsty. Better than a Newcastle Brown Ale, and a perfect beer for hot summer nights.
4
Sam Adams Boston Larger Vienna Lager--Very interesting. This beer is actually the same class of beer as one of my favorites that are readily available at the store...the Negra Modelo. This beer almost had a full flavor and was crisp. Slightly hoppy. Its color was slightly amber and a lot lighter than the Modelo. I'd have to say that I prefer the Modelo...much more distinctive with a greater complexity of taste and body. The modelo is less refined, but I like the bite to it and it tastes just awesome when converted into a Michelada. (click for the recipe)
2.5
Negra Modelo Vienna Lager--The old standby and one of my favorites. This beer is readily found in store in Southern California and has a strong flavor, with a tad bit of a raw and unrefined taste to it. I like it more than the Bohemia. In my opinion the best "Mexican beer" out there. Just say no to Corona and other fake beers.
4

Friday, March 18: Four more rotations in Residency left!

My final off-service rotation in residency ended today. Essentially, it was a vacation from residency ER, but I happened to pick up about 7 shifts at my outside moonlighting jobs. I actually really enjoy working, for some odd reason it doesn't feel like work

Here are some interesting cases that I had in the past week:

A young male with a dislocated jaw (probably one of the most painful dislocations)...after I gave him a bunch of morphine and versed for conscious sedation, he started to laugh (because he got high). I never thought that I would see someone laugh with a dislocated jaw. I started cracking up myself--it was an odd sight. :)

Diagnosed metastatic brain cancer. :( ...I hate giving that type of news....

Had a gentleman present with dizziness. On Head CT, he had spontaneous bilateral chronic subdural hematomas with a 1.5 cm midline shift! Patient was ataxic, and had a positive Romberg's sign, but otherwise was completely normal mentally!

Another lady with metastatic breast cancer presented with respiratory failure. An interesting case since she had no history of asthma, COPD, or CHF. After intubating her, I noticed her peak airway pressures to be high. Chest X-ray showed a big cancer mass. After about one hour on the vent, the patient crashed. I listened to her chest and, sure enough, there were no breath sounds on her left chest--a tension pneumothorax as I expected. I darted her chest, got a rush of air, and proceed to place a chest tube. After cutting through the chest wall, I had another larger gush of air. Unfortunately, the patient died. Point to self: the needle thoracostomy is worthless even though it is the standard of care. If the patient has a tension pneumothorax, dart the chest and cut a hole in the chest immediately...then set up for the chest tube.

After working in the community for the past two months, I have a new found respect for the residency training that I got. The level of acuity at King is severe. Patients present in extremis all the time with diagnoses that are preventable and often curable if they only presented to the ER earlier. I doubt that residents at academic institutions such as Stanford see anything like the severity as King. I undoubtedly feel very prepared to work on the outside, and I'm excited to graduate and practice with autonomy.

Tuesday, March 15: Beeradvocate fallout

I was actually so intrigued by the different types of beers on beeradvocate.com that I decided to go on a beer adventure and learn about all the different types of beers (okay maybe not all beers). So I headed on out to Trader Joe's and then to a Maurie's...a store catering to the beer drinker. In total, I bought 23 different beers (six were in six packs, and one was a four back). Total bill...about $100. I now have enough beer to last me a few months, or a few days if life gets rough.:)

Basically, I got a bunch of stouts, porters, ales, doppelbocks, hefeweizens, barley wines, and an eisbock (which I yet to figure out what that is). Of course, I couldn't pass up on the Arrogant Bastard Ale to which the guy I was talking to (Maurie---the owner--believe it or not) said would destroy my taste buds. Supposively, its doubled up on hops and has a powerful and bitter taste. He said if I like it, I should come back and get the Double Arrogant Bastard Ale. I presume that this one is twice as strong as the one that is already twice as strong!?!?!?

Here is a list of the beers I got including the type of beer it is and its rating from beeradvocate.com. (In order from the pictures)

Beer Type
Rating
Samuel Smith Imperial Stout Russian Imperial Stout
4.36
Bert Grant's Imperial Stout Russian Imperial Stout
3.78
Samuel Smith Taddy Porter English Porter
4.07
Samuel Smith Oatmeal Stout Oatmeal Stout
4.25
Young's Oatmeal Stout Oatmeal Stout
4.01
Young's Double Chocolate Stout Milk/Sweet Stout
4.15
Stone Brewing Old Guardian American Barley Wine
4.10
Stone Brewing Arrogant Bastard Ale American Strong Ale
4.26
Paulaner Hefe-weizen Hefe Weizen
4.16
Schneider and Sohn Schneider Weisse Hefe Weizen
3.92
Aventinus Weizen Eisbock Eisbock
4.12
Mackeson Triple XXX Stout Milk/Sweet Stout
4.15
Sierra Nevada Bigfoot Ale American Barley Wine
4.23
Grant's Mandarin Hefeweizen Hefe Weizen
3.40
Celebrator Double Bock Beer Doppelbock
4.40
Spaten Optimator Doppelbock
3.98
Talon Barley Wine American Barley Wine
3.85
Guinness Pub Draught Irish Dry Stout
3.70
Theakston Old Peculier Old Ale
3.96
Murphy's Pub Draught Irish Dry Stout
3.82
Black Toad Dark Ale American Porter
3.30
Mendocino Black Hawk Stout American Stout
3.64
Original Flag Porter English Porter
3.82

Reviews will be written as I drink the Beers... :)

Monday, March 14: Omakase style

Ever on a quest for the best dynamite (a baked scallop appetizer), I stumbled across Sushi Wasabi...a hole in the wall restaurant next to a 7/11 and a donut shop in Tustin. (The address and phone is 14460 Newport Ave # F, Tustin CA (714) 505-3496 for those of you who are intrigued). Sushi happens to be my favorite food, and I end up going on a lot of match.com dates to sushi restaurants ...so I've been to a bunch of sushi places in the last few months. This makes me a de facto expert on sushi, but obviously not on women (but then again who is???). :)

On first inspection, this place had about zero atmosphere and I was almost fooled into thinking that the sushi would follow in similar suit. How wrong could I be! I almost fell out of my chair because this sushi was so good!

The restaurant is run by a japanese couple, and they only serve omakase style authentic sushi and nothing else. No miso soup, no dynamite, and no green tea ice cream... just Japanese style sushi. There is no such thing as the "california roll" for the fake sushi connoisseur either. One reviewer of the restaurant actually stated that the sushi at Sushi Wasabi is better than the sushi in Japan! Obviously, I've never been to Japan, but I must say that this is the best sushi that I have ever tried.

Katsu, the owner, personally makes all the sushi. When you sit down at the sushi bar, he prepares the freshest sushi from the the catch of the day--there's no ordering (that's what omakase style means--if I'm not mistaking). It truly was an awesome experience as I tried things that were unique and innovative, things that I have never tried anywhere else. The only drawback was the price. This was the most expensive sushi that I have had--$130 for two people!

Unfortunately, my date had less personality than the dead fish sitting on my plate. But I'll definitely be heading back there soon to experience some more sushi from this fascinating place.

Wednesday, March 9: Mountain Surfing

Alrighty, I just deleted my March 8th entry ...point to self: don't write in the blog when drunk...

Anyways, went boarding today with Hines...Had an awesome time. The last time I went I had new Ride Orion Boots of 10 1/2 size. Unbeknownst to me, the inserts stretch out. Needless to say, I had a tough time carving frontside (which was very weird since I never had this problem before--albeit, the last time I snowboarded prior to this year was before med school). I returned the 10 1/2 boot and got the Size 10. Hallelujah! Had no problem kicking out the end of the board...

The day was amazing...It was 75 degrees out! Where else can you snowboard in that type of weather? Of course, the ice turns to a powder mixture and then into slush (which makes life a little harder). But by that time, your quads are burning up from the perpetual "house of pain" (a weight lifting term) and its time to head home. Who's up for the next trip? Do I hear Pedro?

Monday, March 7: Sideways

I actually must admit that I really enjoyed this movie. Now, I'm not going to claim that I'm an artsy type of guy, because I often don't find much art to be all that interesting. Sure I like some art, such as the paintings of Salvador Dali or lithographs of the Four Horsemen of the Apocalypse, :) but I find the pseudo-intellectuals who talk incessantly about art and its meaning to be a little nauseating ...especially when they try to ascribe meaning to things that are meaningless--just walk around in a modern art museums to see what I mean. Anyways, this art flick had something to it.

Obviously, this was about two different personalities and two different approaches to life. One who was pensive and hesitant, and the other who was carefree and dove right in into life. We see the frustration of inaction, and we see the bliss of going all out. Of course, the things you want in life have to be pursued ...lofty ideas, inactive plans, and daydreaming get you nowhere.

I think there is a part of each personality in everyone. Like everything else, there probably is an appropriate balance. If you acted on every whim, you will eventually not accomplish anything meaningful (...you eventually think about the man who was engaged...did it have any deeper meaning?). Likewise, if you failed to act, you simply see the inability to create anything with meaning and it blocks you from the things that do make you happy.

Alright, enough analysis..."Sideways" is a great movie. I'd definitely recommend it.

Side Note: a Great movie that I would also rank as top notch, if you haven't seen it is "Adaptation."

Saturday, March 5: Okay...I'm having too much fun at beeradvocate.com

My favorite beers and their ratings:

Negra Modelo: 3.38
Asahi Black: 3.62
Sam Adams Black Lager: 3.83
Newcastle: 3.32
San Miguel Dark Lager: 3.36
Pyramid Hefeweizen: 3.06
Pyramid Apricot Ale: 3.63
Red Hook Double Black Stout: 4.13 (look at that rating!!!) Only if I could find this in stores!!! (had it at their brewery in Portsmouth--its awesome)
Red Hook Hefe: 3.25
...virtually every oatmeal stout that I've tried at Trader Joe's has been awesome.

Check this out! I think they make a beer specifically for me: Oaked Arrogant Bastard Ale (Oaked Bastard) Rated at 4.55! and in Comes in a 3 LITER bottle!!!...when 2 liters just doesn't make you drunk enough! lol

Looks like many of the top notch brews are from small breweries...too bad its difficult to find them. I'll have to do some hunting over at Trader Joe's to see if there is anything good there. As for comparison, the major brews (which I hate) are rated as follows:

Budweiser: 2.34 (you know the corporate guys paid off a few people to write good reviews on this one ...People who gave the beer all 5's--Yeah, I'll believe that...) And 83% of beer connoisseurs think this beer sucks! Who are the 17% that think this is a good beer???
Miller Genuine Draft: 2.34 also...read this review: In my opinion this is about as bad as a beer can get without having something wrong with it. Laughing my ass off!
Coors Light: 1.91 ...and has a great 92% disapproval rate!
Corona Light: 1.61 HA!!!!! I've always said this beer tastes like piss! Now I have documented proof! I don't know why people say they like it...I would presume because of marketing as the "cool, laid-back" beer. But come on! This brew has a 100% disapproval rate with 90 people having reviewed the beer. In all fairness, Corona Extra is rated 2.18. ..which, unfortunately, is still crappy. :)

Over 21,000 beers on beeradvocate.com...so much beer so little time.

Saturday, March 5: "Why am I not dead?"

I came across this article, Patient survives doctor-assisted suicide, in the news. Alrighty, so how bad of a doctor do you have to be to fail at this??? Turns out that assisted suicide in Oregon has a preference for the use of barbiturates (as far as I can tell). The article goes on to say that it has taken some people up to 48 hours to die! Well Duh! Anybody who knows about the GABAa receptor knows that there are three binding sites--one for barbiturates, one for benzodiazapines, and of course one for GABA. And anyone who has ever dealt with the poisoned patient knows that the patient with multiple drug ingestions is the one likely to have a bad outcome (i.e. death)...whereas overdoses of such drugs like the benzodiazapine class are actually benign. So why not just give a lethal dose of the barbiturates, and throw in the benzos for good measure??? ...since there is a synergistic effect. and if you don't believe me just look at the picture. :)

For those who don't know, the GABA receptor is an inhibitory channel, blocking neurons from creating action potentials (or "firing"). Therefore, overdoses of barbiturates, benzos, and alcohol obviously have inhibitory effects on your brain. Interestingly, small doses of barbiturates and alcohol are stimulatory based on the premise of inhibiting inhibitory type neurons. One of the reasons why you can't fall asleep after drinking....

My favorite "brain cocktail" is coffee and then a Negra Modelo about an hour later... :) (click on Negra Modelo for an awesome review from beeradvocate.com). The coffee wakes you up and the beer mellows you out... I'm actually beginning to really start disliking amber beers...they are just weak with no body, and no flavor!

So anyways, I decided to see if there was a recommended "assisted suicide protocol" (i.e. recommended drugs) on the internet. The next thing I know, I come across this webpage: Self-injection of barbiturates, benzodiazepines and other sedative-anxiolytics in baboons. Okay, now we are just bordering on the bizarre. Interesting study, but I think if I was a baboon, trapped in some cage, with probably the only source of entertainment as being the omnipresence of Jerry Springer on mid-day TV, I think I would happily self-inject as many medications as possible to numb that brain up too. :)

As for euthanasia, I support its implementation...why let people suffer with terminal illnesses? ...its inhumane. ...and yes, barbiturates are the preferred drug for euthanasia in Oregon according to this webpage. In my opinion, why not add a hefty dose of benzos?

Of course, the funniest thing would be a negligence suit against the doctor for failing to provide a lethal dose of narcotics. Where's Johnny (Cochrane) when you need him?

Friday, March 4: Chinois on Main

Had one of the best (out to eat) dinners ever at Chinois on Main the other day! A SIX course meal!!! Here's the Menu:

Tempura ahi tuna sashimi with fresh uni sauce
Chinois chicken salad
Whole sizzling catfish with ginger and ponzu sauce (excellent)
Shanghai lobster with curry sauce and crispy ginger
Charcoal grilled szhechuan beef, thinly sliced, with hot chili oil, cilantro shallot sauce (just awesome--I'd recommend this)
Dessert assortment

Finally, shoot the shit with the waiter (who we actually saw the previous month at Spago's!!!), tell him you had your 21st birthday here (which is true), and the next thing you know, you've got an extra serving of creme brulee!!! Woohoo!

Thursday, March 3: Update on Right Sided MI Patient

WOW! Chalk one up in the save column!!!

I placed a call over to the cardiologist at USC who took care of our patient that we transferred on Feb. 6th (yeah, I've been lazy with the web page lately). Turns out that he survived!!! And my diagnosis was right on the money!!! The CT of the chest demonstrated no false lumens inside the aortic arch--ruling out a dissection. And the Cath Report demonstrated a Dominant Right Main Coronary...just as I predicted! (Wedge pressure was 46!!! --Fruck) To me there was a lot of evidence that made this apparent. The EKG on this patient had ST-segment elevation in lead II that was greater than lead III, an indirect indicator of right-sided MI and the Sinus Node was also out. In addition, the patient was in preload dependent cardiogenic shock. What else would cause that scenario with the exception of a right sided MI? To me, getting a right sided EKG is useless...the patient is clinically telling you that the right ventricle isn't working.

In the cath lab, a stent was placed to open the RCA. Next, the patient was given an IABP (Intra-Aortic Balloon Pump) to decrease the workload for the next few days. Ultimately, the patient did well and lived to see another day!

Medicine truly is fascinating.

Sunday, February 27: Revision of Web Page

Well after reading that some people were running into trouble at work because of their blog, I opted to revise a bunch of entries... I think its well sanitized now. Thank god for the "Thought Police!"

Friday, February 18: "Don't let me Die"

Shot in the left upper chest and in the face, my 20ish year old patient rolls into the trauma center. He complains of belly pain...yet there is no bullet in that direction. His breathing is good, and he is mentally with it... I quickly assess him... and notice a hole in the back of his throat, and he has fairly good breath sounds... I fall back onto our simple trauma algorythms...ABCs (Airway, Breathing, Circulation). "Don't let me die" he says to me as we push in the Etomidate and Succinyl Choline...its the last thing he says as we have just knocked him out and paralyzed his body. I intubate him without difficulty despite the blood and distorted anatomy. Immediately afterwards, the monitor records a rapidly falling heart rate. Pulses disappear. TFA (traumatic full arrest). I dart the chest with a 14 gauge expecting air to come out. I pause...no air. Neck veins? Trachea? My brain is racing. I grab the the 15 Blade and start cutting the chest from front to back. We pry the ribs open with the rib spreader. Minimal blood pours out?!?!? We rapidly find the heart and discover its contents to be hard as a rock. The proverbial Cardiac Tamponade. I think to myself "We can save him." We cut the pericardium open with mayos (scissors) and huge blood clots come out. The heart is flacid but we see the holes in the right atrium anteriorly and posteriorly...A blood/normal saline mixture is rapidly being spilled. Despite all our attempts, futility becomes evident. Code called 20 minutes after arrival.

Monday, February 7: Lets go Boarding

Alrighty, let's see if we can get another snowboarding trip going!

Possible dates: Feb 24th, Feb 25th, March 1st

Boarders: Sonny, Hines, and Hurley???

Monday, February 7: The Manogram

No comment.

Monday, February 7: Herbal Remedies

How about this for circumstances: Had two patients with medical problems related to herbal therapies in the last week.

One patient that drank only green tea and used colonics "to clean up his system" for 4 days, ended up having multiple electrolyte abnormalities including damage to his kidneys... Not too bad since the body would reverse these issues with normal food and water intake. There probably won't be any lasting sequela until older age as kidney function gets progressively worse.

The next patient unfortunately was not as lucky. A young male was rubbing a herbal antibiotic into an open wound in an attempt to make it heal better. By doing this he prevented his normal defense mechanisms from working and he killed off the normal bacterial skin inhabitants, selecting for an ultra-aggressive bacteria--MRSA (methacillin resistance Staph aureus) that lead to a septic state (bacteria in the blood). The bug was so aggressive that he developed a severe lung infection and an empyema (pus outside of the lungs in the chest cavity), and multiple septic joints. Ultimately, thoracic surgeons had to cut open his chest to drain the pus, and the orthopedic surgeons had to cut open 6 joints to clean them out. Unbelievable! Seven operations because of misguided and untested therapies. I wonder what type of lasting problems he will have from all of this. And the sad thing is that he would have done just fine if he used soap and water.

Sunday, February 6: Quote of the Month

You've got to get into it. This is our art...this is our craft."
--Hines MD

Sunday, February 6: Clinical Opinion: Hunting for Dissections

An interesting case came into the ER yesterday. An elderly man had crushing chest pain, back pain a heart rate of about 50 and a blood pressure of about 70 over 35...obvious cardiogenic shock. The cardiac monitor showed the highest ST-segment elevations that I have ever seen--commonly referred to as "tomb stoning" because of the likely outcome. The EKG was diagnostic for an acute inferior and lateral ST segment MI (heart attack) and for an irregular bradycardic junctional rhythm. Mortality for an event like this is above 90%.

The problems: 1) Going to Cath lab is the best way to possibly survive this event. The literature states that your have two hours to get the patient to an interventional cath lab for a PCI (percutaneous coronary intervention), otherwise an inferior but possibly effective treatment may be tried ...i.e. thrombolytics. 2) Patient was strongly positive for a test of GI bleeding ...a relative contraindication for administration of thrombolytics and 3) The chest X-Ray demonstrated a wide mediastinum and had a +/- calcium sign within the mess; both possible indicators of an aortic dissection...an absolute contraindication to thrombolytics.

We decided to transfer to a cath lab and I made the trip over to USC with lights and sirens going off in the paramedic rig. On arrival to USC, the patient was on 20 mcgs of dopamine for blood pressure, mounting a meager 85 systolic and was being demand-paced transcutaneously using 10 mAmps at 70 beats per minute. The patient also had progressive worsen of rales (the sound that water makes when it spills into the airways of the lung)...another bad sign. Labs resulted from the initial blood draw already were positive for cardiac enzymes (troponin of about 5 and CK MB fraction of 55) ruling in a heart attack (duh...). The only treatment given so far that was therapeutic was aspirin.

The next question: Should you rule out a dissection prior to cath lab? The cardiologists wanted the CT scan to rule it out...

My opinion: The axiom of "time is muscle" indicates that something has to be done and it has to be done quickly. In my opinion the patient should go straight to the Cath lab and pass on the CT scan. If the CT scan demonstrates that there is a dissection, the patient is going to die anyways ...guaranteed. No cardiothoracic surgeon is going to operate on an aortic dissection in a patient with documented MI, cardiogenic shock, being paced transcutaneously, and on blood pressure support. An intra-aortic balloon pump would also be like pissing in the wind as it is only a temporizing measure. In addition, cardiac enzymes were already positive and, therefore, the MI is already a known condition. What would be the likelihood of both occurring at the same time? (unless its a Sanford type A dissection extending into the coronaries) The mortality of such an encounter is so high that doing the "standard of care" should really be based on the clinical encounter with all its variables, a cost-benefit analysis, and on the expertise of the treating physicians. Going straight to the Cath lab would give this patient maybe a 5% to 10% chance of survival and possibly fixing a dominant right main coronary (since the sinus node was obviously out, and the lateral V3 - V6 leads showed an injury current as well). Doing a CT would just delay a possible cath and decrease the odds of survival. Do you do what you think is correct, or do you "cover your ass" and get a CT scan?

So if the patient has a dissection in addition to an MI, going to cath lab will accelerate his death, but he would have died anyways. To suggest that there is medical liability for accelerating the patient's death versus just letting him die is asinine ...especially when you think you have a chance at saving his life. In my opinion, looking at these problems from a defensive medicine approach is not better medicine. Quite the contrary, defensive medicine is often times inferior.

...Will update this entry once I find out the results of the CT scan and Cath.

Sunday, February 5: New Job

I'm loving my new moonlighting job at Kaiser. Everything went smoothly. The volume was a little low...saw 10 patients in 8 hours (when I should see a least 16). Anyways, I sent 9 home and admitted one. One thing is for sure, I'll miss being at a trauma center after graduation.

Tuesday, February 1: A-Pillar Tach and Brain Matter Splat

No mercy for what we are doing
No thought to even what we have done

We don't need to feel the sorrow
No remorse for the helpless one

Outside the ER was the evidence ...surrounded by that yellow police tape. ...Another "homeboy" ambulance.

The "ambulance" was that of a modified honda...It looked lowered, had "tricked out" rims... On the inside, a specialized tachometer attached to the A-pillar (the junction between the windshield and the front windows), with some other devices, and a fancy looking manual stick shift knob. A few windows were blown out, a cavitary hole in the door, and a cracked windshield showed the stigmata of lead that flies through the air.

This ambulance brought into the ER a young man with a gun shot wound to the back of the skull. The lead entered through the posterior fossa, straight through the basal ganglia, crossed the midline at the sella tursica, exited the anterior fossa through the right orbital foramen, blew out the eye, and lodged near the eyebrow. Brain matter was being squeezed out like playdough at the playdough factory.

No mercy for what we are doing
No thought to even what we have done

Monday, January 31: Shrapnel and Fallout

The vote in Iraq is over with a 60% turnout...even with gunshots, mortar attacks, and suicide bombers.

Assessment: 1) Ted Kennedy must be upset. 2) The turnout is higher than elections in the U.S. Do we take democracy for granted? 3) Its time to bring the troops home...

The real question: Are countries in the Middle East deserving of Democracy?

Thursday, January 27: Suicide Attempt

Some Jackass places his car on the metro link rails in an attempt to kill himself. Instead he decides against it and gets out of his car, as opposed to simply driving away! Great Job Asshole! Now 11 people are dead, 200 injured, and the cost to fix this problem will be in the millions. Next, our glorious legal system will kick in, he will be charged with murder, and his defense we be temporary insanity. Even if the guy gets what he deserves, i.e. the death penalty, he will sit in some prison for the next 20+ years before the "rahabilitationists" come to his defense and try to get him released. Unbelievable. I could even see the spill out of lawsuits against the MTA. How come there were no seatbelts in the train? How about some padded seats? If it was up to me the guy should be shot today. Why we have to coddle to people who cause us so much pain, suffering, and economic damage is beyond comprehension.

Tuesday, January 25: Diagnosis of the Week

Happened all in a patient without a previous medical history: (the order of our diagnoses made)

1. Shock, Hemorrhagic: Tachy in 130s, BP of 100 systolic
2. Upper GI Bleed: Hemoglobin of 8...patient already lost 1/2 of his blood
3. Diabetes: sugar comes back over 700 (normal is 100)
4. Diabetic Ketoacidosis: Single digit Bicarb, anion gap of 45 (severe)
5. Acute Renal Failure: 2-fold bump in creatinine (only 1/2 of his kidneys are perfusing)
6. Liver disease: Bumped enzymes
7. Coagulopathy: INR of 2 (a measure of blood clotting ability--anything above 1.6 is bad)
8. Variceal Bleeding by endoscopy--one of toughest to control (who gets varacies at age 32!?!?!)

...a few hours away from death...and only 2 years older than me. Yikes! Chalk this one up in the save column.

Tuesday, January 25: Borracho

Yes it happened again... I was verbally assaulted.

However, it wasn't the typical "white devil" remark or the "honky mother @%&~#&" from some inebriated psych patient. This verbal assault came from the mouth a four year old girl. It must be a new low point in my life...

It all started with a rubber glove. You see, we often blow up gloves and make faces on them...the thumb becomes the nose and those fingers become a cool little mohawk. After making our Glove Man, I tried passing him to the little girl. She reached her arms out, grabbed him, pulled him into her body...only to start screaming as if in fear. Huh? So I offered up my hand to take Mr. Glove Man, and she promptly gave him back to me with relief of her yells instigated by the tormenting puppet. How weird was that?

So I offer Mr. Glove Man up again ...because most little kids just love the adorable creature...and she snatched him out of my hands only to start screaming. Again, I offered my hands out and she passed him back. What are we playing here? The hot potato? Very bizarre.

So anyways, after a few rounds...the game gets a little abusive. The next thing I know, the girl lashes out with jaw-dropping attack...and calls me "borracho!" Oh my lord! But she wasn't done there! ...The next thing she said was "calmate". Oh lordy, She essentially just called me a "drunk bastard" and told me to "calm down"...

I cry...

Sunday, January 23: Start Date

Finally have a start date for Kaiser! Woohoo!!! This might mark the end of in-house moonlighting (at least for NSICU). Somehow I'm still working the next eight days. ugh...

Side: Cool article today on weight lifting. And I just started doing squats again... :)

Thursday, January 20: Quotes of the Day

"You be talking to me like I'm a joker. I ain't no joker, I'm the midnight toker!" ...I had to look up "toker" on dictionary.com...how sad is that?

"Crucifer is God's right hand man!" ...a few minutes later she was signing "We are the World" at the top of her lungs. ...now how can you work with that type of entertainment?

Last week's quote: "Hey Hurley! What's really cracking?" ...this was the first thing that a family member said to me in reference to the status of a patient. My response was "huh?"

Wednesday, January 19: UC Berkeley Wellness Letter

Went through the entire list of supplements that you can look at without a subscription.

Only thing that I can see as being beneficial: calcium, creatine (which I've taken for years...but obviously not currently on), folic acid, iron, and a multivitamin. Things that possibly work...Saw Palmetto, St. John's Wort.

Note: Calcium, folic acid, iron, and multivitamins have been supported by the medical establishment for a long time.

Hence, naturopaths feeding patients some astragalus tea = quackery.

Wednesday, January 19: Garlic for Blood Pressure

California has just decided to license Naturopaths, a brand new form of hand-holding 'doctor' a la Pinkus from "House of God." When you don't know your medicine...go hold the patients hand. How fantastic is that?

The echinacea crowd must be ecstatic. Unfortunately, the general population has really gotten confused on this issue and for some odd reason, medications that have specific indications and that have been put through rigorous tests and heavy FDA scrutiny are bad while untested medications by unscrupulous "labs" looking to feed off of this nonsense are good. The damage that this can do is tremendous.

Sure there are medications with known bad side effects such as the recently discovered problems with COX-2 class of drugs and probably the entire non-steroidal anti-inflammatory drug class as well. But taking a medication with a known side effect, in my opinion, is better than taking a medication that has not been proven to do what the manufacturers claim it does and has unknown side effects as well. In addition, the "remedies" espoused by these "professionals" doesn't offer anything that is really life-changing effective. Just look at echinacea ...equal to placebo in effectiveness ...probably an effect of methylxanthines (another world for caffeine). Go read the Berkeley Wellness Letter for their echinacea analysis. It even states possible risks to decrease your immunity!

So the problem is that people taking "natural cures" will think that what they are doing is effective when if fact it probably isn't doing anything. Obviously, there is room for the normal things like eat right, exercise and take some anti-oxidants...so maybe there is a little bit of room for the hand-holders. But when you come into the ER for a headache that just won't go away, and your blood pressure happens to be 210/120...stopping your "Western" medications because of feared "side-effects" and deciding to take "garlic" for blood pressure because you heard it on the radio is a pretty stupid decision. (...and yes, this happened a few weeks ago.)

The beauty about Western Medicine is that it takes ideas and challenges them to see if there is a cause-effect relationship. Eastern Medicine has no such desire to challenge its own concepts to see if these things work. Because once something has been put up to the scientific method, and has proven to be true or false, it is now a principal of Western Medicine. Somebody please email me and argue that Eastern Medicine is based on the scientific method ...I'd love to hear it. And if the research happens to disprove the hypothesis, don't expect the naturopaths to drop it from their armory of placebos.

Just look at this nonsense from the LA Times article:

"Taraviras has drunk astragalus tea to help his body fight a cold, let an unsightly rash run its course rather than take steroids and had an injured ankle checked for a possible break with a tuning fork — a device once commonly used by orthopedists to check for bone fractures."

My analysis: 1) if you eat dog crap in the freezing rain, your cold will go away lest you freeze to death 2) rashes...like those topical antifungals and topical steroids are implicated in multiple deaths 3) I think that I will opt for the "device commonly used by orthopedists to check for bone fractures" called the fricking X-RAY... I don't think I want to walk on a bad ankle the rest of my life because a tuning fork made the right sound.

...by the way. According to the Berkeley Wellness Letter, "Garlic supplements are a waste of money."

Side Note: Health plans, to which I can't name, have decided to implement these homeopathic meds. Its a win-win situation for them. First they don't have to pay for expensive drugs, and second, they lure in the wacky cliental that pays for health care but doesn't really want it in the form it is dispensed ...funny huh?

Aspirin, for those who don't know, is a herbal drug and has saved millions of lives, but it also kills about 19,000 people a year.

Tuesday, January 18: Thanks...

Turns out that "Ghetto Phone" was a big hit. Thanks to everyone for their comments on the webpage...

Sunday, January 16: Should I stop being shocked?

There is always something interesting that rolls into the ER ...especially in the part of LA in which I work. Some of the stories are interesting, or the diagnoses made are bizarre, or maybe its the analysis on the human condition as being something that makes you sit back and just wonder.

I will always remember a few stories. One of the weirdest ones was that of a man with schizophrenia who perceived his testicles as being evil...so he dissected his scrotum, excised the testicle, only to put it in the frying pan and cooked it up!!! Or the fascinating case of the female with Marfan's syndrome who developed an aortic dissection at 8 months of gestation. The list can go on and on...

Another interesting encounter occurred today. A 14 year old presented to the ER with a laceration after an argument...no big deal...but she was also 2 months pregnant! Obviously a sad event... But the shocking aspect about it was the mother was 28!!! How can you be a grandmother at 28!!! I don't know if I should be shocked or amazed....

Side Note: The Ghetto Phone went off again today... and everybody started laughing....how hilarious!

Saturday, January 15: Departure

Rushton has officially moved onto another residency training program. I wish him the best of luck... And that he finishes his military obligations and returns to the LA area...if there are any ERs still open 5 years down the road. I need a snowboarding buddy ...especially since Sonny is moving up north after residency...ugh!

Friday, January 14: Searching for Racism

This was one weird week.

It started out with a guy wanting a narcotic prescription. This happens all the time, but the interesting thing about it was that he attempted to use the recent bad press on NSAIDs to do it!!! He got pissed when I told him I wasn't going to prescribe any of those drugs for his condition and he called me "arrogant." Not too bizarre since that is actually a normal level of politeness at King.

He subsequently asks me "so where you from?" Initially, I thought that that was weird since he was already exhibiting an antisocial/borderline personality disorder. I respond to his question by saying I was from Orange County.

He goes "Ahhh, that explains a lot. You must be a member of the John Birch Society."

"Huh? Um, what's the John Birch Society?" I reply.

As a matter of fact he says, "Its a secret racist white society."

...Now its falling into place... "So I'm racist because I'm white, huh?" I say in a disgusted tone.

He replies "well, ...yeah." While I sat there a little aghast, he then says, "I used to do social work and I can identify your types." Unbelievable...

At that point I was almost done and I contemplated just discharging him home or telling the guy to leave. However, I stuck though it, told the guy that that we were done talking and I was going to finish him up and send him home.

...To which he replied: "Damn, you're arrogant."

LOL

Saturday, January 8: Ghetto Phone Phenomena

Can't hear your cell phone ring from 200 feet away? Need everyone to know what's your favorite rap song? Is it important that everyone within eyesight hear your conversation? Are you a 23 year old single mother of 5? Then you need the Ghetto Phone.

Almost every patient without insurance still has the ability to afford a top-notch cell phone with obnoxious ringtones and retarded walkie talkie functions with those damned annoying beeping noises. Image is everything in South Central and, obviously, the cell phone is more important than buying yourself some health insurance. In fact, I've probably seen about ten patients assaulted in the last two years because someone wanted to steal their phone. ...how lame is that?

Why does virtually every patient without healthcare insurance have a luxury item like the cell phone? This eventually relates back to the carrot and the stick. People have a choice to try and work hard, save money, and take care of themselves. Or they can spend all their money, decry that they are poor, plead that they have too many kids, lament that they can't afford the necessities of life, and then claim the need to suck on the nipple of perpetual governmental welfare dependence.

Many people decide that spending all their money on stuff actually makes more sense than saving. If you spend all your money and then get sick, the taxpayers will have to shoulder your burden and pay the bill. If you save money and then get sick and don't have health insurance, us doctors will practice legal defensive medicine and perform a hoover procedure on your wallet and leave you even poorer than before. So obviously, spending all your money makes more sense if you are making a marginal income such that your savings are not that great and the average of 2-3K per year for health insurance is a relatively large number. If this is the case, then spending all your money and receiving governmental benefits is a logical decision.

A good explanation for this lies in the abuse of governmental programs. Take single mothers as an example. If your "baby daddy" makes 30K a year and you are married to him with 2 kids, you get zero in governmental assistance--you ain't poor enough. Now if you aren't married, and you rent a crappy place (as a guise), your "baby daddy" can still make his 30K and you can go apply for WIC, AFDC, and EITC and pull in over 10K in benefits courtesy of Uncle Sam. Thus making your net "family" income about 40K. This is actually well know in some immigrant communities where all the assets are placed in one person's name such that everyone else is poor and can get free health care and other governmental benefits. Basically, cheating the system to get more money.

Hell, I think I would do the same thing ...there is so much incentive to cheat the system with very limited negatives. This is how the government has structured these programs and it has invited people to behave this way...to claim poverty, to claim victim status, and therefore to get what's "entitled" to them.

Instead of "having your cake and eating it too," it should be "I want my cell phone, and my free health care too." ..The ultimate "bilk the government" scam.

Side Notes: The next time a Cadillac Escalade rolls up in 24 inch chrome spinners with multiple bullet holes in the side and the driver doesn't have health insurance, I suggest the following governmental intervention: 1) Sell the car--i.e. return the lease (the spinners themselves probably cost at least 4K) 2) Use the profits to buy a piece of shit car 3) Give the shit box "new" car to the patient 4) All the money left over goes to the government to pay for his future healthcare since this person is unwilling to pay for his own insurance policy. ...I would love to hear someone argue against this. I can hear it now..."big brother," "privacy," "freedom." But somehow he has the right to shift all the costs onto society and make you and I pay for his healthcare when he clearly has the ability to pay? I don't think so.

You may ask, "When does the Ghetto Phone go off?" It usually goes off 5 minutes after a young male arrives in the trauma center with multiple gun shot wounds. Its actually interesting how fast news travels about shooting victims. The paramedics arrive to the scene of a shooting about 5-10 minutes after the 911 call was placed. The patient is on the gurney in the trauma center in another 5-10 minutes, and then the phone goes off a few minutes after that. Basically, in about 25 minutes everybody knows what's going down in da hood. ...thanks to the Ghetto Phone.

Tuesday, January 4: Dieting Analysis

Here's a little article about Dieting. The interesting thing about it is that there is only "one scientifically solid article" on the issue that looks into the 10 most common diets. Only ONE article! Amazing, since so much money is spent on diet related issues that you would think someone would be a little bit more interested in the topic. Of course, the controls and variables are probably too numerous to count.

I really don't care too much what diet people are on. If fact, I get a little irritated when patients ask me what they should be eating. I think that if you don't know by now, maybe you need to repeat high school.

My usual response to what should I eat: "I don't care what you eat. Get your ass up off that couch and do something you lazy rat bastard!"

Monday, January 3: Running the Squeeze Play

Brain injuries and elevated intracranial pressure is one of the toughest things to manage. In fact, I just did two moonlighting shifts in the ICU where all I did was deal with this issue the entire shift!!! Unfortunately, the brain is one organ that just doesn't respond too well to insults...its an issue with easily offended sensibilities.

Treating these patients is fascinating...On one end you are trying to dry the patient out so as to suck fluid out of the swelling brain using mannitol and normal saline maintenance fluids. Then at the same time you are trying to maintain an adequate perfusion of blood, basically the difference between the mean arterial pressure and the the intracranial pressure (MAP-ICP=Cerebral Perfusion Pressure) using boluses of saline and albumin, and then possibly adding a pressor agent like dopamine. Its tough since getting rid of fluid tend to drop the blood pressure or "bottom out the tank", and giving more fluids increases the swelling. Its a delicate balance with multiple indicators that need monitoring and tinkering. In addition, you end up destroying the kidney...oh well, guess its better to have a brain than kidneys...you can always go on dialysis...

On my last shift, I was treating a patient with cerebral edema, congestive heart failure, renal insufficiency, and hyperglycemia. That was like running the squeeze play with a fricking walker. Anyways, I think I finally mastered it (albeit after some 40 odd Neuro ICU shifts). When the patient's condition changed, I called up the attending to tell him what happened and what my plan of action was. He simply agreed and didn't have anything further to say! A pretty cool feeling since this has to be one the the tougher things to manage in an ICU. The only thing the I can think of as being tougher is the management of ARDS (Adult Respiratory Distress Syndrome). The good news is: I virtually never have to deal with ARDS in the ED, but playing ball for cerebral edema may eventually fall on my lap.

Once again I was able to optimize the patient's condition but it was almost pointless...if your brain is swelling secondary to anoxia from a traumatic apneic event...your future don't look so swell.

Side Note: I once attempted to place a ventriculostomy (from the Doe Report ...a virtual how to sue doctors---awesome) in a patient with a big time shift (where the brain is swelling so much that the brain on one side moves to the other). I felt like I was one of those Vikings doing a little mid evil brain surgery. This patient was memorable since the squeeze play didn't work here. The patient abruptly bottomed out his pressure while on high dose pressor agents, dopamine and levophed. "Levophed or leave em dead." There's not much you can do when this happens...it didn't really matter however...both pupils were blown.

Monday, January 3: Navigant

Navigant is in the news after having produced a 1000+ page document to try and fix the things at King ...Yikes! And that's just the inpatient setting...they haven't even looked at outpatient visits. I'm hoping the place stays open long enough for me to at least finish residency ...I'd hate to have to find a new place with less than six months. We will know in the next two weeks if we will pass the CMS hurdle. Most likely JCAHO will pull accreditation...but the hospital can still operate.

Also, this is a desperately needed hospital. ...the community needs it.

Sunday, January 2: Happy New Year!

Haven't really decided on my New Year Resolutions ...I think I'm doing a pretty good job as it is...and I was thinking more about these issues a few months ago...

I did reach new levels of fatigue ...Worked 6 moonlighting shifts in the last week. And now I have 6 12-hour shifts coming up in a row. Also need to do more paper work for Kaiser and look into establishing a corporation, consider joining an ER group, disability insurance, work on my research project, consider buying a house, follow up requirements, etc... ugh its never ending ...except in 6 months!!!!!

Tuesday, December 28: Mandating Retarded Policy

MLK is back in the news today. This time for supposed failures of the Code 9 Policy by the psychiatric facility...an event that occurs a few times every day. ("Code 9" refers to a situation where "aggressive behavior is likely to occur"...)

The Federal government in all their wisdom wants all confrontations that occur in a hospital to be non-violent and wants to minimize the use of restraints unreasonably. Its great to have bureaucrats telling you how to handle violent patients when they're sitting behind a desk some 3,000 miles away and not the ones dealing with these situations on a daily basis.

Basically, the county safety police have been using such devices as the taser to subdue aggressive psychiatric patients ...a "no, no" in the eyes of regulators. So CMS (Medicare & Medicaid) has threatened to pull funding ...possibly shutting down the hospital permanently.

One of the patients was tasered occurred on my shift. This approximately 6'4" 270 lbs guy was actively psychotic with religious preoccupations. After being brought into the hospital he became a little more agitated and got up out of his chair and proceed to snatch a baby out of the hands of a woman. Staff promptly wrestled the baby away from the man and called security. When security arrived, he became more defiant and the officers opted to use a taser on the man so as to avoid physical violence and trauma. ...The most interesting aspect of this was when the man got hit with the taser...he proceed to convulse on the floor while constantly repeating "Thank you Jesus, Thank you Jesus." Wow...that was something!

Afterwards, the man was actually much better. I'm sure he didn't feel that great (he did avoid a bunch of people jumping on top of him), but then again he was more lucid and actually seemed like he was no longer in his psychotic state ..probably most likely due to Vitamin H--Haldol. The only other alternative would have been for 4 officers to jump in and risk getting a punch or a bite or worse..and why should they take that risk? One thing for sure ...there is no way that I want to jump in and try and handle a psychotic 270 pound man! Unfortunately, the federal government has mandated that this is now my new job--to jump in and take on violent patients twice the size of me ...awesome.

Determining the appropriate response level will always be viewed retrospectively as a failure. For instance, if the man injured or killed the baby, we would be up shits creek. If a taser was used, then it was excessive force. Its a no win situation...you are always wrong in the eyes of regulators or lawyers. That is what these policies eventually state. Great job!

I have seen some crazy stuff. We once had a 6'6" 300+ lbs guy with COPD and Pickwickian Obstructive Sleep Apnea wake up in an extremely agitated state. He ripped out of his soft restraint, pulled out his endotracheal tube, got up out of bed, went over to the next bed and tried to KILL the patient next to him which was a patient on a ventilator also for respiratory failure by strangulation. This guy was totally CO2 narcotic. Three ED residents in the vicinity saw this and ran over to tackle this man. During the skirmish the man toppled and hit the sink ..breaking it clean off the wall! Unbelievable... The patient subsequently improved from his hypercapnia (elevated CO2) and was actually the nicest guy possible ...completely shocked that he attempted to kill someone in his altered state.

In another event, a patient on PCP overcame a police officer and socked him right in the face, knocking him out cold, and then proceed to try and assault other people. Thankfully there was an ED resident that actually did kick boxing in the past who took this guy down with a choke hold.

In the past few years, about 4 residents have been assaulted...one punched in the face just 2 months ago. So my question is: "Who is the federal government trying to protect?" The regulation of every aspect of our job and virtually every aspect about our profession is verging on the ridiculous.

The next time we get a violent 300 pound patient in the ED ...I think I'll call up that 130 pound pencil-pushing policy-promulgating bureaucrat to come take the guy down using those great non-violence tactics ...I'd love to see that.

Tuesday, December 28: Psych

Quote by a traveling nurse:

"The psych here is unbelievable."

Ask me about it... I'll tell you the story about the "Chupacabra" and the "Blue Sweater."


"Just Plain Nuts"

Sunday, December 26: Who Would Jesus Bomb?

I was down on Second Street in Long Beach a few weeks ago ...eating at Open Seasame (...some good Mediterranean Food). Over on the street corner were some people protesting the Iraq war--which I don't have a problem with (although, I think they are wasting their time)--they have legitimate points and I also think that we need to work on an exit strategy and get out as soon as possible.

One of the protestors, however, had a sign that said "Who Would Jesus Bomb?" At first I didn't think too much about it. But on later inspection, it occurred to me that what else better explains the positions of SOME people on the left? First of all, it argues that people who believe that what we are doing in the Middle East is right are either religious or doing it for religious purposes (I would assume the first one). The concept that there may be other justifications for removing Saddam and trying to establish a democracy just doesn't fit with their simplistic belief system that all war is evil, and who better than to attack than the religious right? Second, the side that often refers to themselves as the "open-minded" group that is "tolerant" of other people and beliefs, is actually just as intolerant if not more than some of the people on the far right. They believe that attacking people based on their religious beliefs is open game while any other position that conflicts with their belief system is "racist", "sexist", "closed-minded", or "intolerant." Just look at the ACLU and their recent retarded campaigns. I would argue that they are more intolerant than other groups since they attempt to claim "tolerance" as one of their main principles while at the same time being as intolerant as they want. And finally Third...when you can't effectively argue a point ...start calling the other person names. :)

You will rarely see conservatives out on the street with signs explaining their positions...with the exception of the religious right and the abortion issue (they are just as fanatical as the "no war for oil" group). People who try to understand the intricacies of current events and think about their positions recognize that complex ideas don't fit on a poster board.

Side note: I think I can actually answer the question "Who Would Jesus Bomb?" I think Jesus would bomb the terrorists prior to them attacking on 9/11. If the Nazis were about to mow down a bunch of Jews in a firing squad, and Jesus was standing by with a Mk-19 40mm automatic grenade launcher (pictured to the right), then I hope that Jesus would send the Nazis to a fragmented and splattered death.

There's a difference between Killing and Murdering. Murder is always morally wrong. Killing is not. In the legal world, Murder is illegal, and Killing may be illegal or legal (i.e. justifiable homicide). Although, I would argue that an illegal killing should be called murder or an accidental death ...depending on the circumstances. Thereby making a clear distinction between the two terms.

Addendum: I'm not a religious person, but I do believe in trying to do the right thing...

Saturday, December 25: Mummm!

Wow! Another awesome dinner! Filet mignon with merlot reduction sauce with garlic and mushroom mashed potatoes and red pepper and green bean salad with vinaigrette dressing. All of that followed up with a blackberry panacotta. That's got to up there in the list of awesome holiday meals. Thanks Mom!

Ugh ...can't believe that I work tonight ...I hate working on holidays... I'm sure the ER is full of kids with cuts while running around chasing that new toy. Of course, I'm working trauma, so I only have to take care of the people who received lead bullets for Christmas. And in South Central, the time for giving lead projectiles is year-round. :)

Friday, December 24: Merry Christmas

Hope everyone has a great Christmas!

Friday, December 24: Tats

This was the tattoo of a patient we had the other day:

Loved by Few
Hated by Many
Respected by All
187'em

187 refers to the police code for homicide...Very nice huh?

Thursday, December 23: Successfully Admitting Patients Without Discernable Pathology

"If Age + BUN > 100 then Attempt Admission"

What a great article!!! I laughed my ass off! What would be a better explanation of the crappy stuff that we deal with every day and the conflicting beliefs of patients and their families and the beliefs of the admitting consultants.

Last week I had a patient with PWDP in Fast Track. Its a good thing that I'm actually pretty good at explaining to patients why hospitalization is not necessary. Funny since most people don't want to stay in the hospital, but somehow there is always a segment of the population that isn't sick but wants to stay in the hospital unnecessarily. This lady complained of low back pain and what sounded like trigger point pain all over he body (sounded to me like fibromyalgia...if you even believe in the diagnosis) and she demanded that we do something about it. A true case of "Malignant Fibromyalgia." Eventually after much discussion she agreed to be discharged but was obviously disappointed we didn't solve those chronic problems instantaneously.

Side Note: The next time I hear someone say "What would you do if this patient was your mother?" (or any other family member) I'm going to slap them. If my mom came into the ER, I think I would order every unnecessary test known to man and include a full body MRI for reassurance. The fact of the matter is that we have to try and make the best decisions possible, to make sure that we make correct diagnoses, avoid missing conditions that lead to morbidity of mortality, and to do it without spending too much money. That means that we have to make decisions that do carry some risk. The goal is to try and minimize risk, not to eliminate it completely. If we attempted to eliminate all risk, we would almost never discharge a patient and order excessive and costly tests without really benefiting patients ...almost like the way we practice legal defensive medicine instead of evidence-based medicine. ...and would you really like your medical insurance premiums to triple?

Wednesday, December 22: End of the Year

Last year was a year of great struggle. Although I have made some significant accomplishments, I also had some difficult failings.

Unfortunately, there are so many areas in our lives to which we aspire success that many individual goals conflict with each other. We aspire to grow professionally, to learn our trade to the best of our ability and to be accomplished and successful. We desire to grow personally to be more capable in understanding the people in our lives, to communicate our hopes and dreams, and to develop strong human connections. Doing both at the same time is difficult and eventually there is a cost and a benefit of all the decisions that we make. Finding that balance is difficult, but it is also even more difficult when people in your life have an idea about what your balance should be as well.

I hope that I have learned from my struggles and that I can apply it to my future and approach life from a more prospective viewpoint.

Tuesday, December 21: COX-2 Ramblings

More news on the pain control front ...three different news articles. 1) Celebrex has increased risk of heart disease. 2) Celebrex not as bad as Vioxx...but still bad. 3) Naproxen (although not a COX-2) has increased risk of heart attack and stroke.

These are some painful news articles...Do I need to explain the risks to patients every time I prescribe one of these drugs??? What options are we left with if these drugs are removed from the market? There really isn't too much left. Maybe I should take the Remen approach and prescribe normazaline and tell the patient to meditate. :) (don't worry if you don't understand that...its an inside joke)

The FDA now has got everyone in a frenzy now. All they need to do is come out and say there are risks with every drug! Maybe Vioxx carries a higher risk for these problems, but for many patients that I have talked to, Vioxx was stronger than Celebrex. I'm sure ibuprofen will probably have the same problems as well.

Its time for an insert on every drug prescribed that explains in plain English the risks of these medications instead of having a fold out of the damn PDR (Physicians Desk Reference)...which I don't even understand or even care to read about. The risk should be assumed by people taking the drug and not by companies that make them or by doctors that prescribe them. Its time for some common sense and personal responsibility.

Tuesday, December 21: Boarding

Had a great time at Snow Summit today. Went up with Rushton, Sonny, Jessica, and Jackie ...we'll have to go again before the season is over. Didn't board as well as I used too... I realized that I can't have my leading binding flared and I think that my feet had too much movement in the new boots that I got...had some difficult cutting hard frontside and hence wiped out pretty hard a few times. Hopefully, I'm good for the wear.

The day was beautiful ...clear fresh air, not a cloud in the sky, and a great temperature. I miss the mountains. I've had many outdoor adventures ...whitewater river rafting (Yampa Green in Utah, Middle Fork of the American, and my favorite...the Merced), Bryce, Zion, Arches, Yosemite, Road to Hana, the half-sunken volcano at Mulacai. Snorkeling in the reef off of Florida (I forgot the name), Catalina, and water skiing Lake Perris. This trip has inspired me to do some more. How about instead of Vegas after graduation, we head on up and do the Merced??? Any takers?

My next trip that I want to take is a road trip up California into Oregon, check out Crater Lake, and then maybe adventure into Washington and Seattle. Obviously after residency is done. Maybe I'll stop by and visit Rudd, at his awesome job in Washington...(huh? no nights, no peds, is this really an ER???)

Sunday, December 19: Dr. Lin Injured in Combat

My heart goes out to a colleague of mine who was injured in combat in Iraq. Lt. Dr. Victor Lin, a fellow UCLA alumni and also a fellow graduate at Wayne State University School of Medicine in 2002, volunteered for the service call to help US soldiers in Iraq. Dr.Lin, was injured when an explosive device detonated near his vehicle, sending fragmentation into both of his legs. Dr. Lin is currently at the National Naval Medical Center in Bethesda, Md., but may move between there and other sites in the coming months, as he faces additional surgery and rehabilitation.

Usually military doctors have the option of completing residency prior to active duty. But I knew Victor to be one of those guys who put things in priority and he probably opted to serve his country in front of his own interests. For that, Dr. Lin is a better man than me. I wish him the best as he faces his road to recovery.

Thursday, December 16: Sprinkle Mutant Running Around

Congratulations to Thomas and Kathy Sprinkle on their first addition to their family! Kathy gave birth to a baby boy the other day ...I talked to Tom today and he is having a great time... best of luck, that's awesome...

Thursday, December 16: Most Ridiculous Story of the Week

This article really pissed me off. Basically, Hungarian Jews are suing the US claiming that after the US saved them from being murdered by the nazis and the communists that the loot that the nazis took was not returned to them. Unbelievable!!! If anything, it should be the other way around and we should be charging them for the cost of saving them from their death and the COST OF AMERICAN LIVES lost while saving these fucking ingrates. (sorry for the profanity)

The distortions of the legal system make me sick. Seems like there can be a legal claim for monies owed if some property is stolen, but if American lives are lost in the fight to save these people...well, that's just too bad. In my opinion, the people suing the US government should have been murdered by the nazis... Its obvious that they only know the value of money and not the value of life. After all, what is the cost that the Hungarian Jews owe to the families of the 400,000 US soldiers who died while liberating them from the nazis?

Wednesday, December 15: FRUCK!!!

Ugh...what a nightmare weekend. I came home on Friday last week to find the my computer was off and it wouldn't turn on...the chassis fans turned on and the lights blinked...but no boot. Looks like the mobo and cpu were fried ...FRUCK.

I head on down to Fry's on Saturday morning and buy an Athlon 64 and a DFI mobo. I tried to install it for the next few hours...with no luck. It turns out that the hard disk fails on loading of the sys files. Restoring a ghost image fails as well. Feeling bummed...now I'm looking at a longer repair.

I head on over to PC Club and pick up a new hard disk. I'm able to install to this disk but I can't get the computer to slave my other working HD. I figure out that the new mobo is FRUCKED as well!!! I head on back to Fry's that night and pick up an ASUS mobo...no more crappy brands...

On the way back to my apartment ...I'm exiting the Freeway ...going about 65...and happen to notice a big FRUCKING RACOON about 5 feet in front of my car ...I had no time to do anything... Not only was there a big thud! but my back end rose up off the ground. At first I thought "poor racoon" and then hoped that my car wasn't damaged that bad. I get back to the apartment and look at the front end. ...The bumper is BROKEN in half on the right hand side, the RADIATOR is bent back and the CONDENSER is blown out!!!!! Feeling really bummed now.

I finally was able to install the mobo, chip, and hard disks...but realize that the hard disk that initially failed to boot can't be installed to even after a repartition and format... Crap... That being the case, I just opt for getting a pair of the new SATA drives. (need one to ghost an image on the slave HD in the case of a crash ...which usually means you can be up and running in only a couple of hours.) Not only that ...I go extreme ...I buy an external backup HD ...there is nothing worse than the time required for a total reinstall of windows.

Finally, I've got the OS and disks up and running....but now it appears the the sound card also got fried as well. Ugh!!! Total damage on computer repairs $870 and 20 hours so far trying to fix it (...probably another 20 to get it all configured). Total damage to car ...which is in the shop now..$3,200. Total cost of my Friday and Saturday $1,420. FRUCK!!!

Anyways, I'm back up and running ...still have a tone of work to do...

Thursday, December 9: Chairs with wheels...

Well the LA Times Articles are finished...at least in this series ...I'm sure there will more will be coming out.

Without getting into specifics, it seems to me that many problems at the hospital are completely related to the lack of incentives to do things right and the lack of consequences if you do things wrong.

I often think about the things we do in life along these terms. Am I doing something because I want to and because I think it is right? Am I doing something because I don't want the consequences if it doesn't get done? Or am I not doing something because there is no incentive or the consequences of doing it are substantial? Basically its the "carrot versus the stick." And it seems to me that that there is no carrot and there is no stick. Hence the "Morass."

For the county supervisors, as in the article today, taking action to correct problems might have been perceived as "racist." ...and nobody wants that label, so they opted to do nothing, oops, ...I mean they opted to commission a "task force."

County nurses negotiated with their unions to avoid doing their job, and shifted the work onto the residents working on the wards. Please find me another hospital that has banned giving IV pain medications on the floor? And people are shocked to find the nursing issues so prominent as described in the LA Times?

People were getting paid much more than their counterparts at other institutions and billing the county when they were not even there. Obviously, nobody had an incentive to check to make sure that people were doing their work.

Probably one of the most telling issues in the series on King was that of the workers compensation claims for none other than "falling off chairs." ...probably the funniest part of the whole issue... Here is their graphic.

Yep ...Falling off of chairs with wheels ...I think we need an "in-service" on this subject... (an "in-service" is a hospital term used to describe an educational seminar during work hours on something that you already knew...)

When I was an intern, I overheard a few nurses talking about disability. Basically the nurses stated that through county disability plans, and if you went out and bought supplemental insurance through "AFLAC," worked for two years, and then got "injured," you could actually collect more money than if you were working!!! This was the nurse's goal...to get injured on the job!!!

How could I fault her though??? This is the system that the county created... Basically, the system created an incentive to shift the nursing work onto residents, get paid for extraordinary sick-leave policies, and finally claim that you fell off a chair and can no longer work and have the county pay you for the rest of your life!

Basically they created a huge incentive to cheat the system with zero repercussions if you were caught. ...I'm planning to fall off a chair on my final day of residency... :) That could be worth about 6 million...

In my opinion, if you fall off your chair and hurt yourself such that you are no longer able to work...you are too stupid to live.

Unfortunately, the LA Times in their sensationalism, failed to mention any positive attributes such as the backbone of the hospital...the ER. Our nurses there are hard working, and our residents and attendings are extremely motivated. As a group, the ER Residents scored number 1 in the nation on the National In-Service exam. Sure there are problems at the hospital, but the LA Times needs to present the whole story and not just the things that they think will sell newspapers.

Wednesday, December 8: Snowboarding

Trip planned for Dec. 21st at Snow Summit. Who's game? (We've got room for a few more.)

Current boarders:
Rushton
Hurley

Report: "Nearly 100% of the terrain at Snow Summit is now open with excellent coverage and conditions!"

Tuesday, December 7: Guilt by Association?

Yikes!!! Those LA Times articles are brutal.

Anyways, I updated my resume page ...would like some feedback on my resume ...email me your criticisms. Thanks... Hurl

Sunday, December 5: Huh?

Alrighty now... I'm on the trauma service this month. We get a paramedic run, and over the box (radio) the paramedics tell us that they are bringing in a patient who is an auto vs. ped. victim(i.e. hit by a car). Well, the paramedics state that the initial call was for a man down after a shooting. So the paramedics get to the scene and find a man trapped upside down between two cars such that one vehicle need to be moved by the paramedics to even get to the patient. The paramedics note an obvious deformity to the femur right above the knee with some bleeding.

So the patient comes into the trauma center, he's acting bizarre and can't tell us what happened. The only thing he says is "ouch" and "mommy". (We don't know if he is on drugs...or this is his normal behavior) ...Just slightly odd since he is over 30 years old!!! We look at his knee and there is a nice little hole in it. So we shoot an x-ray of the knee, and sure enough, there's the bullet.

So the question becomes: How do you get trapped between two vehicles, upside down, and also get shot in the knee and sustain a fractured femur??? I'm baffled. This stuff just doesn't make sense.

Side note: Weird stuff comes in to the hospital all the time and you just wonder what people were doing or what they were thinking. My favorite "what the hell were you thinking story" was that of a 23 year old woman who was 8 months pregnant came into the trauma center at 4 am on a Wednesday, drunk, and had just been shot in the stomach!!! Okay... 1) What are you doing when you're out at 4 am on weekday 2) what the hell were you doing getting drunk when you're 8 months pregnant??? and 3) Who did you pissing off so much that they start shooting???

Oh well, what can I say? Is this what happens when Jerry Springer infects your mind?

Saturday, December 4: Ugh...

Well if it seems to be real, it's illusion
For every moment of truth, there's confusion in life

--Black Sabbath

Nothing can be more frustrating that than dealing with conflicts between your desires and things that you have no control over...

Friday, December 3: Synopsis of Vacation Month

Well, My vacation month is over...went back to work yesterday ...ugh... I don't like working for the resident salary of 10 dollars an hour...

Overall, I think I had a fairly good vacation. Sure I didn't go anywhere special but then again when I travel, I'd like to take that special person along for the ride...

I did end up working 10 moonlighting shifts, and I always question myself ...am I a workaholic? Well, I'd have to argue that that behavior is the type that places an inappropriate amount of effort on work at the expense of other things in your life. So I'd have to say that I am not because I try to fulfill those personal aspects of my life ...however, at the same time, I do feel conflicted about it, in that maybe I do work too much. (side note: who can fault me for working NSICU...its got to be the best paying and easiest jobs that I have ever had. ...neurosurgical patients either get better or die irrespective of what you do...) I love that one quote from Fight Club..."The things that you own, end up owning you." --Tyler Durden ...This is something that is easy to fall into, especially in superficial LA.

In reference to work, I actually started at the age of ten with my brother and we delivered real estate brochures. We ended up charging 5 cents per delivery and made an hourly rate of 10 dollars and hour. After working 2 years at that rate, my brother and I upped the rate to 7 cents per delivery and we started making 14 dollars an hour. Wow! ...talk about an awesome job for a 12 year old. Anyways, we only worked about 3 hours a week but it was more than enough to buy the things we wanted and save some money...(It was tough to spend since I made all the money myself and I knew its value...) Because of that I was very different than many of the kids who lived on my street who were spoiled and never worked (...and bunch of them ended up not going anywhere in life)... So the work ethic has been ingrained in me since an early age...

Its very difficult to know the right balance between personal and professional goals. Of course, the thesis of virtually every self-help book written about money ...making money so that you can live a full and happy life. I'd have to say that up until about a few months ago, I think that I was more on the professional side of life. Now I am shifting into the development of my personal goals as many of my professional goals are being realized.

Also, I am thinking about the subject more, and maybe this is the medium to really think about those things so that I have clarity of convictions and can approach life in a more thoughtful way.

My vacation month was rewarding because I did accomplish many goals that I had set out...

I got back into shape. I ran about 4 miles six times..got a little touch of the patellar-femoral syndrome...went to the gym and lifted about 8 times ...thank God for muscle memory ...I'll never get back into the shape that I was in 2002. :(

I learned how to do web design, at least in the basic sense, and also learned how to use some graphic software. And yeah, I'm enjoying this Blog thing... :)

I went on an interview and that went extremely well, and finished my Kaiser application and health screening. They want me to start working in a few weeks ...Yikes! its not like I already have enough to do... (I wonder when life will get a little less complicated??? ...but I doubt that that will ever happen in the near future)

Overall, I think I could use another vacation...

Wednesday, December 1: Spago's

Probably one of the most innovative restaurants that I've ever been to... (and now at their new location! I went three times previously to the location off of Sunset--Its a better location there, but the restaurant was small. This one is much larger...)

...Flemming's a few weeks ago had the most delicious filet ...I think they cooked it in butter! ...I got the Sea Bass, this time ...I can't resist the Sea Bass. :)

I'm still longing for that whole fried catfish from one of the first times I went...

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