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Hurl's Blog


Sunday, July 23: Zen 06

Loved it. Tiff Needell is driving the Z06 Corvette! Mind blowing. Clarkson in Top Gear not as good as Tffy though...

Fifth Gear and Top Gear Reviews

Favorite quote: "I am a child."

Looks like I'm in a car mood. ...and this one was just hilarious:

Tiff rolls the Robin... I love how he compares it to the Rear wheel driving.

Friday, July 21: Powerslide

Well I admit that I have tried this twice in the rain... Pretty fun and I got loose on both attempts and drifted for about 4-5 feet before rationality kicks in and I released the throttle to get it back into line... Maybe one day I'll get enough balls to go a little further.

Anyways, I was perusing on and did a search for "Top Gear" a British program on cars. One of the hosts is Tiff Needell--do a search for him... Completely ridiculous videos... I laugh. Check out: Rear wheel driving, Powerslide, and E46 M3...

This is a good vid as well. German drifting...

Thursday, July 20: fascinating cases of the week

Two cases that I have seen before, but still pretty cool:

Diagnosed a man as having discitis and septic endocarditis. Patient presented with nuchal rigidity, and a history of intermittent fever and chills. Patient had a tunnel right internal jugular central line. On exam the patient had about 20 splinter hemorrhages. pretty cool. Did an LP which showed an elevated protein level of 170 but no RBCs and only 2 WBCs. Admitted the patient and told the internist to order an MRI of the c-spine. Three for three on the case. Very similar to the case that I presented at the Boston SAEM conference in 2003.

Had another case of psuedotumor. Used a 6 inch spinal needle (patient weight was about 320) up to 5 inches and hit CSF on my second attempt (had to reposition the needle to get a better angle to walk down the spinus process. Patient had 22 attempts the last time at an outside hospital. Initial pressure was 400 mm. Drained 20 mL down to a pressure of 370 mm, removed another 10 down to260 mm, removed another 10 down to 210 mm. Pretty cool case... Finally got an answer the the question that I have had in my head for some time now as in how much fluid to remove. Turns out that you can remove it all! Okay maybe not all, but enough to get the pressure down. One of my co-workers who has about 25 more years of experience stated that when used to run the neuro ICU (completely funny since I used to do the same thing) the practice at that time was to bolt and drain as much CSF as possible in skull fracture cases with the idea that the dural tears will repair better.

Did a fun little laceration repair to the ear... threw in 25 stitches of the 6-0. Took me 2 hours to repair. Woohoo. I love those types of repairs... the last one that I did that was pretty fun was the box-cutter to the face that was about 4inches long and transected some facial muscles. Just try and approximate them muscles the best you can and there is nothing better than the running stitch... :)

Sunday, July 16: "Disproportionality", Moral Relativism, and Fanaticism

The middle east conflict is fascinating. Not that it is a great thing, but it is something that clarifies the world. I think that living in the US with its relative naivety about the world, this is an event that illuminates differences in the world along the lines of ideology that the "west" will have to battle in the future.

In the late 80's and early 90's some people explained terrorism as an effect of Israeli occupation of the West Bank and Gaza. Now with Israel no longer occupying those areas, there is no legitimacy to that claim. While the settlements in Palestinian land are obviously/arguably an impetus for conflict (although, one could argue that taking land because of continued violence might be a good reason for perpetrators to stop attacking, most would probably agree that the Israel settlements were morally wrong), the fact that Israel has pulled out, and the fact that there are continued excursions across the border to bomb and murder the civilian population of Israel speaks volumes of the differences in ideology.

The best thought exercise is this: If the Palestinians laid down their arms there would be zero incursions by Israel into their land. If Israel laid down their arms, there would be no Israel tomorrow. The fact of the matter is that Israel is surrounded by an ideology that preaches its destruction. Just look at the Palestinian flag to see that it has the land of Israel on it.

Now one of the more interesting things about the conflict was the media reaction. The use of the term "disproportionality" to describe the Israeli response is unbelievable. What should be the response by Israel to Hezbollah sneaking over the border, killing a few people, and then kidnapping two soldiers? The question of proportionality in the region is this: religious fundamentals would gladly have (and I'm estimating here) about 25 of their own die to kill off one Israeli. The only way to respond appropriately to unprovoked attacks is an escalation of violence where the cost of a continued actions are greater than the costs you are willing to accept. Unfortunately, there is no "political" solution where people come together and "talk" things out. Hell, the violence has been going on for about the last 50+ years. For some odd reason and before I had a better understanding of the conflict, I recall reading the newspaper in high school about the Middle East "peace process" and just intuitively thinking to myself "this isn't going to work."

The concept of "proportionality" is completely devoid of an understanding in the region. Are we arguing here that killing X number of people is appropriate, but X + 1 is excessive? Only a moral relativist could make such an argument, and the response will be inherently criticized by someone at any point as excessive (hence making the Israeli response an extremely political one). While it is unfortunate that Lebanon gets pummeled to pieces, what other way explains to the fanatics that supporting Hezbollah (an elected part of Lebanon) or even the election of Hamas to Palestine has some dire consequences? In my opinion, I think it is the only way in which people will finally start to oppose the radical groups in that region. In fact, I think that it is evident in world opinion (a thing that I tend not listen to since it is more often wrong than right) when the blame for the conflict is placed virtually entirely on Hezbollah. While most of the world is asking Israel for a cease-fire, I doubt that any other nation facing the same circumstances would heed their own advice.

On an ideological plane, it is again an interesting issue. While many in the US critique the foreign policy and throw out thin arguments such as "American imperialism," (evil things like trying to spread democracy) very few will even recognize the trends of 'Islamic imperialism" or "fanaticism" (spreading Islam through violence). One need only look to the regions such are Darfur to see the genocide being brought on by Islamic fascism. To some extent, it shows that fighting this ideology is a moral imperative.

Thursday, July 6: Depression and Obesity

Another fantastic study...The way that this one is reported is just so dumb. Did anyone not know this? ..that would be a better study, in my opinion. In reality, the only aspect that is beneficial is the prevalence rate of about 25%. And that's the only news.

Wednesday, July 5: "I've got to save my liver"

Goals in life... This article is just so bizarre: government housing for "chronic inebriates" with zero stipulations on behavior with the exception that you drink in private.

Fascinating the amount of money that the public spends taking care of these people.

In 2003, the public spent $50,000, on average, for each of 40 homeless alcoholics found most often at the jail, the sobering center and the public Harborview Medical Center, said Amnon Shoenfeld, director of King County's division of mental health and chemical abuse.

Hobson's group expected the annual cost for each new resident of 1811 Eastlake to be $13,000, or a total of $950,000. It cost $11.2 million to build and is paid for entirely by the city, county, state and federal governments.

This is an article that everyone should read since a lot of people think that we "neglect" this specific population. Its evident that some people chose this as a lifestyle. I was floored to learn that they gave them a stipend every month and took trips to the grocery store to buy more alcohol. I often treat this patient population and we spend tons of money in terms of labor, diagnostic studies and of course time occupying a bed that can be used to treat others. Not to mention the chronic abusers that call 911 20 times a day to get transported to the ER, where by law, a physician has to waste time with more often than not a bogus complaint. The odd thing is that I think that hospitals probably could save money by making a shelter themselves and giving out food as opposed to "treating" people in the ER. Of course, if they did do that then they would have legal liability if anything bad happened on the "hospital' grounds.

Side: I especially like the line that it was "paid entirely by city, county, state, and federal governments." Like that is a specific entity.(maybe it should read: "taxpayers" to be little more precise) The other fascinating aspect... since its opening, 4 of the 75 residents have died! Sheesh..


Wednesday, July 5: Fantastic realization...

I just realized that virtually all cars (at least the performance ones) have the tachometer on the right and the speedometer on the left. I wondered about it when I initially got my car since I thought that the speedometer was more important and should be more visible on the right. Not even thinking about it, I realized why today. Driving home from work I blipped the throttle prior to coming into a hard corner. Bizarrely (I don't think it is a word--but it sounds cool) I was half asleep and I had a moment of zen... sitting right there in my peripheral vision was the needle sweeping up, reaching a little peak and right before it started falling down, I let out the clutch back in to achieve downshifting nirvana. ...I'm a tard. :)

Since the tach is more in the visual field as opposed to the speedometer, you can keep an eye on the road, and rev-match with much more precision if the tachometer is better visualized. Maybe in a few months, I will again try heel-toe shifting.

Tuesday, July 4: Missile Fizzle

I laugh... Kim Jong Il playing the "missile card." I actually find this so funny. Il is such a peon that he has to launch a few missiles on the 4th of July. Then the missile fizzled! I wonder how many people ended up dead for that error. On the serious side, Kim Jong Il is a fanatical paranoid idiot. The world will be a better place with Il dead...

The best way to summarize the 5'3'' tall, 4 inch platform shoe wearing, Kim Jong Il is the song from "Team America":

I'm so ronery
So ronery
So ronery and sadry arone
There's no one
Just me onry
Sitting on my rittle throne
I work very hard to be number one guy
but, stiwr there's no one to right up my rife
Seems rike no one takes me serirousry
And so, I'm ronery
A rittle ronery
Poor rittle me
There's no one I can rerate to
Feewr rike a biwd in a cage
It's kinda siwry
but, not reawry
because, it's fiwring my body with rage
I'm the smartest, most crever, most physicawry fit
but, none of the women seem to give a shit
Maybe someday, they'wr awr notice me
And untiwr then, I'wr be ronery
Yeah, a rittle ronery
Poor rittle me...

Kim Jong-Il in all seriousness, must suffer from missile envy. And if you don't believe me, ask yourself this question: Why did he name it the "dong". I rest my case.

Prediction True: Saw the intro for Spiderman 3 the other day. Woohoo. So excited they are doing the alien costume (symbiont). That has got to be one of the best story lines from the comic series. Interesting since the resolution to the conflict is based on the neogenic nightmare which is a very long and complex story line... My initial recommendation would be to do a multi series release with 6 full length films of the neogenic nightmare spaced every 4 months from the theatre. That would be awesome.

Saturday, July 1: one year out

Wow... exhausted from an ?easy? day at work, I marked my one year anniversary from graduation. Looking back, I think that very few people understand the level of devotion that one places when signing up for a job like this.

Med school is four years and residency another three. Seven years of long hard hours. I probably averaged anywhere from 60 to 80 throughout that time and often had 100 hour work weeks. From a financial perspective it has some definite short term cost with about 160K in tuition, and an income of about 220K (income during residency because I worked my butt off). Hmmm, doing the math, that equals about... hmmm, calculating after taxes... yep... about zero dollars. I'm not necessarily complaining since I feel very fortunate to be where I am at. All that I am saying is that I have put in some hard work.

Anyways, its nice to be a year out, making some money so I can enjoy life a little more. Of course over the last year, I continued with my trend and worked about 270 day or about 2700 hours. Arghhh... so tough to try and get ahead.

From a numbers perspective, I have treated just under 5000 patients, wrote about 2000 to 3000 prescriptions and maybe (a complete guess) 800 admissions... :)

Interesting cases for the month (at least the few that I remember):

1) Middle aged female with complaints of palpitations and malaise. Tachy at 120 with a low voltage EKG. Patient also complained of bloating sensation. I did a bedside ultrasound to find a 1 cm thick gallbladder wall without stones and a large pericardial effusion. Patient's liver enzymes were normal, but within 2 days, the patient was dead from an idiopathic (autoimmune) fulminant hepatic failure. Liver enzymes went from 100 to 7000 in 36 hours and the INR went from 1.0 to 2.0 in the same amount of time... Yikes... The gastroenterologists have never seen a case like that before. Feel sorry for the family... patient was a hard-working, health conscious woman with no past medical problems.

2) Diagnosed lung cancer in a 37 year old female!!! Yikes too young... Another sad case, and the ER is not the best place to diagnose cancer, especially when the disposition is discharge home and follow up with an oncologist. Commentary: it may sound odd, but discharge is the right thing to do. Admission to the hospital (especially when nothing new will be done) is a waste of resources, money that is required for acute interventions.

3) Diagnosed Central Cord Syndrome and a Cauda Equina Syndrome obviously not in the same patient...

Monday, June 19: tingly sensation up and down the spine...

Opened the mailbox to find an envelope with the letters ABEM on it... my heart suddenly slowed to something like 40 a minute... I'm near-syncopal. Opened it up and skipping a beat.... Woohoo!!! Passed oral boards! so happy :) ahhh, what a fantastic feeling...

Anyway, what have I been up to... stopped writing in the blog for a while...since I wrote a piece, left it on without saving the file for a day or so and then the power failed and I lost it. Argghhh!!! Oh well, I'll get back to writing once I stop working so much... Coming up: trip to Miami to visit with friends. :)

Friday, May 26: The Omen

Evil, my stray cat that I feed, is out of control. In the last month he's brought me 5 birds and 4 lizards to my doorstep... I laugh. This cat is crazy.

Picture of Evil when I wake up in the morning... he's always out there waiting for a handout... I know what he is thinking as well. Give me some food and I will bring you another bird. :)

Friday, May 26: UFC 60

Upcoming ..Gracie versus Hughes... Wow, that is going to be an awesome fight.

I've always loved Gracie from the day of UFC 1. This guy would fight multiple opponents in the same night and destroy them with submissions. Even took out guys over 90 pounds heavier than him. On the other side, Hughes is an unrelenting powerhouse who has dominated his weight division for some time. Who will win? Don't know... height advantage to Gracie. Standup to Hughes. Submissions to Gracie, stamina and chin to Hughes. The interesting thing about this fight is that both fighters in the past have imposed their will on their opponents. With Gracie wanting to go to ground, and, I think, Hughes wanting a standup, I would assume that most of this fight will be in the clench or in the guard. X-factor: Gracie high kick because of the height advantage??? Prediction: Hughes. Too strong and smart enough to not get submitted. If Gracie wins it will be due to a rear-naked choke.

Monday, May 22: machine breaks down

Ugh... crash and burn. For some odd reason, I always seem to try and do too much. Over the last month I've been hitting the gym hard, running about 12 miles a week and trying to add more lean mass. All that while working about 5-6 days each week. Not a good combination, especially considering that I get to treat those near-death 22 year olds with those ever so dangerous viral syndromes. Now I'm under the weather. Arghhh... Hazard of the job.

Other than that, the cool case of the week: Hyperkalemia at 7.9. Interesting in that the patient had dialysis the day before and then presented with dizziness to the ER. All I have to say was thank God for pattern recognition. Patient had peaked T's, a PR greater than .3 and and QRS of 130. Actually the first time that I have seen that three-combination in an alive patient. All the hyperkalemic patients that I have seen are either just peaked T's or sine-wave arrests. Turns out that the AV fistula was in a low flow in about to fail.

Thursday, May 11: Procedures by Google

Cool case of the week: Did a debridement of a dry socket! Okay, sounds boring, but then again this was the first case that I have come across in 4 years. And it was fast and rewarding...

How to do it... do a google search!

Hitting the inferior alveolar nerve: Insert needle about 1 cm above the occlusal surface of the mandible, 1 1/2 cm medial and across the opposite side of the mouth at an angle of 45 degrees. Depth of about 1-2 cm. Inject about 1-2 mLs of anesthetic. Fastest nerve block that I ever did. Pretty cool. :)

Monday, May 8: Priceless

I read this oft-mentioned article on the "Stay-at-home mom would be a high paying job". All I have to say is that there is "research" and there is common sense. So I find it funny that someone would try and ascribe a dollar value that is absolutely huge to the job of "stay-at-home" mother. Logically speaking, if the value was really $134,121 (a completely ridiculous number since it goes to 6 digits long--these people need to understand "degrees of significance"), then no mother should go to work unless they were making more than 134K. If they made less than that number and went to work, then there would be a "value loss" to deciding to work.

This study only proves the point that there are 3 types of research: 1) research that has common sense, proves the obvious, and is correct, 2) research that contradicts common sense and is wrong (and often politically motivated), and 3) real research such as "is zyprexa better than lithium at controlling mania"?

The conclusion that the value is 134K violates common sense. True, staying at home may be a "priceless" or an extremely "valuable" experience since there may be no amount of money that could get some people to leave home to go to work. But those descriptors are ones of emotional content and are not economic.

There is no doubt that staying at home to raise kids involves a lot of work, but those are the "costs of living." Nobody goes around calculating the cost of all the activities they do... If someone makes a sandwich would that value be akin to the hourly wage of somebody working at Subway? Its a ridiculous comparison. The only validity of such an argument is when you look at the cost of doing an action versus paying someone else to do it (i.e. you spend the time to buy the necessary ingredients for the sandwich and then make it yourself).. The real cost-benefit question that everyone makes on a daily basis is: should I go to work and make some money and then try to do all the other chores or opt to pay someone else to do them. For instance, I have come to the conclusion that it makes no sense for me to ever wash my car, garden maintenance, or clean my house (once I get one). I could spend the time at work, make more money in an hour than the cost to wash my car or do chores which could obviously take more than a few hours.

The next step that these "researchers" should have done was to look at the difference of going to work and then coming home to do more chores versus just staying at home. The marginal difference in the work done is the true value of staying at home. Of course, making a calculation such as that throws in a huge fudge factor which would make too complex to answer outright.

Thursday, May 4: Done (I hope) with Oral Boards

Opportunity cost of not working to study for this test: $7,000
Cost for Banana Republic suit (I love it) with new shirt and tie: $550
Cost for exam: $1,200
Cost for plane trip: $260
Cost for hotel room: $150
Done with the test (of course if I passed): Priceless tired of taking tests.

Anyways, visited my friend from med school and went out to celebrate... Mummm. juicy steak at Wollensky's Grill.

Friday, April 28: Playdough Factories

Mexico decriminalizes small amounts of drugs... ...cocaine, heroin, ecstasy and pot... !?!?!?!?!

I'm baffled... I can understand the arguments for legalizing marijuana (alcohol is much more dangerous--blah, blah, blah..--have yet to hear someone propose prohibition II). I guess its obvious that I would oppose such an action--why make more drugs legal? (...and how would you quantify if a person was under the influence while driving?) But to decriminalize cocaine and heroin is just unbelievably stupid.

I find it funny that the anti-tobacco campaign is so strong yet legalization of drugs is a "progressive" policy. Having treated patients who have been heroin addicted, all I have to say, is that there is no "cold-turkey" with this population. I've talked to many people at a drug-rehab facility (AKA methadone distribution facility) in Detroit where I did two weeks of "intake" for heroin addicts during med school. The story that I got was "I tried it a few times and then I couldn't stop." Eventually, everything then revolves around heroin. I remember talking with one pale and cachetic lady who was already in withdrawal with her shakes, piloerection (goose bumps) and holding her belly as if to help with the nausea. I asked her her social history ...turns out that she had like a half-dozen kids, all wards of the state. But that was obviously not her concern. Instead, her only concern was getting some methadone to take the edge off the withdrawal which she simplistically described as "it feels like I'm going to die." I then asked her last usage.. only 3 hours prior to coming to the clinic! She ultimately used heroin about 8 times a day! Had to wake up in the middle of the night and use again so she could sleep! The cost of a bag... only 10 bucks. She went through 560 bucks a week for her habit! ...while of course drawing state assistance.

In my opinion, any politician who advocates making heroin legal should be forced to use heroin 8 times a day for a week and then abruptly stop. I think that the research has shown by that time alone, the chemical changes in the brain are so profound, it is akin to quitting smoking after 10 years of continuous usage. I'd like to see the politician then go through their entire life savings, lose everything including their family and then advocate for such a drug. Only a complete idiot would argue for such a law.

Cocaine is a different story as there are probably a lot of high functioning users in powerful places. But its a drug with unbelievably bad side effects. During residency in South Central LA, I saw a bunch of heart attacks and hemorrhagic strokes from cocaine. I have a few memorable cases... one was a 42 year old male came in with chest pain and V-tach. On arrival to the ED, he was alert, oriented, throwing out expletives and of course in V-tach at about 180/min... he got one defib at 200, said "What the fuck was that!" and crashed and burned like I have never seen before. He went from talking to dead so fast my head was spinning... he went faster than people I've seen shot in the head with their brain being squeezed out. These playdough factories had at least enough common sense (or brainstem) to go opistotonus when jamming an ET tube down their throat.

I have no idea how many young males I saw with hemorrhagic strokes...Since I worked the neuro ICU, it was probably in the hundreds. And every week we got at least one great organ donor through the doors in the ER with the pupils blown and that glazed over look from their last high.

The only good that legalizing these drugs can do, is increase the number of entries over on

Wednesday, April 26: Art of Agnes Hurley (1916-2006)

"Madonna of the Rocks" by Da Vinci. Painted in 1991.

"Street in Cordoba" with "The Mesquite" in the background. Painted 1991.

Rest is peace. We will miss you. Love.

Friday, April 21: Nails to the Head

This was a great one... Whenever you think you are having a bad day, somebody has got it worse.

Friday, April 15: Suffocation

Had a third case of Ludwig's angina in my career the other day... Interesting in that he came in with just unilateral submandibular swelling (looked like an abscessed submandibular salivary gland), and within about 2 hours he had almost progressed to the entire submandibular space being involved. Because it was just one side I went ahead and CTed it. When he came back he started to drool and was unable to swallow.

From what I can tell, it appears that this infection was once know as "the suffocation" since the tongue gradually increases in size and the involvement of the submandibular space pushes the tongue upwards and backwards, progressively closing off the airway. Reminds me of my favorite Seventh Son songs... Infinite Dreams.

Infinite dreams I can’t deny them
Infinity is hard to comprehend
I could hear those screams
Even in my wildest dreams

Suffocation waking in a sweat
Scared to fall asleep again
In case the dream begins again
Someone chasing, I cannot move
Standing rigid a nightmare’s statue
What a dream when will it end
And will I transcend?

Restless sleep the minds in turmoil
One nightmare ends another fertile
Its getting to me, so scared to sleep
But scared to wake now, in to deep

Even though it’s reached new heights
I rather like the restless nights
It makes me wonder, it makes me think
There’s more to this, I’m on the brink
It’s not the fear of what’s beyond
It’s just that I might not respond
I have an interest almost craving
Would I like to get too far in?

It can’t be all coincidence
Too many things are evident
You tell me you’re an nonbeliever
Spiritualist? well me I’m neither
Would you like to know the truth
Of what’s out there to have the proof
And find out just which side you’re on
Where would you end, in heaven or in hell

Help me, help me to find my true
Self without seeing the future
Save me, save me from myself
Even within my dreams

There’s got to be just more to it than this
Or tell me why do we exist
I’d like to think that when I die
I’d get a chance some other time
And to return and live again
Reincarnate play the game
Again and again and again

Wednesday, April 12: Stressed out...

Ugh... got oral boards on May 1st. I don't think I will ever have had such a psychologically intimidating test. Its not that the material is difficult, its just trying to play mind games with theoretical patients. Obviously it much more simplistic in real life since you do things naturally... things that you don't really think about. Oh well, I have 16 hours of oral board prep tapes to listen to, and probably will try to review the major emergencies. I set aside the last 10 days of the month to prep for them.

On the bright side... once I am done with this test. I AM DONE. DONE. DONE. DONE!

...everything else is easy.

Friday, April 7: Potpourri

Thrombolyzed my 7th patient in the last year... 2 strokes and 5 heart attacks. 2 STEMIs in the last week! It actually pretty amazing how important your nursing staff is getting these patients to you in time. My last patient had a door to doctor time of 10 minutes! Understandable though since the patient in that case took forever to answer a question... Oh well, all I need is an EKG, chest pain, no contraindications and they sign the consent for the TNKase. This was actually a pretty amazing week... had two patients who I gave subcutaneous injection of epinephrine. A 5 year old kid who was minutes away from respiratory arrest, and a lady whose airway was about to swell off from a seed allergy. Called anesthesia for this one and they did an RSI and were only able to see swollen arytenoids folds, no cords, and intubated her with a mere 6.5 tube!!! Whew on a razor's edge.

Interesting article:

Harry Browne talks about Bush's spending. Amazing in that Clinton had an inflation adjusted spending rate of 1.6%. (one of the lowest in history--and probably because a disciplined republican congress.) Now Bush is signing everything and spending is through the roof. In fact he has not vetoed ONE bill. A complete loss of direction by the reporklicans... Makes you sick, because eventually and even with "tax breaks" a higher deficit and higher national debt just means delayed higher taxes. Milton Friedman once wrote that he was not concerned with deficit spending in that if private sector growth outpaced deficit spending (or grew faster) then it made economic sense. As for my belief that this is the current situation ...I don't think so (distressingly).

Monday, April 3: Go Bruins!

Saturday, April 1: Black Cloud?

What a day... UCLA Dominated LSU... shocker since UCLA looked so vulnerable in the last few games. Arghhh... I'm working monday night.. :(

Black cloud... Yep, that's what the cardiologist called me after I was treating a patient for intermittent chest pain without EKG changes, and as I was in the process of admitting him to rule out MI, when he decided to MI right before admit orders were written. Patient went from NSR to STEMI in his inferior leads and atrial fibrillation at a rate of 120. Yikes... note to patients: If you plan on having an MI please have a diagnostic EKG when you come in the front door and save me the psychologic stress. Note to self: Don't get too excited. Breaking open an ampule of metoprolol that leaves glass in your thumb doesn't make you look too much like a professional... Also, calling the resuscitation cart the "crash cart" and yelling for it from across the room probably does little for relieving anxiety in the patient. needs a new name, but what else is going to get nursing attention? I laugh...

...Funny, I'm now know as the guy "who gave me (the cardiologist) that third degree heart block with torsades."

Other things during the week:

Rhinoscleroma: a chronic granulomatous infection in the nose. Patient blew his nose and tissue would fly out.. gross.

Tardive myoclonus. Yep, myoclonus and not dyskinesia. That was one weird diagnosis. Patient also had Parkinsonianism as opposed to Parkinsons. Etiology, chronic ingestion of reglan (a sister drug to the neuroleptics.)

Zoster in V1 of trigeminal branch (of course the ophthalmologic division branches off from there). If there is uveitis (i.e. cell and flare on slit lamp) without keratitis, then steroids are indicated. In addition, retinitis needs to be excluded. Out of all the singular diagnoses that I make, zoster and gout has me writing about 5 drugs for each condition. Zoster: acyclovir, prednisone, motrin, vicodin, amitryptaline. Gout: indocin, vicodin, colchicine, prednisone, allopurinol (if uric acid level is high and starting one week after resolution).

Cosmetic repairs... I'm actually much better than I was in the past. The key is to getting resected tissue to come together is freeing the tissue from its base. I have found that doing this followed by throwing vertical mattress stitches and then running 5-0 or 6-0 surgipro with a cosmetic needle leads to unbelievably good repairs. The idea of "under tension" should really be emphasized for the structures that potentially may pull the repair apart and not necessarily the throws themselves...

Had a near respiratory arrest in a 7 year old asthmatic patient... great case. Haven't had one in a while. Patient was able to turn around a little with some SQ epi... Note to self: dose of magnesium is 25mg/kg and the pediatricians go as low as necessary although under age 4 I think I would just intubate.


Thursday, March 30: Borrowed Time?

I've been following the story about Delphi and GM for some time since I made the prediction that GM would likely go belly up (recent news article). Its not a hard prediction to make. US workers are paid much more than foreign competition, have a legacy of extremely costly health care in the US (where when the family tells me that I should resuscitate a trached/pegged anoxic encephalopath --brain dead-- patient to keep alive at the cost of 250K per year lest I get sued for not doing the family's wishes) (actually happened again a few weeks ago), and the auto companies have a product lineup that went the wrong way (as in larger and more gas consumption) when the world was seeing oil costs soar and likely stay higher permanently if not go even higher. In my opinion, GM will declare bankruptcy within 8 months.

The economics in the US is a pretty scary topic. Looking back, I think that the reason why we have such a high level of living is that the people who left us this country worked their asses off. That and of course the economic structure was there to do so--such as a free market. While the US was innovating and at amazing rapid rate with the help of an open monetary policy (supply side), a well regulated banking system, and of course a tax structure that favored the development of wealth, the rest of the world was stagnated by a multitude of issues. China had communism and of course an isolationist mentality which diminished trade and innovation. India was just slow with developing--for reason I have not looked into. Europe has been establishing a more "progressive" socialist environment where health care is free, every worker gets 2 months off per year, and taxes were so high that there was little incentive to start a company. Compare the number of jobs created in europe following WWII versus the US. I think that we developed about 240 million new jobs while they had produced on 20 million (I'd have to check my numbers to be sure). France is a great example of how things are going wrong...the frogs are complaining about the first job law which gives employers the ability to fire a worker within the first two years of work. Huh? is having a job now a right??? From my perspective a job is a privilege, the fact that students in France thing that it is a right and that they believe that they are being educated to be "exploited" by the workplace is the product of 1)stupidity and 2)socialism --- which, I would argue is indistinguishable. Companies like Airbus receive huge subsudies...much more than in the US (although the U.S. gives it back in terms of tax breaks). (As an aside, this is why I support getting rid of taxes for larger corporations so that they can complete with foreign companies that receive government subsidies). Of course France is so jealous of the US, that they attack on a legal level U.S. corporations such as Apple and their hugely successful iTunes store and go after Microsoft for just about any feature included in the operating system. (okay my last aside--of course Microsoft does exert some monopoly power, but they are not a perfect monopoly meaning that they cannot control prices like a true monopoly--hence the term effective monopoly since Linux is not popular and underdeveloped and Mac OS and apple products persist to be too expensive.)

Getting back to the scary aspect about the US economy is that the US has been borrowing about 5% of its money per year for the longest time, spending is out of control with the US being in Iraq for too long, and with entitlement program even expanding by 50% under George W. Bush (who is the worst president in a long time--there are very few policies that he has carried out that I would even consider to be conservative.), and the deficit has expanded to just under ten trillion dollars. Who will pay this debt? Its certainly not going to be the voting baby-boomers or the current socialist hacks in D.C. Of course we see the result of these policies...the dollar has been sliding for a long time, wages have remained stagnant, and the cost of living is going up. Production jobs are moving to nations that do not have high labor and health costs, and the somewhat funny aspect is that unemployment has actually dropped probably because people are forced to work harder to make ends meet.

To some extent the success of the US has been that fact that people could work hard, innovate, and make money. In the past this was in a global structure where there was not much competition since the structure in other counties did not exist. Of course, now the emerging markets are maturing and the question for the future will workers in the US compete against foreign workers who are willing to work twice as much for less than half the pay? ...essentially, a climate that makes America look like Europe for the last few decades. I can only presume that things in the US will get worse with time unless we cut back entitlement spending, cut military spending, make health care less expensive (eliminate duplication and severely restrict the ability to sue--i.e. make medicine incentive-based), only allow immigrants into the US that bring the ability to make wealth without the risk of crime (nor the subversion of low-paying jobs), and converting to a loser-pays legal system. (From an economics perspective, the legal system and excessively expensive health care are burdens to economic growth.)

Saturday, March 25: Happenings

Yikes... just finished my 71st shift of the year... That's typically what most ER docs do in about 5 months. Hence the decrease in blog entries.

Interesting cases:

Treated a patient that was in the national news. Realization: any semblance of a medical problem in a well known person potentially equals admission. You don't want to be prominently displayed on the evening news as the doctor responsible for a bad outcome. That could be a career ender. I wonder what the ER doc and cardiologist who treated John Ritter have gone through...

Had a cool case of V-tach that I treated with amiodarone (actually the first one that I have seen in 4 years). Underlying rhythm was AFib with RVR and a rate dependent BBB. Etiology: GI bleed with PNA and sepsis.

My may 9th patient died. Patient received over 40 units of blood in the ICU (that mean he/she lost 3 times the normal amount of blood). Even a selective embolization by interventional rads failed.

Go Bruins...

What a whacked out game... 50 to 45 over Memphis to reach the Final Four. ?!?!?!?!?!?!?!? Maybe they can bring their A game versus LSU... It will be exciting. :)

Saturday, March 11: Bizzare

I must be messed up in the head... Had two more GI bleeders come into the ED and I so wanted to drop in a cordis, but i settled for what was available...some weak-ass 18 gauged peripherals. . I love resussitations...and taking care of people who are about to crump is always exciting/stressful event. Unfortunately, my previous patient did not survive... she developed shock liver and progressed to DIC. Either way, today was the first day of having fun after I got my ass kicked on Wednesday. Still looking for some more good cases... as for things that I have really found to be enjoyable... Displaced fractures of the upper extremity, gun shots to the chest, neck and head, massive GI bleeders, and STEMIs...

Thursday, March 9: Nuts

Yikes... had one of my most medically severe patient ever (probably top ten) without being blatantly dead(i.e. a grade IV SAH). Saving some time with the whole explanation, lets just say that the paramedics picked this patient up at home for "found down" and did nothing but transport the patient, only to drop off a patient in the ER who was NOT breathing and had NO pulse and an irregular cardiac rhythm at 30! No intubation. No line. No BVM. Are you kidding me??? The explanation... "she wasn't like this a minute ago...". Well obviously you can't get a line because she has no pulse! I tubed her (no meds... GCS 1-1-1) and dropped in a subclavian cordis and resuscitated her... she's still alive after 36 hours of ICU treatment and if she survives it will be an absolute miracle...

Anyways, if you want to know the full story, give me a buzz and I'll it tell to you... probably one of the most fascinating stories that I have come across yet in the ER. I'll never forget this one...

Sunday, March 5: Crime and Punishment

Interesting story on how an Iranian international student at UNC decides to run over 9 people in the "quad" to avenge the perceived death of Muslims around the world by the U.S. The interesting aspect about this crime is that prosecutors are contemplating using an anti-terrorism statute to prosecute him. Fortunately, nobody was killed and from my understanding they were not seriously hurt. My analysis: I find it odd that an additional charge needs to be applied to put this guy away forever. Is the penalty for attempted murder of 9 people not strong enough, or do we have to throw in some fudge factor to make it longer and make it sound more ominous???

Idiot analysis in the article by (bold type added by me) David Schanzer, the director of the Triangle Center on Terrorism and Homeland Security at Duke University and UNC-Chapel Hill, said it is fine for students to voice their dismay, but that they should be cautious.

"(They should) understand the roots of it and understand the strategies for addressing it in a constructive way," Schanzer said.

Huh? ..."understand the roots" of the fact that he tried to run over and kill 9 people... Some people are so politically correct that they suffer from head-in-ass disease.

Anyways, I opted to do a search for "hate crime" on since this is also one of those fudge factor "feel good" ideas to attempt to regulate beliefs and thoughts as opposed to actions. (Obviously you can tell that I support judgement of actions over interpretation of ideas/thought. ...Schanzer, on the other hand, would probably try to rationalize with the driver of the truck right before it plowed him over.) So I came across this article... Basically, a woman was charged and pled guilty to a "hate crime" for extorting/conning two old guys out of a bunch of money. The D.A. office charged that targeting people who are older is a "hate crime"??? Huh?(and if you don't believe me its here as well) My analysis: How stupid is this "hate crime" statute??? If conning two old guys out of money does not hold a long enough sentence, then make the crime for conning people harsher! Claiming that trying to con people who can be easily conned is a hate crime is absolutely retarded! Imagine the range of implications that you could throw into a "hate crime" charge... maybe, trying to con wealthy people out of money is a "hate crime" as well, since one would be obviously targeting the "identifiable group" of people with money. How laughable does that sound? Basically, the statute (if it has an application here) tries to interpret motivations such as taking advantage of people who have bad judgement. Essentially, one must argue that the logical extension to this charge is that if you are a criminal, you must diversify your crime against all segments of society... I laugh. :)


Wednesday, March 1: Lazy

Been lazy with the blog again... More focused on weight lifting, running, and working. Trying to get as much of that stuff in as possible.

What have I been up to???

1) Shopping spree: discovered Banana Republic. Love their stuff. I've always wondered why I could never find stuff that would fit me well... Going to the normal brand name stores yielded less than desirable results since most clothes are made for the typical male and is not fitted enough.

2) Taxes...ugh this is a mess. My jaw is slacking over the amount of taxes that I paid ...absolutely ridiculous and sickening. What is even more scary is that the next president will 1) most likely be a democrat because Bush has really blown it and therefore 2) Taxes will be going up.

3) Political analysis: As evidenced by the recent violence and killings over a fricking Mohammed cartoon, the fact that a terrorist government was elected to lead the Palestinians, and the fact that Iran will probably proceed to make nukes while the UN sits around with their thumb up their ass, it is now obvious to me that any rational approach to establishing democracy in a religiously fanatical state is unlikely to occur. My recommendation: pull out of Iraq, let the radicals bomb some mosques and blow up each other up. The US is fighting an uphill battle and pulling out, which would unfortunately destabilize the region, sounds like a good idea. I'm sure oil will go up to 100 bucks per barrel, but I am well situated in oil stocks... :)

4) Interesting cases over the last month:

Patient presented weak and dizzy. EKG showed third degree heart block with a very low bundle escape rhythm (QRS of 140!) at a rate of 30! Not only that her QTc was 480 and so then she decided to throw some torsades de pointes (TdP) that lasted 20 seconds on the first run, causing the patient to pass out. Fortunately she went back to her third degree, but I nearly shat my pants. I was seconds away from shocking her... In reference to TdP, I've never run a isoproterenol overdrive, nor have I paced one transcutaneously (and most everyone that I have talked to have never done it either). But I did learn a few pointers from the cardiologist who was oh so happy to come in at midnight on a Friday... Whenever a patient presents with a potentially lethal arrhythmia, its a good idea not only to place the pacer pads on, but also to run a test on the voltage required to capture in the event that overdrive is necessary. In addition, the rate for overdrive is greater than 140/min. As for atropine, it tends to only work for high bundle escape rhythms where the QRS is more narrow (i.e. junctional escape), but there is no downside to giving it a try.

Older male with a DDD pacer presented with crushing substernal chest pain. I ran his EKG for a good 45 minutes which was all over the place... heart rate went from the 90's up to 150s... and I could not get an EKG to stay regular for longer than 10 seconds! Anyways, right when the cardiologist comes in, the rate slows to 80 but with still a paced rhythm. The anterior leads show big convex STs. The cardiologist orders TNK even though its a paced bizzare. I find it odd that what is taught in emergency medicine is sometimes so different from how many of the other specialties practice. According to ER textbooks, you cannot analyze a paced rhythm... The cardiologist stated that in this situation you presume a STEMI from the paced morphology and give the thrombolytics. Either way, the TNK failed and the patient went to rescue cath which showed a nearly occluded LAD.

Aside: Good example of how things differ in reality than the textbook. Diltiazem for atrial fib rate control blows. If the patient has no contraindications, the first line drug by the cardiologists is metoprolol. I've switched to this style of practice now for the last 6 months and I think it works much better. Infected stone, unless they are really symptomatic goes home... Of course, a lot of clinical judgement is used in this situation ...I've seen one patient die from an infected stone.

Saturday, February 18: The Constant Gardner

Okay watched this flick the other day. And all I have to say is: what a shitty movie. Almost as crappy as Syriana.

I will admit that I tend to judge movies by their title, and I lament having not gone with my gut instinct on this one and saved myself 3 hours. The premise of the movie is that an evil pharmaceutical corporation is testing experimental drugs on the impoverished people of Africa while concealing the fact that the drugs are in fact knocking off a few homies, and, of course, its all in the attempt to sell the future drug to cure MDR TB (multi-drug resistant Tuberculosis). Although the plot is formulaic, I will admit that the movie caught my attention.

Myth #1: Obligation to help. The main implication in the movie is that the western world is allowing Africans to die off by not providing people who are stricken with disease appropriate drugs. Its almost a comical scene when a doctor trying to help out the indigent people complains that he only gets the left over drugs that have expired to treat people in the village when the next thing you know, the place is being overrun by bandits on a killing spree. Seems to me the they don't need drugs, they need guns! Not only that, the other half of the population is dying off from starvation. How drugs become the focus of attention in Africa is beyond me.

Issue #2: Intervention in Africa has been a disaster. Just look at Somalia. We go in there to try and get rid of some warlords and get food to starving people. The next thing you know, the US is now an "occupational" force there to get the "resources" of Africa. It was almost comical when some in this country came made that claim. In addition, countries like Zimbabwe (or however you spell it) expelled the white owned farmers from their country a few years ago. Now they are dealing with rampant starvation...

Thing #3: Drug companies are evil. I've always liked this one, especially from the radicals from PETA who promise never to use any drugs. But when they come down with cancer, the next thing you know they are taking anything and everything that pharmaceutical companies have discovered. From my perspective, nobody is forced to take drugs. The fact that you have drugs available to you is a benefit. People can decide if they want to take them or not, and the fact that pharmaceutical companies make a profit is a good thing. If they lost money, then there is no more innovation.

Cost/Benefit #4: All drugs have side effects. Patients simply need to be informed about the risks and they can decide if they ultimately want to take them. I had one patient about a month ago who presented with a massive left MCA stroke that knocked out the right side (hemiplegia) and knocked out speech and language reception. Patient arrived within 1 hour to the ER and I explained the risks/benefits to the family of thrombolytics and obtained consent for treatment. Unfortunately her symptoms did not improve, and she converted to a hemorrhagic stroke a day later. But if you look at it from the cost/benefit perspective, its the only good choice. Option 1: Do nothing. Be incapable of using the right side of your body and incapable of talking or understanding speech for the rest of your life. Option 2: Thrombolytics. Downside is a bleed in the brain (who knows if it would have converted anyways--very few have gone to stat MRI) and a worse outcome. Upside, you regain some function back ...maybe some ability to move the body and communicate or understand other people. So the funny part about the theory in the movie actually makes sense. If a MDR TB (multi-drug resistant strain of tuberculosis) was spreading across the world and there was no drug that treated it with the exception of "Dypraxia" then I think I would take the drugs! Again, its up to the individual... die from an "untreatable" strain of TB, or potentially die from a dangerous drug. Funny, the more I think about it, the more it sounds like the treatment for cancer. Either die from cancer or take your chances with chemo.

Tuesday, February 7: New Years Resolution Accomplished!!!

Woohoo. I'm so excited. I finally accomplished a goal that I have been working on for years. Yep, I got the recliner chair with massage! Lofty goals huh?

Love it! Its my best purchase ever...

Tuesday, February 7: Geeky Tech Stuff

Figured a few interesting things out on the computer...

1) has a nifty little proggie called autoruns that looks at all the things that run on your computer and allows you to search via google if these things are actually necessary for running or have conflicts/security threats. Obviously its for the advanced user, but I found at least 4 things that I didn't want running. Most likely its a buildup of junk programs from running this operating system for the last 3 years. Autoruns, registry mechanic, and running msconfig.exe are absolutely necessary for running the problem-plagued PC. Not to mention having Norton Ghost and GoBack, and of course a firewall and a couple antivirus/spyware programs. System is finally running without one single problem. :)

2) Graphics tuning: Tuning my new LCD was actually a pain in the butt, but I finally figured it out. Even though the monitor comes with advanced image software to "get the best picture," it doesn't work properly unless you have a video tuner on the graphics card end as well. Therefore, you actually have to run two tuners at the same time to get the best picture. After looking at the viewsonic in the store, I was not completely impressed with the image, but I figured that I had to tune it once I got it home and it would look better than what the store tuned it at. I tried for a week to get it right but then did some more reading on it to figure out that the graphics card has an output level and irrespective of how well you tune the image on the monitor, if the graphics card it putting out too much gamma, the image will look washed out. Too complex in my opinion and I doubt that most people running a PC would figure it out. Probably one of the bigger problems when you have so many options/vendors/products when running Windows. Anyways, I decreased in gamma output got rid of some washout and image bleed so now I am sold on the quality of the LCD (but not with the crappy viewsonic customer support)...way better than a CRT in terms of brightness and contrast, but worse off if looked at tangentially. In my opinion, Windows needs to do what Apple does. Switch to higher levels of technology and leave the legacy stuff behind. Maybe that will eliminate some of these problems.

3) Figured out how to run total DNS control with web hosting on Ugh... it not like I have to know enough as it is.

Tuesday, January 24: Redacted

Very bizarre. I started writing this one a while ago and never didn't get too far... So I'm finishing it up on the 1st of February.

Anyway, the daily show ran a clip of Hillary with her "plantation" comments--a fantastic slip up if I've ever heard one. So I was revisiting my thoughts on this issue, and it turns out that the Daily Show removed the clip from their webpage!!! They censored themselves!!! Are you kidding me? Me is disappointed. So I did a search on google and the funny thing is that it is on all these conservative webpages. I'd venture to guess that the Hillary political machine is up and running to quash the bad press. I laugh ...they must have pressured the daily show into removing it.

Here is a link to the video (albeit on a conservative page)...

The comment is pretty brazen... But the really unbelievable comments came from the Barack Obama who tried to spin the comments. He stated the that comments were intended to demonstrate that "there's been a consolidation of power by the Republican Congress and this White House in which, if you are the ordinary voter, you don't have access." Please. Hillary talking in front of a black crowd on Martin Luther King Day talking about plantations...

Thursday, January 18: RIP

My professional series CRT monitor bit the big one... So sad. :(

Got it used two years old in 1998 for a meager $220. At that time it was about a $600 monitor... Great colors, easy on the eyes.

Anyways, went out and got the Viewsonic VP2030b... Its pretty good, but I still like those CRTs...

Sunday, January 15: CSI Effect and Coleman

The story of Roger Keith Coleman is a fascinating one. Convicted of rape and murder and sentenced to die, opponents of the death penalty were certain that this was their case of their "innocent man." A man who was wrongly accused and executed in 1992. The potential case that opponents stated could overturn the death penalty.

In fact, a book titled May God Have Mercy: A True Story of Crime and Punishment was written proclaiming his innocence. Amazingly, some lawyers and "advocates" (an absolutely hilarious read now) have spent greater than a decade trying to prove his innocence and overturn the death penalty since they believe that raping murders should be given three meals a day, exercise time, and heart-bypass surgery. Much to their dismay, a post-execution DNA test confirms his guilt.

Funny amazon review on May God have Mercy:

A must read for death penalty proponents!, February 26, 1998
Reviewer: A reader
This book might well change even the hardest of hearts. If there is ever a reason to abolish the death penalty, the case of Roger Keith Coleman is it! His lawyers missed a filing deadline by one day -- and since that time his claims of poor assistance of counsel and factual innocence were never heard in a court of law. Instead, he was executed over a technicality for a crime he most probably didn't commit. A must read for anyone interested in the state of our criminal justice system.

The DNA tests showed that Coleman was unique to 1 in 19 million. Since the blood antigens found on his semen narrowed him down to a 0.2% probability, and given that the fact that two independent events occurring at the same time is the product of the individual probabilities, this places the likelihood of Coleman committing the crimes (the inverse of the two probablities--1 out of 10 billion) at 99.99999999%.

Anyways, I find the DNA evidence in crime to be an interesting subject. Ever since the OJ case where the contradictory dual argument was devised of 1) the blood was planted and 2) the DNA testing is wrong. Well its either one or the other as they happen to be mutually exclusive.

Today its now the CSI Effect... a phenomena where jurors expect hollywood style evidence and the proverbial smoking gun. A quote from the article.

Last year in Wilmington, Del., federal researchers studying how juries evaluate scientific evidence staged dozens of simulated trials. At one point, a juror struggling with especially complicated DNA evidence lamented that such problems never come up "on CSI."

Maybe another reason to go to the three judge panel and get rid of juries... ...I think I'm just rambling now... :)

Tuesday, January 10: Coot-Off

Woohoo! The Daily Show is back online! Just died laughing watching the Coot-Off!

Tuesday, January 10: Clarett and Vick

I've been pretty busy... but I'd have to say that this is one of the more interesting stories of the year in reference to Maurice Clarett of Ohio State University. Of course these events occurred about ten days ago...

Anyways, Clarett was one of the top 5 college football players in 2002, but just happened to blab his mouth on how he was getting special treatment at Ohio State which prompted an NCAA investigation. OSU kicked him off the team and then he attempted to enter the NFL draft early. The NFL rules mandate that players must be 3 years out of high school before entering the NFL. Clarett sued the NFL claiming racism but is rebuked by the Supreme Court. A year later at the NFL combines, Clarett is detrained and runs slow. He goes number 101 in the draft, and even waives a $413,000 signing bonus and instead opts for performance based incentives which could potentially earn him much more. Then with the Broncos, he proceeded to drink alcohol while in the weight room, further demonstrating that he is an idiot. Eventually he allegedly ends up robbing a person at gun point just about a week and half ago. Amazing. Clarett went from potentially going top 5 position in the NFL draft with a multi-million dollar signing bonus to a $50,000 bail bond.

Now a lot of people mess up their lives by doing dumb things... Typically people place blame on their "condition" or on "society" for their ills. But its always interesting the people who have every thing going for them to screw up so ridiculously stupid.

Take case in point, Marcus Vick...

Thursday, January 5: Truth Serum

Alrighty... somehow "truth serum" popped into a conversation... Funny since its the same drug used in lethal injection.

I decided to do a little research on it for fun on Wikipedia. Sure there is more fiction to "truth serums" than fact, but its actually a pretty interesting topic... If you inhibit some of the higher cortical functions, and one to which I would stipulate as being "lying" (at least more complicated than the truth), then potentially any sedative or hypnotic could be considered a "truth serum."

Eventually I found myself on wikipedia's "lethal injection" topic to see if anyone had written on the subject previously in reference to pentothal... To my dismay, I read the section entitles "controversy". Obviously it was full of crap... So I cut and pasted my little research on "Drogas of the Death Penalty" into a new section. Ha! I'm a contributor to Wikipedia! How funny is that?

Interesting how I made some modifications to my original entry and over time other people have already done some editing... Check it out! Lethal Injection

It will be interesting to watch how the text gets modified over time.

Tuesday, January 3: Anti-schedule

Alrighty... call me a greedy bastard... ended up working 17 out of the last 19 days. Because of the holidays, it was time and a half for most of the shifts. Whew... At least I got the next few days off...

Best case over the stretch... Thrombolyzed a 40ish year old male. Very odd in that I have put in a lot of hours and only had two thrombolytic cases in the last 9 months... Anyways, got those drugs on board in a door-to-drug time of 13 minutes. One of the interesting things is that supposively the troponin level is not a prognostic indicator??? (I find that bizarre) Either way, I'd like to get some more STEMIs... It was a great case... the patient was extremely grateful and I was glad I could help him out.

Interesting: AHA states no nitrates for suspected RV infarction. I don't think this is actually practiced. I think that any patient with suspected RV infarct (ST segment greater in Lead II versus Lead III or ST-segment elevation in rV4) should get fluids to load up the tank and then IV nitrates starting at a low dose and titrating as tolerated.

Most bizarre: Had two cases of Wolf-Parkinson-White (WPW) in a row... Frequency in the population according to the literature is 1/1000. Two cases in a row is 1 in a million. Side: emedicine states that you can even use adenosine in WPW. (A lot of contention on this drug in WPW.) I think adenosine is useful in its diagnosis...

Worse case: Pronounced a 29 year old the other night... Suspected cause of death: alcohol intoxication and aspiration.

Thursday, December 22: Great Cases this Week

Myasthenic crisis: Background--Myasthenia gravis is an autoimmune disorder where the acetylcholine receptor is destroyed, which leads to progressive weakness with repetitive activity. Crisis occurs when the weakness gets so severe that breathing is impaired. The incidence of this disease is about 2 in 1 million and its prevalence is 14 in 1 million (which sounds very odd unless the life expectancy once you get this is 7 years).

Untreated MG carries a mortality rate of 25-31%. With current treatment (especially pertaining to acute exacerbations), the mortality rate has declined to approximately 4%.

Anyway, a patient came into the hospital with a viral infection and worsening weakness. Eventually the patient required intubation to have a ventilator breath for her. These patient should not get paralytic agents during intubation especially pancuronium and succinylcholine because prolonged paralysis can occur. Ideal agents include etomidate, methohexital, and pentothal... Actually a pretty interesting in reference to my "drogas of the death penalty" entry. Yeah, I know, I'm a nerd.

Spinal Stenosis: This is a condition when the canal for the spinal cord gets too small and the cord is impinged. Its actually a pretty common condition. Typically people get pain that is shooting up and down the back which is always a disheartening complaint since so many "failure to thrives" have it. The most common aspect about this is weakness with some aspect of the upper extremity and its typically in nerve-root distribution (i.e. affects a certain nerve in the neck). So its probably easy to simply call this a radiculopathy..but the real distinction comes in determining if there are any "long tract" signs which bumps it up to a myelopathy. Myelopathies are emergencies whereas radiculopathies are not. Anyway, enough of the mumbo-jumbo. Had a patient who complained of weakness in the forearm extensors. Initially I was thinking that he had a radiculopathy since that's the vast majority. But when he got up to walk he had an unsteady gait. I've only order two stat MRI (I forgot what my first one was for) but this one was pretty good. MRI showed cord edema at about c4-c5. Woohoo. That made my day. Maybe it sounds odd, but if I sent him home he may have become a quadriplegic.

Anyways a reference for me:

Long tract signs:
Motor: upper motor neuron dysfunction is characterized by weakness, spasticity, increased tendon reflexes, and Babinski responses. Bilateral leg weakness (paraparesis) is the commonest presentation of spinal cord dysfunction, but quadriparesis, monoparesis or any combination of limb weakness can be seen. Acute transection (or similarly severe lesion) can cause a spinal shock with flaccid paralysis and diminished tendon reflexes. This is temporary: spastic paralysis will usually supervene.
Sensory: The characteristic finding is that of bilateral sensory loss below the level of the lesion. When spinal cord pathology is suspected, the physical examination should be designed to detect sensory levels in the limbs and on the trunk. The modalities lost depend upon the tracts involved.
Autonomic: Many autonomic functions can be affected, but clinically the most useful symptoms relate to bladder control. Loss of descending inhibition of segmental reflex control leads to urinary urgency and incontinence. Acutely, however, lesions may be associated with a flaccid bladder and urinary retention, be segmental reflexes become active.

Thursday, December 15: Bias

Interesting article on Media Bias. I still think its funny that people who disagree with a news outlet think that they are politically motivated, yet those that report in-line with their belief system are unbiased.

Wednesday, December 14: Beating a Dead Horse

I found the whole Tookie affair to be quite interesting. Out of all the political issues that I enjoy talking about, I find the Death Penalty to be one of the most interesting. To some extent, I think it is because it's such a straight forward issue. But the really fascinating part is the convoluted anti-death penalty arguments.

In researching my previous entry about the drugs used in the death penalty, I came across a bunch of webpages that actually claimed that the drugs do not make a person unconscious and that the person really experiences excruciating pain during the execution and the only reason why they can't scream is because they have paralytics in their system. This is just absolutely retarded. I typically find that when people do not have strong arguments in favor of their position, they happen to throw in a bunch of unimportant non-sequiturs.

If the complaint is that these are the wrong drugs to use, why not recommend another cocktail?

My cocktail: Versed 20 mg (5x normal dose), Pentothal 5 grams, Etomidate 100 mg (5x normal dose), Rocuronium 500 mg (10x normal dose), then the Potassium. The three first three drugs are in sufficient doses to knock a person out independently of each other.

Some other things that I found interesting:

Tookie: Tookie actually was not an original co-founder of the Crips. People on both sides of the debate liked to claim this since it sounded more dramatic the "transformation" of a "reformed" man to anti-death penalty advocates versus the history of brutality and "legacy of violence" of founding the infamous gang by the pro-death penalty advocates. In reality, when the Crips were formed, Tookie was in a detention center. Its true that he joined the gang when it was just starting up, but he was not a co-founder.

Tookie was well known in the community for his brutality. In addition, weighing in at 300 pounds of muscle, he was easily recognized. Since any victim that he left living would be easily able to describe him and because of his notoriety, Tookie had to kill his victims so as to eliminate witnesses and not get arrested.

The Crips were technically a business. When Tookie went out to the outlying communities and killed people off, members of the Crips were pissed off since this brought undue attention to the gang. Because of this, when Tookie was arrested there was an attempt made on his life in prison. Also, fellow gang members testified against him because of the attention he brought to the gang and because some in the gang were upset about his claim to be one of the founders.

In prison, Tookie planned an escape where they planned to shoot prison guards on a bus with a new "pump" (shotgun) and then blow up the bus with dynamite to confuse the authorities as to who actually escaped.

Jesse Jackson: Jesse came out to protest the execution... but when asked by John Ziegler to name the names of the victims in the crimes, he was unable to do so. Ha! Really good Jesse. Come out to protest something you have no clue about.

News Agencies: Did a few searches for news on I put in "Tookie" and then tried out a few combinations: "murderer," "murder," killings," and "killing." I found it interesting that most news agencies had a difficult time accurately characterizing the crimes of this man. Most articles referred to his crimes as "killings," yet he was convicted of murder. Hence, he is a murderer. Or is the connotation too negative and it hurts Tookie's feelings?

Tuesday, December 13: Drogas of the Death Penalty

Sodium Pentothal (thiopental): Dose 5 grams. This is an ultra-short acting barbiturate ...causes loss of consciousness and is often used for anesthesia induction and for medical induced comas. The typical dose is 3-5 mg/kg and induces loss of consciousness within 30-45 seconds at this dose. A person who weighs 200 pounds (about 91 kilograms) would get a dose of about 300 mg. A five gram dose (14 times the normal dose) probably would induce unconsciousness in 5-10 seconds. The interesting thing about this drug is that it is ultra-short acting... within seconds it is in the brain and in about 30 seconds it reaches its peak brain concentration with about 60% of the total dose finding its way to the brain. Within 5 minutes, the percentage in the brain falls to about 15% (since the drug redistributes to the rest of the body) and this is when the effects wear off for the typical dose and consciousness returns. The half-life is 3-8 hours and the concentration in the brain languishes around about 5-10% of the total dose during that time. When a mega-dose is administered, the concentration in the brain during the tail phase of the distribution stays higher than the peak concentration found in the induction dose for general anesthesia. This is the reason why an ultra-short acting barbiturate can be used for long-term induction of medical comas. With a five gram dose, consciousness will likely be regained in about 5-6 half-lives or anywhere from 20-50 hours. However, the side effects of such a high dose are respiratory depression (depression of the brainstem respiratory center) and vascular collapse (cardiovascular myodepression), and therefore without medical intervention such as intubation this is a lethal dose by itself. This class of drugs is the type used for medically assisted suicide.

Pancuronium: Dose 100 milligrams. This is a non-depolarizing paralytic--basically it blocks the release of acetylcholine at the neuromuscular junction. Acetylcholine is required for the muscle to contract. A depolarizing paralytic such as succinylcholine has a much faster onset of action and is the preferred drug in the emergency room if there are no contraindication when intubation is required. The problem with succinylcholine is that it causes the whole body to contract and fasiculate, probably a "distressing" sight to people who may be observing the death penalty even though the person is completely knocked out and would not even be aware if they were being cut in half with a chainsaw. The typical dose for pancuronium is 0.1 mg/kg. I typically use 10 milligrams when I need to paralyze a patient after I intubate them. I'd prefer rocuronium, but I've only got access to the pavulon. I've had to do this probably about 10 times in my career. With a 100 milligram dose, the onset to paralysis is probably about 15-30 seconds and the duration of paralysis would probably be 4 to 8 hours long. Of course, paralysis of respiratory muscles leads to death much quicker. In the ER, we usually have a few minutes to intubate patients before anything bad happens, but I have seen a few very sick patients who have arrested right after rapid sequence intubation (RSI).

Potassium: Dose 100 MEQ. (milliequivalents) Potassium is an electrolyte that is 98% within the cells. But having 2% outside of the cell has great implications for cells that generate action potentials. Typically, we give patients potassium when it is low in their blood and there are strict protocols on how it is to be given. The usual dose is 10-20 MEQ per hour. It has to be given slowly since it takes time for the electrolyte to move into the cells. In lethal injection, this "drug" affects the electrical conduction of heart muscle. Hyperkalemia (elevated potassium) causes the resting electrical activity of the heart muscle to be lower than normal. Normal is about -60 to -80 mVolts. Making the resting potential even lower slows conduction and reduces the ability of the muscle to "depolarize" and contract. EKG changes include faster repolarization (peaked T-waves), PR interval prolongation, widening of the QRS, and eventual sine-wave formation, and asystole. Patients dying from hyperkalemia (usually secondary to renal failure) is well known in the medical community. These patient have been known to go from normal to dead in no time flat.

Monday, December 12: Tookie III

I find it interesting a lot of the rhetoric surrounding Tookie, and I especially like how the issues get distorted.

Redemption versus Revenge
Rehabilitation versus Retribution

I love the implications of those lines, but I think people are missing the boat when they view the death penalty as being motivated by "retribution" or "revenge." Sure there may be feelings along those lines, but how about looking at it from the perspective of justice. If you commit the ultimate sin, what is the ultimate punishment?

Interesting issues on the Death Penalty:

Morally Wrong: The worst argument against the death penalty is the idea that by killing murderers the state is just as guilty morally as the murderer. This is pure idiocy. I have no respect for people who don't understand the difference between murder and killing. Its almost comical when I hear people throw out the line "Thou Shalt not Kill." So fighting the Nazi's in WWII was morally wrong as well? A terrorist hijacks a plane and is about to fly it into a building... Would killing the terrorist be morally wrong too? The real translation is "Thou Shalt not Murder." The killing of a Nazi about to execute innocent women and children or the killing of a terrorist prior him murdering 3,000 people is morally correct.

One argument that once a murderer is in prison and taking that person's life does not protect society is also incorrect... which brings us to the next topic...

Innocence: The RAND corporation did a survey of prison inmates at one time and discovered that 85% of them were innocent. Ha! I'm sure in the past, that some innocent people have been put to death. Since 1978 when the death penalty was re-instated, there has not been one proven case of an innocent person put to death. The anti-justice crowd (my politically correct term for those against the death penalty) will have you believe that hundreds of innocent people have been put to death. This is not true and only proves the point that they are willing to lie.

The execution of an innocent man is a difficult issue even though there have been over 550,000 murders since 1978 yet only 1000 executions. To me this states that only people who have committed the most severe crimes and who have had the greatest level of evidence against them are sentenced to die. Right now there are about 5,600 people on death row (If I recall correctly). The addition of DNA evidence in fact will make the execution of murderers even more accurate...

Now for some people, the potential to kill (murder) an innocent person is reason enough to get rid of the death penalty. The interesting aspect about this argument is that by not executing murderers, more innocent people will be murdered. In fact, there have been more prison guards, other inmates, and innocent civilians murdered by repeat offenders than people executed by the State. So by the State's failing to execute murderer, innocent people are guaranteed to be murdered in the future whereas the hypothetical execution of the innocent person in the modern application of crime and punishment has yet to be proven.

Ultimately the question becomes: Are you willing to let hundreds maybe even thousands of innocent people be murdered to try and avoid the execution of an innocent man?

"Cruel and Unusual": Cruel is a matter of opinion, and unusual is based on frequency. topic

Costs: It is expensive to execute a murderer ...somewhere along the lines of 2 million dollars. But the people who are arguing against the death penalty are the ones making the costs higher ...unending appeals with both a State and Federal component. If the argument is that the costs are too high, why not severely restrict the appeals process. If murders are executed within a year of their sentence, you probably will actually be saving the State probably over a million dollars. Hence, you can go buy books for the school children.

Deterrence: (revisited)

"If we execute murderers and there is in fact no deterrent effect, we have killed a bunch of murderers. If we fail to execute murderers, and doing so would in fact have deterred other murders, we have allowed the killing of a bunch of innocent victims. I would much rather risk the former. This, to me, is not a tough call."

John McAdams - Marquette University/Department of Political Science, on deterrence


LWOP: Life without possibility of Parole. Now this is an interesting topic... (one which I had not thought about in the past) If the maximum penalty in a state is LWOP, then there is almost no disincentive to murder again. Imagine a fugitive who has an offense punishable by LWOP. That criminal logically would do anything to avoid being captured... including murdering again. In fact, I'm sure someone could do research and definitively prove that LWOP is an incentive to murder.

Arbitrary: This one is a non-sequitur. To argue that some murderers get the death penalty whereas others don't does not mean that the punishment for the crime should be abandoned. Some people like OJ Simpson and "Baretta" have murdered yet the justice system failed (probably because of retarded juries). These two murderers are now playing golf. Hence, if you applied the same logic, it is arbitrary that murderers or any other criminal be punished for anything. There definitely are flaws, but that does not mean that you get rid of the judicial system.


Wednesday, December 7: Tookie II

The average criminal commits an estimated 8 violent crimes before they are arrested for one. This explains the fact that 90% of crimes are committed by 10% of the criminals (the impetus behind the 3-strikes law). That being said, I am dumbfounded that some people argue that Tookie was "innocent" of the close range shotgun deaths of Albert Owens and the Yang family. Actually, I think repulsion is more like it... There just happens to be a segment of our society that is so blinded to reality that it makes you feel sick. The co-founder for the Crips gang in South Central in all likelihood is probably guilty of a bastion of other crimes for which he was never caught. Not only that, he has refused to even admit guilt and apologize to the victim's families... some rehabilitation. Read the LA County DA response to the petition for clemency... one amazing read.

In the late 70's and the early 80's, gang violence was off the hook. One of my attendings at Martin Luther King Jr. Hospital was a surgeon at the time and they were averaging sometimes up to 20 deaths per day and there was a few times that she even did surgery in the waiting room! In the last few years, we have seen about 2,000 gun related visits to the emergency room and into the trauma center per year with probably about 2-4 fatalities per week. The bloodiest day that I remember was 5 deaths... The legacy of gang violence continues today. Thank you Tookie.

Tuesday, December 6: Terminology

I recently read an article in reference to same-sex relationships. One person interviewed in the article believed that using the term "civil union" denoted second-class citizenship. Out of all the times that I have come across this issue it seems to me that the vast majority of people are willing to give same-sex couples the same legal rights as married couples (with the one exception related to the adoption of children, where most people believe children should be placed with a preference to heterosexual couples and then to homosexual couples). Yet out of all the articles in the mainstream media not one has touched upon the idea that taking the religious concept of marriage and attempting to redefine it is offensive to religious people.

There are many areas in the legal and tax code that relate to marriage. Technically, it is a violation of the Separation of Church and State, but when your country was discovered by religious people I'm sure there will be some long standing interplay between the two. Take for example adultery in marriage. The act alone is not a crime but during divorce proceedings it is salient argument in the distribution of assets. I think it would be funny to hear the ACLU come in on this issue and argue that penalties for extramarital affairs is unconstitutional since it violates the separation for Church and State. Anyways, that was a fun thought experiment.

In relationship to the original topic, I think there is a reasonable middle ground. Grant people the right to join in civil-unions with the same legal benefits as married people. They get what they have been wanting--equal treatment under the law. Meanwhile religious people get what they want--respect for the institution of marriage.

Monday, December 5: Stupid Time

Arrrghh... My reflections on a completely retarded night of work:

1) If you are admitted to some other hospital for 6 days and subsequently discharged home... please have some idea about the reason why you were there and the ultimate diagnosis. Saying that you were never told a diagnosis is just retarded and I don't believe you. Whenever I hear this crap, the first thing that pops into my head is that the ultimate diagnosis is probably supratentorial. (Supratentorial: as in above the tentorium and akin to "failure to thrive.")

This is your tax dollars at work. Spent on completely worthless medico-legal workups without any benefit to society.

2) Please think about the reasons why you are coming into the ER. I shouldn't have to pull teeth to get a history. And yes, it should be logical and in story form.

3) Finally, please no more histrionic patients for the rest of the month!!! I've definitely had my share... If I ask you what were you doing when you started getting chest pain, please do not respond: "I was trying to decide if I should start cooking now or go to the store and do the shopping." Yes this was an actual response to the question. Unfortunately, I did not ask what were you "thinking" I was asking what were you "doing"!!! in physical activity.

In the ER, the severity of the patient's illness often impacts the level of compensation. Imagine a patient who requires a doctor continuously for a good hour in order to save the patient's life. This is billed as "critical time." In my opinion, we should start billing for the time wasted trying to figure out stupid questions like what is the name of the "little white pill" that you have been taking for the last 20 years. Yes, I propose that we call this "Stupid Time."

Sunday, December 4: Tookie

Opponents of the death penalty are out in force, and again they are spewing nonsensical arguments. My favorite claim is that the death penalty is not a deterrence to murder. The original argument came from an economist who argued along the lines of rational decision making (i.e. a consumer of murder will make logical decisions based on the consequences--how bizarre does that sound?). Ultimately, the argument revolves around the idea that murder is an irrational decision and therefore the consequences of that action are not a deterrent to the crime. I think this is an interesting argument, but common sense forces me to dismiss all arguments that claim there is no deterrence to murder by having a death penalty.

I do find it amazing that people have actually done "research" to try and claim absolutely that there is no relationship. They are not arguing that it is a very small influence on the decision to commit murder, they are arguing that it is never an influence. Logic dictates to me that at some point in time, with millions of people, and with the range of rationality from irrational to completely logical understanding of the consequences of one's actions that someone has decided not commit murder based on the fact that they value living. I would probably agree with death penalty opponents that there is not a great deterrence to murder by having a death penalty, but claiming that there is absolutely no deterrence is intellectually dishonest.

The effectiveness of any deterrence is the product of the likelihood of being arrested for the crime, the likelihood of being successfully prosecuted for the crime, and the likelihood that the specific penalty is imposed. This brings up one of the more interesting aspects about the deterrence debate. By filing incessant legal challenges, demanding delays, and calls for clemency, the people who are opposed to the death penalty are the ones minimizing its effectiveness as a deterrence.

The fact of the matter is that, irrespective of its strength as a deterrence, the death penalty is a moral imperative. If life is invaluable (on an ideological plane), the penalty for taking it must also be invaluable.

Wednesday, November 30: Budget Shortfall and Health Care Politics

Interesting LA Times article...

Reading this article was amazing... whenever anyone tried to do anything to change how things get done in the county system, there was opposition at every turn. Every few years, the county hires a new director of DHS, mandates the he fixes problems, and then they tie his hands behind his back and nothing gets done. That director quits, a new guy gets hires and tries to fix the same inherited problems and yet again... opposition at every turn. Its no wonder why the newspaper reports crisis after crisis after crisis. With the estimated budget deficit for LA Department of Health Services of 866 million in three years it looks like we are headed to another one.

Wednesday, November 30: Non-Interesting Case of the Week

Yep its the holiday season and already a few patients have contemplated Harry Carry (article on the etiology of that term)... The drug of choice? ...ETOH. Daemon alcohol.

Of course most of these problems correct themselves with time...but one patient I saw got pretty close after taking a bunch of nortriptyline and had a QRS of 104! (okay, maybe not that exciting--140 is getting near the threshold) By the way his alcohol level was over 450. Probably enough to make me go into Holiday Heart Syndrome... The real question is: who the hell is still prescribing the TCA class for depressed patients? Why not just stick to the SSRIs??? I've seen one case where the ingestion was near lethal... Patient came in obtunded with a GCS of about 2-2-2. We intubated the patient and gave them the full gambit: gastric lavage (love those EWAL tubes), charcoal/sorbitol, bicarb boluses. That was a great case...

eMedicine: Tricyclic Overdose: "Mortality/Morbidity: Fatality before reaching a healthcare facility occurs in approximately 70% of patients attempting suicide with TCAs. Tricyclic antidepressants are the number one cause of fatality from drug ingestion. Only 2-3% of TCA overdoses that reach a health care facility result in death."

Tuesday, November 29: Fat Tyra

Haha... This was one was pretty funny. Tyra puts on a "fat suit" (click on "Fat Tyra")! I'm in disbelief...

Saturday, November 26: Salubrious

Woohoo! Today is my day off and we're celebrating Thanksgiving... I could use the calories... Been pretty steady with the gym and running for the past month and my body is just a tad achy... Time to over-eat and go comatose... :) Either way, happy late Thanksgiving everyone!

Tuesday, November 22: Ironic

How bizarre! Soon after an election measure to improve education accountability was shot down, LA Mayor Villaraigosa is attempting to reform LAUSD. I find this so funny... My opinion is this: The county voted strongly against prop 74, and the message is clear that LA county residents want an inferior educational system that continues to be one of the worst in the nation. If it ever comes to the ballot, I will be voting "no" for this measure out of pure spite. :)

Thursday, November 17: Izakaya

Musha...Loved it. Intrigued following a review from the LA Times, I headed on down to this Japanese "tapas" place in Torrance. I'm always on a quest to try different foods and this has got to be up there in terms of excellent dining. It wasn't rated to high on, just a 22, but it came highly rated for a fun experience from a friend.

Now there is the traditional dinner where you get a big entree and a bunch of non-exciting sides, but the truly great food most likely was the appetizer. Wouldn't it be awesome if the entire dinner was a bunch of appetizers? To me, that's was izakaya experience felt like ...very interesting and excellent dishes... I recommend the ascari, the octopus omelet, and the lemon pepper chicken... That's right lemon pepper chicken at a Japanese restaurant! The sashimi was good, but once you have had sashimi from Z's in Alhambra, the standards for excellence are set too high... The most bizarre was the dessert offering... maple syrup creme brulee?!?!?! I guess I'll have to get the black tea ice cream next time... :)

Wednesday, November 16: Nader and Jackson weigh in...

I laugh... (article)

Are these two "leaders" so marginalized that they have to come to the defense of T.O.? Huh? Getting benched for the rest of the year after a series of team violations, one in which he threatened everyone on the team to a fight, too tough of a punishment ? Oh, I feel so sad...

Now in all seriousness, wouldn't it actually be refreshing to hear a community "leader" say that what the Eagles did was the right thing to do. That you can't behave like a jackass without repercussions...

Oh well, one of the many reasons why I like the college game much more than the pros...

Wednesday, November 16: Unfunded Liabilities

As one of my friends said, "you think they shut down the machine that makes $100 bills at night?"

Article. After reading this, you realize that neither the spendocrats or reporklicans have the answers...

Friday, November 11: Foolish Proletariat

Election analysis...

Prop 73: I can understand the defeat of this one, there are reasonable arguments against it. In my opinion, the abortion rate in California probably much lower than it should be. I've seen one patient who was 27 and had 10 kids! Ridiculous... Guess who will be footing the bill for those kids the rest of their lives?

Prop 74: Okay... when I discussed this one with colleagues I could not get one logical reason to vote against it. The best that I got was something along the lines of "Arnold is power hungry" and its "costing millions for the election." Unbelievably, they agreed with the logic of the proposition but refused to vote for it??? Makes no sense. I can only assume that people who voted against the proposition are mindless automatons (or simply teachers thinking about self-preservation when they burn out and don't care anymore). I find it funny that people complain about the cost of the election. Like spending 56 million by the teachers union to perpetuate mediocrity is a noble endeavor.

Maybe this one should be on the ballot. Prop 81: If your doctor kills off your family member through gross negligence but has been working for two years, the doctor is exempt from losing his medical license, job and cannot be sued... Now that makes sense! :)

Prop 75: Democrats obviously had an incentive to vote against this one... Unions, government employees, and lawyers have been enriching themselves under the guise of democratic ideals for many years. In that time, governmental pension obligations ballooned 1600% (2000 to 2003) to about 3 billion a year. I think its perverted how the state was running huge deficits, yet democrats were still voting for pay raises and additional pension benefits to be shouldered by an even higher tax burden. Government should be required to provide a comparable contribution based 401(k) retirement plans as in the private sector. Not stupid formulas like work for 20 years, retire at age 42 and we will pay for the rest of your retirement. Its a retarded environment under which this state is run. Its no wonder why companies continue to leave...

This is the one that I was really hoping would pass. Blocking this proposition retains the power structure of the Democrats (union money), and therefore continues the conflict of interest between public employees and public expenditures. This is why people like the CT Tech who I described previously, irrespective of how little work he does, or how many patients have bad outcomes because delays in care, will always have a job.

To argue that Arnold was doing this to increase his power is naive. He has spent over 25 million of his own money to try and fix the problems with the state. He's not in it for the money (he's already a multimillionaire) as opposed to the previous governor. Speaking of him, what did Gray Davis do besides making a 36 billion dollar deficit? As an example, Arnold was able to bring about changes in the workers comp laws. In fact, he put a guy that I know out of business. He was making about 3 million a year in profit running "workers comp" clinics where they overcharged for prescriptions drugs to the state, and there was an incentive for both the doctor and the patient to cheat the system. He closed shop based on the rule changes. Sounds to me like Arnold's doing the right thing. LA Times report:

According to a DispenseXpress price list, doctors can clear $65.50 every time they dispense a 90-tablet bottle of 800-milligram ibuprofen. They can buy the common painkiller from DispenseXpress for $9.19, but under current workers' comp rules, they can bill insurers at a rate of $74.69 per bottle.

I find it amazing that someone in a state bureaucracy actually wrote these rules. This is one of the reasons why the role of government should be as small as possible.

Prop 76: Balanced Budget Proposition... If you make a comparison of the "red" states to the "blue" states, I think it clearly points out the differences. There are a large number of states that don't have any state income tax. Meanwhile in California, you have a huge state tax, a big sales tax, and even bigger property tax (since housing is so expensive) yet the legislature continues to run a deficit. Its bullshit that they claim that they need more tax revenue... Its either the other states are run by people who are smarter and more efficient or California is run by wasteful morons?

Prop 78: Why this one did not pass is beyond me... Written in response to the threat of prop 79, drug makers realized that they had to offer something that was a little more favorable to them. Ultimately, they spent about 80 million to defeat 79 and promote 78. When both of these failed the real winner ironically was the drug companies!!! Now if you are a marxist, 79 sounds better, but at the minimum if you voted for 78 you could have saved the state some money when it contracts out for medical prescriptions. Voting against this proposition was a mistake as the state will continue to pay the drug industry premiums...

But drug executives are "dancing in the boardrooms" despite the defeat of their own measure, said Bob Stern, executive director of the Santa Monica-based Center for Governmental Studies. "They don't care that 78 went down…. They really wanted 79 to lose."

(I errored in my previous entry...the HJTA supported 78.)

Final Analysis: I'm going to hurl...

Sunday, November 6: Painful

Ugh... 6 1/2 hours of testing. When will it ever end???

Anyways, the test went fine... But now I'm freaking out about orals coming up in the Spring!!! I have no clue how long I will have to study for that one. In some respects, its more of learning how to play the game right. How to go from Altered Level of Consciousness (ALOC) and Febrile and cover all the bases... infectious processes (meningitis, pneumonia, urospesis, etc..), endocrine (thyroid storm, toxicosis), environmental (heat stroke), vascular (subarachnoid hemorrhage, intracerebral hemorrhage), drugs (neuroleptic malignant syndrome, seritonin syndrome, sympathomimetics, etc..) and whatever bizarro complex out there... Basically, its cast a wide net and narrow it down... Otherwise the diagnosis may change...

Most important test: MCAT
Most time spent studying: USMLE Step 1 ...probably about 360 hours
Most difficult test: Coming up in the spring...ugh

Friday, November 4: Test? What test?

Written EM Boards on Sunday...ugh! I am so tired of tests.

Too many tests:

College: 140
Med School: 50
Residency: 33
Written Boards: Sunday
Oral Boards: Spring


Thursday, November 3: Special Election Analysis

Prop 73

Proposes to require parental notification prior to a minor getting an abortion. I think this is a good idea. There are a lot of problems that can occur with any medical condition or surgery. Depending on how advanced the pregnancy, a woman wishing to terminate a pregnancy may get methotrexate, a dilation and curettage, or a dilation and evacuation (yes... the crush the skull and hover procedure). All of these procedures have risks: bad drug reaction, bleeding, infections, perforation of the uterus, blood clots, death, etc... I don't think that 13 year old girls should be trying to treat and hide these potential problems from parents because they don't want to get grounded. I see a bunch of these kids, and I am sorry to say these are not the smart ones. I remember one 16 year old girl who asked me every 5 words that I spoke to explain what I was saying... she didn't understand words like "indicated," "adverse"...yikes! I didn't know if it was pitiful or sad.

Aside: Please do not come into the ER after you find out that you are pregnant requesting "Plan B" (oral contraceptive to prevent pregnancy following unprotected sex) . Plan B, in addition to Plan A (crossing your fingers), seems to have already passed. Its time for Plan C. :)

Prop 74

As I already mentioned, it only makes sense to vote in favor for this one. I'm still aghast that rules exist to keep incompetent teachers who don't do their job on the public payroll. Of course the only people voting against this one is the teacher's union which has spent over 56 million (of teacher union dues) to enforce the status quo of poor performance. 56 million dollars ...unfruckingbelievable! Are these core democratic principles? Not doing your job and getting a pension after 20 years? The democratic party is obviously opposed to it since it hurts their power structure of government, unions, and lawyers. If you vote against prop 74, you are part of the problem. Period.

Maybe Democrats are "evil" and want to "hurt children?" Opps... stole one from the democrats. LOL The funny thing is that voting "NO" actually does hurt children...

Prop 75
Yep, the teachers unions spent over 56 million to oppose a common sense measure to ensure that people actually do their job! This is the main reason why anybody with some sense of right and wrong should support this measure. The democrats oppose it since this is the main way in which they get political contributions ...through the extortion of its members. If you are really pro-choice, why not give people the choice on whether or not they want to make political contributions.
Prop 76
Balanced Budget Amendment. The democratic controlled legislature has been spending more money that it receives forever. Right now there is an estimated 6-8 billion dollar deficit. If that deficit doesn't close, it likely means that the tripling of the car tax will return or an additional 1% increase in the sales tax will be levied. I'm not in favor of more and more and more taxation... Its time that the legislature starts spending money appropriately. Now if you oppose this measure, I don't want to hear a word about how the federal government has been overspending. Of course, I think the republicans in Congress have been fool-hearty with their excessive spending. Very irritating...
Prop 77
Judges determine redistricting. I don't know about this one...but I voted yes. :) What's the worse that can happen? Its already a democrat controlled state.
Prop 78
Discounts on Rx Drugs. The Howard Jarvis Taxpayers Association came out opposed to 78 and 79. I think that I would rather have one that the drug companies designed versus a governmental run bumbling bureaucracy.
Prop 79
As above.
Prop 80

Ha... Opens the loophole for the lawyers that was originally closed by a proposition in the last election so that they can sue without a plaintiff. Remember the Trevor Law Group that was disbarred? Amazing since the California BAR is not a governmental entity ...its self-regulated. Meanwhile the California Medical Board is a governmental agency. Interesting how the democrats support regulation and supervision of virtually all industries with the exception of their primary constituents--lawyers.

Example of a Trevor Law Lawsuit:

According to The Press Enterprise (Riverside, Calif.) the Trevor Law Group and a one-man, for-profit enterprise named "California Watch Enforcement Corp." sued the owner of a motorcycle shop in Riverside for abbreviating the words "on approved credit" (O.A.C.) in a print advertisement. According to the owner, he got a letter from the Trevor lawyers saying they'd accept $5,000 to settle the matter out of court.

For some odd reason, its a proposition written in relation to energy regulation. All I've got to know is the above detail to know who it is written by, and, therefore, oppose it.

Wednesday, November 2: CME

Get your free CMEs here:

Required 12 hours on Pain Management:

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Thursday, October 27: OFF

Interesting LA Times article on the Oil-For-Food program... The shit hits the fan and the UN is standing downwind...

"The report is the fifth by Volcker and concludes a year-long, $34 million investigation that has faulted Annan, his deputy, Canada’s Louise Frechette, and the Security Council for tolerating corruption and doing little to stop Saddam’s manipulations."

"Revelations of the program's failures have also severely undermined the credibility of the U.N..."

In my opinion, if the UN was not corrupted by kickbacks from Iraqi contracts in the OFF scheme, the international community probably could have done its real job as described in resolution 1441. Instead, the manipulation of the security council by OFF ultimately lead to the UN Security council to violate its own resolutions ...probably the greatest impetus for the Iraqi war.

Other Good News: Harriet Myers withdraws her nomination to the Supreme Court... Yikes that was one scary nominee. I've got my finger's crossed that Bush will support someone who is pro-abortion. In my stolen opinion, pro-choice happens to be misnomer. Many in the "pro-choice" camp are anti-choice for school vouchers, anti-choice for union dues going to political contributions (i.e. prop 75), etc... So why not just call it like it is? As for the other camp, you probably could still call them the pro-life since they would probably oppose pulling the plug on a 120 year old demented patient with the Locked-In Syndrome. (Just so you know ...about the only things preserved with the "locked-in syndrome" is consciousness, the ability to look up and down, and feel pain.)

Conspiracy or not? the question. Since John Roberts was untouchable, Democrats were promising a big fight with Bush on his next supreme court nominee... Knowing this, did the Bush administration offer up a sacrificial lamb? Are they that smart? ...I doubt it... lol

Wednesday, October 26: Public Employee Unions...

Prop 74 has got to be the litmus test for who has been bought and sold on self-interest versus public good.

If the measure is approved, some teachers say, it could rid California schools of ineffective instructors who curse at students, or talk on cellphones and show "Legally Blonde" during class. Other teachers fear that it would drive talented, low-paid teachers with master's degrees into more lucrative professions.

The only people I could imagine opposing this would be the teachers who might be at jeopardy for losing their jobs due to unsatisfactory performance. Any teacher that works hard and cares about their job will never be at risk for getting fired. And every teacher that sees their colleagues slacking off is definitely going to be voting for this one.

The funniest argument against this measure is the claim that by extending the probationary time from 2 years to 5 years would discourage teachers from coming to California. What bullshit is that? If you are a teacher and your main concern is that you will get fired in three years because of poor performance, we don't want you here in the first place!!! Like I said before, as long as a teacher cares about their students...they will have their job. Of course the Democratic Party opposes firing any incompetent teacher who doesn't give a shit. They're unionized...

I simply find it amazing that the rules have been set up such that teachers CAN'T be fired! In LA, there are about 40,000 teachers of which only 2 were fired in the last year presumably due to criminal activities. Hell, imagine if you had a government doctor who was tenured and could never be fired ...wouldn't you just love to get him for your next emergency!

It's amazing how much power is held by public employee unions. Just a few years ago, the bus mechanic for the MTA went on strike until the City council capitulated and offered the union unprecedented pensions to be available to its members after something like 20 years of work! Not only that, they were paid about 40-50% more than a private sector mechanic in an equivalent position.

One case that I am personally familiar with involves a CT Tech at my residency program. Over the last 15 years, the physicians in the radiology department complained about his work ethic and his rude behavior in an attempt to get him removed. In the last 8 years, the physicians in the emergency department tried to get him fired twice as well since he would do just about anything to avoid doing his job. But according to his "seniority status" and his union contract, it was impossible to remove him. He's still there.

When you can't fire somebody, where's the motivation to work?

Some good quotes from the article:

"If you're doing a good job and you're working hard, you really have no reason to be afraid of losing your job," she said.

"Some people see tenure as 'Oh, now I don't have to work as hard,' " Calabrese said. "If you think after three years you don't have to work as hard, what will you think in 25 years?"

...Larry Sand, a teacher at Webster Middle School in Los Angeles, said one teacher on his campus was transferred to another school after she sunbathed topless on the athletic field during third period. "It just moves the dirt under a different rug. It's terrible," he said. "So the children at our school have one less bad teacher, but the children at another school have one more."

Monday, October 24: Diagnoses of the Week

GBM: Made one of those bad diagnoses the other day... Glioblastoma Multiforme. Patient presented with stroke symptoms... on the CT there was an ICH in the parietal lobe, surrounded by large areas of edema. Turns out that the high grade growth of these cancers causes significant edema versus some of the edema you would see with a purely hemorrhagic stroke. Also turns out that these malignancies grow so fast that they become clinically significant with 3 months of arising, and because they grow so fast, they often outstrip their blood supply and end up bleeding into themselves. ...and that's how my patient presented with a large intracerebral hemorrhage, tumor with surrounding edema, and a 2 mm midline shift.

Pertussis: HaHa... I had a few docs chuckle at me when I ordered a pertussis culture in an immunized child the other week. ...the culture and DFA came back positive for Bordetella parapertussis. Supposively, there have been about 200 diagnoses in LA County this year... funny thing about the diagnosis ...I had to write for prophylaxis for the entire family that was living with the little girl... 6 other people!!! Arghhhhh...

Sunday, October 23: Bird Flu

Its happening already!!! Got my first patient who actually asked if their viral syndrome was the Bird Flu!!! Dios Mio! It not even in the birds in the US yet! I hope this is not an indication for the upcoming flu season...

Speaking of H5N1 the specific strain of the influenza virus that potentially my convert to human to human transmission, still trying to figure out if Tamiflu (oseltamivir) would be effective in the outbreak... right now I've got a 3 day supply but the pharmacopeia says its BID for 5 days. Maybe some other drugs will be helpful in a outbreak ...amantadine, zanamavir... much cheaper than the Tamiflu... I initially read that this strain may be resistant to Tamiflu. Oh well, wondering if they will be able to develop a vaccine against it ...I've already got vaccinated for this year... but its not the H5N1 type...

Side Note: H5 stands Hemagglutin type 5 and N1 stands for Neuraminidase type 1. The Hemagglutin protein binds the virus to the cell and the the Neuraminidase protein facilitates its entry. If you have antibodies to these proteins, then the virus would be unable to infect cells since the binding sites would be blocked.

Friday, October 21: Ugh

Back in the gym... got that painful/pleasurable feeling after weight lifting yesterday. Didn't really lift too much (that's me on the right)... the decadron really robbed me of some strength (its a catabolic steroid ...breaks muscle down versus anabolic roids which builds muscle up). It might be a few months before I get back to where I want to be, but its a good start.

There are always challenges in life... My challenge has been to keep a balance between the different goals that I wish to achieve. In terms of focus, I think there is interesting distinction between the sexes. Men often try to focus on one problem at a time, and try to resolve those issues. Women on the other hand happen to multi-task much better. For me, I've obviously been too focused on career in the past. I don't know... it might be one of my greatest strengths and, at the same time, one of my greatest weakness.

Either way, I have resolved to approach life in a more balanced fashion... I think I'll focus a little on weight lifting for the next few months, decide if buying a property makes financial sense, and really start looking for that intangible connection...

Tuesday, October 18: Mindset

I looked back on my life for the last seven years and realized that I have probably dedicated about 60-90 hours a week to accomplishing my goal of becoming a doctor. I don't regret my decision to work that hard, I think this is one of the best jobs that is out there... I really do love it.

Sure there are frustrating times when patients disagree with what you are doing, high-pressure situations where your gut tangles as you deal with near-death patients, or when your soul tears up as you tell a mother that her kid has just died. But overall, the rewards are intangible. Just last week, an 87 year old man hunted me down in the ER to give me a piece of gum and thank me for taking care of him... It was truly heartfelt...

I've had to make some sacrifices. But I think its finally sinking in on where I have arrived. I realize that I control my schedule, I can work as little as 2 1/2 shifts a month and still pay all of my bills. Why I have worked 60 hours a week for the last 3 months makes no sense... Its time to get back into the gym, maybe work on on that six-pack again. And its time to start looking for that other piece of the puzzle...

Its time to bring balance back to my mind, body, and spirit...

Sunday, October 16: Decadron: 54 hour half life

Went back to work today... Decided to cut out from my pre-imposed vacation since I felt like I was not accomplishing much. Physically, I have felt like shit. The decadron really did a number on me... I felt on edge, restless and jittery like a bad caffeine overdose. When I talked, I stuttered. I could barely hold a pen steady to write.

Everyone talks about the balance between mind, body, and spirit. I think over the last 7 or so years, I have been working almost exclusively on the mind. To some extent, the idea was to "sacrifice now" and reap the "rewards later." Maybe to some extent it was just my imprinted psyche telling me that whatever I was doing, it wasn't enough. Who knows? I happen to be my own worst critic.

I tried to give attention to other areas of my life, but residency is a different beast... it seems to be all encompassing. Especially since the responsibility is enormous... Making medical decisions that really impacts peoples lives... Its an odd feeling.

Anyways, went back to the the one thing that I know I am good at It felt good to get back in the swing of things, and to forget about some of the other failures in my life. Yes, everyone has failures, unless you have but one dimension. The best part of the day was when a co-worker mentioned that I was one of the best doctors to come out of King in a long time. Of course, Choi, Hardik, and Hill are recent grads who I thought were unsurpassed... But that is besides the point. Probably one of the nicest compliments that I have ever received...

Heading back again tomorrow...

Friday, October 14: Accumulated Shit

I've been feeling down for the last few days ...I don't think I've ever had a bad response to a drug...but this decadron is making me feel sick...

Anyways, I don't know what got a hold of me...but I ended up throwing a ton of shit out. In fact, I'm ready to throw everything away...Keep my computer, recliner chair, TV and some other assorted stuff, move to a new place and start all over with new stuff.

For the longest time, I felt like I have lived like a student... white board on the wall with markers, bookcase full of books that I will never pick up again (now most of them are in the trash now), desks holding worthless stuff... accumulated junk. Highlighters (when did I ever use a fucking highlighter?), three-hole punch thingy, notebooks of lectures. I counted eight 3-ringer binders full of lectures. Threw away another 300+ journals...There's no way in hell that I will every be able to read all of them. With every week, there are three more journals in the mail for me to read. The schizophrenia of trying to keep textbooks of information in your head makes you want to puke.

Life has changed significantly since residency ...I no longer worry too much about money. Funny, since I was so worried about it when I was a resident... Now I'm fucking throwing it away... bought two new pairs of shoes, wore them twice, and decided I didn't like the feel. Threw them away too.

Some of the things that troubled me in the past still persist. It's a struggle to find the important things in life... I'm ready for a complete change.

Thursday, October 13: Daemons in my head...

Yikes...its 3:30 in the morning ...and I'm still wide awake.


...or maybe its just the decadron?

Wednesday, October 12: Post-Op Synopsis

Looks like everything went well with my surgery yesterday... Got some versed in pre-op and the last thing I remember was being wheeled off to the OR, and then waking up 2 hours later in recovery. Versed is a wonder drug... Just wish I could use it more often in the ER when I have to perform painful procedures on patients... Legally its a difficult drug to administer because outside reviewing bodies such as JACHO and CMS (centers for medicare and medicaid services) believe that any combination of opiates (pain control) and benzodiazapines (anti-anxiety) is a conscious sedation procedure requiring cardiac monitoring, immediate airway control and 1:1 nursing and doctor supervision (which happens to be a huge strain on the ER). Unfortunately, these rules results in a detriment to patient care since low dose benzos probably would make visits to the ER much more pleasant and not lead to any excessive sedation.

Speaking of painful procedures... I knocked out at 2 year old kid a few weeks ago so I could repair a laceration on her forehead. Just make sure the nurse gets the ketamine in the muscle!!! If the ketamine goes into the subcutaneous fat, you get a conscious sedation that takes 20 minutes before it starts and takes over an hour for the kid to wake up.

Anyways, my ENT doctor discovered that I had fractured my nose in the past ...unbeknownst to me. When the septum heals it usually repairs deviated since there is nothing to splint it to the midline. The severity to which will dictate resulting complications, with one passage way getting obstructed and the contralateral side getting too much airflow causing hypertrophy of the inferior turbinate and even more airflow obstruction. Therefore the only way to get airflow in is to mouth breath when you have a significantly deviated septum or turbinate hypertrophy.

Basically I got my septum straighten (septoplasty), both inferior turbinates fractured and moved to the side (turbinoplasty), and two cartilaginous splints placed subcutaneously above the nasal flares to maintain patency (prevent nasal valve collapse). Who knew that the nose could be so complex? eMedicine article: excellent read since its a problem that you see not to infrequently in the ER but usually presents as a combination of allergies and severe post-nasal drip syndromes which are always difficult to ferret out.

Downside: can't do anything for the next few days! ugh.

Highest regards to Dr. Victor Strelzow...Its nice to find docs who really care about what they do...

Tuesday, October 11: "Put them in the Iron Maiden."

Wikipedia's the Iron Maiden!!!

Interesting fact: Uday Hussein had one made so he could torture people for intolerable infractions... like if you didn't win the soccer game.. Article here.



Monday, October 10: UAW Zugzwang

Interesting news on Delphi filing for bankruptcy...My prediction: GM is likely next, and I'd bet that Ford will follow within a few years. In reference to manufacturing, the productivity of the American worker compared to compensation has been falling for some time now. The cuts in compensation is the only way in which companies can operate in the global economy, and to some extent, this could be the beginning of the end for the large labor unions ( in their negotiating power). Unfortunately, pensions and benefits are sounding like legacy concepts, just look at the recent airline bankruptcies. The UAW has got to see the writing on the wall, as any move that they will make eventually "throw themselves onto the sword." In my opinion, this news is more important that the destruction caused by the hurricanes, since the damage of not doing anything to address the cost of doing business in the US will be worse than Katrina.

Side note: Zugzwang refers to a chess position where the mere fact that you are forced to move (yet not a forced move in and of itself) puts you in a worse position that not moving at all. The classic masterpiece was with Nimzowitsch in 1923 called the "Immortal Zugzwang." Even though white has more material, he has no moves left...

...Love the notation by Nimzo in the above link... I still remember reading about the "Outpost" in his book "My System."

Sunday, October 9: 5-0

Awesome game! Bruins beat the Bears in an undefeated match up 47-40... coming from a 12 point deficit in the fourth quarter. I'd have to say that this was one of the most exciting games that I have seen. Loved that fake punt on 4th and 2...

Favorite memorable game: UCLA over USC in 1994 at the coluseum...had nosebleed seats but a real roller coaster of a ride. UCLA went ahead with about a minute left in the game, but the Trojans came 98 yards and had a 3rd and goal play which we intercepted... My stomach was churned after that one...

Worst UCLA loss was versus Miami in 1999. Final score something like 60 to 66... Blew the chance for a National Championship that year (record was 10-0 prior to that game). It was just impossible for the UCLA defense to stop Edgerrin James. So much more exciting than the Pros...

Saturday, October 8: Web 2.0

Interesting article on how the internet is changing. Wikipedia...who would have thought? In my opinion, more interesting than Google Earth... Anyways, you'll find some interesting links there.

...Looks like I'm still Web 1.0. Maybe one day I'll figure out how to put some dialog in here---but not right now, I'm just too busy.

Saturday, October 8: "Bird to Person to Person" and Random Thoughts

Ha...just watched Bush talking about the Avian Flu... (click on hot wings) I can just imagine somebody explaining the problem to him in the exact same fashion.

Couldn't conservatives find anybody smarter for the job other than this guy? ...the damage that he will do to conservative ideas and image will definitely last a long time. To some extent, I wondering if a democrat would have been more fiscally conservative. Obviously, I'll probably never vote for a democrat since they are always in support of higher taxes, irrespective of the level of taxation, in order to pay for their income redistribution schemes. And more importantly because they are pro-lawyer they are therefore de-facto anti-doctor. As an example, Feinstein and Boxer are still voting to block medical liability reform. Meanwhile the high cost of health insurance has caused the number of uninsured to rise by a few million in the last few years. Maybe fighting for the "little guy" means saying "no" to their biggest political contributors--the lawyers? It's obvious who bought them off.

Even though California already has some liability reforms, the lack of reforms in other states still has implications within the state since insurance providers operate on a national level. A quote from the medical liability reform page:

Money spent on litigation costs in Florida, Pennsylvania, Oregon, or elsewhere affects national insurance carriers who provide coverage to California doctors. To compensate for increased litigation in other states, even California doctors and hospitals are paying more in premiums, and those premiums are passed along to all California citizens seeking healthcare. Some medical liability insurance carriers have even pulled out of the national medical liability market thereby reducing competition among the remaining carriers, and reducing the availability of liability insurance to doctors everywhere, including California.

Anyways some random thoughts: ...things that Bush needs to do before he leaves office with a reputation lower than that of Carter:

1: Pull out of Iraq. The military is is not a humanitarian, peacekeeping, or a nation building force. We already learned that lesson a few times, ie. Somalia. Its time to pullout and let the stabilization go to somebody whom the "islamofacists" don't want to Jihad off the planet. ...Still trying to think of who that is...
2: Appoint someone to the bench who is pro-abortion. Any attempt to reverse Roe v. Wade will be the death of the conservative party. In my opinion, there probably needs to be a higher abortion rate since it seems to me the the people who can't afford kids reproduce at a rate much higher than those that can. Of course, the people who can afford kids do so because they have made the choice to take care of themselves first unlike the millions who depend on the government to get by. Favorite bumper sticker: "Work Harder: Millions of People on Welfare Depend on You."
3: And please cut spending!!! Its the Generation X who is going to have to pay all these bills...and with a negative savings rate in the last quarter, that doesn't look like a viable plan.

...ugh too much writing today...

Friday, October 7: Recuperation

Went all out... did 240 hours of work last month, and none of it was sleeping--in residency I did up to 270 hours of work regularly but typically 60-80 hours was sleeping since I did moonlighting in the ICU where I was paid to sleep. Last month, I opted to go all out since I hope to be finding a place to live in pretty soon and I'm getting some roto-rooter action on the nose... Whoo-hoo! Work really hard and then spend some vacation time for a surgery. Oh well, I'm off until the 21st... :) I'll need the time to recuperate.

Yep, for the longest time I've been a mouth-breather and I finally decided to do something about it... so my ENT doc is going to straighten my septum, break my turbinates and push them to the side and finally cauterize some nose tissue out. Yes "cauterize" the aesthetically pleasing term substituting for "frying away." I'd be nice to be able to breathe like a normal person. Hoping that everything goes well so I can get back to work and start saving some more money... I'll have more expenses once I get a place...

Its a scary thing to be buying in this market ...luckily the place that I am hoping to get sold at its current price about 10 months ago by a "flipper" who happened to get cold feet and backed out of the deal. To many market watchers, the "peak" in the bubble occurred somewhere in June. But then again who knows what the market will do? I hope that I don't lose a bunch of money on the deal, but one thing is for sure ...I can't live in a 490 square foot apartment forever. In addition, if I live in it for at least 5 years, it should survive any market dip.

Tuesday, September 27: Cases of the Week

Best Outcome of the Week: 50 year old female with a pretty large stroke. Aphasic (unable to talk), right facial droop, RUE 3/5, RLE 4/5. Gave front-loaded TPA and the patient started speaking within one hour. RUE got up to 4/5 strength and RLE went to 4+/5.

Thrombolytics for strokes still freaks me out. That intracranial bleed rate of 6.3% means a bad outcome in 1 out of 20 patients who receive the drug. Of course, that is from the medical legal standpoint. ...if I ever stroke out, give me the TNKase. Yeah it's not FDA approved yet for this purpose, but I'm sure that efficacy of TNKase will be better than TPA.

Worst Case of the Week: 30 year old male choked on a burrito and died... Sheesh...

Sunday, September 25: Hurleyism

"Sounds like a bad case of severe retardism."

Trying to clarify with the Hospice Doctor the discrepancy between the family's desire to have a terminal cancer patient be full code yet be on hospice care the same time...

The whole point of hospice care is so that you can have a dignified death...not someone cracking ribs while doing CPR, nor intubating the patient and inflicting more pain and torture on a person who no longer has a voice or even a quality of life... Its called "terminal" for a reason.

Friday, September 22: Funniest Webpage Ever

Boycott (click on "Good Ol' Boycott") Absolutely died laughing on this one... "Are you sure about that?"

There are so many other good ones...

Guns for Tots

Popping a Big Tent

Thong of the South

Have fun...

Friday, September 22: Peanut anyone?

You just can't make this stuff up...

Patient with a peanut allergy decided to try and suck the candy and chocolate off of a Reese's Pieces piece of candy. WTF??? Yes in her attempt to get a microscopic amount of chocolate, she also got airway swelling, wheezing and a rash. Excellent!

Wednesday, September 20: Six Month Synopsis

Been working in the "real" world for the last 6 months and things are going great.

I'd have to say that I definitely see the benefit of working for an HMO from the emergency physician stand point. Out of all the systems to provide healthcare, I have vastly improved understanding of them all. Private health care systems (i.e. fee for service) are the fastest at getting things done. In these environments, ER doctors are more likely to admit patients who may not need admission since the admitting doctor can bill the third-party payer. Of course the incentive is money, and obviously fear of lawsuits, which makes it fairly expensive. HMO's in my opinion, do the work efficiently without the perversion of making medical decisions from a money making perspective or from an excessive defensive medicine stand point. I'm pretty impressed with the HMO setting...

At this point, I'll abstain from commentary on government run health care... :)

Other than that there is a huge difference in the level of acuity. In residency I intubated over 60 patients (as the primary doctor). In the last 6 months of working in the private sector, I've only intubated 2... I'm going through withdrawal... where are my crumpers?

Monday, September 19: Please tell ME your medical problem

ARRGGGHHHH! Saw a patient today who only told me his past medical history was only that of hypertension. I did a work up and ascribed his complaints to a benign process that did not need acute medical intervention. Anyways, after writing the order to discharge the patient home, his wife wanted to talk to me. It's at that point that they finally tell me that he had a life threatening medical condition in the past that required a surgical procedure to save his life! HELLO! I think that falls under PAST medical history! ...especially since its a problem that can recur! Yikes...

The history expanded the differential, but an addition test ruled out the new possible diagnosis and I ended up sending him home with my original diagnosis anyways. When I asked why he didn't tell me that ever so important piece of information, he stated that he told the triage nurse...

I just find it so irritating that I make decisions that could mean the difference between life and death with BAD information. Sure, we make decisions with limited information all the time, but that's when the shit is hitting the fan. I wonder how many other people I have seen who don't have the common sense to answer questions accurately. Yep, some of that information is "in the computer" but its impossible for me to read twenty some odd pages of medical text on every patient ...especially when it gets busy and you start shotgunning (ordering tests that may not be necessary) things...

My most common irritation (and probably every other doctor for that matter): Patient's who don't know the the names of the medications that they take, or even worse, why they even take them... I think there should be an extra charge every time I hear the phrase "I take the little white pill."

I've actually had one patient who was on only one pill for diabetes for the last 20 years yet did not know the name of it. Unbelievable...

Sunday, September 18: Go Bruins!

It wasn't pretty but the Bruins beat OU! 3-0 for the start of the season!

Saturday, September 17: Question of the Week

"Doctor, can you get me some teeth?" ...LOL

Conversation of the week: Patient's chief complaint was that he didn't want to pay for his drugs at the pharmacy. Didn't have any health insurance, but yes, still wanted it for free.

Doctor: "You have three options. You can 1) pay for the medications at the pharmacy, 2) not fill your prescription, or 3) go to a county facility and get your medications for free."

Patient: "I don't like those options. What are my other options?"

Doctor: "There are no other options. Those are your options."

Wednesday, September 14: Energy, Environment, and Economics

Following Katrina, Bush decided (i.e. was told) to release oil from the SPR (strategic petroleum reserves) in a continuation with his retarded damage control campaign. I'm sure he'll be claiming some credit for the lowing of oil prices on the global market which is a completely mute point ...since the problem is not with oil...its with refining it! Now if he released a pre-made refinery from the SPR then that would be a different story...(that was sarcasm, if you didn't figure it out).

Refineries were running at 97-98% capacity (meaning we were almost already at the breaking point anyways) prior to the hurricane and when it knocked off a bunch of refineries in the gulf, refining capacity dropped into the low 90's as a percentile. So the price jump in gas was all supply and demand, since if there was no change in price, the demand would exceed the supply and a shortage would have developed (i.e. no gas at the corner store). Oil could be going for one dollar a barrel on the world market, but the supply-demand curve would still be dictating the same price. You can't be consuming 98 barrels of gasoline when you only make 92. And the only way to prevent a shortage is to raise prices such that consumption drops to the 92 level. Hence, the underlying cost of the oil is not even a factor!

Anyways, I've always found the relationship between energy, the environment, and economics to be fascinating. This article talks about how there has not been a refinery made in eons since nobody wants one in their backyard, and the environmental constraints in California almost make it impossible. ...which makes for an interesting little interplay.

Like everything in life there is a cost and a benefit. The benefit of a cleaner environment is the high cost of gas. Just like the benefit of preserving natural habitats is the high cost of real-estate (that and of course too many people). At some point the people who argue for preservation of the environment such that no new refineries need to be built need to say that they don't care how much it costs poor people who will have to spend an even greater disproportionate share of their income to transportation and housing costs.

To say that you know what the optimal balance between these issues is a little ridiculous. On one hand, making a few new refineries could lower prices and make a stronger economy, but on the other hand, the excessive consumption of oil and its eventual depletion is only curtailed by higher prices. Sure depletion may not occur in our lifetime, but how about our children's lifetime? or even our grandchildren's? I'm not selfish enough to be only worried about today. In my opinion, the higher prices are a good thing so maybe we will start thinking about energy consumption on a long term basis.

Side Note: Everyone's definition of a gas guzzler: Anything that gets less gas mileage than my vehicle.

Tuesday, September 13: Jury Duty

What an unbelievable waste of time! Spent all of Tuesday sitting and waiting to be called up for a potential court case. About 120 people showed up and they did not even call one person!!! Of course, my strategy worked out perfectly! I rationalized that Monday was probably the busiest day of the week for the start of new trials and with most trials lasting a few days, the selection of new jurors on Tuesday would be less likely. (As a professional, you can select the day that you are able to show up as opposed to being on call for the entire week.)

Either way, systems like this always get me irritated ...leave it up to a governmental entity to completely waste people's days. On one hand I'm happy I wasn't selected for a court case, but in reality it's not like I would even be selected for one anyways. When was the last time a highly educated white guy ever was selected for a court case that didn't want to be on a jury (in Los Angeles, that is)). Like they say: "Juries are made up of people not smart enough to get off of them."

I figured I was easily off of any case that involved a criminal charge. All they had to do was: 1) Look at the color of my skin (and of course male--see footnote below) 2) Look at my educational background, and 3) ask me if I had any preconceived prejudices ...which is an obvious "yes" answer. DA's don't have 97% conviction rates because they try the marginal cases...

If it was a civil case I would have been in a tougher position. If the case was between two private parties, I think the best strategy is to downplay the importance of the charge which probably should have the plaintiff attorney kicking you off of the case since you would sound like someone who couldn't be convinced that the earth was round. If the case was against a company, all you would have to do is state something along the lines of "deep pockets" and "financial gain" and again the plaintiff's attorney would have you out the door in no time.

In summary: Criminal case: piss off the defense attorney. Civil case: piss off the plaintiff attorney.

Side Note: The Menedez trial in the 80's, the two kids who shot gunned their parents to death for financial gain but blamed their action on "alleged abuse," had an initial split jury of 6 men voting guilty and 6 women voting not guilty. The presumed difference: rationality versus emotionalism... ...or does someone else have a good explanation for the gender differences? Opps, touching on some racy subjects here...

Final note: Thinking that I am not a "good citizen" because I would actively try to get off a jury doesn't apply here. I've testified before, and all I can say is that I was surrounded by idiots and the the whole process was tedious and extremely painful... Even though it was a great experience to see how things don't work. In addition, I think I would have been homicidal in a few days and that would have been slightly problematic... :)

Sunday, September 11: "Sticky Trabeculae"

Had my first ever diagnosis of acute glacoma...(at least I first thought). Amazing it took over three years to run across one, and equally amazing that I didn't strangle this patient since he would not stay still for the air-puff tonometer!!! Took about 40 attempts! Aha Carumba!!! (IOP 43) Anyways, turns out that the ophthalmologist diagnosed him as having open angle chronic glaucoma secondary to "sticky trabeculae" from chronic uveitis. Odd...

Happened to reduce a nursemaid's elbow almost by accident... It was in my head as a possible diagnosis, so I played around with the elbow and felt a pop... Problem solved. :)

Had a case of Dengue Fever... Sounds like a very interesting and exotic disease--wrong. Turn out that there are four different strains, and only the hemorrhagic Dengue sounds like the dangerous one. Otherwise its just supportive care with fluids, tylenol, and anti-emetics just like any other viral illness.

Final case: Patient with a headache consistent with a subarachnoid hemorrhage had a CT that did not show blood but actually showed the aneurysm instead. (Usually its the other way around.) No need for a lumbar puncture since clinically they get treated as if it is a ruptured aneurysm. Transferred the patient to the neurosurgeon who put some wires in to clot off the aneurysm. Patient was in "surgery" (patient didn't actually get a a interventional procedure) for multiple hours and it took multiple attempts. Now I see why the neurosurgeons make so much money... Yikes...

Saturday, September 10: Stuff

Got my fingers crossed!!! Put my name in on an awesome condo complex with a great 180 degree view of the ocean and with city lights. Will find out if I've got it in October. Wish me some big luck... I'd love to live there...

Got job offer number 4!?!?!? Yikes! This one sounds good as well... Its part time, and I'm thinking of taking it. I've already got a full time job starting soon (14 shifts per month). The part time one is for 6 12-hour shifts a month. ...I don't know yet... Maybe it's too much work. Already per diem at two other hospitals. A part of me says that I need to "catch up," and to some extent its an unhealthy idea...

Congratulations to Nicole, my cousin, on her wedding day! She looked beautiful...

Tuesday, September 6: Hurricane Politics

Getting more absurd by the day... Politics is leaking into a natural disaster and some are trying to blame the Republicans (evil white men who may have even invented hurricanes!!!). Of course, making fun of George Bush is easy since he sounds like a buffoon most of the time, but really, most of the blame lies with the 62% of residents who stated prior to the hurricane, that if an evacuation order was given by the government, they would not leave! Not a problem with transportation...just an outright disregard for common sense. Yep, 62% of the population that happens to live below sea level! ...and many who can't swim! In my opinion, most of these victims are victims of themselves. And to top it all off, there are thousands who still refuse to leave the city! Like the government will keep on delivering breakfast, lunch, and dinner on a raft every day. ...ugh.

The irritating aspect of this is now Bush is on the defensive and trying to save face. So the next thing you know, there will be an all out effort to spend billions (40 Billion so far) of dollars to reconstruct New Orleans, to make stronger levees, and better pumping plants. All for a city that continues to SINK! I can't wait for the next hurricane to hit New Orleans...then we could blame the destruction on George Bush who decided to "rebuild."

Monday, September 5: Damn Racist Hurricanes!

Yep. This weekend was filled with some of the dumbest news ever. Not only were there more people shooting at relief workers in New Orleans as they try and fix the place up, the "civil rights" leaders were throwing out the race card as they complained about how the relief didn't come fast enough since most of the people stuck in New Orleans were black. Those damn racist hurricanes!

My 4 cents:

1: If the government told me that there was a 20% chance of a category 5 hurricane hitting my city in three days ...I would find "any means necessary" to escape. That's like telling me in California that a 10.0 earthquake has a 20% chance of hitting Long Beach in three days ...I'd probably make sure I was in Las Vegas the very next day drinking and doubling down on my suicidal King. If I couldn't leave because I had no car, then I think I would at least get to some open area. Likewise if a hurricane was barreling down on me in New Orleans and I was too stupid to leave, I think I would have at least hunkered down on some frickin high ground! instead of the below sea-level areas. What were these people expecting???

2. There should not have even been a relief effort if people followed what the government recommended. So the anger of the delay is retarded. Don't follow the recommendations and then claim "I'm an idiot, you must save me." How about some gratitude for someone taking the time to save your ass, lest you have to walk out of the city and save yourself.

3: Sure the are many poor and disabled people that would have had difficulty exiting, but I think that this accounts for a very small percent of the tens of thousands who are now struck there. A great quote that I read was about some dude who couldn't find his car after the hurricane hit. Hey Jackass, did the idea of using the car to get away make a little bit of sense BEFORE the storm hit??? :) (...okay, maybe I'm sounding a little mean)

4: I don't think the "race' card applies accurately enough here. I would more likely call it the "dumbass" card and the government discriminates against idiots who 1: don't follow orders to leave, 2: make provisions to take care of themselves if the don't leave (i.e. head to the superdome with a few days supply of food and water) and 3: finally, don't have the common sense to leave even after the hurricane is gone.

Thursday, September 1: Form 18

My first Form 18 in the last 6 months... Yikes! Used to fill these out on a daily basis.

I have fallen from grace, and my ashes are scattered
No longer of passion and flesh
My flame is alive, though my wings have been shattered
They lay my body to rest

My spirit is breathing, my senses are pure
Like reincarnation, my soul will endure

Back on earth...
The spirit, it never lets go

Like fountains of sorrow, the faces are crying
I'm witnessing all of their pain
Death is so final, for only the living
The spirit will always remain

Bury me deep, just to cover my sins
My soul is redeemed, as the journey begins

Back on earth (you feel me)
Back on earth (reveal me)
Back on earth, the spirit it never lets go

Another dimension, a river of life
I'm twisting, I'm turning, my soul is in flight

Back on earth (you feel me)
Back on earth (reveal me)
Back on earth (still breathing)
Back on earth (reliving)

Wednesday, August 31: Prilosec for Choledocholithiasis

Okay... This was a bit funny. A young female was seen in urgent care the other day (also known as "Urgent Scare" because you never know what type of train wreck they will dump onto the ER). In all fairness this wasn't the most typical presentation. Her complaint was epigastric pain somewhat constant with some nausea but no vomiting, fever, or chills. Now for this "gastritis" she was taking vicodin, flexeril?, pepcid, and tums. Kind of odd, huh? (In all seriousness, the best medication there was tums.) Anyways, she had been told before that this was from too much acid... and so that's how she ended up on Prilosec and sitting in front of me with the exact same complaint very the next day. Yep, sitting in front of me and as yellow as could be! Yikes, I didn't even really have to exam her since the answer was staring me right in the face. Interesting aspect about that--the husband didn't even notice the color change--odd. I threw the ultrasound machine on her and sure enough ...there was her huge gallbladder filled with stones and sludge. Lab results: Bili: 5.5 WBC: 16.9. Yep, Prilosec for choledocholithiasis...

Side Note: I love the admission process for these cases. Its always a wonder who will end up taking the patient... eMedicine quote: "Management of choledocholithiasis is a multidisciplinary affair and requires the expertise of various medical specialists" Medical translation: a lot of finger pointing and saying "admit to the __________ (enter any specialty here that is not your own) service."

Sunday, August 28: Sham Acupuncture

This was a good one ...Surprise Finding on Acupuncture for Migraine. Turns out that acupuncture is virtually no different than sham needling...or simply placing the acupuncture needles anywhere. ....Not like it sounded like an effective treatment anyways ...a reduction of about 7% headache frequency. The funny thing--just being placed on the list to get treatment reduced headaches by 1.5% (I doubt that this is the control group since obviously nothing was done). So the next logical step they took was to assume that the benefit was either from the release of some pain mediators versus placebo effect. ...I have a different idea...if you really think its through the release of pain mediators, why not head on over to the gym? I'd bet there would be a better effect than a meager 7%.

I've always found those "meridian maps" to be a little sticking needles into the feet actually helped to cure diabetes or poking the ear to fight cancer ...please. Anyways, I decided to look up some meridian maps of the body and found a great one explaining where to put the needle in your fricking farm animal... This is just retarded. I should start drawing maps and selling them at the hippie conventions--one of the few groups that believes in anything.

speaking of migraines...

Interesting article: Only approximately 20% of patients with migraines are on prophylaxis. ...No wonder why so many bounce into the ER. Probably the best drug rep dinner was when the headache specialist discussed this very issue. That one has proved invaluable ...because it seems to me that very few docs know how to appropriately treat them. Best line in the article:

About 50% to 75% of patients given any of these drugs [Topamax (topiramate), Depakote (divalproex), certain beta blockers, calcium channel blockers, and anti-depressants] will have a 50% reduction in the frequency of headaches, but the doses required may lead to intolerable side effects. For this reason, it is important start drugs as a low dose and increase gradually.

Seems to me that 50-75% is a bit better than 7%. Its either the acupuncturists are a bunch of quacks, or I should open up my own sham needling practice.

Wednesday, August 24: Gouged to Death

Tired of getting gouged...
Cost of medical license renewal fee 4 months ago: $800 (every 2 years)
ABEM written Board Certification test: $800 just sent in
ABEM oral certification: $1200 (next spring)
...and the list goes on and on: ACLS, BLS, PALS, ATLS, DEA, CME, LLSA they want me to join ACEP for $660!!!

Result: Regulated to death.

Tuesday, August 23: Gout from Hell

...Had a patient yesterday which I diagnosed by joint aspiration as having gout in one of his knees. Sent him home on motrin and colchicine only to have him bounce back the next day with gout now in both knees and both ankles!!! Ugh... Felt bad for the guy so I threw the pharmacopoeia at him. Hit him with 6 of morphine, 0.6 of colchicine, 50 of indocin, 30 of toradol, and 60 of prednisone. In 3 hours he is pain free (according to what he says)... so I write for some tramadol, vicodin, prednisone, in addition to to his already prescribed motrin and colchicine. I explain the medications for a good 20 minutes to family and he says he is ready to go... but fails road testing....UGH! Gout from Hell!!! My first ever admission for gout...

Interesting cases of the week: Patient presented with writhing abdominal pain nausea and vomiting with some whacked out wretching. Before I even talk to him, I see from across the ER and peg him as a kidney stone. But it turns out that on exam, all the pain is epigastric (and he is very tender there). CVA tenderness, no flank pain or radiation. I'm intrigued... He states that he has been to the "academic" hospitals on the east coast and nobody can figure it out. He even says he's been here before and a CT was done and was negative. Anyways, ordered a CT KUB (without contrast)...comes back positive for multiple small little stones. :) That case made my day.

Monday, August 22: Contrarian Views

Think a second time on these ones...

Here's an article that actually argues the US should put a higher tax on gas!!! Hmmm... now that's different. Financial news is always replete with negative news... Recently, its been a non-stop talk about the cost of gas or the housing bubble (if there is one). As for the later, its got me wondering when I should jump into that juggernaut. Now for the cost of gas, perturbs me more on how much people talk about the current price versus thinking about measures that decrease its consumption and prolong this as a viable energy source.

George Will writes an interesting column on the very subject about nominal versus inflation-adjusted cost of gas... Great Quote:

But in America, every pleasure quickly becomes an entitlement, so Americans regard as a civil-rights outrage the fact that today's relatively low price of a gallon of gasoline—relative to prices in other years—is 67.5 cents higher than last year's very low price. Americans relish the pleasure of self-pity, so only a spoilsport will mention that since 1980 the share of consumer spending that goes for energy has declined from 9 percent to 6 percent.

I think for the last 6 months everyone's been talking about this subject ...I'm just a little sick of hearing people complain about it all the time. Sell your Hummer and have a "nice warm glass of shut the hell up!"

On a side note, I'm glad I didn't get the M3... I'm loving my 330 with its 0-60 of 5.9 seconds and 24 miles a gallon. ...getting a little better at blipping the throttle and getting a tighter rev-match with the hard down-shifts. :)

Thursday, August 18: BTK

Dennis Rader, AKA "Blind, Torture, Kill," sobs at his sentencing... ...makes you want to hurl...

Out of all the people that deserve the death penalty... this guy should get his tomorrow. Instead, he will sit in jail at the cost of about 25K a year for the next 30 some odd years... He'll get better health care than a good percentage of the population, be fed three nice meals a day with exercise breaks and a good supply of reading material... Sure its not club med, but when this guy gets to live while his ten victims rot away in the ground, it simply cheapens the lives of those whom he killed and in my opinion further torments the victim's families.

Here are a few quotes from this article:

“This man needs to be thrown in a deep, dark hole and left to rot,” she said. “He should never, ever see the light of day.” ...unfortunately, this would be deemed cruel and unusual.

“As far as I’m concerned, Dennis Rader does not deserve to live. I want him to suffer as much as he made his victims suffer.” Again, seems to me like there is a disconnect between what this guy did and the sentence he received.

I find it very odd that this guy was sentenced to 175 years. Like making the sentence ridiculously long sends that extra message that what you did was really "bad"??? Hmmm, so that's 17.5 years per victim? why the .5 years??? ...makes no sense.

Anyways, here are a few Dennis Prager quotes on the death penalty.

"There are those who argue that precisely because they so value human life, they oppose the taking of a murderer's life. They argue that you cannot teach that killing is wrong by killing. But that is the same as arguing that you can't teach that stealing is wrong by taking away a thief's money or that you can't teach that kidnapping is wrong by kidnapping (i.e., imprisoning) kidnappers."

"There are many good reasons to be wary of taking the lives of murderers -- such as insufficient evidence, corrupted witnesses, distinguishing between premeditated murder and a crime of passion -- but love of life or a commitment to biblically based values are not among them."

Sunday, August 14: Random Stuff

...been pretty lazy with the blog lately.

Very odd ...was offered two more full time positions. Cool since I wasn't really even looking. Its nice to know that you are respected by peers ...because in residency it tends to be quite the opposite.

Had a case that really chapped my hide the other day. I presented a patient to the internal medicine doctors, and stated that the patient was having CHF symptoms (nocturia and dyspnea on exertion) and needed a cardiac echo in addition to admission in order to rule out an infarct. Next I hear him talking to another IM doctor about how the chest x-ray was obviously not CHF. Very irritating... since I never said that the patient was in failure, I said that he was having symptoms of CHF...two completely different things! Anyways, the patient's x-ray had an enlarged left ventricle, EKG had LVH with inverted t-wave possibly consistent with strain, and his blood pressure was 170/115. Now obviously there was no pedal edema or JVD, but have you ever heard of LEFT-sided diastolic dysfunction??? So he then orders a helical CT to rule out a PE?!?!? I felt like walking over and teaching him a little about his own specialty, but I exercised some restraint. Ugh ...still irritated about the whole thing...

CT was obviously negative. The cost of which is on the order of $1000...sheesh.

...oops, got to get to work...

Monday, August 8: "...its on the computer"

Read this for fun... its a rant by a triage nurse at an ER dealing with all those "true" emergencies.

The line I liked the best was--"its in the computer." I absolutely hate this when patients say I'm going to be searching in the computer for the reason why your primary doctor sent you to the ER for the next 30 minutes when you can just say simply say the reason that you are in the ER. And I'm supposed to be reading your entire medical history before and seeing the patient anyways??? I don't think so...

The next time that someone says this, it's obvious that they are not sick enough, and I'm going to go "to the computer," eat lunch, check my email, use the restroom, and come back in a half an hour... Maybe then the person could explain why they are in the ER in that ever so long 10 second explanation because its not in the computer! :)

Tuesday, August 2: The Application for Privileges is in...

I took the job... Wish me luck. :)

Sunday, July 31: The LaQuisha Factor

Yep...The LaQuisha Factor. How do I start?

Basically had a young teenage girl with a minor 1.5 cm cut that required sutures. A simple 5 minute lac (laceration) repair and discharge home right? Well, how about a 1-hour ordeal instead!?!?!? Nothing gets me more irritated than having to deal with the most ignorant of people. ...and I've had my fair-share, but this was unbelievable. The details are a little mundane, but all I can say is that I was unable to finish the job and someone else had to step in and sew up this social reject and deal with the dumbass family that also appeared to have been pushed though the educational system by default. The funny part--her name was the same name as the newly titled social phenomena known as the "LaQuisha Factor."

So what exactly is the "LaQuisha Factor?" Turns out that when children are given "ethnic" sounding names and specifically those in the black culture that there is a measurable detriment in terms of expectations and outcomes for success. Here is the link to the research article. ...and the abbreviated synopsis.

So what damage occurs to kids who are given such a name? Well in the educational system, here are some of the likely outcomes:

• More likely to score lower on tests.
• Less likely to meet teacher expectations.
• Less likely to receive high-quality attention and instruction.
• Less likely to be referred to gifted programs than more commonly named siblings.

Interesting line: "The study found that such names, often associated with lower socioeconomic status, account for 15% of the black-white test score gap, a factor greater than class size or a teacher's level of expertise."

Amazing that just a name relegates a person to such low expectation greater than the extent of how good your teachers are.

Wednesday, July 27: Worthless

Echinacea found to no better than placebo... Turns out that Americans spend 300 million on it every year. Yikes!!! In my opinion, there should be a stupid tax placed on this product of 500%. I'm sure the fanatics will argue that this was just another study paid for my western medicine (National Institutes of Health funded). Yeah, and like the people selling/making the echinacea are the unbiased party???

Monday, July 25: Brutalized...

Woke up today at 2pm... slept for 14 hours. Yikes, I guess that is a pretty good indicator of how nuts my Sunday shift was...

Sunday, July 24: BMI vs. AGI

An interesting study comparing weight and weight loss with wealth... Now this one was funny since it attempted to be politically correct. Obviously, you don't need to be a rocket scientist to figure this one out ...I think common sense would tell you the general answer. The line that I liked best is this one:

Other researchers, according to Zagorsky, have speculated that heavy people may face discrimination in the workplace, which could lower their incomes. Obesity might also raise a person's spending, on food or treatments for obesity-related health conditions, for example.

Hmmm... I think I could think of anther reason as well that the "researchers" might have skipped. How about WORK ETHIC ?!?!?! Wouldn't you think that there are some people who are just plain lazy??? Sheesh...

Sunday, July 24: Hippocratic Method

Had a pretty awesome case anterior shoulder dislocation with loss of distal pulses. Interesting since his hand turned blue within minutes of arriving to the ER (and somewhat scary)--I've probably seen over 50 shoulder dislocations, but never any with a vascular fact its not really even discussed in the literature. I went ahead and gave him some mo'fine and started with some traction counter-traction in an attempt to reduce it.. After gently pulling for about 30 seconds to stretch the muscles and realizing that I probably should put it in the first attempt, (I had to do it fast since I was also trying to manage a hypotensive bradycardic patient in the other room, so a conscious sedation was out the question as well.) I decided to convert to the Hippocratic Method... ...yes that great method where you put your foot in the guy's armpit and pull the arm until the humeral head clunks back into place. The last time I did this method was in med school... I'll have to admit its odd to place your dirty shoe in someone's armpit, and of course I got a dirty look from one of the nurses...but when it clunked back in on the first attempt, no more dirty looks... :)

Pulses returned immediately and his hand was pink again in a few minutes. Turns out that according to the vascular surgeon, no angiogram is needed. I guess this is logical since we never get angiograms for virtually every other dislocation with the exception of the knee... a reference to peripheral vascular injuries.

Monday, July 18: Handel yourself in the morning...

I found this fascinating... Bill reads the New York Times and some other newspaper about the college admissions process. A four part series if you happen to have a good 30 minutes of time... the story is a few months old but interesting nonetheless.

Part 1
Part 2
Part 3
Part 4

Monday, July 18: Interesting things at work...

Had a classic case of postpartum preeclampsia... Four days after delivery, headache with photophobia/floaters, a blood pressure of 199/116 (MAP 143!!!), 3+ pitting edema up to the knees, and non-fatiguing hyper-reflexive deep tendon reflexes. Got the patient admitted in 20 minutes...even before the nurses were able to start the magnesium drip.

Had a pretty cool distal amputation of a finger with nail bed laceration. The nail came out in one piece so I was able to sew up the germinal matrix with some 6-0 cat gut and replace the nail to splint it open. I recommend not throwing surgeon's knots and sticking to just 3 square knots ...otherwise the knot is too bulky ...learned that lesson a few months ago, and the smaller the suture the better. Ended up doing a little ronger action on the distal phalanx as well. :) I love hand stuff...

Wednesday, July 13: Random Thoughts

Case of the Day: Typhoid Fever!!! Amazing case... Febrile. Pulse temperature dissociation. Low white count. Exposure to family member who was diagnosed with salmonella on blood culture. Right upper quadrant pain and Murphy's sign with a bedside ultrasound showing thickened gallbladder wall. Total bilirubin bumped at 2.5 along with elevated transaminases... (I was washing my hands the entire day...) The medicine doctors and even the surgeons were intrigued as well. Of course only the typhi species of salmonella can cause biliary involvement. The history of Typhoid Mary. ...probably one of the most famous epidemiological detective stories ever.

Activists in LA are going after the LAPD again...this time after an 18 month old was killed when some deranged lunatic decides to start shooting at people while holding his baby as a human shield. What do you expect the police to do? Eat a lead sandwich? These people are fricking morons. I think that next time some whack-job starts shooting we should send in the human-rights advocates and those ever so caring lawyers planning to sue the taxpayers. Hmmm... I wonder if they will change their tune when lead starts humming by their ears???

Pol Pot (I find this guy amazing ...right up there with Jim Jones)...still beyond my comprehension why ideologues still believe in this shit. A few links:

"When he came to power in 1975, he quickly set about transforming the country into his vision of an agrarian utopia by emptying the cities, abolishing money, private property and religion and setting up rural collectives. Pol Pot's radical social experiment claimed the lives of countless Cambodians. Anyone thought to be an intellectual of any sort was killed. Often people were condemned for wearing glasses or knowing a foreign language." Link

"The ratio of deaths to population made the Cambodian revolution the most murderous in a century of revolutions." Link

...any guess to where he was educated??? Yep France... I love how they went around and killed the intellectuals. Huh? Are you not an intellectual yourself? What type of perverted world did this guy come from?

Maybe someone should tell the "End Poverty Now" crowd that utopia is in the French Guyana?

Tuesday, July 12: End Poverty Now Crowd

The wackos were out in force at the G8 Meeting demanding "End Poverty Now."

Sometimes I am just at a loss of words to understand some of these concepts. First of all, I don't even think it conceptually makes sense. There will always be a spectrum of wealth unless they desire to go back to extreme communist ideals of Pol Pot and kill off the educated...and make everyone poor. Throwing money at the problem is also unlikely to change much either...just look at the results from the US's "war on poverty" which has supposively been going on for the last 30+ some odd years. In addition, this is the same crowd that assails the United States when we try to do something good like give food to the Somalis or try to remove a dictator and oppressive regimen in Iraq. In my opinion, the US needs to stop foreign aid. Instead of coming to us for money, why don't they go to France (Cheese-Eating Surrender Monkeys) and get some money from them...

Monday, July 11: Caffeine

Interesting article on caffeine in modern life. Just remember--One pot of coffee equals 4 hours of sleep.

Monday, July 11: Question of the Night

Me: "Ma'am, do you feel nauseous?"
Patient: "No. It just feels like my stomach is upset and I'm going to throw up."
Me (with a big smile on my face): "Um, that's what nauseous means..."
Patient (laughing): "Oh yeah."


On a completely different subject, a clarification: In reference to my May 17th entry, a friend informed me that the number one source of income to the Mexican economy is their state run oil company. Number two happens to be money sent back to their country from abroad.

Sunday, July 10: What do you think of my poker face?

Probably the reason why I won so much money in Vegas!

...just take at look at that chip advantage!

Wednesday, July 6: Modern Drunkard

Who's got the most "Street Cred?" How about "Flava?" Some of life's toughest questions answered on a single webpage ... Modern Drunkard Magazine... yes dot com. Who would have thought?

When it comes to people who get so drunk that they end up comatose in the invariably is one of those crappy yellow mass brewed brands sold to the gullible or its those cheap "high" alcohol content malt liquors... Yes, "Magnum," "Old English," and "Colt 45" comes to mind... Its an amazing sight to see a person degenerate into frank delirium tremens...(in fact I've seen one patient die from this...) The wacky hallucinations of patients in severe withdrawal prior to the onset of DT's is just unbelievable.

Here is a great analysis of the beers...this one is good for a few laughs... Obviously, you can see how the commercialization of these products targets an extremely focused part of the market. By the way, where is my Mickey's? ...the honky forty. :)

...and if you really wanted to know what your horrorscope says...its all right there. ...Is it just my opinion..or are these just a little off?

Final note: You know you are drunk when your favorite drinking game is Do A Shot Every Time You Do A Shot.

Wednesday, July 6: Ambigrams...

Just started my second book by Dan Brown ...Angels and Demons...last week. Picked this one up since the The Da Vinci Code was awesome! ...great suspense. I'm almost done with Angels and Demons. I don't think I have ever read a book so fast. Of course, I did have the last 5 days off from work. :)

Brown carries his themes to the extreme...its very interesting. The part I like the best is the ambigrams ...words that are written so that they can be read backwards and forwards.

Halfway through the book, I decided to look at the cover again since its was written in similar style to the other ambigrams and sure enough, Angels and Demons can be read backwards and forwards... I'm very impressed... Here are the other 5 ambigrams in the book...the last one isn't on this page'll just have to read the book.

I'm going to have to go back to Rome and figure some of this stuff out... :)

Tuesday, July 5: "The Book Says..."

Back from Vegas... It was a bitter sweet trip and it was tough to say bye to a bunch of people who I may never see again... :(

The trip was great... a bunch of newly second year and third year residents also went... I don't think anyone will ever forget Bill's classic nylon-looking black shirt with a a row of white stars on each side with dice buttons nor his $1,500 dive playing $25??? Craps... (what the hell are you thinking?), or Geirahn's miraculous $2,700 dollar climb in a few hours at the blackjack tables, or Hrak's drunken antics (boy, you need some valium), or Sonny, who didn't gamble but decided to put a twenty dollar bill into the quarter slots, and with a nine dollar total investment wins a fricking $1,000!?!?!? ...are you kidding me!

Anyways ...stayed at the Paris Hotel...very nice. Who would have thought that you can still "surrender" in blackjack there? Ha! Don't you know your history??? Either way, the crepes there were awesome... ..wish they had some French Onion Soup ...I love that stuff... Brings back the memories from my trip to the Momart district in Paris when I was younger...

I went ahead and splurged ...spent a good amount of money... Went to see a Circ du Soleil Show, a few nice restaurants, and had my first ever profession massage ever... ...and like a complete dumbass, I ordered the Deep Tendon Muscle massage... Supposively, its not for beginners, but it definitely felt good with the exception of the raking of my soleus muscles...damn that was painful... In the end, my hamstrings "kicked" her off a few times as she tried to break down the the biceps femoris. The massage therapist stated that she had never been "kicked off" three times in a row. Eventually, she recommend that I get some Yoga tapes... Hey what can I say??? Obviously, I've been working too hard in the past few years.

Analysis: (Yes nothing is complete until I over analyze it.) Why do people always say "The book says..."??? It makes no sense to me. Sure there is an optimal betting strategy based on the cards in front of you to try and make the most money. The thing that I find funny is that even with betting "by the book," the long-term return on Blackjack is 97%...basically meaning you are most likely going to lose. In reality, the "book" should actually say "don't gamble" ...unless you really want 97 cents on the dollar return...

...once I get everyone's pictures emailed to me ...I'll put up a slideshow. Somehow, I didn't take too many pictures at the awards ceremony, the graduation dinner nor the vacation.

Anyways...back to work tomorrow... :)

"Saving lives, making a difference." ( Jones would say)

Friday, July 1: Flash in the Pan...

...and just like that, its over...

Finally completed residency today, a culmination of work that had its inklings of a start in high school, challenged by the chaos of social distractions in the first two years of college, and a long struggle just to get into medical school the subsequent two years after school.

I always viewed medical school as a great sacrifice ...studied beyond what I thought was possible (although most others worked far beyond my capabilities), and it was a great expense to some personal growth and it unfortunately lead to a long-distance growing apart with some close friends, but of course I made even stronger friendships in med school...and I'll sure some of us will be life-long friends ...I wish them all the best of luck, and maybe I can visit them it their far away states some day.

Residency was definitely a lot of longer were grades the measure of your career, instead, competence of understanding, diagnosing, treating medical problems, and in dealing with difficult and challenging patients and working with medical staff and collogues professionally really required a full complement of skills and dedication to make it work. Of course, I think I worked too hard and lost focus on some of the important things in life and made some bad decisions personally along the way. Sometimes, you just wish you could have done better ...I'm better at figuring out what is going on with a patient, than with what is happening in my own life...

With graduation comes a great sense of relief, but it comes with some sadness... I wish I had someone special to share this moment with. I wish all of my friends were not leaving to other states. I wish I can find that proper balance between personal desires and profession goals. And I wish to all my friends that they are successful in their careers and that they stay in touch...

I'd like to thank all of those who have helped me in this long know who you are... I appreciate it beyond words...

...its off to Vegas... wish me some luck there... ;)

Wednesday, June 29: Down to the Final 12 hours!

Woohoo...Last shift tomorrow...then its BBQ followed by Vegas!!! I think life will dramatically change with residency completed...but of course it brings new challenges. The good thing is that I can face these challenges on my own terms as opposed to having them dictated to me...

I feel like Hans-Joachim Stuck kicking ass in a BMW M3 GTR on the Nurburgring circuit. Click for the white-knuckled, stomach curdling ride... ( I love the sound of that machine when he downshifts...)

Results of the 2005 Nurburgring 24 Hour Race... BMW takes 1st and 2nd place...

Sunday, June 26: 4 More Days!

Woohoo! Graduation day in 4 more days! Tonight is Graduation dinner. Tomorrow is drug rep dinner, Thursday is BBQ. and Friday morning is Vegas for 4 days!

Slept in this weekend. Woke up at 11 am on both Saturday and Sunday... Feeling very refreshed and relaxed... Stress level is very low.

Of course, I started this morning with some hazel cinnamon coffee followed by a Framboise Lambic... mum! Now its pre-party drinking with the Spaten Optimator... :)

Sunday, June 26: Batman Begins!

Loved it! Great dialogue in this movie with those classic one-liners ...probably more introspective than regular movies. Awesome movie ...almost as good as Spiderman. Next up, the Fantastic Four? Cool... The comic series turned into movies have all been good with the exception of the Hulk.

...Now only if they can do the Neogenic Nightmare series from Spiderman...that series is worth probably 6 movies just like Star Wars. I would bet however that the Alien Costume with Venom would probably be one of the best picks to fit on the big screen.

Friday, June 24: Great conversations of the day...

Conversation of the Day #1: Cocaine washout woman who complains of headache and has a fever. Head CT demonstrates diffuse cerebral edema and she can only stay awake of a few seconds. I'm trying to evaluate if she has papilledema with the ophthalmoscope prior to deciding whether or not an LP can safely be done. Anyways, she's not compliant with the exam, so I tell her to "count to twenty." She replies, "20, 19, 18, 17..." and then she falls asleep... ugh! I go find a panoptic ophthalmoscope which has a much better retinal view than the standard one and, wake her up 20 minutes later... she continues "14,13,12..." and falls back asleep. Ahh how funny... :)

Conversation of the Day #2: Nurse is placing an IV on a homeless drunk lady who had her surgical wound open up and was septic, yet at the same time popping vicodins and taking swigs from her pint... (no point in trying to take away her drugs lest she would then just scream for drugs from us...) So the patient gets pissed off and yells out "why don't you just skewer me and put me on the BBQ!" :) ...then some smart ass, responds... "do you recommend any seasonings?" ...I love bizarro world...

Thursday, June 23: No more Beeper!

I absolutely hate the sound of my beeper. Rarely know who is calling and what it is for. In addition, there is that unwritten expectation that you have to return all calls immediately or why else would you be carrying a beeper? Turning this thing in was awesome! ...No more electronic leash...

Tuesday, June 21: Zebra

Interesting case of the week... Pt. with a past medical history of stroke and an indwelling foley complains of feeling weak. Paramedics state that the patient is alert and oriented at the house but is obviously altered on arrival to the ED and had changed significantly from initial presentation. Blood pressure is low and the patient is tachycardic. The foley bag shows an infected urine and the lungs have inspiratory and expiratory wheezing with jugular distention... patient has no history of tobacco use nor congestive heart failure. We bolus the patient some fluids and start dopamine and intubate the patient because his is hypoxia and of course altered. Blood pressure barely comes up so we start levophed... Chest x-ray shows pulmonary edema. The nurse changes the foley bag and even after 4 liters of fluid and trying to prop up the blood pressure we notice no urine output. Changing the foley lets out about 700 mLs of infected urine. Patient eventually puts out 2 liters of urine and the wheezing disappears. Eventual diagnoses: Obstructive renal failure (creatinine 7), septic shock, and cardiogenic shock. Very interesting... The best part about it...the family was more interested in the soccer game on TV than on the condition of the patient according to the paramedics. Huh! :) I guess everyone has their priorities...

Thursday, June 16: Attack of the Potato Bug!

Yep... Chief Complaint of the night: I got bit by a potato bug! (and they even brought the squashed bug in so we could all marvel at its ugliness)

Now if you have even seen one of these bizarre creatures, the next question pops into your head--"how the hell did you get bit by a potato bug?" Of course the speed at which these things move is on the order of centimeters per hour...

Anyways, a google search for "potato bug" revealed that there is some definite fondness for this creature found at none other than I'm at a loss of words, but this was pretty funny... especially the anatomy description.

Have fun...

Another cool page... uglybug

Wednesday, June 15: Final Night Shift!!!

The best thing about medical education is counting off the final times that you have to do something... Taking incessant numbers of tests, call nights, off-service rotation, etc... the list is almost never ending. Tonight is my final night shift in residency! Woohoo. ...and of course, graduation is just 2 weeks away... :)

Out of all the things that I hate, working a 13 hour night shift that starts in the early evening to be the absolute worst. I don't have a problem if it is an 8-hour shift...but 13 is just brutal. The next day after a night shift is worthless since you are so tired... Even with two days on and two days off, I still tend to find myself so burnt out that I almost can't do anything else... I'd rather work 12 hour days 7 days in a row as opposed to night shifts...

Tuesday, June 14: We live in a bubble.

Went shopping for a house the other day... ...not a good experience. Makes you want to put a finger in your mouth and vomit...

Tuesday, June 7: I want "1"

Hartge seems to have placed a V8 with 450 horses into the 1-series... I'm drooling...

Tuesday, June 7: Defensive Medicine

Interesting article on the prevalence of defensive medicine... Doctors’ lawsuit fears may hurt health care

...approximately 93% of physicians engage in defensive medicine, ordering unnecessary tests, doing unnecessary procedures that do have risks, and avoiding interventions that may have risks but are on the whole beneficial for the patient.

A good example is that of stoke care. About half of all medical malpractice lawsuits are for patients who did not receive thrombolytic therapy for their stroke and the other half of medical malpractice lawsuits are for those patients that did receive thrombolytics and had a bad outcome. Seems like you are damned if you do and damned if you don't.

Some medical problems are all legal such as aortic dissection and pulmonary embolism... Extremely difficult diagnoses to make and even if the diagnosis is made, a bad outcome is almost guaranteed. Hence, any delay in making these diagnoses is now a legal problem.

And now you see why your health care expenses have increased by about 30-50% in the last few years... Thank you legal system. :)

Monday, June 6: Pork: "The other white meat."

This has got to be the worst case of neurocysticerosis that I have ever seen... To put this into perspective, last year everyone got excited when we saw two active cysts on one patient. We counted the number of active cysts in this patient to be about 65!!! (On these two cuts alone you can see 33!) These images are just nuts... Sonny is working on the write-up for the Annals of Emergency Medicine... The patient's chief complaint... headache.

So what exactly is neurocysticerosis? Put down your food prior to proceeding... Neurocysticerosis is caused by the tape worm taenia solium found in improperly cooked pork ...and happens to make your taco you buy down on the street corner in Mexico a little more spicy (occurs in nations where sanitary conditions aren't that great). Tape worm eggs ingested in contaminated food hatch in the stomach and the little larva invade your intestinal wall and take up residence in your muscle and your brain rent free. Cysts are formed around the growing larva and eventually the larva die because they are in the wrong place... The rupture of these cysts may cause severe inflammation and neurological damage. The worst complication being that of a seizure disorder...(or blindness if it happens in the eyes).

Point to all of those who opt to travel to Mexico... Don't eat the pork!

Memorable conversation with a different patient with the same problem after explaining what we had found:

Pt: ?Hay animales en mi cabeza?
Me: Si, hay animales en su cabeza...

But it was only a fantasy
The wall was too high as you can see
No matter how he tried he could not break free
And the worms ate into his brain.

Pink Floyd

Sunday, June 5: "Greedy lawyers abuse the system to milk American business dry"

Excellent series on the need for tort reform...

Some interesting points: (direct quotes from Gary Witzenburg)

In just the three years between 1997 and 2000, U.S. businesses saw a 300-percent increase in federal class actions and an incomprehensible 1000-percent spike in state class actions filed against them.
More than 16 million lawsuits are filed annually in state courts - one about every two seconds
The average U.S. family of four pays a "tort tax" of $3380 a year in higher prices, insurance rates and health-care costs
Trial Lawyers, Inc. often takes between 40 percent and 70 percent of the award for its fees and costs
80-90% of Asbestos cases are fraudulent
Every American Car has $1,500 of health care expenses for its workers (costs not shared by foreign competitors)

Part 1

Part 2

Saturday, June 4: Therapeutic LPs...two in one week!?!?!?

Headaches... Yep, headaches account for about 10% of presentations to the ER. Most of the time its nothing serious ...something that makes the presentation a headache in and of itself... Do I do the entire "work-up" or do I call it headache resolved after I narc them up??? Obviously in today's medical malpractice world we tend to buzz their head and offer a lumbar puncture. ...oh well, it only costs about $1,500 every time we do it... I'm still amazed at how many people allow me to put a 4 inch needle into their back...

Usually the LP is a diagnostic tap ...looking for blood from a sentinel bleed (which has never been positive in my experience), or for signs of viral or bacterial infection. This week was different ...finally came across two diagnoses that require therapeutic LPs (and I've been doing this ER thing for 3 years now)...ones in which there is too much spinal fluid and removing the excess fluid is beneficial as opposed to just to diagnostic.

The first case was an elderly man with Normal Pressure Hydrocephalus ...a clinical syndrome of confusion, ataxia (difficulty walking), and incontinence (although he was on dialysis and didn't pee). He had the classic Head CT of dilated ventricles out of proportion to the sulci. Anyways, I went ahead and did an LP on him and drained about 40 mLs of CSF ...cerebral spinal fluid (emedicine recommendation to remove 50 mL)...which was quite painful since it took about 20 minutes to drain that amount. Supposively, improvement clinically occurs 3 hours after the LP ...unfortunately I was at the end of my shift and didn't stay around to see if it worked. Nonetheless, very interesting...

The next patient was was referred to the emergency room for bilateral papilledema. Reportedly he had progressive worsening of vision over the last 8 months...but no headache. His CT of the head and orbits was mass lesions. So anyways, I went ahead and did an LP and his opening pressure was 46 cms of water ...yikes! Diagnosis: Idiopathic Intracranial Hypertension (normal is 8-18) So I put the stylet back into the needle and told the guy to hold on... meanwhile, my co-worker checked the internet to figure out the amount of CSF to pull off... ..very odd, there is no information on the internet on how to do it... I opted to drain 22 mLs and then I rechecked the Intracranial Pressure (ICP)... it drops to 26. I then drain another 10 mL and the ICP drops to 20. Finally I drain another 10 mL and recheck the pressure and it is still at 20. At that point I stopped... Anybody with feed back on the procedure for therapeutic LPs in IIH??? I'm sure neurologists know more...but then again you have to find a willing neurologist...

Thursday, June 2: Soooooooo Tired.....

Whew ...finished 13 days in a row... this has got to be the best way to get out of shape. Ugh.

Monday, May 23: Viagra for Sex Offenders!

Great Job! Another well thought out plan by people in the government. Turns out that convicted sex offenders on medicaid have been getting free Viagra courteously of Uncle Sam... It makes you wonder about what type of special bureaucrat retard is making these decisions... Of course you don't want to violate these people's rights... huh? Rights to free Viagra??? Sounds more like a case of Head-in-Ass disease.

Read the article here.

...Interesting... The titles of the news articles outside of the US: US government gives free Viagra to paedophiles compared with title of news article in, lets say, Boston: Feds say states can deny Viagra to sex offenders on Medicaid

Sunday, May 22: PWDP!

Straight from the pages of Admitting Patients Without Discernable Pathology I had my greatest admission to date. A middle age Indian male who was just in India for a few weeks and had developed a fever about 5 days ago associated with some sweats that went away spontaneously. For the last two days prior to presentation he again had fever associated with sweats and generalized malaise and myalgias. The patients was also tachycardic and febrile, and the only thing that was abnormal with his blood work was a slightly elevated white count. ...So the only thing that I could conceivable think of was malaria... a diagnosis which mandates admission for serial blood smears since the intermittent seeding of the blood with protozoa may initially have negative results... Ha...

When admitting marginal patients, select an appropriate diagnosis. The ideal diagnosis is exotic, difficult to disprove, and mandates hospitalization. Some of my favourites are Tumarken's otolithic crisis, familial periodic paralysis without hypokalemia, and Oppenheimer's progressive hemorrhagic leukodystrophy.

I'll have to follow up on this one... :)

Sunday, May 22: The end is in sight!

Woohoo! I looked at my tentative schedule for July ...I'm working 12 days! and I've got 19 days off... Ahhh, how awesome will that be! Haha... 3 1/2 shifts equals my resident salary for one month... I'm going to be loving it. ...I imagine that I'll pick up some more shifts ...otherwise I wouldn't know what to do with my time...

Wednesday, May 18: Presentations of the Month

For some odd reason, I've been feeling a little prolific lately even though its fairly evident that I wasn't the best English/Composition Student. Yes, I failed my AP Composition exam in high school a 2 out of 5. :( But I know why I failed ...I happened to throw a little political ideology into a few of my essays... I probably ended up pissing off some easily offended peon. Haha... I got a 3 out of 5 on my AP Literature... now that was amazing because I am pretty damn illiterate. I will always remember in high school my AP Lit class. Mrs. Cole would have us write "in-class" essays and before we would start writing she would single out Harrison and Hurley..."please come up and talk to me before you start writing." Poetry... not my forte. :)

Anyways, a 42 year old female comes into the ER with a chief complaint of "cough." The triage nurse performs vitals and gets a basic past medical history. The patient appears to be in moderate distress so she is moved back into the Main ED. As the nurses are putting her onto the gurney, the patient arrests! Great timing! There is no better place to decide to die than in the Emergency room... We immediately started CPR and intubated the patient. Putting the patient on the monitor revealed the culprit ...ventricular fibrillation. Shocking a few times and ultimately giving some amiodarone, we get a rhythm back! Talk about bizarro world... This patient actually survived without any neurological impairment. Interesting since if it occurred outside of the hospital she would have died or be brain dead... Etiology: new onset congestive heart failure and a hypoxia induced arrhythmia.

Arrghhh... tomorrow is day number one of 13 days in a row...

Tuesday, May 17: How to put your foot in your mouth...

Vincete Fox quote:

"There is no doubt that Mexican men and women, full of dignity, determination and a capacity to work, are doing the jobs in the United States that not even black people want to do there."

This has got to be up there with some of the stupidest things ever said by a politician. Not only did he insult Blacks...he insulted his OWN people... I laugh... In the article that I read while I was at work, he next called up Al Sharpton and Jessie Jackson and invited them to come to Mexico to work on immigration reform... Unbelievable. This guy has balls.

For those who don't know. The greatest source of the Mexican GNP is actually money sent back to Mexico from workers in the US. This is the reason why the Mexican government encourages illegal immigration...gets rid of people so that they don't have to spend money on social aid programs and then when they end up working in the US, they send cash back to Mexico. With that being said, Mexico is doing everything that it can to increase the rate at which illegals cross the border.

Of course, politicians representing the US are a bunch of pansies and haven't done anything except provide more incentives to people to come across illegally. Meanwhile, Mexico has a brutal extradition policy for anyone trying to enter illegally into their country from central America. ...Yet America is the "racist" one...

Read the article here.

Monday, May 16: Muscle Memory

Well its been a solid three months of going to the gym... I'm on a Q4 day schedule and I'm loving it. Haven't been in this good of shape in about 3 years. I've still got a good way to go however. Gone are the days of 4 days a week and and hour and half each day. If I can get back up to 185 pounds and get my six pack back I'll be a happy boy. :)

Other than that, I'm counting the days towards the end of residency... Its a bitter-sweet feeling. In college, I lost touch with a bunch of friends when I went to Detroit. Then when I left Detroit, all my good friends stayed behind. Now, I'm graduating and staying in the area and all my co-workers are leaving to high-income earning places. Ugh ...I could go to Texas and work for probably 15 years and then retire. In SoCal, I think I'll probably have to put in a good 25 years...arghhh... Maybe after a few years, I'll cut back... I don't know... too many questions to which I don't know the answer.

Wednesday, May 11: The 1 Million Dollar Bullet

Just nuts... So I'm in the break room at work stuffing my face with some food since we technically don't have an allotted "break" to eat during our 12 hour work day and up on the TV is this nuts car chase. The helicopters chasing show the driver with pretty damn good clarity. He his holding the steering wheel at the 6 o'clock position is hauling ass at about 100 mph weaving in and out of traffic like its a Sunday drive. The next thing you notice is that he takes his hands off of the wheel, grabs a pipe and takes a pretty long hit. A few seconds later he exhales a huge plumb of white smoke. HA! I laugh...the guy's smoking crack!!!

Eventually, the guy's front tire blows out, the chase eventually comes to a stop and the "suspect" starts to run with a gun in his hand. The police unload a bunch of rounds and the guy is fatally wounded. Call me evil, but I think he deserved what he got. However, that was not the case with a fellow employee... A nurse inside the room says immediately after the shooting that the police killed him and said "he wasn't doing anything." Huh? Yeah ...another police homicide... Whatever ...seems like no matter what the police do, there is a certain segment of the population that can't pull their head out of their ass. The news reporters then say that police actually found two guns! The nurse then says that the police "planted that" and "I don't trust the police.". Unbelievable... I laugh. Anyways, a wise man said "never argue with an idiot, people won't know the difference." ...So I dropped that conversation quickly... lol

I definitely have to say that the Long Beach Police Department deserves a medal. If you think about it, this career criminal (he was driving a stolen car that he obtained from a home invasion robbery) would have only been a burden to the rest of society...the cost of a trial, a bunch of appeals, and lets say 30 years in prison at the cost of 30K per year, probably totals about 1 million dollars. In my opinion, that was best possible outcome... ...and this is how all police chases should end!

Monday, May 9: The Great American Beer Crisis

Ha! I'm a beer yuppie according to this article. Interesting article on the economics of beer consumption.

Excerpt from the article:

When the economy is booming, we pound a six-pack of Bud with our buddies and watch the game. When the economy is lousy, we pound a six-pack of Coors with our buddies and watch the game. When the economy is flat, we pound a six-pack of Miller with our buddies and watch the game. This is why companies that make beer—like those that make diapers, electricity, and cereal—have countercyclical stocks. When the economy hits a soft patch, investors take refuge in them.

Sunday, May 8: Squirrels

To avoid more questions about squirrels... a definition:

A squirrel is a migratory animal often found in the wild on somebody's doorstep inebriated with the pungent smell of urine and built up bodily secretions that even lava soap and a fire hose would have difficulty removing. ...Or maybe its just a specific phobia of shampoo? Who knows? In the Spring time, the squirrel makes his appearance, but this shadow of a soul no longer predicts anything about the seasons like the Groundhog. Instead, it simply implies that someone needs to call 911 to get this "creature" as far away from "me" as possible. Paramedics rush to the scene, don on protective wear, attempt a medical intervention such as ammonia in the nostrils to see if the squirrel is still alive. After a barrage of twitching from the noxious fumes and an eventually organization of spastic movements to remove the lovely smelling salts, the squirrel responds with a rash of expletives surrounded by some incomprehensible mumbling, and the now "patient" is promptly shipped to the nearest ER where we readily recognize our frequent patron with an "Ahhh shit, not him again" greeting. Chief complaints range anywhere from "I done fall out" (also known as a DFO) to "where is my food tray" to complete silence until that cocaine and amphetamine washout has run its 12 hour course. Invariably, laboratory investigations reveal a 400 blood alcohol level, cocaine metabolites, and the head CT documents the progressive deterioration and atrophy of the frontal lobe, that part of the brain used for life's unimportant things such as personality and thinking. Some squirrels may be dangerous, especially if they have not been taking their daily vitamins and have instead been trying to silence the voices with such herbal remedies as "angel dust," "crank," and "crystal." Ultimately, the true danger of the squirrel does not lie with squirrel himself. Instead, the squirrel chews up your resources, distracts you from the truly sick and ultimate screws you over when they finally decide on their one thousandth visit to the ER, to finally go to ground permanently.

Thursday, May 5: Quote of the Day

Halfway through his shift..."I think 60% of my patients are cocaine positive" -- Geirahn.

Ha... I laugh. Attack of the squirrels.

...He's lucky that the Squirrel Master was working that day... :)

Wednesday, May 4: DOMS

I took the last two days off... and I must admit that it was a bizarre sensation. I passed up on the opportunity to pick up 6 different shifts ...something that doesn't really fit with my personality. Maybe I was feeling a bit run down form the previous month's triad of excessive work, stress, and lack of sleep even though I have been conditioned to it over the last 7 years. ...I probably worked too much last month. Sure it was nice to have raked in more in one month than I did as an entire year of personal trainer (...although, I didn't really try too hard at that since I knew it was a temporary job), but I felt like I was shifting thing out of proportion. Instead of work, I opted to play some basketball, hit the gym, run along the beach, do some stretching, and cook a little ruffy... Of course, I'm still reading the Da Vinci Code...and it is confirmed that I am the slowest reader ever... I must be mental. Anyways, I still can't imagine how much free time there is with a forty hour work week... you just get to do so much stuff. Whenever I hear about people complain about their 40-hour work week, a little voice in the back of my head says "what the f#@% you talking about..."

Its interesting since there is one person who I know who burnt themselves out by going all out all the time. While another person I know who is already practicing emergency medicine who only works 2 shifts a week! Two shifts a week??? Its amazing that you can live in LA with only 8 days of work and have some 22 other days off. I wouldn't even know what to do with my time... Its a very odd spectrum on what people decide to do...

Right now, I am feeling the effects of DOMS ...delayed onset muscle soreness. As opposed to the mental fatigue of too much work I decided instead to kick my ass in the gym. Did two sets of almost everything for the upper body and then ran three miles.... and I must say that I'm feeling great even though I could barely move earlier today... :)

Sunday, May 1: War Inside my Head

Speaking of beer, this guy presents to the ER at around 1 pm in the afternoon with a laceration to his scalp and to his hand and is covered with dried blood. Turns out that he was out at the club and drinking (yes...14 Coronas ...I always am intrigued at what people drink...that got a smirk out of me) around 2 am in the morning and got bombed out of his mind. He then decided to assault himself over the head with a beer bottle "to see if I could break a bottle with my head" ...turns out that you can!!! lol... ...this happens to be one of those chief complaints where you just can't prevent yourself from laughing. I guess its a good thing that the patient was laughing too since he also realized how retarded it must sound...

Anyways, he said that he was too drunk to go to the ER after knocking the noggin and decided to go home and sleep it off. ...another great decision. He then says that he woke up at 9 am...but only decides to go the ER after realizing that he had a pretty large that only took about 4 hours to figure it out! So after sewing him up, he says to me, "Damn, my mom's going to give me a spanking." Very odd since he was 24 years old... lol

...this is what happens when you still happen to listen to heavy metal...

Side: Another fantastic presentation as per a colleague, Dr. Lightburn. Patient presents with a chief complaint of stabbed to the elbow after getting into a fight.

So Lightburn is sewing up the wound, when the patient says "I hear voices." Lightburn immediate stops, drops his jaw, shakes his head, and says "huh?" Turns out that the patient got into an argument with himself and subsequently stabbed himself during the altercation. oh weird can things get???


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