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...
Gear and Top
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
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 youtube.com and did a search for
"Top Gear" a British program on cars. One of the hosts
Needell--do a search for him... Completely ridiculous videos...
I laugh. Check out: Rear wheel driving, Powerslide, and E46
This is a good vid as well. German
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,
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
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
Thursday, July 6: Depression and Obesity
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'
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
out...wow! 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 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.
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
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 state...as 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
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
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
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
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
...so 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
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
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 www.darwinawards.com.
Wednesday, April 26: Art of Agnes Hurley (1916-2006)
"Madonna of the Rocks" by Da Vinci. Painted
"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 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 ...living on a razor's edge.
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
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. ..it 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
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 becomes...how 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.
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
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,
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
Sunday, March 5: Crime and Punishment
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,"
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
Anyways, I opted to do a search for "hate crime"
on news.google.com 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
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 rhythm...how 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
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!!!
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
Figured a few interesting things out on the computer...
1) Systinternals.com 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 GoDaddy.com. Ugh... it not like I have to know enough as
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
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
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
Anyways, went out and got the Viewsonic
VP2030b... Its pretty good, but I still like those CRTs...
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
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
(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
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
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
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
Take case in point, Marcus
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
It will be interesting to watch how the text gets modified
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%. ...emedicine.com
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
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
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
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
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 news.google.com. 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
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. ...next
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.
"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
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
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
Monday, December 5: Stupid Time
Arrrghh... My reflections on a completely retarded night of
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"!!! ...as 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
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
Yep its the holiday season and already a few patients have
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...
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
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
Tuesday, November 22: Ironic
How bizarre! Soon after an election measure to improve education
accountability was shot down, LA Mayor Villaraigosa is attempting
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 Zagat.com, 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?"
After reading this, you realize that neither the spendocrats
or reporklicans have the answers...
Friday, November 11: Foolish Proletariat
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
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
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
Most important test: MCAT
Most time spent studying: USMLE Step 1 ...probably about 360
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:
Med School: 50
Written Boards: Sunday
Oral Boards: Spring
Thursday, November 3: Special Election Analysis
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. :)
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...
|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
|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...
|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.
|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.
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
Wednesday, November 2: CME
Get your free CMEs here:
Required 12 hours on Pain Management: www.ama-cmeonline.com
Free CME: www.freecme.com
Thursday, October 27: OFF
Interesting LA Times article on the Oil-For-Food
program... The shit hits the fan and the UN is standing
"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
"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
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? ...is 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,"
"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
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!!!
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
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 ...work. 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 ...got the Iron
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 (...as 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
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
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
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
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
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
...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
(click on "Good Ol' Boycott") Absolutely died laughing
on this one... "Are you sure about that?"
There are so many other good ones...
Popping a Big Tent
Thong of the South
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
Patient: "I don't like those options. What are my other
Doctor: "There are no other options. Those are your
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
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
almost make it impossible. ...which makes for an interesting
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
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
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 surgery...got 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
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
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
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
I've always found those "meridian maps" to be a little
ridiculous...like 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...
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
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,
...next 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). ...no 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...
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, ...it 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
Anyways, here are a few Dennis Prager quotes on the death
"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
...oops, got to get to work...
Monday, August 8: "...its on the computer"
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 this...like 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
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
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
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
a pretty awesome case today...an 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 compromise...in 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
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.
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."
...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
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
on caffeine in modern life. Just remember--One pot of coffee
equals 4 hours of sleep.
Monday, July 11: Question of the Night
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
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
Patient (laughing): "Oh yeah."
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
When it comes to people who get so drunk that they end up comatose
in the ER...it 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 ...you'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
...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." (...as Jones
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
Residency was definitely a lot of work...no 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
journey...you 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
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 www.potatobugs.com.
I'm at a loss of words, but this was pretty funny... especially
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...
Tuesday, June 7: Defensive Medicine
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...
So what exactly is neurocysticerosis? Put down your food prior
to proceeding... Neurocysticerosis is caused by the tape worm
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.
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)
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.
than 16 million lawsuits are filed annually in state courts
- one about every two seconds
U.S. family of four pays a "tort tax" of $3380 a year in higher
prices, insurance rates and health-care costs
Lawyers, Inc. often takes between 40 percent and 70 percent
of the award for its fees and costs
of Asbestos cases are fraudulent
American Car has $1,500 of health care expenses for its workers
(costs not shared by foreign competitors)
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 normal...no 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
...got 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
Arrghhh... tomorrow is day number one of 13 days in a row...
Tuesday, May 17: How to put your foot in your mouth...
"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"
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
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 laceration...one 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
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 geez...how weird
can things get???
Go to Archives
to View Past Entries.