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Jeff Hurley MD On Line Journal
Graduation Day:

On Line Journal

Wednesday, December 1: SCI

Turns out that some experiments in Korea have shown promise for stem cell to regenerate ...what I would presume to be the lower motor neuron. In Med School, we were taught about Wallerian degeneration and it seems to me that this would occur on the spinal cord and its dependent alpha motor neuron. Well it seems like there were able to demonstrate some results through the injection of stem cells. Looks like my initial impression of Spinal Cord Injuries and their potential repair was wrong (see my prior entries). ...I'm sure that patients in South Central could use some it since we see so many penetrating spinal cord injuries.

I'm still pretty skeptical for some of the other interventions such as treatments for cerebral palsy. ...But there are definite areas in which I'm actually shocked the progress of medical science has not advanced at at more rapid rate...such as in the treatment of diabetes ...after all its only Insulin!!!

Oh well, I'll stick to my original argument however, that this is not something that should be placed in a statewide proposition where only Californians end up footing the bill.

Tuesday, November 30: Pizza and Beer at Hurl's Place

UCLA versus USC on Saturday at my place...Woohoo...Go Bruins!

Yeah, our season hasn't been the best but a win hear would be like winning the lotto...and equally as likely...

Either way, I do have duct tape to tie up O'Neil if his team starts winning so it should be fun no matter what happens....

I'm taking beer requests, and wine cooler requests from Alwyn... :).

Monday, November 29: Sex in the City

According to HBO's "Sex in the City," the appropriate time to "get-over" a relationship is 1/2 the total time spent in that relationship. Yikes ...I'd have to hit 31 before I could start dating again??? Come on...

In relation to past relationships, I don't actually think that the term "get-over" applies to well. There are many lessons we learn from past relationships, and even though those relationships did fail that doesn't mean that we just "forget about it" like the words "get-over" imply. I think there is a happy middle ground where you realize that there were good things in past relationships and there were bad things is past relationships. Eventually, you come to the realization that the relationship wasn't working...but that doesn't mean you have to forget the good times...

I think a more appropriate term is to "move on". There is no point in dwelling about the past or imagining what could have been. Its only self-defeating and blocks you from moving into the future and creating the strong relationship that you desire. For me, I've decided to put the past behind and start searching for the important things in life that will make me and the ones I care about happy... Its time to lead the charge into the mouth of hell...(go read my October 24th entry)

Maybe all those past relationships are really there so that you do make mistakes and subsequently realize them. That way, future mistakes can be avoided and a stronger relationship with a future mate can be made. That is not to say that problems will not occur in the future ...relationships definitely are work...and you constantly have to think and reflect on them and make compromises.

My biggest fault in the past was my focus on education and career in that, unbeknownst to me, I neglected in some part my relationships and didn't devote enough attention to them to understand what was going on...the underlying hopes and desires, conflicts and pain...

That being said, I now can approach life better from this perspective...and find that woman that will make my heart flutter...fib and eventually go V-tach and asystole... :)

Saturday, November 27: "Think Outside the Box"

I've always liked the line "think-outside-the-box." I never really understood it ...Maybe because I'm "trapped-inside-the-box" and unable to think for myself....hmmmm...yeah, that's it! Nailed it right on the head!

Well the "think-outside-the-box" crowd is back and they are advocating the "Mileage Tax."

Basically, they believe that instead of taxing gas, the government should tax the number of miles that people drive. Here is the LA Times Article:

Tax motorists based on the number of miles they drive?

The concept is gaining currency among the think-outside-the-box crowd as a way to bolster sagging transportation coffers while eliminating the politically unpopular tax on gasoline. But it may be an idea that only a policy wonk could love.

--LA Times article here. (you'll have to log in)

Unbelieveable...These people are retarded! Maybe it should be changed to "think-your-way-out-of-a-paper-bag" crowd.

Alrighty... when you drive a car, the more you drive the more gas you burn and the more gas tax you pay. Therefore, the Gas Tax IS a "Mileage Tax" (unless you sit in idle all day). The gas tax therefore punishes people who either drive too much or drive gas guzzlers. Seems to me that that is exactly what type of tax the government should support. Something that encourages consumers to buy fuel efficient cars and live closer to work.

The only difference between the gas tax and the "Mileage Tax," is that the "Mileage Tax" taxes people who drive gas guzzlers less...and people who drive fuel efficient cars more (relative to the current scheme).

Another quote from the LA Times: "It's not an idea to be taken lightly," said Martin Wachs, director of the Institute for Transportation Studies at UC Berkeley. "It's revolutionary."

..."Revolutionary" my nut sack ...Stupid is more like it.

Imagine that instead of just upping the gas tax, they decide to add a "Mileage Tax." Then the government would have to create a whole new bureaucracy to monitor the system...Make sure every car has a GPS system, test it to make sure it works, ensure that the computer systems are all connected and link to the gas station, ...etc. Thus, the overhead to the collection of the tax is substantial (...and I'm sure GPS devices ain't that cheap either). ...and it doesn't even address the question about out of state vehicles. Meanwhile, the Gas Tax is a near perfect tax...easy to collect and virtually no overhead because it exists already!!!

...Which raises the question? What the hell is the point of the "Mileage Tax"? ...anybody???

I think the next time someone says "think-outside-the-box" I think I will just opt for experience, knowledge, logic and common sense...

Friday, November 26: Run Lola Run

Life is one big Run Lola Run ...eventually you'll get things right... :)

Thursday, November 25: Bryan Hurley

This kid is already out of control ...I think we need to get Dr. Phil involved with this one!

Launch the SlideShow

Thursday, November 25: Turkey Day

Giving thanks to Family and Friends. :)

...and the fact that there is only 7 more months left in residency!

...not giving thanks to MORE Kaizer paperwork. ...I hate paperwork and jumping though hoops.

Wednesday, November 24: Vioxx Redux

Well it turns out that maybe the entire class of selective COX-2 inhibitors may have problems--Read the article here. Seems like the risk of stroke and heart attack double when on these medications. Those finding are somewhat interesting in that we obviously have known the benefit of aspirin (a COX-1 and COX-2 irreversible inhibitor) and knocking out platelets to prevent stroke and heart attack. With the belief that COX-2 was more specific for inflammatory events, and COX-1 for platelet adhesion, it was logical that a COX-2 specific drug would therefore not be protective for stroke and heart attack. The shocking news is that while it is not turns out to be a pretty substantial risk! ...and the lawsuits have already started flying in, which is obviously not shocking.

But wait a second...the most common side effect of the common pain medications is in the NSAID class with GI bleeds. According to the article, 16,500 people die every year and there are 133,000 ER visits related to complications of aspirin and motrin. (If aspirin wasn't so old and generic, and it was still on patent, I would bet there would be huge lawsuits against that manufacturing pharmaceutical companies...)

Of course, the legal problem would be if the company knew about the complications and did not divulge that info. Then that would be criminal...but that's hard to prove, and even if they did that, it doesn't negate the fact that Vioxx may still be a good drug for people with pain.

It seems to me that if you are in pain, and you need pain relief, that the doctor should explain some of these risks and that you agree to assume them. Of course, as an ER doc our decision tree looks like this:

Drug Effectiveness Side-effects Legal Implications (Lawyer insinuations)
Tylenol Not really effective Rare lethal side effects if taken improperly "You didn't treat the patient's pain."
NSAIDS (motrin and aspirin class) Fairly effective GI bleeds "You didn't explain the risks of GI bleed enough."
COX-2 Very effective GI bleed unlikely, but increased risk of stroke and heart attack "You didn't explain the risks of stoke and heart attack clearly."
Opiods Very effective Addiction, decreased level of consciousness "The patient fell asleep at the wheel and killed those pedestrians because you gave too much!"

Either way, we are damned if you do and damned if you don't. I just love how the legal system treats doctors like criminals.

Side note: Barry Sears, author of The Zone Diet, wrote extensively about the prostaglandins and argued that consuming the right ones would be favorable for weight reduction, the control and inflammatory conditions, improve circulation (a prostacyclin function), and a bunch of other things..(I it too long ago). Overall, I think he was talking out of his ass, since he used his knowledge of biochemistry and basically explained what he wanted to explain to the layperson. Looking back he did make one argument (in his ridiculous attempt to say that aspirin is a bad drug... aspirin has saved more lives than anything else even with its complications) that stated if you grossly knock out the prostaglandin or leukotriene production, that there is greater production of "unfavorable" prostaglandins ...which is a plausible outcome. Based on the results with Vioxx, Sears may have a legitimate point (only on this point though!). If this is true, then not only is Vioxx problematic, Bextra and Celebrex would also be in jeopardy. If the problem is only with Vioxx, then its obviously a Vioxx problem.

Side note #2: Redux is Phen, in the famous Fen-Phen valvular lesions thingamajiger. A lot of "horizontally challenged" people were pissed off that Fen-Phen was removed from the market...its one of the few weight loss drug combos that was effective. Seems to me that some people are willing to take risks, and as long as people understand those risks and the cost to society is minimal (in that bad outcomes, are not shifted onto the public sector) that these should be options for people to make on an individual basis. Virtually every medical problem has a cost and benefit...its about time that patients start taking responsibility for assuming some of the risks and not shifting everything over into the legal arena. There is no such thing and no risk-free medicine...and bad things happen. Trust me, I'm a doc. :)

Tuesday, November 23: Executions

Yesterday, another young man of about 20 years old came into the trauma center having been shot in the top of the head. The bullet entry wound had significant blast effect to the skin indicating a very close range shot ...almost execution style. I took care of him in the NSICU where his ICP stayed at 40 irrespective of any intervention. The only questions I had... was his brainstem going to survive? Organ donor? Trach and PEG? or Herniation and death? Mannitol wasn't changing the outcome here...

Invariably we get at least 1 person shot to death a week and the most was 4 in one day (that was the night..whew, still remember that one!--seven patients in 30 minutes, 3 chest tubes, 2 thoracotomies, 3 went to the OR, one DOA, and one stable patient ...3 patients survived).

The first time I saw an execution style wound was during intern year ...a 16 year old male was shot directly on the vertex of the head...his body dumped in a field. I still remember sitting there just staring at the patient, wondering what the hell happened... The only thought that came to my head ..."the shell of a man."

A sad commentary on life in the inner city...

Click on the Image to the left to see the full graphic.

Monday, November 22: Smoked by the Evo VIII

EnlargeDriving down the 710 a few days ago, a modified Evo VIII zooms by ...probably going at least 100 mph. Some traffic eventually slows him down, and I catch him at the 270 degree interchange to the 405. For some odd reason he takes the outside lane... I'm going about 65 mph and drop it into 3rd gear ...I take him through the first half of the curve on the inside and then I hear a high pitch whine... as he drops his car into second and blows by. ...I got my revs up to 6500 but to no avail ...beaten by two car lengths... :( ...Of course I should have dropped mine to 2nd gear...but that would have been pretty damn harsh...(and I'm still babying my beemer).

That Evo VIII is one awesome car. Sure its not as sweet looking as the Performance Package 330i, but its got some awesome performance. Yeah, the STI is up there as well...but that is one ugly car... And who wants to drive on rails when you can get loose???

Addendum on Dec. 4th: I tried dropping the clutch down to second while going about 50 mph...revs went up to about 5500 (my revmatch was obviously not enough)...and with a redline of 6800, obviously I wouldn't be able to spend much time in that gear anyways... This is much different than my last car where I could hit 60 in second, and 90 in third...but not to different. This car has much more power so its just a harsh transition.... I still have yet to drop the clutch...

Criticisms on the Performance Package 330i: the car needs a limited slip differential ...I'd want the car to burn rubber when starting off fast and doing a rapid turn...Also it need a lighter flywheel...the rpm drop from 1st to 2nd gear is too slow and makes the match a tad bit more difficult...even with the lock valve removed from the clutch slave.

And on a final addendum note: If you ain't driving a stick... you ain't driving...

Sunday, November 21: Environmentalist?

I remember being called by a pollster prior to the election. They asked me if I was an which I replied, "everybody's an environmentalist." She was taken aback and asked, "well what do you mean?" I said, "I mean, everybody wants a healthy environment, the question is how much of a balance do you want from business growth versus protection of the environment." I think she was confused since she probably never thought about the issue in terms of a cost-benefit analysis.

That being said, I happened to listen to Rush Limbaugh the other day--which I try to avoid. (Prager is on at the same time on AM 870) He was talking about how big his SUV was and then subsequently played a song about the same thing. What an idiot! I hate the fact that he is the "voice" of the conservative party ...probably the same way people think about Michael Moore as being the "voice" for liberals--with the exception of the lunatic left. Obviously, Rush was alluding to personal freedom and free markets versus government intervention and regulation. I, however, happen to agree with many on the left concerning this issue and increased governmental intervention is needed.

First of all, we are too dependent on oil as our energy source. This creates problems as our economy is tied to the unstable totalitarian regimes of the Middle East. Price fluctuations, as we have recently seen, is a powerful force for inflation. Unfortunately, we have no other choice at this time, and creating a cheap substitute is just not on the horizon. Thus, we are at the mercy of factors largely outside of our control. If oil becomes too expensive, jobs and quality of life will be affected. Therefore, there is an indication for the government to intervene.

Second, there is a finite supply of the cheap energy source on this planet. Unless, we start to use it wisely and convert to alternative renewable sources, we will simply run out and future generations will be adversely affected. Therefore, government has a responsibility to not only account for the current state of affairs in the US but also for future generations (try to tell that to the AARP!).

Governmental intervention is the only way in which some reasonable middle ground can be reached where the cost of increased regulation are balanced by the benefit of decreased dependence on the commodity. The US currently consumes about 25% of the world market of oil. That's just huge! Trying to decrease that number by just a small amount would stabilize production versus demand, and hence, stabilize cost. ...and possibly preserve oil for future generations.

The primary way in which government can do this in the short term and the long term is to affect the fuel efficiency of vehicles. If we were able to convert vehicles though natural turn-over of cars to more efficient vehicles and away from SUVs, then we would actually decrease the amount of oil that we would consume, and thus the price on the world market would drop. Enough with the people who complaint about filling up their cars or getting cheap gas is some God-given right. ...Get a more fuel efficient car.

Government could do this through a few different ways. 1) Mandate to car manufacturers a MPG rating or 2) Graduated taxes on vehicles as their fuel-inefficency increased. I like the second one since there is still a market based approach.

However, when it has come to the government chiming in on this issue, they invariably approach it in the wrong way. Instead of looking at gasoline from the consumption side, then look at the output side in terms of pollution. California is obviously well known for this by regulating emissions. Sure you can have low emissions, but when you are still burning a ton of gas and driving a gas guzzler you still will pollute the environment and of course consume too much gas. ...Its almost exactly like the carpool lane.

If government was smart, they would try to affect the production of more fuel efficient cars and hence affect the supply of gasoline. Of course, that would have to meet the approval of the public voting the politicians in, and in that way, with so many people voting for Bush and Kerry (depending on how you want to look at it), there are just too many dumb people for a rational approach to gasoline consumption to be realized. ....people on the far right driving gas guzzling SUVs like Rush, or, to use Rush's term, "environmental wackos" demanding cars that burn gas without pollution. ...Take a pick on who is dumber... I'll abstain...

Saturday, November 20: Counterintuitive

The Carpool Lane: Many people believe that the carpool lane actually is good for the environment and improves traffic. Nothing could be further from the truth.

1: Only a tiny percentage of people use the car pool lane. Why? The time saved in the carpool lane is spent in travel to pick up and drop off co-workers. Thus, here is no time saving unless the commute is a far one ...and who lives very far from work, yet is close to co-workers? There is a loss of freedom and flexibility when you have to rely on other people. People's lives are extremely complex with both parents working and children with transportation needs as well. That loss of freedom is something that many Americans are not willing to part with. The cost of gas still remains pretty low..(as I like to say, still less than a gallon of gatorade)..even though we have yet to steal all that oil in Iraq. Therefore, very few cars are removed from the freeways.

2: A study was done that looked at freeway speeds with a carpool lane and without a carpool lane. The results: 1) Speeds increased by about 30 miles per hour. 2) Rush hour started 1 hour later than normal. Therefore, the carpool lane is self-defeating for almost everyone.

3. If there are virtually no fewer cars on the road, and the time spent in traffic is substantially increased, then the amount of gas burned actually increases. Getting from point A to point B going 10 miles per hour and with lots of idle time burns a lot more than 40 miles per hour with a few more cars. Therefore, the carpool lane is actually more damaging to the environment.

4. In terms of safety, having a lane that is going very fast next to a slower lane probably has led to more car accidents than two lanes going similar speeds. Also with a larger road, drivers can maintain more distance from other drivers thus increasing safety if the carpool lanes was open to everyone.

So why do carpool lanes still exist. Reality to some people is less important than ideology.

...also federal funding for road construction is tied to the carpool lane, and who wants to eliminate it and appear like an evil "anti-environmentist"???

...although, New Jersey was successful in getting an exemption by the feds and has eliminated carpool lanes...

Friday, November 19: Bush, Greenspan, and other Gremlins

Bush and his "Mandate?" You've got to be kidding! Half of America hates Bush, and if he goes stronger as a conservative, it will just make it more likely that a big shift of power could occur on the next election, just as it did in 1994 when Clinton virtually lost all ability to get any of his programs through. Bush has to be extremely careful not to place Supreme Court Justices that want to reverse Roe v. Wade. That move would probably alienate the majority of moderates in the US. I think he actually is cognizant of this fact is appointing more socially moderate about that for strategery? :)

The Republicans and their spending is out of control ...where the hell is fiscal responsibility? The only thing fiscally sound is that the Democrats are not in office spending more than the Republicans.

...However...its a big power struggle...if the Republicans don't spend it and make a huge deficit ...there would be no rationality to try and contain entitlement spending (almost an indirect attack on the "money supply"). Its almost as if they are forced to spend more so that spending in other fields doesn't increase. I guess I'd rather have a deficit with money spent on project that are conservative based as opposed to the same, if not larger deficits with greater entitlement expenditures. Of course, Friedman would argue that deficits are not the problem and the growth is the answer...but how much more productivity gains can we still squeeze out?

Greenspan said today that the trade deficit and fiscal deficit could be a future burden to the economy. Of course, fixing the trade deficit would violate WTO policies, and the fiscal deficit only is likely to get worse as our pyramid gets more top heavy.

Basically, in reference to the trade deficit, foreign investors may pull their money out of the US causing a sharp fall in stocks bonds and leading to higher inflation. Its a very odd fact that half of US securities are held by foreigners.

The CPI (consumer price index) rose 0.6% while the PPI (producer) rose 1.6%. Sure some inflation fears were abated with the CPI being less than the PPI...but the real question looms: is this a a cost-push inflationary pressure? With the surge in energy prices, and the obvious PPI jump, I think that this may be the case, I can't see how it could be demand driven. Cost push inflation as opposed to demand pull inflation is a stronger inflationary pressure and has actually lead in the past to deflation. And deflation is probably the most destabilizing economic crisis that we know of. (read here on the spiraling demise of deflation).

Wednesday, November 17: Quote of the Day

"Have you ever looked at an ape? They have no buns." states Dennis Bramble. Thus explaining that the difference between humans and apes is that humans were designed to run. Huh? My ass! Humans were designed to sit on the couch, drink beer, eat pizza, and watch football!

"If natural selection did not favour running, the scientists believe humans would still look a lot like apes."

Question: Have you looked at your butt in the mirror lately?

Oh shit.. ..I think I need to go for a run... :)

"Humans were born to run" article here.

Tuesday, November 16: Read 'em an weep, the dead man's hand again.

Margaret Hassan, a 59 year old woman and director of Care International who was dedicated to helping Iraqis for the last 30 some odd years, was found the other day in the street with her throat slashed, and her arms and legs cut off. Badly beaten, her identity has yet to be confirmed. Murdering one of the few people that was willing to help the Iraqis...unbelieveable.

The news media calls these people enemy combatants, resistance fighters, or insurgent forces. Why don't you call a spade a spade? Or does the word "terrorist" just have too negative a connotation and adversely affects self-esteem? After all, we don't want to offend the sensibilities of the fanatical.

Ronald Reagan gave his famous, "Evil Empire" speech against the objections of virtually everyone on his staff. If anything, we need more clarity of definitions and more clarity of convictions. Instead of "wrong war, wrong place, and wrong time," maybe people will see that ridding the world of these people is actually a good thing.

The "dead man's hand" is Aces and Eights, two pairs.

Tuesday, November 16: WebPage Overhaul

I just completed the redesign of the internal workings of the webpage. ...Its actually not that hard. Yeah, it looks the same...but I had to get rid of all the crap that was hidden beneath it. Now my links actually work and I have figured out how to do a picture slideshow in javascript. Designing and creating a webpage is actually pretty enjoyable once you figure out some of the basics.

Monday, November 15: Putting the "F" back into Freedom

"We've lost all intelligence, we have no intelligence." Ha! Team America was one awesome movie. I was expecting another Michael Moore bash America movie but I was pleasantly surprised. ...especially coming from the creators of South Park ...which I can't stand since it is so moronic.

I loved how they lambasted the actors in Hollywood. Of all the things that I don't like, actors and their lame ass opinions has got to be near the top. Why Americans listen to these buffoons is beyond me. Of course, I still don't understand the fascination with other people's lives who you don't even know and are so inconsequential.

Turns out that the following actors promised to leave the US if Bush was elected: Alec Baldwin, Rosie O'Donnell, Ed Asner, Whoopi Goldberg, Cher, Phil Donahue, Rob Reiner, Barbara Streisand, Jane Fonda, and Danny Glover.

Why make a stupid statement like that? Like its a veiled threat that we could lose the wit and charm of Rosie in the US? Blow it out your ass!

Sunday, November 14: Code Blue Story

One of my most memorable code blues came during the end of my first year. Working in the critical area of the emergency department, I signed on at 7 pm and assumed care of a 40ish year old man. He had just came into the ER complaining of shortness of breath and chest pain only a couple hours before. The patient was in obvious septic shock, and rapidly decompensated despite all interventions. The patient was intubated just prior to my shift.

The chest x-ray on this patient showed bilateral severe pneumonia, lab work demonstrated that he was bandemic and azotemic. Despite 4 liters of normal saline and both levophed and dopamine, his pressure would not come up and he had no urine output. The patient had an ABG which showed a severe acidemia, and a PaO2 of 60 despite 100% FiO2! Yikes!, I thought...ARDS (acute respiratory distress syndrome) is just not one of those diagnoses you make for a patient who walks into your emergency room. I proceeded to place a central line and put my seeker needle to the side. After completing the procedure, I looked over at the needle and the blood left in the needle had separated out. The bottom layer was obviously red from the red blood cells, but the serum was GREEN! I had never seen that before. Obviously, we knew which bug we were up against--Pseudomonas aeroginosa. Crap, may as well throw in the towel now.

But we have a great axiom in the ED..."don't let people die in your ER." So I worked tirelessly to get this patient into an ICU and a bed became available in a few hours. Meanwhile I had the patient on 20 of Levo, and 30 of Dopa. Has anyone seen a patient survive with that level of pressor support??? ...not I.

Anyways, I was getting the patient ready for transfer upstairs. Virtually everything we could have done had been done. As we were moving the pumps to the gurney, both the Levo and Dopa got air in the lines--stopping the pumps temporarily until we we able to clear them. The patient, who was originally at 150 on the heart rate rapidly dropped down to 120. The nurse asked me if I wanted to abort the transfer. ...I said no. We got the pumps working again, and started moving the patient through the ER. I looked at the monitor and the patient was still at 120 even after a restart of the pressors. "Oh shit" I thought ...this might be an interesting transfer. So I called over to Dr. Brutscher for some help with the transfer, to which he happily replied with his ever so happiness. (Nothing gets Brutscher down--he's a great guy)

So we were out of the ER and moving. Brutscher subsequently looks at the cardiac monitor and notes the rate to be about 110 and says... "hmm, I don't see any P-waves."

...moving a little quicker, we get to the elevator, and get in. I look at the monitor and the heart rate was 100. At the top, of the elevator ride the monitor is now showing 100. I look at the monitor, and say... "hmmm, that QRS looks wide." The elevator doors open and we get out...the monitor is now showing 90.

...running now at virtually full speed with the gurney, we get to the front of the telemetry floor. The monitor now shows 80... "oh fuck" was the only thing I could think of--we knew it was imminent. We get the doors open and watch the rate drop to 60. 100 feet left to go to get to the ICU ...we're pushing...

We make the final turn, and BAM! the patient goes straight to asystole. I open up the door to the ICU and Yell..."get the crash cart!"

The nurses respond with..."ahh no, you've got to be kidding..." In their ever present and actively paralyzed state, I run over to the crash cart and rip it open. I find bicarb, and push it in, I next find D50 and push that in, and bark some orders for Insulin, I next find epinephrine and push that, and finally I find the first drug I should have had, calcium chloride, and push it as well. We're bagging the patient and doing CPR and eventually get his heart rate going again...back at 150. Whew...

"Holy shit" I thought. "...that was one whacked out transfer."

I got back down to the ER to continue working on my 4 other critically ill patients. Overhead, in the next 2 hours, there were 4 code blues called...and the patient eventually passed away.

...This is one case that I will never forget...

Friday, November 12: Veteran's Day (albeit yesterday)

I often have a revolving debate in my head on who is the most influential people in my life with the exception of parents ...obviously they are most influential because they deal with your internal interaction with life. But I'm talking about external forces and those that have shaped your belief system and ideology. One person that comes to mind is Pat Tillman.

Society in general has moved away from asking questions about life from the perspective of right and wrong. Instead, people look at life from the perspective of fairness or equality. The problem with this perspective is that one person's equality is not fair to the next person, and the other person's fairness does not equal equality for others. Therefore, virtually every social issue can be manipulated to have the desired policy outcome. Trying to decide right and wrong and its inherent costs and benefits is what makes life challenging. In fact, I'll be the first to admit that answering questions from this perspective is a difficult endeavor.

Tillman was one of those people who put the question of right and wrong ahead of everything else, even with the costs so high. He is a true American.

"War is an ugly thing, but not the ugliest of things. The person who has nothing for which he is willing to fight, nothing which is more important than his own personal safety, is a miserable creature and has no chance of being free unless made and kept so by the exertions of better men than himself" -- John Stuart Mill

On another note: Special Veteran's Day notice to WWII vet Grandpa Hurley at the age of 93. Grandpa Hurley was apart of the team that cracked the Japanese code and he subsequently went on to fight in the pacific theatre and receive a purple heart for his struggles. He later served out the rest of his military career in Germany as part of the intelligence community. We are all grateful.

Thursday, November 11: Reasonable Doubt

During my intern year, I was called into court to testify as a material witness. The case involved a young man who happened to be using a little bit of the PCP and crashed his car into a parked car. I still don't know the full story, but he may have been trying to evade police. (You don't get to hear the testimony of other witnesses when you are a witness yourself.) Anyways, the patient was brought into the ER by the police and was essentially catatonic (lack of facial expression, words, and behaving paranoid--common reactions to the "Angel Dust") and exhibiting a sympathetic toxidrome (tachycardia, hypertension, sweating, and a low grade temperature). We got some simple stuff to perform a medical clearance... urine toxicology screen and an accucheck, and observed him over the course of about 4 hours. During this time the patient became less catatonic, more verbal and elusive in his "explanation" of what happened.

The court proceedings were ridiculous. I was called into court 3 DAYS IN A ROW! To do what? Tell the jury that a clinical encounter consistent with PCP, and improvement consistent with the time frame of PCP intoxication, and a positive urine screen was likely due to PCP???

Great questions I was asked:

  • "How long have you been a doctor?" which I replied "8 days." :)
  • "How many times have you seen PCP intoxication prior to this episode? ..."once"
  • "How many times have you seen PCP intoxication now in your career?" ..."about 20 times, and looking back, I am more certain that the diagnosis that I came to was correct" (The public defender didn't like that one.)
  • "Is it possible that the patient's behavior could have been due to schizophrenia?" ..."no, schizophrenia doesn't get better all by itself".
  • "You stated earlier that Altered Level of Consciousness may be due to either medical or even surgical conditions. Did you do anything to make sure that a medical or surgical condition was not present?" (my internal response in my head..."damn you're a dumbass") ...but after a long winded explanation I essentially stated "well, the patient is here and no medical or surgical condition has since been identified. Therefore, when I see a patient that has a clinical presentation consistent with PCP, clinical improvement consistent with PCP, and a urine toxicology screen positive for PCP, my diagnosis is PCP intoxication." (this was like the third time that I said that too, but the public defender was pretty dense to realize that another question like that was only going to dig himself a larger hole.)

Obviously, the attack on my credentials was counterproductive, so the public defender next goes to step 2 of how to defend criminals--"who collected and took the sample up to the lab?" Unbelievable, so you can't argue innocence ...I mean, reasonable doubt....any other way, so now you have to attack the "evidence collection technique"? Public defender: "Did you observe the patient urinate?" ...umm, "no, ...I try to avoid watching patients pee." --the jury liked that one.

The ridiculous thing about this whole affair was that it took 3 days, every 15 minutes another juror had to use the bathroom, and every ten minutes there was a side bar. One juror feigned illness to get back to college. 15 people had to take a week out of their lives for a driving under a controlled substance offense (which is worse that a DUI). The judge was pulling out his hair. And I sat there wasting time on a case that should have pleaded guilty to out of court for a lesser penalty.

Anyways, I got into a discussion the other day about reasonable doubt. Here is the definition:

REASONABLE DOUBT - The level of certainty a juror must have to find a defendant guilty of a crime. A real doubt, based upon reason and common sense after careful and impartial consideration of all the evidence, or lack of evidence, in a case. Proof beyond a reasonable doubt, therefore, is proof of such a convincing character that you would be willing to rely and act upon it without hesitation in the most important of your own affairs. However, it does not mean an absolute certainty.

In the case of Scott Peterson, there may be doubt that is reasonable...In fact there may be doubt about every crime ever committed. Maybe Joe Blow has an evil twin? Is it possible? Sure, but is it reasonable? Maybe...but that is not the definition. The definition is that of doubt that is reasonable in the context of all other information. So even if one little piece of data may be difficult to place in a case, that does not mean that you throw out the rest of the body of evidence. Unfortunately, many jurors are just not smart enough to understand such a concept.

Also, you end up selecting 12 people who (given the election results on how divided we are as a nation) will eventually have one or two people who are opposed to punishment that may involve the death penalty. These people have no problem letting a murderer go free lest they themselves send someone to Old Sparky (the origin of "judicial lightning").

In my opinion, this guy is the most guilty person ever. What reasonable evidence exists that does not point to Scott Peterson? And, yes, people have been convicted on circumstantial evidence.

The jury system is broken. Its time to move to a professional jury system that understands the law, that incorporates maybe 3 people--maybe judges, and is capable of handling information in a timely manner---not like a ridiculous 6 month trial at the cost of a few million dollars. There is no point to have 12 people. The more people on the jury, the more likely you are to get a fruitcake who will be opposed to even giving the guy a spanking.

Yikes...that took too long. ...for an uplifting song... list to Metallica's "Ride the Lightning"

Tuesday, November 9: Congratulation and Thanks

Congratulations are in order for a good friend of mine, Ryan Hines. Hines already got a job in North Carolina upon completion of residency. It's got to be an awesome feeling... All I have to say, is that he is a rat bastard for leaving...I'll miss him a bunch.

Unfortunately, I've been pretty unlucky...all my best friends: Thomas Sprinkle, Kai Bickenbach, Todd Otten, Jeff Janowicz, Dan Buerkel, Ron Thies, Chand Anne, Chris Port, and Dave Freccero live outside of California. I really do miss them a lot. Hines is another truly a great guy and good friend and I will surely miss him. ...Hines, we've got some golfing to do this month...and I'll have to smoke you again for like the second time! Watch out for my long game, because its the only game I got...

By the way, Congratulations to Kai and Niki whose wedding I was at last May, and Todd and Angie who recently had their first kido. I'd better give Buerkel a call, I'm sure he is going to be doing Cardiology at U of M next that guy scored like 99% on everything is just beyond me...

Also, special thanks to my attendings Dr. Kahsai, Dr. Kare, and Dr. Sniederman for writing me letters of recommendation to Kaizer. These attendings are great people each with great attributes to which I aspire my future ER practice to be like. Sniederman for his dedication and support, Kahsai for his personal perspective and insights, and Kare...well... how about, Kare for his ability to get his car sideways and his love of Iron Maiden... :) (just kidding, Kare for his direction and his friendship).

Monday, November 8: Stem Cell Addendum

Well, the LA Times business section had an article yesterday in reference to the Stem Cell Research "Stem Cell Firms Bet on Big Payoff". It looks like the large and small pharmaceutical companies will be reaping the rewards of this bill. What will happen when one of these private companies develops a drug or a potential cell line with therapeutic potential at taxpayer expense? Will they give it back to the people who foot the bill? Unlikely.

Anyways, it seems like the majority of people who voted for the proposition didn't know that they were throwing money into the pockets of corporations and venture capitalists. Funny how the left argues against corporate welfare, but ends up voting for it. ...and ain't it nice to have a bunch of uninformed people decide fiscal policy???

Monday, November 8: The Economy and Jobs

Another interesting article in the LA Times (I think it was in the opinion section) was that on the economy, jobs, and the election. Of course the spin from the left was that people voted their morals if they voted for Bush, versus voting for what... Reason??? if they voted for Kerry. Well the funny thing about this article was that they essentially stated the fiscal policy by the federal government had minimal impact on jobs since the major factors that dictated jobs was the global economy, trade agreements, and the business cycle. Essentially, the economy and the employment rate runs irrespective of what happens in D.C. This is something that people who have understood fiscal versus monetary policy have known for a long time.

I liked this article because maybe it explains to a better extent why people didn't vote for Kerry. Either 1) Kerry is a Keynesian economist and practices a policy that has been largely discredited (The era of Keynesian economics in over, Monetary Policy...and if you don't believe me read an excerpt of JFK speech below) or 2) Kerry was lying to the American people about his ability to affect the economy with fiscal policy.

I, of course, assumed the later. Kerry did promise so much during the campaign that the estimated increase in the size of the federal government was about 2 trillion dollars. Now how about that for a reason not to vote for Kerry? Sure you may have differences about the Iraq war or need for the French to approve of our actions, or maybe even legitimate social issues such as civil unions and abortion. But I would argue that people still vote their pocket book and didn't want higher taxes (except for Californians). If anything, I would argue that there was more "reason" not to vote for Kerry. ..unless you believe in more lawyers, laws, taxes, and a security council veto over America is a good thing.

Side note: Was JFK a conservative? or a monetary policy advocate? Read this: (doesn't he sound like a conservative) Full speech here--and you can listen to it in full audio! (I found this to be nerdy can you get?)

"The final and best means of strengthening demand among consumers and business is to reduce the burden on private income and the deterrents to private initiative which are imposed by our present tax system — and this administration pledged itself last summer to an across-the-board, top-to-bottom cut in personal and corporate income taxes to be enacted and become effective in 1963.

"I'm not talking about a "quickie" or a temporary tax cut, which would be more appropriate if a recession were imminent. Nor am I talking about giving the economy a mere shot in the arm, to ease some temporary complaint. I am talking about the accumulated evidence of the last five years that our present tax system, developed as it was, in good part, during World War II to restrain growth, exerts too heavy a drag on growth in peace time; that it siphons out of the private economy too large a share of personal and business purchasing power; that it reduces the financial incenitives [sic] for personal effort, investment, and risk-taking. In short, to increase demand and lift the economy, the federal government's most useful role is not to rush into a program of excessive increases in public expenditures, but to expand the incentives and opportunities for private expenditures.

Side note: Biography on the most influential economist of our time: Milton Friedman, the father of Monetary Policy.

Sunday, November 7: The Myth of Sisyphus

Tartarus, the lowest level of the underworld, was where the wicked souls were sent to serve punishment from the Gods. Sisyphus, known for his cunning ability and his wisdom, was one of its inhabitants. Having betrayed Zeus, Sisyphus was sent to the underworld only to trick Hades in showing him how handcuffs worked and slapping them shut when Hades demonstrated them. With Hades chained, no one on earth could die, infuriating the Gods. Hades then summoned the God of War to liberate death.

Sisyphus' disrespect for the Gods landed him the delusive task of rolling a stone bolder up a mountain only for it to roll back down eternally. " [there] no more dreadful punishment than futile and hopeless labor."

To me, the seven years of medical school and residency have seemed like that eternal task where hard work and perseverance can often drown out other aspects of life. Fortunately, there are events that challenge you and make you remember the important things in life. One of events occurred recently, and I can only be thankful that I am now more aware.

Read here an essay on the Myth of Sisyphus.

"The struggle itself toward the heights is enough to fill a man's heart"
--Albert Camus

Saturday, November 6: "The Father of Modern Terrorism"

Arafat, the founder of the PLO and often referred to as the "Father of Modern Terrorism", appears to be on his death bed. Of course the country that ran to his aid would be none other than France. What else would you expect from the frogs?

In my opinion, the world is really messed up. This is the man who received the Nobel Peace Prize, for what ...starting up the intifada? I'm not completely shocked ...after all, the United Nations elected North Korea to head the Human Rights committee. That is akin to making Josef Mengele the hospital director of medical ethics. (Mengele was fondly referred to as the "Angel of Death")

The interesting aspect about this story, which I was unaware of until just a few days ago, is that during his career, western news agencies would show him speaking against terrorism and suicide bombings while at the same time arabic news would show him praising the actions of martyrs and preaching the destruction of Israel.

It turns out that this is a common practice... Remember "Baghdad Bob", the guy who wanted to slap everyone with his shoe? He was the guy made famous because he claimed that "There are no American infidels in Baghdad. Never!". Meanwhile in the background, there were American tanks rolling around. "I triple guarantee you, there are no American soldiers in Baghdad"...I like that triple guarantee...when two just doesn't cut it...

Well, the same thing occurred again in the Arafat case. France and Israel were stating that he was in a coma and on life support. The arabic news agencies interviewed some leaders in Arafat's organization who claimed this was all lies and that Arafat was not on life support and that he was still leading the PLO. Unbelievable...

Anyways, Arafat's net worth is estimated to be anywhere from 300 million to 4 billion dollars. Meanwhile, virtually everybody in the West Bank and Gaza is dirt poor. Now that, in my opinion, is worth another Nobel Peace Prize. Either that or he should get the Nobel Prize for physics for inventing the suicide bomber...(special thanks to Bill Handel for that last line).

Side note: "Baghdad Bob" eventually committed suicide. His famous sayings here.

Thursday, November 4: "The Blue Team"

A few days ago, on election day November 2nd, its 5 am with 2 hours left on my shift ...completing about 110 hours of work over the last ten days ...I'm cruising along. I've got November virtually off with the exception of volunteer moonlighting shifts and the free clinic. I'm jazzed.

Over in the corner, I noticed a slightly tearful girl. I went over to see how things were going and try to cheer her up. The 8 year old had sustained a both bone forearm fracture from a fall while using the her bed as a trampoline (where is OSHA when you need them?). Initially when she came in she was in a ton of pain. We gave her some morphine and then opted to do some conscious sedation using Ketamine. The whole process of placing the cast went smoothly by the orthopedic surgeon and the intern. It seemed to me that everything should have been getting better for the girl. I proceed to ask her what was going on:

Me: "Hey, what's wrong?"
Girl : "I'm upset, I'm going to miss school"
Me: (semi-shocked) "Oh don't worry, you'll be back in no time."
Girl : "No, you don't understand ...I'm going to miss the election."
Me: (shocked and amazed) "Oh really, who you votin for?"
Girl : "The Blue Team"
Me: (wiggin out) "The blue team? who's that?"
Girl : "Its where we watch the states turn blue"
Me: "Yeah, but who's that."
Girl : (looking at her mom) "Its uhh, um, John Kerry!!!"
Me: (feeling dejected) " mean George Bush and the red team..."
Girl : "No, John Kerry, the blue team"

No matter how amusing and entertaining, I was actually disappointed in that an 8 year old was so concerned about such an event. Isn't childhood about having fun, while at the same time learning about the world? How did political ideas get so deeply planted in this girl's head. I don't think I was even aware of politics at that age. I read the LA Times daily when I was in high school, but the development of an ideology and an understanding took much longer. I could only rationalize this as the emergence reaction from Ketamine withdrawal. (...unique effects of dissociation, patients undergoing ketamine sedation experience a sense of semiconscious bodily detachment as they awaken) :)

In all seriousness though, the classroom should not be used to espouse your ideology on your pupils. The job of the teacher, and especially at this age isn't to tell your students that the republicans are "evil", its to teach them to reed, wright, do mathe and spell stuf. Especially in Los Angeles, where illiteracy runs rampant...

Maybe you actually agree with the above teacher, and educating kids on the election process is a good idea (never happened in any of my classes when I was growing up). If that's the case, then imagine if you were a liberal and your child's teacher was Bill O'Reily. Then it would not be okay??? Ahhh, I see how things are......

Side Note: the second graphic represents the breakdown by counties ...interesting little map...

Monday, November 1: BLS BS

Alrighty, ...for those who don't know...BLS equals basic life support (EMTs not paramedics), and BS stands for, well, BS.

A 30ish year old man arrives via BLS with a chief complaint of abdominal pain after "drunk and fell of his bike". Supposedly he had a "screwdriver" in his pocket and he subsequently "has a puncture wound to his left flank." (this is what I was told by the EMTs)

I went over to the patient and attempted to get a history...It sounded like this:

Me: "What happened sir?"
Pt: "ahhhh"
Me: "Come on sir, tell me what happened?"
Pt: "arrrggg"

So getting a history was futile and I had other patients to see. Obviously, this guy was intoxicated and possibly on I thought, lets move on to the physical exam. I proceed to press on his belly and not only did I get rigidity, rebound and guarding, I also got proptosis...his eyes bulged out like none that I have seen before! Hah, I just coined a new physical exam finding. the way, there was a small puncture wound in his left flank.

But I was does someone get peritonitis so quickly from a screwdriver puncture? So I looked at his vital sheet which was all normal (afebrile, heart rate 65). "Crap" I thought, I better just buck up and start antibiotics, order an imaging study (CT Abdomen/Pelvis), and call the trauma surgeon. Anyway, the trauma PA comes down to the ER. After spending about 10 minutes with the patient he comes out and tells me that he thinks the patient may have been shot with a "BB gun" while riding his bicycle.

My response was at first "huh???" ...and then, "oh shit, maybe this guy was shot???" (but not with a BB gun---which probably wouldn't do much--maybe a real gun). So I promptly moved the patient over to x-ray and had them shoot a KUB (basically an x-ray of the belly). Sure enough, there sat a bullet in his belly, sitting right there on the RIGHT side!!! The thing crossed the midline!

The weirdness doesn't stop there. So two attending trauma surgeons come down to evaluate the patient. One has the insight to say "we are just consultants". Huh??? The guy has abdominal pain and a fricking bullet in his belly...congratulations...its now your patient. The other one orders a cross-table lateral (which I have no problem with) but then proceeds to state that he wasn't going to operate on the patient until a CT was performed that showed he had bowel injury. Isn't that what ridigity, guarding, and rebound tell you??? Unbelievable. Next he wants to bet me that the patient doesn't need an operation! How professional is that? Betting on patients? I refused since you can only lose doing that, especially since he was the surgeon.

Ultimately, the CT of the belly showed free fluid (crap)and a ton of free air. The patient had a huge hole in his colon and subsequently a convenient colostomy was placed after a nice washout of the belly.

Moral of the story: Wacky shit happens at K^%&.

Sunday, October 31: The Deulfer Report

One of the most interesting stories of our lifetime will be that of Saddam Hussein and Iraq. Not only for its political implications, but because of the changing dynamics in the world and its global impact.

I first read Sun Tzu's Art of War in High School and have tried to approach conflict/debate by understanding the other person's viewpoint. This way to interpret life and its interactions, for me, has proven to be one of the most effective ways in how I interact with other people. However, when I thought about Iraq and Saddam I grossly failed..and everyone else did. Maybe it is more a lesson in Game Theory that can be drawn from these conclusions. But one thing is for certain, this has to be the most interesting story that I have ever come across in my lifetime.

I first alluded to the America's plan for containment in the middle east in a previous entry, which will probably be viewed retrospective as a very effective policy. This plan was effective because we understood the psyche of the two nations (Iran and Iraq) and we adapted to changes in that region (fall of the Shah) extremely well.

When it came to Saddam, however, we all got it wrong. Our interpretations based on Saddam's violent history lead CIA analysts to believe that if Saddam ordered the development of WMDs, that any failure would lead to the torture/killing of those who failed in his demands. Therefore, our belief was that an active WMDs program was still under development. The observation that Iraq continually violated 17 UN resolutions for 12 years and was blocking inspections of facilities by the IAEA and UN inspectors supported this belief. Logically, why would you try to conceal weapons if you didn't have them? It makes absolutely no sense.

The ultimate reason for with was that Saddam believed that in order for him to survive he HAD to have the APPEARANCE of having weapons of mass destruction. Two reasons for this:

In Saddam’s view, WMD helped to save the Regime multiple times. He believed that during the Iran-Iraq war chemical weapons had halted Iranian ground offensives and that ballistic missile attacks on Tehran had broken its political will. Similarly, during Desert Storm, Saddam believed WMD had deterred Coalition Forces from pressing their attack beyond the goal of freeing Kuwait. WMD had even played a role in crushing the Shi’a revolt in the south following the 1991 cease-fire. (CIA Report)

In addition, Saddam viewed Iran as his greatest enemy in the region and did not believe that the US had the stomach to attack Iraq and oppose the UN Security Council. After all, we had been compliant with the UN during the first Gulf War, and we were struggling to get a coalition/UN support for enforcement of existing UN resolutions (which included 1441--use of force if Saddam was non-compliant). Thus, Saddam believed that by saying he had WMDs, he could deter not only the US but also that of his greatest perceived enemy, Iran.

Saddam was also extremely astute politically on the global arena. Through the Oil for Food Program, he was effective at diverting profits from oil sales and bribing foreign leaders, especially France, Russia, and China. These monies were directly placed into the personal coffers of these political leaders--unbeliable...3 members of the Security Council absolutely bought and sold by Saddam. Again, here is the condensed CIA report:

  • Saddam’s primary goal from 1991 to 2003 was to have UN sanctions lifted, while maintaining the security of the Regime. He sought to balance the need to cooperate with UN inspections—to gain support for lifting sanctions—with his intention to preserve Iraq’s intellectual capital for WMD with a minimum of foreign intrusiveness and loss of face. Indeed, this remained the goal to the end of the Regime, as the starting of any WMD program, conspicuous or otherwise, risked undoing the progress achieved in eroding sanctions and jeopardizing a political end to the embargo and international monitoring.
  • The introduction of the Oil-For-Food program (OFF) in late 1996 was a key turning point for the Regime. OFF rescued Baghdad’s economy from a terminal decline created by sanctions. The Regime quickly came to see that OFF could be corrupted to acquire foreign exchange both to further undermine sanctions and to provide the means to enhance dual-use infrastructure and potential WMD-related development.
  • By 2000-2001, Saddam had managed to mitigate many of the effects of sanctions and undermine their international support. Iraq was within striking distance of a de facto end to the sanctions regime, both in terms of oil exports and the trade embargo, by the end of 1999.

Instead of us believing that Saddam was being told that had WMDs from his generals, and that Saddam legitimately believed he had them, it appears that Saddam knew he didn't have WMDs but opted to lie and say that he did. Saddam's Game Theory was that lying about having weapons of mass destruction would avert an invasion from either Iran or from the US. How wrong could he be!

One of the more interesting aspects about this whole process was the Oil-For-Food Scandal. It turns out that foreign leaders who opposed the US, did so because Saddam was paying them. Chirac's cronies were given money, Putin got the money direct-deposited, and China received a chunk of change as well. Read an analysis just mind-boggling!!!

"Saddam's clever manipulation of the voucher system was a brilliant success,” to the extent that, according to Deulfer, “sitting members of the Security Council were actively violating resolutions passed by the Security Council.”

Its funny how some people in our nation, such as Michael Moore, believe that the US is the great evil. How do you reconcile the fact that the US operated on a moral ground and that every other nation that opposed the US did so because they were bought and sold by oil. How funny is that?

The contents of the Duelfer Report. Here is the analysis by the Heritage Foundation on the oil for food scandal. If you don't believe a conservative webpage, then read the article directly from the CIA (pdf file).

Saturday, October 31: Prop 66 - The Attempt to Reverse the 3 Strikes Law

This has to be the litmus test for stupid people. It is a carefully crafted proposition to gut the 3-strikes law. Claiming to "fix" the law, it allows repeat violent criminals who obtained their 3rd strike while doing something that was deemed not violent (such as robbery) a free pass out of prison.

When criminals are convicted for 3 crimes and the first 2 happened to be for violent crimes, I don't care if the third conviction was for stealing candy from a baby, these people belong in jail. If you argue that these people should be out of prison, then why don't you "rehab" them in your house. I don't want them anywhere near me. Not to mention the fact that the average criminal will commit about 10 crimes before they are caught and convicted on one crime. These 3-strikers are career criminals. Statistics show that something like 80% of all crime is committed by about 10% of the criminals. The three strikes law is the way to close the door on these career criminals. After all, Al Capone was finally caught on evading taxes and not on organized crime and murder.

In my opinion, I think the 3 strikes law should apply to non-violent felonies as well. If you commit 3 felonies, what would be the rational to keep these people out of prison? They will finally learn their lesson after 4 felonies convictions? Prop 66 - opposed by every law enforcement group.

Saturday, October 30: Stem Cell Research Disingenuous

Proposition 71 is the biggest fraud on the ballot. Sponsored by the large pharmaceutical corporations, it simply provides for funding of stem cell research and doesn't change the laws on stem cell research like the debate on the nation forum. In essence, it is corporate welfare on the back of emotional issues in an attempt to fool voters into giving money to corporations. If the prospect of cures for diseases exists, then academic and the private entities should go about their research in normal fashion. Why do they need to go to the general public?

I liked the commercial about the guy with cerebral palsy who argued in favor for stem cell research. Do you really think that giving stem cells to these people will correct their problems? First of all, embryology is extremely complex and only understood along some general concepts. Second, the brain is the most complex and least understood organ in the body. And third, every brain injury is extremely complex in and of itself. If you really believe that giving stem cells to cerebral palsy or spinal cord injuries represents a potential "cure", then you must also believe that giving stem cells to stupid people will make them smarter. Or for that matter, giving stem cell to geniuses will make them clairvoyant soothsayers (just a little redundant).

The estimated cost for this program is 6 billion dollars over the next 30 years. How can that make sense when we are in a huge budget deficit? I'm not against stem cell research, as I'm sure some stem cell research will answer some medical questions and maybe even a few treatments or cures may even be developed. I'm against the deception and play on emotions to trick people into voting for corporate welfare. Vote no on per the Howard Jarvis Taxpayers Association.

Friday, October 29: The Loneliness of the Long Distance Runner

The exhaustion and repetitive nature of work often makes time seem like it stands still, like you are neither progressing or regressing. In The Loneliness of the Long Distance Runner (#618,150 on the Amazon sale ranking) the protagonists rationalizes a structure of society and interpretations of morality...all the while running over a "no-man's land of unrelenting frost-bitten earth"...a state of mind where time stands still and the only thing that is real are your thoughts.

Its no wonder why people exercise with music ...listening to yourself think all the time only makes you wonder about the possibilities or the futility of it all. Running for me and having circular thoughts within my head happens to be an escape from the the demands of life ...a way to clear out the mind and explore ideas in life. Maybe more clearer rationalizations can be made outside of where time stands still?

Currently, I'm on day number 4 of 7 with 12 hour night shifts. I feel like the long distance runner where repetitive laps in a nondescript land have made time stand still. I did, however, pass one hurdle application to Kaizer Permanente is complete. :)

The line is getting nearer
But do you want the glory that goes
You reach the final stretch
Ideals are just a trace
You feel like throwing the race
Its all so futile

Wednesday, October 27: The Flight of Icarus

To loftier aims, and make him ramble high'r,
Grown wild, and wanton, more embolden'd flies
Far from his guide, and soars among the skies.
The soft'ning wax, that felt a nearer sun,
Dissolv'd apace, and soon began to run.
The youth in vain his melting pinions shakes,
His feathers gone, no longer air he takes:
Oh! Father, father, as he strove to cry,
Down to the sea he tumbled from on high,
And found his Fate; yet still subsists by fame,
Among those waters that retain his name.

Trapped on the island of crete by Minos, Daedalus and his son, Icarus, fashion wings from feathers. Warned by his father not to fly too high, Icarus got caught up in the moment and ignored his father's his "wings turned to ashes, to ashes his grave."

..Learning to fly is a time honored ambition ...however it is not a feat anyone could achieve on their own.

Tuesday, October 26: Blakemore

One of the great rewards of emergency medicine is doing procedures. Not just any procedure though ...procedures that have the potential to save lives.

I have always valued the synthesis of knowledge with that of working and creating something with your hands. Fortunately, I have had the opportunity to use this knowledge and these skills to save the lives of probably about 3 patients. These were cases that I felt that I was integral is saving...and that if someone else was there the outcome might have been different. Sure the number sounds low, but almost every doctor can diagnose common medical problems and treat the patient with medications and potential avert a fatality. In my opinion, the rubber meets the road in high intensity situations with little time left in the patient's life and no time for mistakes. Unfortunately, many of these adventures that we go on don't pan out so well ...Today was one of those days...yet oddly enough, it was highly rewarding.

The placement of the Sengstaken-Blakemore Tube (note the big tube in my patient's X-ray on the right) is indicated for uncontrolled upper GI bleeds likely from esophageal varices secondary to liver cirrhosis. These patients are unstable for intervention by the gastroenterologist, and the only thing that can be done is the placement of this archaic device. Our patient appeared to have a history of alcohol abuse and had a witness arrest in the field. On arrival to the ED, the patient had but a faint pulse and no indication of neurological integrity. His initial blood level of 15 (normal) dropped to about 6 after a fluid resuscitation ...indicating that the patient had lost more than half of his blood through internal bleeding. Obviously, the literature indicates an extremely high mortality rate. The only option left was the blakemore.

Many procedures we do as ER docs are barbaric, but this procedure was just nuts. I crammed a huge tube down this man's nose, failed in the first 6 attempt until it finally went all the way down into the stomach. I got one x-ray to confirm placement. Next I infused air into the distal balloon and shot another film. I tugged back on the tube until I felt that I was pulling strong get good apposition to the cardia of the stomach. I then inflated the esophageal component up to 40 mm Hg and wa-la...the blakemore was secured. Finally, I got another film to verify that everything looked good and this is what I got. Not the best placement, but it seems to me that it was effective in decreasing the bleeding. Two things for sure: 1) I wasn't about to play with it anymore to get a better position, and 2) this is one procedure that I think I can do without in the future. It was extremely time consuming, and we all know the eventual outcome. If you lose more that half of your blood, its probably time to meet your maker.

Nonetheless, I was proud of having applied the blakemore... knowing full well that it meant nothing ...a very odd feeling, and one that happens virtually every day.

Addendum: Special Thanks to Dr. Sonny Hayatavoudi in working together to place this thingamajig. The patient died the next morning...and it was all Sonny's fault. :) ...just kidding...

Monday, October 25: Proposition 64

Seems like the democrats are bought and sold by trial attorneys. This is, in my opinion, the only proposition that is straight forward, truthful, and makes complete sense. No other state in the nation has this legal loophole. Basically this proposition prevents lawyers from suing companies on behalf of the public without a PLANTIFF. Seems like some lawyers (i.e. the Trevor Law Group) were shaking down companies with threats of lawsuits only to get lawyer fees and settlements to "avert" a trial (usually at about 5K per settlement). Seems like this happened to 17,200 small companies last year. Trial attorneys...the largest collective PAC ...would obviously oppose this one. Why work when you can legally steal? The recommendations by the California Democratic Party here.

Monday, October 25: Elections in one week

Few people know that John Kerry voted against the first gulf war. Of course he covers this by throwing blame at the the first George Bush. I've heard it all too often that "we didn't go far enough" or "finish the job" the first time. Funny how you can be wrong about what is politically, strategically, and morally correct but then have the insight to know the strategic endpoints...when you were against it in the first place.

The logic behind stopping the Gulf War was rooted on multiple lines of reason based on how we perceived the world at that time. Removal of a dictator would destabilize the region. Shities in the south would align with the Shities in Iran. The Kurds would break away in the north. With a fractioned Iraq, it could be conceivable that a solitary fundamentalist totalitarian regime could spread through the middle east and thus destabilize the world economy. (yes, because of oil). That's why for the last 20 years we supported Iran and then we supported Iraq because we feared what would happen with these religious zealots if one became dominate and took over the region. In addition, the mandate from the UN at that time did not authorize the US to depose Saddam. Funny, since people who support Kerry think that they need UN approval to do anything, yet in the past we should have opposed the UN and gone ahead with Saddam's removal. Can you say non-sequitur?

John Kerry voted for the second gulf war ...probably based on similar information that the president had. Of course, noncompliance with inspections was one of the reasons, but there were strategic and moral reasons as well (unless you believe that women in the middle east deserve rape, torture, and no free speech, or the murdering of dissidents is just swell). Kerry voted against supplying the troops after the war started. Then he comes out and criticizes the administration for failing to give the troops what was needed.

How the hell did this happen?

Well the answer lies in the democratic primaries. When Dean was leading in the initial primaries, Kerry was forced to become "anti-war". After winning the primary, Kerry now had to move to the middle...and has since toned down his "anti-war" message with plain old propaganda. ..."a stronger america".

Well, Nobody really understood his stance on the issue so he clarified it during the first debate. In the debate, he stated he had a "plan" no less than 12 times. Here is an analysis of of Kerry's positions ...a virtual how-to on speaking out of both sides of your mouth. (Dennis Prager analysis) ...I loved this article.

I'm not a big Bush Fan. I don't think he has all the attributes that make for a great leader. I do believe that he is driven by moral purposes, and that is good enough for me. Id rather have someone with principles, than someone who will say anything to get elected. Just look at all the promises being made. Kerry is trying to give you everything--Bush on the other hand isn't really promising much. Maybe if Bush was more "presidential" and could speak out of both sides of his mouth, maybe then more people would respect him?

Sunday, October 24: NT Conceptualist?

Wow...this whole article kind of nails it on the head...NT Conceptualist ...Maybe I'll do a full analysis later... I think somewhere it even calls me a "rat bastard". :) lest I jest...

Sunday, October 24: Who am I?

Well I took a Myers-Briggs Test and I scored differently on two tests. Here is one one result:

  • moderately expressed extrovert
  • moderately expressed intuitive personality
  • very expressed thinking personality
  • moderately expressed judging personality

    Turns out that I tested as an ESTJ or an ENTJ. Seems like I view my relationship with the world as an extrovert, which explains my interest in social issues, politics, economics, and science, and less so with things that are interpreted internally such as art, architecture, and less with impressions. I seem to be well balanced between the "Sensing" and the "iNtuitive" since I look at things in a concrete way but on an ideological plane. Maybe I can call myself a practical ideologist? In terms of Thinking versus Feeling...well that's a hands down Thinking...I actually think that I am too thinking, and possibly too critical, yet I think I am very fair about it as well. I don't let these ideas and criticisms affect my feelings and interpretations of myself and others. Some take it in the offensive, but to those who know me, they understand my intentions. (an oxymoron for myself, since I am strongly in favor for the judgment of actions and not intentions on a global level, yet not on a personal level.) And finally, I scored as Judgmental (big shocker huh?). I prefer the "destination over the journey". What else describes myself other than delayed gratification. Sometimes, I wish it was not true, but I have always been the work hard now, reap the benefits later type person.
  • The two categories that I fall into are deemed "The Field Marshall" and the "Supervisors". Characteristics that I think describe myself (omissions of things that I don't think really describe me):



    in tune with the established, time-honored institutions and ways

    comfortable in evaluating others and tend to judge how a person is doing in terms of standard operating procedures

    promote the work ethic

    outspoken, a person of principles, which are readily expressed

    live in their Extraverted Thinking functioning, thus, their prime directive is in discovering that which is true and logical in the events of the real world

    impatient with those who do not carry out procedures with sufficient attention to those details

    humor is frequently centered around something or someone being off center or behaving abnormally

    Laziness is rarely viewed with ambivalence nor benevolence

    not afraid to stand up for what he believes is right even in the face of overwhelming odds

    Clarity of convictions endows these Thinkers with a knack for debate

    ...often leading the charge into the mouth of hell (I like that Line)

    there must always be a reason for doing anything, and people's feelings usually are not sufficient reason

    in their devotion to their jobs and can easily block out other areas of life for the sake of work

    expect a great deal of their mates, who need to possess a strong personality of their own, a well developed autonomy, many and varied interests, and a healthy self-esteem

    ABSTRACT in communicating and UTILITARIAN in implementing goals, can become highly skilled in STRATEGIC ANALYSIS

    Ever in search of knowledge, this is the "Knowledge Seeking Personality" -- trusting in reason and hungering for achievement

    skeptical about the future, solipsistic about the past, and their preferred time and place are the interval and the intersection

    Highly self-critical

    Does that mean I fall in the same category as Napoleon??? I quiver in disgust! (or maybe I should realize that this was when France was a real nation, instead of a bunch of fairies) Derived from the following webpage: Myers-Briggs

    Friday, October 22: The Last 6 Years

    The last 6 years has been the most challenging in my life. Along the way, I have had many struggles spiritually, intellectually, and physically. Its all coming together now with that light at the end of the tunnel, and time will lead me to the place that I want to be. I owe a great deal to my friends and family who have helped me along. I am the person I am today because so many people did care...

    Friday, October 22: The Caduceus

    "Here we see his full power of transcendence, whereby the lower transcendence from underworld snake-consciousness, passing through the medium of earthly reality, finally attains transcendence to superhuman or transpersonal reality in its winged flight." -- Joseph L. Henderson

    Mercury, the messenger of the Gods and deliverer of information carried the Caduceus as his symbol. In Greek Mythology, Mercury (Hermes) once threw his staff at two fighting snakes, and the snakes have been entangled ever since. Not only was Mercury the messenger of the Gods, he was associated with commerce, wealth, and leading the dead to the underworld. Interestingly, Mercury was well known for his trickery. What other symbol could you think of that would be more appropriate for the medical profession? Trick somebody, take his money, and lead him to the underworld! Ha...How funny is that?

    In reality, the transcendence of the medical profession is a profound one. One where hard work, knowledge, wisdom, experience, compassion, communication, skill, intuition, and desire come together. The complexity, challenges, and excitement are too extensive to describe. I am truly grateful for the opportunity to practice emergency medicine.

    Read an analysis of the Caduceus on this webpage. A collection of essays on symbols and the human condition...Man and his Symbols by Carl Jung.

    Thursday, October 21st: On-Line Journal Started

    Well, here goes nothing...lets see how long I keep this thing going.

    CouNT DoWN To GRaDuaTioN:

    Jeff Hurley MD On-Line Journal | home

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