Dear reader: you probably think this is going to be some sexist rant - well, worry not - and what's wrong with being sexy?
Back in the Holocene Epoch, when I was a med student, women made up about 10% of the class. Today, the total medical student population is about 55% women and 45% men and still about 90% nerd. "So what?", you say. Well, in 20-30 years, women will be the majority of practicing physicians and I wonder how this will change the field. (yes, I know the Holocene continues to the present day - that was a subtle joke for the geology geeks out there - wow, I'm a dork).
Let's start with Larry Summers, former Secretary of the Treasury and President of Harvard, who dared suggest that it may be an interesting thesis to explore that men and women have some innate differences. How dare he?! In the words of Joseph Conrad, memorably mumbled by Marlon Brando: "the horror, the horror". Now I'm no Freudian - anatomy does not necessarily equal destiny - but I quickly learned during my first GYN examination (ahh, memories...) that there are some differences no one can deny.
Actually, I figured it out way before this speculum enhanced moment, when I had sex with my sister (I'm kidding - it was my first cousin). The point? Men and women ARE different, and if you deny this you are an idiot (see, a woman would never say that).
Has the practice of OB-GYN and pediatrics, now with a majority of female MDs, changed? Peds... I'm not sure. My sense is that women generally like to go to women about women problems - so, in the case of OB-GYN, a double-X majority has probably improved the field (no, not a bra size, perverts - I'm talking chromosomes).
Can women do the 'macho' jobs: hip relocations, endless cardiothoracic nightmare surgeries, Gracie jiu-jitsu on the drunk in the ED? Undoubtedly, the answer is yes. Why they would want to go into clinical medicine at all is another question, best answered by a psychotherapist or, at a minimum, Oprah.
Is it even reasonable or helpful to try to make any generalizations about this? I don't know - but it is an approaching reality. My field (pathology) has alot of women. Some are great. Some suck ass and couldn't tell the difference between a fibromyxoid sarcoma and a myxoid fibrosarcoma (we are really good at naming things in a clear way). I realize generalizations can be hurtful, but they can be interesting: why are 41% of California public university students Asian; why are there very few women scientists in academia; why are all Catholic high school girls sluts?
Bottom line: women and men are different; woman-dominated medicine will probably be different from man-dominated medicine; no one can predict what this new landscape will be like; and who's going to fetch me my coffee?
Tuesday, June 26, 2007
Sunday, June 24, 2007
Whither the Generalist?
Panda Bear, MD had a very interesting post on primary care medicine up on his blog recently. He is currently an EM Resident after spending a frustrating year training to be a Family Practitioner. He also brings his characteristic USMC sense to the subject of chiropractic 'medicine', but I will not comment on that here except to say that I agree with him.
Something terrible has happened to internal medicine and family practice in the past decade. Traditionally, internal medicine was considered to be "adult medicine" and family practice physicians had, as the name implies, mastered a broader knowledge base including pediatrics and Ob-Gyn. Necessarily, they sacrificed some detail for the sake of a broader base. In that regard, they were, arguably, the forerunners of the Emergency Physician. I used to explain what I do to by telling people I would be "like a family practitioner specializing in emergencies".
Twenty years ago, when I was a medical student (and then a resident) the internists were jumping over each other to get procedures, to put in central lines, and to run codes. Their training was rigorous and I decided against internal medicine because of the level of detailed knowledge required. I liked the immediate gratification of procedures and emergency care but I didn't care a lick for long-term management. I knew that the fine points needed someone with more focus than I could produce consistently. Also, general internists, twenty years ago, only called in the specialists, well, for special cases. They ran codes and managed patients in the ICU and did it well.
I have always viewed internists, especially the ones I trained under at medical school, as upholding the best traditions of medicine. Within their ranks were some of the most brilliant people I've ever met, doctors who emanated knowledge and compassion and who taught me, well, that I shouldn't be an internist.
However, since the specialty of Emergency Medicine has become a prominent player in almost all major hospitals, the internists and generalists have stopped taking care of critically ill patients. They have also stopped taking care of "unstable" patients. They only care for patients after they have been "stabilized", usually by a combination of EMS and Emergency Physicians and Nurses. Or, they take patients in transfer from the ICU or SICU where an 'intensivist', usually a pulmonary/critical care specialist, has directed their care.
So what do the general internists and family practice docs do these days? They manage chronic diseases like diabetes and hypertension, they provide early diagnosis of many conditions with insidious onset such as cancer, arthritis, and lymphoma . In smaller communities they may still do some orhtopedics, some psychiatry, and, in fact, the whole range of non-surgical care. I'm sure that some family practitioners still (foolishly given the malpractice climate), deliver babies.
Most generalists have been forced to employ midlevel providers (Physician Assistants and Nurse Practitioners) to see enough patients to make enough money to make any money. Many times, they don't really see patients anymore but merely provide oversight.
Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me.
What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.
What if you have abdominal pain and call your physician or even your surgeon if you have one? They will tell you to come to the E.D. for evaluation. After all, where else can you get a STAT CT scan? Is there still a surgeon in the United States that will take a patient to the operating room based on a clinical exam and patient history?
If you call the nurse line you will get the same response. Or, you can eliminate the middle-man and just come on in. Bonk on the head. E.D. Laceration? E.D. Vomiting blood? E.D. Medication adjustment? Call your internist for a follow-up three or four weeks from now or come on in.
I am not happy about this situation and I am not criticizing internists or family practitioners in that I do not think that this was planned or desired. I think that internists know more about medicine than I ever will or care to, but what are they going to be doing ten years from now? We have made it easy for them to opt out of high liability care and they have opted.
The reality of it has been striking especially since, at our facility, our hopsitalists (internists who confine themselves to hospital practice) have begun demanding 'complete workups' prior to admitting a patient from the E.D. Rather than taking Mr. Smith, with unstable angina, directly upstairs after initial stabilization in the ED, they now won't take him without all his tests being complete including his CT of the chest and his horizontal stool-velocity. If a test is pending when a patient is sent upstairs I am sure to hear about it as an 'incomplete workup'. Well damn!
When the E.D. is popping and the E.M.S. crews are bumping into themselves in the ambulance bay the best thing I can do for everyone is to stabilize and move the patients. If it's not so bad then I always complete my workups and always review the patient's prior admissions. But not accepting an admission because the diagnosis is in doubt or the workup is partial? I mean I know there's lots of paperwork to do but to call me upstairs to do a lumbar puncture on a patient admitted three days ago? Can you really not do one? Didn't you do them in medical school? Internship? Residency?
By insisting on this level of completeness from me the hospitalists, internists, and many surgeons have aced themselves out of caring for the critically ill and are losing their clinical judgement and skills for lack of use. In the meantime my skill and knowledge base is increasing. Hell, internists in my town don't even manage the sorta-ill or the kinda-ill anymore. Like most things in life, true gut-knowledge comes through repetition. If you haven't run a code in three years then I understand why you don't want to run one today. I don't know why they don't see this but they don't. Job security for me? Sure. But I'd rather do Emergency Medicine.
Something terrible has happened to internal medicine and family practice in the past decade. Traditionally, internal medicine was considered to be "adult medicine" and family practice physicians had, as the name implies, mastered a broader knowledge base including pediatrics and Ob-Gyn. Necessarily, they sacrificed some detail for the sake of a broader base. In that regard, they were, arguably, the forerunners of the Emergency Physician. I used to explain what I do to by telling people I would be "like a family practitioner specializing in emergencies".
Twenty years ago, when I was a medical student (and then a resident) the internists were jumping over each other to get procedures, to put in central lines, and to run codes. Their training was rigorous and I decided against internal medicine because of the level of detailed knowledge required. I liked the immediate gratification of procedures and emergency care but I didn't care a lick for long-term management. I knew that the fine points needed someone with more focus than I could produce consistently. Also, general internists, twenty years ago, only called in the specialists, well, for special cases. They ran codes and managed patients in the ICU and did it well.
I have always viewed internists, especially the ones I trained under at medical school, as upholding the best traditions of medicine. Within their ranks were some of the most brilliant people I've ever met, doctors who emanated knowledge and compassion and who taught me, well, that I shouldn't be an internist.
However, since the specialty of Emergency Medicine has become a prominent player in almost all major hospitals, the internists and generalists have stopped taking care of critically ill patients. They have also stopped taking care of "unstable" patients. They only care for patients after they have been "stabilized", usually by a combination of EMS and Emergency Physicians and Nurses. Or, they take patients in transfer from the ICU or SICU where an 'intensivist', usually a pulmonary/critical care specialist, has directed their care.
So what do the general internists and family practice docs do these days? They manage chronic diseases like diabetes and hypertension, they provide early diagnosis of many conditions with insidious onset such as cancer, arthritis, and lymphoma . In smaller communities they may still do some orhtopedics, some psychiatry, and, in fact, the whole range of non-surgical care. I'm sure that some family practitioners still (foolishly given the malpractice climate), deliver babies.
Most generalists have been forced to employ midlevel providers (Physician Assistants and Nurse Practitioners) to see enough patients to make enough money to make any money. Many times, they don't really see patients anymore but merely provide oversight.
Now, what happens if you have chest pain? If you go to your general internist's office and he or she finds out you have risk factors for cardiac disease and are over 30 you will likely find yourself in an ambulance on your way to see me. If you call the nurse "answer line" they will tell you to go to the "nearest emergency department". Or, you may choose to come directly to me.
What if you need quick lab results? What if you have vomited yourself into dehydration and need an IV? Go to the ED.
What if you have abdominal pain and call your physician or even your surgeon if you have one? They will tell you to come to the E.D. for evaluation. After all, where else can you get a STAT CT scan? Is there still a surgeon in the United States that will take a patient to the operating room based on a clinical exam and patient history?
If you call the nurse line you will get the same response. Or, you can eliminate the middle-man and just come on in. Bonk on the head. E.D. Laceration? E.D. Vomiting blood? E.D. Medication adjustment? Call your internist for a follow-up three or four weeks from now or come on in.
I am not happy about this situation and I am not criticizing internists or family practitioners in that I do not think that this was planned or desired. I think that internists know more about medicine than I ever will or care to, but what are they going to be doing ten years from now? We have made it easy for them to opt out of high liability care and they have opted.
The reality of it has been striking especially since, at our facility, our hopsitalists (internists who confine themselves to hospital practice) have begun demanding 'complete workups' prior to admitting a patient from the E.D. Rather than taking Mr. Smith, with unstable angina, directly upstairs after initial stabilization in the ED, they now won't take him without all his tests being complete including his CT of the chest and his horizontal stool-velocity. If a test is pending when a patient is sent upstairs I am sure to hear about it as an 'incomplete workup'. Well damn!
When the E.D. is popping and the E.M.S. crews are bumping into themselves in the ambulance bay the best thing I can do for everyone is to stabilize and move the patients. If it's not so bad then I always complete my workups and always review the patient's prior admissions. But not accepting an admission because the diagnosis is in doubt or the workup is partial? I mean I know there's lots of paperwork to do but to call me upstairs to do a lumbar puncture on a patient admitted three days ago? Can you really not do one? Didn't you do them in medical school? Internship? Residency?
By insisting on this level of completeness from me the hospitalists, internists, and many surgeons have aced themselves out of caring for the critically ill and are losing their clinical judgement and skills for lack of use. In the meantime my skill and knowledge base is increasing. Hell, internists in my town don't even manage the sorta-ill or the kinda-ill anymore. Like most things in life, true gut-knowledge comes through repetition. If you haven't run a code in three years then I understand why you don't want to run one today. I don't know why they don't see this but they don't. Job security for me? Sure. But I'd rather do Emergency Medicine.
Thursday, June 21, 2007
Soothsayer
Here is the future of medicine, 6 degrees of Kevin Bacon style:
1. Universal health care becomes law, is deemed a "right", and government becomes even more involved.
2. More people pour into the system, be it clinics or ED's, because it is "free", even though it really is already "free" to due unfunded federal mandates.
3. The increased govt. oversight leads to more paperwork, more QA bullshit, more pneumonia, CHF protocols, such that the actual number of patients that can be seen by each provider per hour or shift goes DOWN.
4. Fewer persons desire to spend a majority of their lives studying, training, and SUFFERING, to treat patients who consider them only a drone government worker who is obliged to see them no matter what, thus decreasing the pool of providers even further. I know if my children show an interest, they will quickly be steered in another direction.
5. The upper middle class and wealthy will continue to get excellent health care in a timely manner (which they should have the right to do), due to the exodus of the smart and financially savvy doctors going into "private practice" to see their own patients (ahh, the good old days). This is how it is in Great Britain. Trust me, I lived their for several months. The discrepancy in good care and "cattle care" is pretty profound.
6. This brings us to even more persons overloading an already burdened system, seeing providers who are disgruntled that they even chose this profession because they are doing more paperwork than medicine while govt. overseers are breathing down their necks. Imagine the post office line, but with people bleeding, vomiting, and sharing stories about their genital warts.
You get the picture.
7. Kevin Bacon (I had to end with him)
Before all you bleeding hearts say "You should do it for the love of it, etc etc ", this job sucks (ED work, shifts, nights, drunks) and most people DO do it for the desire to care for others, and also to provide a decent living for their families. At least in the beginning. But I am sure even Mother Teresa every now and then said to herself "Come on people, enough is enough." Well, maybe she didn't, but I am.
1. Universal health care becomes law, is deemed a "right", and government becomes even more involved.
2. More people pour into the system, be it clinics or ED's, because it is "free", even though it really is already "free" to due unfunded federal mandates.
3. The increased govt. oversight leads to more paperwork, more QA bullshit, more pneumonia, CHF protocols, such that the actual number of patients that can be seen by each provider per hour or shift goes DOWN.
4. Fewer persons desire to spend a majority of their lives studying, training, and SUFFERING, to treat patients who consider them only a drone government worker who is obliged to see them no matter what, thus decreasing the pool of providers even further. I know if my children show an interest, they will quickly be steered in another direction.
5. The upper middle class and wealthy will continue to get excellent health care in a timely manner (which they should have the right to do), due to the exodus of the smart and financially savvy doctors going into "private practice" to see their own patients (ahh, the good old days). This is how it is in Great Britain. Trust me, I lived their for several months. The discrepancy in good care and "cattle care" is pretty profound.
6. This brings us to even more persons overloading an already burdened system, seeing providers who are disgruntled that they even chose this profession because they are doing more paperwork than medicine while govt. overseers are breathing down their necks. Imagine the post office line, but with people bleeding, vomiting, and sharing stories about their genital warts.
You get the picture.
7. Kevin Bacon (I had to end with him)
Before all you bleeding hearts say "You should do it for the love of it, etc etc ", this job sucks (ED work, shifts, nights, drunks) and most people DO do it for the desire to care for others, and also to provide a decent living for their families. At least in the beginning. But I am sure even Mother Teresa every now and then said to herself "Come on people, enough is enough." Well, maybe she didn't, but I am.
Wednesday, June 20, 2007
A Gift from the Onion
Let's take a break from the daily macabre comedy that is modern medicine and get a good laugh courtesy of The Onion.
Monday, June 18, 2007
Notes from the Underground Morgue
(Editors note: For those of you new to this blog ETOTHEIPI, the contributor writing here, is a board certified pathologist who has performed many autopsies. The autopsy report from the current case in L.A. which is generating so much press can be found here)
Here are some notes on the autopsy report from the previous post "Emergency Bleeding". Review before continuing or this will make little sense.
1. Ignore the scratches on the last few pages of the report - it is unreadable - those are just notes at the time of autopsy and are all incorporated into the typed text. The only thing additional I picked up was the presence of multiple tattoos - which personally shocked me.
2. Take note of how they removed the tongue. My favorite part of the autopsy. You open the chest, reach your hand up through the neck and by cutting along the inner aspect of the jaw, you loosen the tongue and then rip it out through the neck and chest. Just good clean fun.
3. Note the NORMAL aorta. I think it is a reasonable guess that this 5'6", 274 lbs., tattooed beauty, has elevated cholesterol and eats like a starving rhino let loose in KFC. Why is her aorta normal? It's probably alcohol. It is a well known phenomenon that alcoholics have great vessels - sure your liver fails - but you can't get something for nothing.
4. Bottom line: the report states that the inflammatory reaction to her colon perforation was consistent with an acute process. She probably had a dilated colon from drugs and pre-existing divertics from being 'eating-challenged' - hence abdominal pain. One of her divertics got blocked by poo - possibly a 'Corn-Nut'. It got inflamed and burst. End of story and life.
5. Shit luck for the docs / triage folks who missed this - would like to hear comments from said persons on picking up an acute abdomen in a such an 'adipose-gifted' individual.
6. Lastly, it doesn't strike me that this alcoholic, obese, meth-addict had much concern for her own personal health. She died and it was her own fault. Now the hospital and docs will be out a few million. Sure insurance will pay, but guess where that money to pay comes from... yep, the docs who pay ridiculous premiums (>100,000$/year pre-tax!!! for some). Hmmmm... I pay lots of money so someone who has no respect for herself can get rich... Oh wait, she's dead. We all lose.
Here are some notes on the autopsy report from the previous post "Emergency Bleeding". Review before continuing or this will make little sense.
1. Ignore the scratches on the last few pages of the report - it is unreadable - those are just notes at the time of autopsy and are all incorporated into the typed text. The only thing additional I picked up was the presence of multiple tattoos - which personally shocked me.
2. Take note of how they removed the tongue. My favorite part of the autopsy. You open the chest, reach your hand up through the neck and by cutting along the inner aspect of the jaw, you loosen the tongue and then rip it out through the neck and chest. Just good clean fun.
3. Note the NORMAL aorta. I think it is a reasonable guess that this 5'6", 274 lbs., tattooed beauty, has elevated cholesterol and eats like a starving rhino let loose in KFC. Why is her aorta normal? It's probably alcohol. It is a well known phenomenon that alcoholics have great vessels - sure your liver fails - but you can't get something for nothing.
4. Bottom line: the report states that the inflammatory reaction to her colon perforation was consistent with an acute process. She probably had a dilated colon from drugs and pre-existing divertics from being 'eating-challenged' - hence abdominal pain. One of her divertics got blocked by poo - possibly a 'Corn-Nut'. It got inflamed and burst. End of story and life.
5. Shit luck for the docs / triage folks who missed this - would like to hear comments from said persons on picking up an acute abdomen in a such an 'adipose-gifted' individual.
6. Lastly, it doesn't strike me that this alcoholic, obese, meth-addict had much concern for her own personal health. She died and it was her own fault. Now the hospital and docs will be out a few million. Sure insurance will pay, but guess where that money to pay comes from... yep, the docs who pay ridiculous premiums (>100,000$/year pre-tax!!! for some). Hmmmm... I pay lots of money so someone who has no respect for herself can get rich... Oh wait, she's dead. We all lose.
Sunday, June 17, 2007
Berserk
A screaming madman was brought into bed 6 the other day. Even though we are used to screams in the E.D. this was different. This was not a schizophrenic man's scream, it was not a drunk man's scream, it was not a coked out man's scream ,it was the scream of a man with a live insect in his ear. It was the scream of torture.He was working in the yard and a bug flew right into his ear. No shit. As soon as I heard what the problem was I ran to the pyxis and got some lidocaine with epi 1%. I ran into the guys room and shot the liquid into his ear, and, immediately, out crawled an unhappy beetle who was quickly squashed under my foot.
Crazy man became nice man. Torture ended.
Friday, June 15, 2007
A Script for the Sopranos (courtesy of HIPPA)
HIPPA, which stands for something, is a federal law which attempts to protect patient privacy and confidentiality. Now it's not as if it wasn't protected before, it's just that with paperwork in trash cans, phone calls inquiring about patients, and talk in hallways and elevators there was a concern, and no doubt, some real instances, where sensitive patient information got into the wrong hands. Enter the bull in the china shop known as the federal government.
Without getting into the law's specifics or requirements (because I care about as much about it as I do about whom Paris Hilton is currently boning) I offer you a typical conversation between physicians about a patient in accordance with HIPPA (and the Sopranos).
Doc 1: "Hey doc, did you take care of that thing with that guy?"
Doc 2: "Which guy was that?"
Doc 1: "You know, the guy with the thing on his hoo-ha?"
Doc 2: "Oh yeah, the guy from the other day?"
Doc 1: "Yeah, that guy."
Doc 2: "We took care of it."
Doc 1: "Any problems?"
Doc 2: "Not really, but his family... geez, they are a problem!."
Doc 1: "Anything I need to know about?"
Doc 2: "If you see them again and you have a problem give me a call and one of my associates or I will take care of it."
Doc 1: "Good to go. We are talking about that fat young guy right? I mean the young male 'person of mass'?"
Doc 2: "No, damn, I was talking about the thin old guy."
Doc 1: "I don't know him."
Doc 2: "Oh."
Doc 1: "Never mind."
Doc 2: "See you later."
Thursday, June 14, 2007
Emergency Bleeding
This is terrible. We will never hear the whole story. A "Los Angeles Hospital" is in huge shit trouble now and this poor woman is dead. The story is a bit confusing because she is placed both in "the hospital lobby" (in which case a "Code Blue" should have been called and doctors and nurses should have run to the lobby) or she was the E.D. lobby in which case the triage system failed miserably.
A million dollars says that there is much more to this story that, if told, would make this less shocking. As the lawyers on both sides are already flexing though we will never hear it. This kind of publicity will generate a settlement, and soon.
And hey, which presidential candidate from will be the first to cite this case and bend it to their agenda? Odds?
A million dollars says that there is much more to this story that, if told, would make this less shocking. As the lawyers on both sides are already flexing though we will never hear it. This kind of publicity will generate a settlement, and soon.
And hey, which presidential candidate from will be the first to cite this case and bend it to their agenda? Odds?
Tuesday, June 12, 2007
The Deuce?
So is it just me, or is naming your colostomy bag weird? Does naming it "Blake" make it less weird? I thought not. I spend ten minutes in the room talking to some gal about her abdominal pain and she keeps talking about "Blake" and how often he gets "changed" and I finally had to ask because she seemed a bit old to have a kid. What the hell am I doing? Where the hell am I?
Thursday, June 07, 2007
Back From the Desert
Well, the conference is over. Turns out the place was actually a large city, with lots of lights and people. Memorial weekend is one of the busiest out there, and the posers were out in full force. I did feel very old at a couple of the venues, especially Hard Rock poolside. Got to see Dred Zeppelin for the first time in years. Felt like a chaperon, but did enjoy the show.
Anyway, the conference was good. 911 actually showed up and was awake for most of it. The gist of many of the talks was don't do anything but reassure the patient that they will get better with time. This is great with me, because I don't want to do anything at all except put a tube down your trachea, give you a jolt of electricity, pump you full of drugs and send you upstairs. If you don't need these things, you can probably go home.
As for the meme you could basically copy what 911 doc so eloquently said, but I will add a few.
1. I am a conservative. Sure I had my more liberal days as a wayward youth, but that was before I had a family or a paycheck. With both of these, I can't see how sitting high in a California redwood reading Jack Kerouac, spouting some asinine diatribe about a socialist utopia and wealth redistribution, or telling other people to buy "carbon credits" (what???) while I fly in my private freaking jet across the country, will benefit me, my family or my country.
2. I love my country. I admire the young men and women who have sacrificed and are sacrificing now for the U.S.A. in the military. I believe that if you don't like our country, you should either vote to change your leadership, work within the leadership that was elected, knowing that in a democracy a new election will come, work on a grass roots level to change things, or shut the hell up and leave. Don't try change this into a Stalinist/socialist haven, and sure as hell don't try to establish a caliphate.
3. I believe law abiding citizens should have guns, and more of them should have concealed carry permits. I don't hunt, but I own guns, and I would Charlton Heston you if you tried to take them (you would have to pry them from my cold dead hand). The people I am referring to would deter the thugs and psychos who wish to do harm, or would at least shorten their rampages. I am a news hound, and in my nearly 4 decades I have yet to see a heinous crime carried out by a concealed carry card holder, but I have seen them stop some misanthrope in his tracks who thought he was the only person with a weapon.
Anyway, the conference was good. 911 actually showed up and was awake for most of it. The gist of many of the talks was don't do anything but reassure the patient that they will get better with time. This is great with me, because I don't want to do anything at all except put a tube down your trachea, give you a jolt of electricity, pump you full of drugs and send you upstairs. If you don't need these things, you can probably go home.
As for the meme you could basically copy what 911 doc so eloquently said, but I will add a few.
1. I am a conservative. Sure I had my more liberal days as a wayward youth, but that was before I had a family or a paycheck. With both of these, I can't see how sitting high in a California redwood reading Jack Kerouac, spouting some asinine diatribe about a socialist utopia and wealth redistribution, or telling other people to buy "carbon credits" (what???) while I fly in my private freaking jet across the country, will benefit me, my family or my country.
2. I love my country. I admire the young men and women who have sacrificed and are sacrificing now for the U.S.A. in the military. I believe that if you don't like our country, you should either vote to change your leadership, work within the leadership that was elected, knowing that in a democracy a new election will come, work on a grass roots level to change things, or shut the hell up and leave. Don't try change this into a Stalinist/socialist haven, and sure as hell don't try to establish a caliphate.
3. I believe law abiding citizens should have guns, and more of them should have concealed carry permits. I don't hunt, but I own guns, and I would Charlton Heston you if you tried to take them (you would have to pry them from my cold dead hand). The people I am referring to would deter the thugs and psychos who wish to do harm, or would at least shorten their rampages. I am a news hound, and in my nearly 4 decades I have yet to see a heinous crime carried out by a concealed carry card holder, but I have seen them stop some misanthrope in his tracks who thought he was the only person with a weapon.
4. I believe in personal responsibility. It is the role of the govt. to protect me, provide infrastructure, and help the downtrodden ( read: those who CAN'T help themselves, although I really believe even this service is more efficiently performed by religious and other private groups) and least among us, at least until they can get on their feet. That is about it. It is not to provide cradle to grave services, thereby instilling generation after generation of a "where's mine" or in the case of certain NATURAL disasters "where's the boat?" mentality. As a corollary to this I am against affirmative action. I believe need based (economic) help for college students is appropriate on an equal footing, but I never want to spend a single second of my life explaining to my son why, although he worked hard, scored as high or higher on the test, he didn't get the promotion, position, job etc. because his skin happened to be a certain color or he had testicles. That just isn't going to happen.
5. I believe the French (this also applies to Quebec, as you think you are in France) are smelly, jealous people. I have traveled there many times, but don't plan to go again until Euro Disney annexes the French capital, cleans it up (smells like urine) and makes it one of their theme areas. The can have Johnny Depp for all I care. One thing I do admire is their ability to be lazy and smug at the same time. In honor of this and since I love college football, I propose Saturdays in the fall be National France Awareness days, where all businesses, including hospitals, (excluding beer and chip stores) will be closed to allow me to sit on my butt and do nothing, smell horrible, and still enjoy myself soaking in ALL the glory that is football.
6. College "professors" frighten me. I hope that in 18 years I can teach my child enough and prepare him well enough to be able to fend off the left wing liberal wacko crap they spew to the lemming masses at most of the campuses. I also hope that he is good enough at golf that even if he has to go to college he can concentrate on his game and not their socialist diatribes. The old saying "Those who can do, those who can't teach" applies today in colleges more than ever. They say they want to encourage free speech, but only if that speech falls in line with their thinking.
7. Elvis was a genius. If you don't go through the entire range of human emotion listening to Don't Cry Daddy, Kentucky Rain, and An American Trilogy, in that order, then you are a soulless robot and have no reflection in the mirror.
8. I believe the Judeo-Christian work and moral ethic are what have guided this nation to greatness, and a lack of these relegate us to mediocrity. I try to instill these values in my kids, attending church as often as my horrible schedule will allow. The founding fathers did not want congress to establish a state religion, which is appropriate in a pluralistic society. But they knew the value of a moral compass, (not moral relativism) and even celebrated a day of religious observance (thanksgiving) after the Constitution was ratified. In addition, most people forget the second clause of the 1st amendment, the one about making no law prohibiting the free exercise of religion. The ACLU seems to have forgotten that as well.
That's all folks.
Tuesday, June 05, 2007
The Doors of the ED
I don't know what it is about the doors to the ED but they need to be studied. It happens many times a shift that a patient's symptoms will get miraculously better right as they are brought back to a bed. Kid's fevers vanish, abdominal pain goes away and patients tell me they're hungry, and diarrhea dries up. Sometimes it works in reverse though and I think it's a result of people feeling safe once they make it to the bed. The mind is powerful.
I have never seen a dude with flop-sweat before but I just did. EMS brought in a 40'ish Hispanic gentleman with shortness of breath recently and the minute he hit the gurney in the ED he just freaked. EMS said he had been quite calm in transport. When I was called into the room he was pouring sweat and wouldn't sit on the bed. He was up, he was down, he was yelling "I can't breathe" (and even though he was able to form the words indicating he was breathing, the most he could get out was those three words), he was drowning, he was dying.
We intubated him rapidly and the X-ray showed bilateral pneumonia or diffuse heart failure. Then the picture got confusing... His rectal temp was 104 but his white count was normal. His BNP (an indicator of heart failure) was elevated, but not markedly so, and his EKG and cardiac enzymes were normal. His blood pressure was in the mid two-hundreds and we couldn't get it below 180 with a nitro drip so we switched to cardene which is rapidly becoming the drug of choice for hypertensive crises. I gave him lovenox empirically in case he had a massive PE but his D-dimer was normal. His 30 minute cardiac markers, which I ordered to see if he was trending up, were normal.
We flew him quickly to the Mecca somewhat stabilized but without a definitive diagnosis. I felt a little vindicated the next day when I talked to the ICU fellow and they still didn't have an answer. Scared the shit out of me (and his wife)! He is now off the vent. Cocaine? IV drugs? Flash pulmonary edema? Another form of Zebra? I hope to hear someday but I rarely get follow-up. Hopefully he walked out of the hospital.
I have never seen a dude with flop-sweat before but I just did. EMS brought in a 40'ish Hispanic gentleman with shortness of breath recently and the minute he hit the gurney in the ED he just freaked. EMS said he had been quite calm in transport. When I was called into the room he was pouring sweat and wouldn't sit on the bed. He was up, he was down, he was yelling "I can't breathe" (and even though he was able to form the words indicating he was breathing, the most he could get out was those three words), he was drowning, he was dying.
We intubated him rapidly and the X-ray showed bilateral pneumonia or diffuse heart failure. Then the picture got confusing... His rectal temp was 104 but his white count was normal. His BNP (an indicator of heart failure) was elevated, but not markedly so, and his EKG and cardiac enzymes were normal. His blood pressure was in the mid two-hundreds and we couldn't get it below 180 with a nitro drip so we switched to cardene which is rapidly becoming the drug of choice for hypertensive crises. I gave him lovenox empirically in case he had a massive PE but his D-dimer was normal. His 30 minute cardiac markers, which I ordered to see if he was trending up, were normal.
We flew him quickly to the Mecca somewhat stabilized but without a definitive diagnosis. I felt a little vindicated the next day when I talked to the ICU fellow and they still didn't have an answer. Scared the shit out of me (and his wife)! He is now off the vent. Cocaine? IV drugs? Flash pulmonary edema? Another form of Zebra? I hope to hear someday but I rarely get follow-up. Hopefully he walked out of the hospital.
Monday, June 04, 2007
You Americans!
Apologies up front my dear American friends. I know it is unkind of a guest to criticize his host but I just must be heard. Having an expert knowledge of a particular form of ''medicine''... well, I just wonder about you. I see here that some American soldiers who were recently captured were killed by Al Qaeda. Come to think of it I have not heard of any American prisoners of war... I wonder why that is?
I'm sure these unlucky soldiers were brought to the brink of death by torture many times before they died as that's just what crazy jihadists do. Then I read about the first-class medical and humanitarian care given to the Al Qaeda prisoners taken by the Americans. I must laugh! I know that with certain medicines (and certain techniques that I learned back in 1985) that I could extract much useful information from these swine, but hey, it's a different world today right?
I am anxious to see if this 'enlightened' American strategy works to deter future terrorists and if it garners useful intelligence. I know that your various human rights groups are somewhat appeased by the kind treatment of the fanatical islamists, but in my country, well, we don't have human rights groups (at least not for long). HA! I jest. I do miss the old days though (sigh). Good luck with your new approach at war, but if you need my assistance I am always ready to lend a syringe, some pavulon, and some hemostats.
I'm sure these unlucky soldiers were brought to the brink of death by torture many times before they died as that's just what crazy jihadists do. Then I read about the first-class medical and humanitarian care given to the Al Qaeda prisoners taken by the Americans. I must laugh! I know that with certain medicines (and certain techniques that I learned back in 1985) that I could extract much useful information from these swine, but hey, it's a different world today right?
I am anxious to see if this 'enlightened' American strategy works to deter future terrorists and if it garners useful intelligence. I know that your various human rights groups are somewhat appeased by the kind treatment of the fanatical islamists, but in my country, well, we don't have human rights groups (at least not for long). HA! I jest. I do miss the old days though (sigh). Good luck with your new approach at war, but if you need my assistance I am always ready to lend a syringe, some pavulon, and some hemostats.
Saturday, June 02, 2007
Friday, June 01, 2007
Thank You America
Thank you MDOD staff for your kind welcome. I hope I will be able to add constructively to the discussion about American "Health Care" from a more, well, realistic perspective. First might I suggest that you invite all malpractice attorneys on a complimentary "mystery cruise" which I will be happy to plan with some contacts that I have (I will personally see to their comfort). Secondly, I can arrange for collection of all past due medical bills, again, through some dear friends that are currently in this country seeking employment. Also, I can set up a free stay at a very fun "camp" for all current employees of JCHAO (did I get that right?) and also for certain non-medical administrative personnel at all American hospitals. Finally, I would like to arrange a special treat for all physicians specializing in the treatment of fibromyalgia and all physicians who believe that their feces is non-offensive. I do believe that these "core measures" will give you a good start in resolving your current "crisis". In this space I would like to personally invite Senator Clinton to accompany her fellow attorneys on the aforementioned cruise.
хороший bye для теперь
хороший bye для теперь
Welcome Dr X
We at M.D.O.D. would like to welcome to the fold a physician who calls himself "Dr. X". He hails from mother Russia and has come to the United States by a rather circuitous route that he refuses to divulge to us. He certainly appears, after speaking with him over a secure phone connection, to be a physician. Not surprisingly, he has some very strong ideas about medicine and other things. We have agreed to allow him to post here on a trial basis and are hoping that his unique perspective will add to the fun. Welcome to you sir.
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