The title of this blog is supposed to remind me of my blissful days when all that mattered was paddling out to a breaking set and getting hammered by breakers pounding the shore. In life so many things seem like breakers pounding us.. threatening to drive our efforts at making things better into the rocks. When viewed this way, life seems too serious, too much captured in the vortex of energy that occurs at the shoreline. The shoreline offers much besides, and closing my eyes, I try to remember sitting in the wet sand, letting my feet be washed by the water and the warm sun beating down on me and the cool taste of a pina colada... is there only seriousness to be had at the vortex? Or does the vortex of sun, sea and surf offer misty spray? Delights of dolphins? Children playing in the sun? Frisbees and beach blankets?
Saturday, March 05, 2011
Tuesday, May 11, 2010
In light of previous posts on physician ethics in natural disasters such as the Haiti quake, and public health emergencies such as the H1N1 outbreak, I watched an interesting related discussion on UC TV by Ben Rich, bioethicist at UC Davis.
Tuesday, January 19, 2010
Shortly after midnight January 10th, 2010, a magnitude 6.5 earthquake hit Northern California according to the US Geological survey.
Trivial news coverage included this story from the Times Standard in Eureka on NBC about a dog who sensed the quake and bolted out of the room before shaking started
The US quake caused some property damage, but our neighbors to the south were not so lucky.
Three days later, on Tuesday Jan 12th, the Haiti quake was faithfully recorded by the USGS and the tsunami system even predicted there would be NO tsunami.
According to the timeline published by the Merced Sun Star, aid started pouring in to the country quickly, however delivery of that aid was problematic due to the security situation.
By the time the USS aircraft carrier Carl Vinson brought it's aircraft to bear on the situation on Friday, the Israeli defence forces had already set up an advanced field hospital and begun saving lives.
In other words, Israel, a country in ANOTHER hemisphere, had boots on the ground and a secure hospital next to the airport in the amount of time it took the Americans to send an aircraft carrier.
To summarize, the American military response to the Haitian disaster was to send an aircraft carrier when there was a functional airport capable of handling an advance field hospital and supplies, then they proceed to airlift water by helicopter to this airport and guard it with paratroopers from the US 82nd airborne.
The paratroopers which could have been flown FROM the continental US within minutes of a disaster are sent to guard supplies at the airport. Shouldn't the US have started airlifting supplies to drop points from it's Air Force bases rather quickly? Couldn't the 82nd Airborne be sent to guard these drop points? Why in an age of air superiority is the US Military relying on ships to get it's troops in theater?
Why wasn't an advanced US field hospital simply airlifted to Haiti immediately with a unit of troops to guard it? Israel managed to achieve that from another hemisphere, without an embassy undamaged by the quake (the US embassy was not damaged in the quake)
In the US, by the time the Israeli forward field hospital was ALREADY set up, volunteers from local universities such as the University of California at San Diego were shown on local news, packing medical supplies. Desperate emergency physicians in the US were prepared to go to help armed with bandaids, when what was really needed was surgeons and operating rooms for debridement.
The desperation on the faces of these American Physicians and the CNN reporter is evident. They are amazed Israel has managed to achieve what they cannot.
While most media coverage focuses on who is wearing what at the Golden Globes, the football playoffs, and the Leno/Conan controversy brouhaha causes the media to point fingers at NBC, NBC news has reporters and physicians on the ground in advance of the real substantial aid arriving. Dr Nancy Snyderman at NBC called the response within 48 hours and up to 148 hours a "civil war kind of medicine".
A facebook post by a surgeon lamented that he was unable to assist because MSF did not have him on their list of emergency doctors. This reminds me of my residency colleague lamenting the fact that during Katrina the US government sent a swamp boat full of soldiers armed to the teeth to a hospital in New Orleans without space to evacuate casualties.
According to the Merced Sun Star, civilians were treated in Haiti on the USS Carl Vinson on Saturday only after being diverted due to weather. News broadcasts showed Haitian civilians being evacuated by US forces clutching their US passports. What about the quake victims without US passports?
The United States has never winked at invading, sponsoring the military coup of Haiti's original democratically elected president.
As proven in Rwanda, in New Orleans, and every day in America's inner cities, it seems the US Government just doesn't care about black people. Happy MLK Jr. Birthday America. It's a week after a terrible disaster gave you an opportunity to shine, and so far Lady Liberty is looking pretty tarnished for those poor sick hungry masses.
The title of this blog post comes from an aptly named 2008 Irish documentary about Haitian aid workers, in which a weekly convoy of trucks set out to bury people in Haiti. This was BEFORE the earthquake.
I couldn't say whether dogs can really predict earthquakes, but I can say that it doesn't take a genius to spot institutionalized neglect and racism.
The sad thing is that this Haitian tragedy didn't have to happen. It could have been prevented. As Three Cups of Tea author Greg Mortenson and Bill Moyer explained on PBS, for every American troop sent to Afghanistan to be maintained there for a year it costs a million dollars. How much could that money achieve with simple seismic improvements, basic preventive medicine, and a ready and able worldwide disaster relief task team which could be dispatched on a moment's notice anywhere in the world? Sounds like a job for Israel.
Tuesday, September 08, 2009
Tourists in Carlsbad often stop and ask me where to go to see the highlights of North County San Diego. For the best tour of Coastal North County San Diego, hop on the Coaster, a regional transit service running from Downtown San Diego to Oceanside. The views from the train are stunning, and coastal lagoons can be seen in a way not appreciated from the freeway or beach. The Coaster allows access to prime beach communities, outdoor activities, and shopping along the way, and is a great way to see what the region offers. Here are some of favorite picks.
The train leaves views of Mission Bay and Old Town to weave through the Sorrento Valley and Eastern Miramar Region. Along the way, keep your eyes peeled for rustic scenes reminiscent of California's ranch days. The satellite dishes near Qualcomm in Sorrento Valley and the occasional fighter jet or helicopter overhead from Miramar Air Station serve as a reminder of the high tech activities of the area.
Leaving the Sorrento Valley behind, the train breaches onto the coast near Torrey Pines. If your eyes are peeled you may see a deer or many birds off to the left. Runners and hikers alike appreciate the trails that run from Torrey Pines to Del Mar along a bluff protected from the hum of cars. The Coaster runs right through Del Mar and the racetrack is visible from the train. Stop in Solana Beach to stay in resorts like the Auberge, or dine along the beach at Poseidon or Jake's. Head to Pizza Port in Solana Beach for grub and grog before hitting the Belly Up for some live music or stroll through the Cedros Design District.
Cyclists love North County for the ability to ride unimpinged by cross traffic from North to South along the Ocean. To get to Cardiff, get off at Encinitas and go south. In Cardiff, you may spot surfer Rob Machado at Swami's , or meditate inwards at the Self Realization Fellowship. At the end of the day, for seafood try the Chart House or the Beach House in Cardiff by the Sea.
Get off the train in Encinitas for shopping at the Lumberyard or Encinitas Main Street, or just walk north up the Pacific Coast Highway and enjoy a coffee at Pannikin in Leucadia. If you are just after some simple eats, stop in Encinitas and you are sure to find what you are looking for, even if it is hard to find a raw food dish. Don't miss Lou's Records or Shatto and Sons Shirts in Leucadia.
The Coaster allows you to see some wildlife that is otherwise vanishing in Los Angeles and downtown San Diego. See birds in the numerous North County Lagoons north of Torrey Pines, and walk alongside coastal sage at Poinsettia Station. It is too far to walk, but from the Poinsettia Station you may access Lego Land, the Four Seasons at Aviara,shopping at the Carlsbad Forumand the Carlsbad Outlets, and the La Costa Resort and Spa.
Thursday, August 13, 2009
OK, so this is a gem, I received this email (edited for privacy) from an emergency medicine interest group. Why didn't I try and study the AED needs of the mariner community?
When I was doing my residency in New York I sent an email to the FDNY EMS and they weren't interested in putting AED's in the main subway switching stations. They did a preliminary look at the rates of cardiac arrest near a subway station and found it would not be cost effective.
I had an idea to create legislation to put AED's in every television in America, with onscreen instructions in how to use them.. That would probably have saved lives.
Clearly I was not thinking along the right path. I should have taken off and sailed for a month and put the whole thing to rest.
"My name is XXXXX and I am currently a chief resident of the XXXXX Emergency Medicine Residency Program. I have sailed for many years and have an interest in the field of maritime medicine. I plan to do a one month elective at sea on a XXXX sailboat in the Caribbean. I plan to study the medical needs and insight of the mariner community's medical needs, specifically as it relates on on-board AEDs. I was interested if you could forward this to section members that I might talk with further about their expertise relating to this issue and possibly partnering with them on this research initiative. I appreciate your assistance and look forward to hearing from you."
Thursday, July 30, 2009
So if Jet Blue would put a webcam on the wing and have it look down or ahead, or heck, even back at the plane, then display the image on their seat back monitors they could make every seat a window seat! They could even put a cam in the cockpit so we could see the crew in flight! Wait. Maybe we don't want to see that. Is this just another idea for halfbakery?
Thursday, March 12, 2009
I just ran across this pic as I was reorganizing my photos. It is a pic of the clock in Union Square, New York taken March 12, 2009.The clock is called "The Metronome", and is part of an art installation. I learned this mostly by talking to a homeless man asking for money. The numbers from the left signify the time of day. Thus, this photo was taken at 07:14. AM, forty five seconds into the minute. The numbers reading from the right indicate the time remaining in the day. Thus, from right to left, there are sixteen hours, forty five minutes, and fourteen seconds left in the day. The numbers in the middle signify tenths of seconds.
Sunday, December 28, 2008
It's that time of year again. Time for the in-training exam. Here are my review notes for this year, updated as I compile them. Originally posted to Google Docs but there is a 500 KB limit on files. Re-posted to my drop. If you would like to contribute, comment.
Friday, December 05, 2008
There is nothing quite like watching surgery, as viewers of Gray's Anatomy will agree.
However, when the surgery is on yourself, and you happen to be having open heart surgery and you happen to be awake the whole time, I am not sure I would agree. This study, from Italy, examines the outcome of patients who undergo open-heart surgery while on cardiac bypass, while awake. Awake bypass surgery has actually been around for several years, first performed in the UK in 2003, first performed in the world in 1998, and in the USA in 2000. To watch an operation, check it out here. It's not quite like this dramatization, in which a talk show participant takes out his own heart.
Wednesday, December 03, 2008
So, the eternal kvetching point for patients exposed to ultrasound in the Emergency Department is, oooooh, "that ultrasound gel is cold".
I wondered why it feels so cold when it is kept at room temperature? For that matter, why can you touch a blanket when it is at room temperature, and it does not feel cold, whereas a stethoscope, or a metal counter may feel cold.
What is it about the sensation of cold that makes some things which may be 78 degrees seem freezing when your body is at 98 degrees, yet when the temperature of the air is 78 degrees you do not feel cold?
And as another question, does this have any diagnostic significance? Does a patient's response to cold indicate anything clinically? There are conditions with weird temperature findings, so-called hot cold reversal or dysesthesia. For example, ciguatera is a condition in which involved seafood can contain ciguatoxin, which can cause strange neurologic findings, including hot cold reversal.
I went back into the advanced thermodynamics and sensory physiology of my youth and looked all this up...hmmm. Didn't find much.Probably something to do with the specific heat of a substance.
Apparently there is something which scientists are calling the menthol receptor. There is even a knockout mouse!
However, you can actually purchase ultrasound gel warmers. Now that is a posh ER that has those!
Saturday, November 22, 2008
Most days I take the D, N or Q train across the Manhattan bridge from Brooklyn to Manhattan. This is an excellent time to check your email, send a text message, or just take in the view.
The pic above is of a boat named for PO Scarangella, taken by "Tom Hoboken", from flickr.
One morning, I happened to have actually had a cup of coffee prior to getting on the train, and was looking at the wonderful view of lower Manhattan across to the Brooklyn bridge when I saw the harbor police boat... The police officer appeared to be throwing something overboard, perhaps an anchor... The boat appears to be there every morning, and it seems like it would be a wonderful job- to be paid to sit on a boat in the morning and watch the sunrise and just hang out with the waves rocking against your boat...then I thought about it some more, since my secret ambition apart from working an emergency department would be to save lives on the water... What does the harbor patrol officer do?
Is this part of the counter-terrorism effort? Does this boat come to the assistance of people who fall off ferries? Shouldn't the Coast Guard be doing this instead of interdicting drug traffickers? Then the terrible thought crossed my mind.. do they look for jumpers ? Are they paramedics, all set up to intubate the jumper with signs of life? Do they do chest tubes for the inevitable pneumos and have a thoracotomy set up?
I did a little research, and found the story of a woman who apparently jumped from the bridge and was rescued, a Boston paramedic assigned to harbor patrol who hilariously tells the story of a Chinese sailor talking back to Coast Guard dispatch, "never mind color of boat! halfway down!,you come now!", a feral cat rescued from a liveaboard boat by a California harbor patrol, a story about a man who jumped off a gay pride party yacht and was then shot and killed after scuffling with harbor police after his rescue, a story about a beaver rescued from the East River while Harbor Police were on patrol during the Pope's visit to NYC, and a piece about kayakers who got too close to the waterfalls and had to be pulled out of the East River, and the interdiction of drug smugglers by police divers who have been known to sleep in the rudder compartment of cargo ships.
So that's what they do!
While looking around, I found an impressive collection of photos of water traffic in this blog about New York Harbor...
So it is exceedingly cold now in New York, and most likely for this reason, a mouse appeared in my house. Now, the ecology of urban living is most interesting. I have noticed in the past few days a peculiar smell in the local bodega, it smells like cat piss. Now, this is the whole reason I started going to this Bodega, because it did not smell like either cat piss or gas from the gas refrigerators. So I asked the staff in the bodega and they said they had a cat, but that they have not seen the cat in a while... so perhaps the street cats are pissing in the bodega because it is so cold outside... I will be most happy when the street cats learn to use a litter box.
Wednesday, November 19, 2008
A concise listing of things to know about shock, hopefully to be updated frequently.
Shock is defined as inadequate perfusion to meet the needs of tissue metabolism.
Shock can be compensated or decompensated.
Decompensated shock is defined as shock plus systolic hypotension, or
IF BP is unmeasurable, defined as absent distal pulses, prolonged capillary refill, cool extremities, tachycardia, altered mental status (decreased level of consciousness/responsiveness)
Maximum allowable heart rates.
newborn-to 3 months- 85-205.
3 months to 2 yrs- 100-190.
2 yrs to 10 yrs 60-140.
>10 yrs 60-100
MINIMUM acceptable blood pressures
below 12 hours of life and less than 1 kg of weight. 39 systolic.
12 hours of life, 3 kg neonate- 50 systolic
neonate- 96 hours of life- 60 systolic.
Infant- 1 month to 1 year- 70 systolic.
child from age 1-10 =[70 + (2x age in years)]
child age 10 plus= 90 systolic
Criteria for dehydration in children.
minimal (<5%)dry MM, plus or minus tachycardia plus or minus decreased UO.
there will be NO depressed fontanelle, sunken eyeballs, abnormal turgor, cap refill prolonged, weak pulses, hypotension, hyperpnea, altered mental status, or acidosis.
moderate (5-10)positive for dry mm, tachy, depressed fontanelle, sunken eyeballs, decreased uo, PLUS or MINUS turgor, altered, acidosis.
severe (>10) requires weak peripheral pulses, hypotensions, hyperpnea, altered mental status, acidosis, high urine sp grav.
class 1,2,3,4 hemorrhage
up to 750 mL blood loss, pulse less than 100, normal BP, normal or increased pulse pressure, rr 14-20, UO >30 mL/hr (0.5 ml/kg), slightly anxious mental status, replace with 3:1 crystalloid:blood.
up to 1500 mL blood loss, pulse >100, normal BP, decreased PP, RR 20-30,UO 20-30,mildly anxious. replace with 3:1 cystalloid:blood.
up to 2000 mL blood, pulse >120, decreased BP, decreased PP, RR 30-40, UO 5-15, anxious/confused, replace with crystalloid and blood.
>2000 mL blood, pulse >140, decreased BP and PP, RR >35, negligible UO, confused/lethargic, replace crystalloid and blood.
Metabolism generates ATP which keeps biological membranes intact and functioning (brain and cardiac).
ATP can be generated through anaerobic and aerobic metabolism.
Although seemingly logical, ATP cannot be injected directly into a tissue to improve performance, for a variety of reasons. British Journal of Anaesthesia 94 (5): 556–62 (2005)
Anaerobic glycolysis does not require oxygen or mitochondria, it occurs in the cytoplasm. It generates lactate and acid as a byproduct, leading to lactic acidemia.
Aerobic metabolism requires oxygen and the electron transport chain of the mitochondria, it takes longer than anaerobic glycolysis.
For perfusion to occur, cardiac output must be maintained, which requires heart rate and stroke volume. CO=HRxSV
ejection from auto
death in compartment
pedestrian thrown or run over
speed > 40 mph
deformity >20 inches
intrusion > 12 inches
extrication >20 min
fall >20 ft
auto vs pedestrian >5 mph impact
motorcycle > 20 mph or separation of rider and bike.
two or more prox long bone fx
amputation proximal to wrist/ankle
pen trauma to head, neck, torso, extrem prox to elbow and knee
open and depressed skull fx
combo trauma plus burn
Sunday, July 20, 2008
My hiatus from blogging of late has been more to do with commuting to Elmhurst than with an absence of things to say... The empty stretchers are how I like to leave the ER every morning, the sunflowers welcome me home, and the waterfalls mark the ebb and flow of each day. Poetic, hmmm?
Thursday, May 22, 2008
The success of preventing central line infections requires more than a cursory approach to sterility at the bedside, and this is important in the Emergency Department just as much as anywhere else in the hospital. In fact, when I asked a fellow surgical resident how they gown and glove, they said, "the nurses do it for us". In the emergency department, we do not have scrub nurses, and therefore, we must learn how to gown and glove in a sterile fashion. The following sequential approach is recommended when you have time, eg, probably not going to be useful in a code situation, and with all medical procedures, this is not something you should try without appropriate supervision and guidance.
I recommend that you watch the following videos online and try to observe the specific maneuvers which could be eliminated or changed to improve sterility.
If you watch the videos carefully, you will see a few outright violations of sterility, and you will see other maneuvers which are recommended but in fact increase the number of manipulations which increases the chances of transmitting infection.
In the following excellent video by doctors Nicholas Johnson and David Howes, we see a violation of sterility at 07:57 (when placing drape, gloved finger touches the patient's clothes), then at 08:14, the same gloved finger then manipulates the line while attempting to preflush it.
The main idea in doing a procedure to maximize sterility is to minimize physical contact between agents which could transmit infection. So, this means doing the procedure with as few steps as possible. In fact, doing a CLEAN line is faster than doing it in a way that will be dirty, because you eliminate unnecessary maneuvers and demonstrate efficiency of technique. Every movement should be purposeful and crisply and expertly executed.
If you have every worked with tissue culture, cell culture, in a flow hood, in the operating room, you will have learned the microbiologic approach with strict attention to sterility. Pasteur was such an advocate for sterility he wanted people to wash their hands with pure alcohol. In the flow hood, you have access to a flame to sterilize your equipment, and each manipulation is accompanied by a passing of the pipette through the flame. You do not have a flame in the clinical environment, which means you MUST minize contact between objects.
Some of the recommendations below go against what you may have been taught.
choose the site. (if there is bad lung, use that side.
avoid pacemaker side)
make sure the patient has no allergies to lidocaine.
choose an assistant and know their name and experience with procedures. tell them what you are going to do.
verify patient identifier, site, side and procedure with your assistant.
ensure monitoring is in place. make sure you can see the monitor.
1.Gather supplies. You will need a mayo stand or bedside table, central line kit, a line dressing kit, a biopatch, a gown kit with gloves inside, and ONE 10 mL saline flush, and gloves if not inside your gown kit. your nurse or assistant should get a CVP pressure monitoring kit and prepare it.
2. Do not open the kit. Leaving the kit open while you are getting ready exposes the kit to the air, and air carries germs. It is important to remember that one of the greatest discoveries in medicine, that of penicillin, was made when a mold drifted from an open window onto a bacteriologic plate, perhaps from the lab below Alexander Fleming's at St. Mary's hospital. Keep the kit closed until the LAST possible minute, right before you are ready to stick the needle. Think about it, why is cell culture done inside a flow hood? To minimize aerosol and droplet spread of infection.
3. Do not flush the line ahead of time. Flushing the line first means you let the saline sit there in the bucket in the tray exposed to air, then you introduce liquid which is a really good vector for infection, then you let the line sit in the tray with the liquid for a while, which means the line is sitting in a wet medium in the tray, which means that anything that fell on the tray is now on the surface of the line... BAD.
4. For the reasons above, DO NOT put saline flush into the TRAY UNTIL the line is inside the patient, and ONLY when you are ready to flush the line. Remember that the flush packaging is dirty, and have your assistant hold it high above the tray and away from any objects, and squirt it into the tray pocket only. I recommend minimizing the amount of fluid, and not putting it into the bucket in the bottom of the line kit as seen in this video.
5. Choose the site and prepare. Move monitor leads, oxygen lines etc out of the way, and have an assistant hold the patient's head if necessary. Put the patient in trendelenburg if they can tolerate it, otherwise you can do this right before you are ready to go, adjust the bed height, put the table with equipment where you want it, have a trash can for waste ready. Remove watch/jewelry. Wash your hands, with soap or surgical scrub, scrub each finger individually, like you were taught in the OR.
6. Clean the IJ and subclavian site so you can switch if necessary. Open the central line dressing pack or just get some chlorhexidine (since this is all you want). Clean the site with alcohol swabs first, let it evaporate, then once over with chlorhexidine. Remember if you use iodine it has to be dry to work. Take the top of the central line kit off only, but do not take the packing out and do not unfold it.
7. Get yourself sterile. You will be able to tell if someone used the right technique by looking at them in the final outfit. Watch this video and observe that the gloves come up the wrists and cover the gown's collared sleeve.
Put your cap and mask on. If you have big hair, tie it off so it is under the cap. Get your gown on. Have an assistant tie your gown, remember which part you grab while you spin.
Notice that in this video
at 1:12, the operator allows the nonsterile portion to snap over the wrist. This is NOT the appropriate technique when you are wearing a gown.
To appropriately place the gloves while wearing the gown, you must use the "closed technique" . You must study this technique carefully.
Grab the sterile gloves package with the gown sterilely through the gown sleeve, open the package, spread it out so it is a sterile field.
If your sterile gloves pack is not in the gown kit and you prefer to use a specific size, have an assistant sterilely drop the inside of the gloves package onto the gown pack field. The closed technique means you pick up the base of either folded glove with one hand, pick it up high off the field so the glove is not flopping around on a dirty surface, put your fingers through, open them inside the glove, putting the fingers aligned in each finger hole and the fingers through the finger parts since you need them for the next step, but DO NOT pull the double folded portion of the glove over the gown.
If you have BIG HANDS, your hands may get stuck inside the gown sleeve while doing the closed technique. If this is a problem, you can go partially closed, by inserting your fingers so the tip of the gown sleeve is precisely at the crease of your thumb so your fingers stick outside the gown and the elastic part of the sleeve is covering the thenar and hypothenar eminence/half of your hand.
In this way, you can use your fingers to pick up the base of the glove, pull it over the other hand's gown sleeve, but leave the folded part of the glove folded since you now DEFINITELY have a nonsterile portion on the gown sleeve, where your finger touched the outside of the gown sleeve at the point at which your opposing finger picked up the base of the glove, this spot will be covered after you put on the other glove.
Now, use the gloved hand to pick up the other glove by hooking under the folded surface of the glove and inserting your other hand into the glove, now you can bring the glove entirely around the gown sleeve, so that there is overlap of about 2-3 inches of the glove over the gown sleeve.
With this gloved hand, now hook UNDER the folded glove on the first hand. It is important to hook UNDER, since you touched the folded part of the glove before. Bring the folded part of the first glove up over rest of the gown sleeve, ensuring overlap. Be careful NOT to touch the gown with your gloved hand since there is a spot of dirtiness on it from where you put the glove on at the first step.
Note in this video, at 00:10, the operator touches the finger to the nonsterile folded inside of the glove and allows it to snap to his wrist, this is incorrect, he then touches this dirty zone at 00:40 when he readjusts, violating sterility of the right hand.
The operator should have gently dragged the nonsterile portion up the left wrist, and then hooked over from the sterile inside with the sterile right hand to cover this contaminated spot.
Now you are sterile.
8. Now that you are sterile, you may use your sterile fingers to unfold the contents of the central line kit. Remembering that you are sterile, take the chloroprep that comes in the kit, and now do a second cleaning of the site. Your site should already be free of obstructions and have been cleaned first. in this second cleaning, start in the middle of the site and spread outwards in progressively larger circles. Put the prep thing in the trash which you have placed nearby so the nurse or anyone who is watching is happy. Don't throw it on the floor, or just anywhere, they will think you are careless and a slob, and they will think you have not taken pains to be sterile.
9. Finish unfolding the kit. Get the drape. The drape has a white absorbable side and a blue nonabsorbent side. the main thing is that you want the absorbent side to be UP, so that if there is blood, it will be absorbed and not dripping and running everywhere. Now, take your drape and put it over your site. Remember that in any sterile field, you assume that only the central portion is sterile. You must confine yourself to working in the middle. In your brain, subtract about 6 inches to a foot (20 cm) from the edge of the field and do not touch anything in this border zone.
In this video demonstrating ultrasound guidance at 3:53, the hand of the operator is very close to the edge of the sterile drape. Note also at 3:39 in the same video that the sleeve covering the probe touches outside the drape, then at 3:59, the sleeve is draped across the sterile field, at 4:09, the left hand of the operator is pressed against the edge of the sterile field. Be careful when adding steps to minimize unneccessary contacts. Multiple manipulations decreases sterility.
10. Now that your drape is ready, and you are in place, make sure you can see the monitor and your assistant can see the patient. Pick up the lidocaine. You are going to give a medicine, ask your assistant to read the container label to ensure it has not expired- (how long has that kit been sitting on the shelf?). Verify the patient has no allergies to lidocaine. If the lidocaine is in a vial, take a 4X4 or other sterile gauze to hold over the vial while you crack the vial (you do not want to get cut by the sharp edges of the vial, this has happened to me, it means you have to get gloved up again. Draw out some lidocaine. Administer the lidocaine and probe towards the clavicle in the subclavicular space if doing a subclavian, always aspirating before injecting. If you are using the seeker technique to identify the IJ, remember that you do not want to inject lidocaine into an artery if you can avoid it.
11. Now you are ready to insert the needle into the subclavian. Do not take the wire feeder or the dilator or anything out of the kit. With your nondominant hand, stabilize the chest, identify the sternal notch, and hold the chest wall down. Move the bevel so that it is aligned with the numbers, and maintain appropriate bevel orientation (bevel edge to the feet in a subclavian so that the wire goes down and not up. Insert the needle. When you have flashback, take the syringe off the needle, and stabilize the position of the needle, so that it does not move out of the vessel. Pick up the wire feeder from the kit, and advance the wire. It is not necessary to touch the wire feeder against the needle hub, doing so puts force on the needle and can move it out of the vessel. Simply advance the wire into the needle hub without touching the wire feeder against the needle hub.
12. Keep your eye on the monitor while advancing the wire. Dispose of the wire feeder. Slide the needle off the wire and put it in the sharps pincushion. Maintain the wire in the air, and control it. Do not let the wire touch, drag or flop on the drape or skin. Remember that the skin around the puncture site is technically not 100% sterile. Keep the wire high in the air. Get a sterile 4X4 and place it at the puncture site so that the leading edge of the wire rests on the 4X4 and not on the drape or the skin. In this video , at 5:45, notice the blood is oozing everywhere, this could be prevented by a gauze pad.
13. Take the scalpel and orient it parallel to the wire. Go along the wire, and insert the scalpel into the puncture site, slightly dilating the site. See it here at 6:30 in the video . Slide the dilator over the wire. Dilate. Take the dilator off, place it in the tray.
14. Pick up the central line. Do not flush it. With economy of motion, slide the line over the wire, taking it directly in a straight movement from the tray to the wire. Do not let the line drag on the skin, keep the line in the air while you insert it over the wire. Advance the line until the wire comes through the brown port. Insert the line to the desired depth. Watch the monitor. Notice in this In this video , at 6:24, the end of the wire is flopping all over the edge of the drape. Maintain control of the end of your wire and keep it high and away from the skin and edge of drape.
15. Take the wire out, it is wet and bloody, dispose of it. Now your line is in, there is a piece of gauze where you had it before to stop oozing from the site. Do not be concerned that you have not flushed the line. Put the caps on the port sites.
16. Take the biopatch and place it blue side up, put the bridge holder on the line.
17. You may now get an assistant to sterilely place 10 mL of flush on your tray, being sure to squirt the liquid only, and NEVER allow the nonsterile flush container onto your sterile field. Take a sterile syringe and draw up the flush. From the ports, aspirate air and blood from the line, holding the syringe higher than the line, then flush each line.
16. Suture the line to the skin, in three positions.
17. Place the dressing on the line, label it as per hospital protocol.
18. You may now ask your assistant to connect the line to a CVP monitor and confirm waveform and pressure. Doing so at this stage will confirm you are not in an artery.
19. Clean up and dispose of sharps, wash your hands, get a chest x ray and write a procedure note, always note the cvp pressure. Come back and tell your patient how things went, or if you got phone consent, call whoever consented and tell them how things went.
Tuesday, May 13, 2008
One of the major goals in placing a subclavian central line is to avoid pneumothorax and other complications.
To avoid pneumothorax, time the entry of your needle with respirations, much as a surfer would time a wave to catch it at the right time.
Basically, you identify the clavicle with your first probe with the big needle, then redirect, aim towards the sternal notch, and sit, right under the skin, getting in the flow of the respiratory cycle. As the chest rises and falls, time entry of the needle into the vein with the falling of the chest. This will avoid hitting the lung. If you do not obtain access, pull back and wait until the next wave of exhaled air and chest fall.
This diagram from the AHRQ's web Morbidity and Mortality on central line complications shows approximately where you would sit, like a surfer in the outside break, waiting for the chest to come into position for an attempt.
There appears to be consensus that for an IJ, it is the standard of care to use ultrasound guidance for access, this does not apply to all patient contexts, particularly the emergent setting.
A question that could be posed is whether it is useful to use ultrasound to avoid a pneumothorax in subclavian placement, not for the purposes of directing the needle to the vein, but to AVOID directing the needle into the lung. Here is one group that has looked at the question of avoiding pneuomothorax generally. An older review of ultrasound guidance by Skolnick suggests that the axillary vein is the preferred site in comparison to the subclavian for avoidance of pneumothorax due to the lateral position of the axillary vein in relation to the lung. In a complicated series of surgical patients, using predominantly the subclavian approach, Fry, Clagett and O'Rourke et al used ultrasound and specifically address the issue that the plane of the ultrasound image is parabolic (see their figure), thus making it very important to keep the needle in the middle of the image in dynamic access.
The New England Journal of Medicine has a video on some of the other complications that can happen with subclavians, here . A better example of things that can go wrong is here, where a case is presented
It seems obvious that a fracture of the clavicle or ribs in the area would be a relative contraindication to placement of a subclavian, carefully inspect the chest x ray before and after placement to make sure there are no broken bones, particularly in elderly patients who may have fallen and have rib fractures. I have seen a case of a 97 year old lady who had fallen, and a right posterolateral rib fracture was identified only on the post-IJ line placement film (the initial portable film was poor quality). To avoid this, carefully palpate the ribs, clavicles, and chest wall prior to access.
The NEJM video does not mention what to do when the line goes up instead of down. There is some debate about what causes this, some say it is the orientation of the bevel and some say it is the direction of the j tip on the guidewire, other factors may include the anatomy of junction of the IJ and the subclavian at the inominate. The J tip was introduced by Blitt primarily to advance catheters through the external jugular into central veins.
One group (Le, Jin, and Guldner) at Loma Linda replicated this and found it was the guidewire direction that determined the direction of the subclavian, a j tip pointing up led to the placement of the wire going up 100% of the time in a simulation model.
In this case, if access is needed, it may be wise to advance the line not as far as you usually would so that the line does not show up in the brain, and continue to use the line if necessary using non irritant solutions until other access can be obtained, eg avoid solutions like concentrated D50 to avoid thrombophlebitis.
Speaking of surfing and the upper chest, surfers who do laybacks are prone to surfer's rib , an isolated fracture of the first rib. To see why this can happen, check this out!
The "metadata" for this post is that it is my first attempt to use Connotea, which is like del.icio.us for doctors, cool ways of organizing articles based on tags!
Blitt CD et al (1982) J- Wire versus Straight Wire for Central Venous System: Cannulation via the External Jugular Vein. Anesthesia and Analgesia 61(6): 536-37.
Braner DAV et al (2007) Videos in Clinical Medicine. Central Venous Catheterization: Subclavian Vein. NEJM 357: e26.
Fry WR, Claggett GC, O'Rourke PT(1999) Ultrasound Guided Central Venous Access Archives of Surgery 134:738-741
Giacomini M, Iapichino G, Armani S, Cozzolino M, Brancaccio D, Gallieni M. (2006) How to avoid and manage a pneumothorax. J Vasc Access. 7(1):7-14.
Le J, Jin P, Guldner G(2008) Subclavian Central Line Misplacement: Is it Needle Bevel or Guidewire Direction that Influences Line Placement? Western Journal of Emergency Medicine 9(1), Article 39.
Skolnick ML (1994) The role of sonography in the placement and management of jugular and subclavian venous catheters. AJR 163:291-295.
Tripathi, Dubey, Ambesh. (2005) Direction of the J-Tip of the Guidewire, in Seldinger Technique, Is a Significant Factor in Misplacement of Subclavian Vein Catheter: A Randomized, Controlled Study. Anesthesia Analgesia 100:21-24
Monday, May 05, 2008
After my first day of a lighter rotation, had a chance to bike down to Bay Ridge and see the sunset from both Sunset Park and the Brooklyn Army Terminal. Got some amazing views of lower Manhattan and the harbor. Saw a suggestion to kiss and sail... will have to check this out when the NY Water Taxi renews ferry service soon... Also you can probably make out in some of these pictures (may have to click and zoom), that Ikea is now built in Red Hook and their store is prominently visible!
Thursday, April 24, 2008
Last week I had the chance to treat three patients who had pets, all with dogs. They were all very attached to their pets, and they all lived alone with their pets, as many people do in NYC. Two out of the three needed to be hospitalized and were very sick. I do recognize this is a small number, and as much as I understand the need for randomized controlled studies, I agree with the authors of this paper, sometimes an observation is all that is needed to change things. However, if one ER resident can come across this problem in one week, think of the thousands of people in NYC who live alone with their pets and who are hospitalized under emergency circumstances, often without the ability to return home to arrange for a petsitter. After spending time contacting 311, 911, and the NYC Humane Society, I learned that there is NO government agency in the city of New York who will go to a hospitalized patients home and help arrange for pet care unless the party in question wishes to give up their pet permanently. Not even if the patient is being hospitalized AGAINST THEIR WISHES.
I did some research and there are various pet sitters in NYC, everyone knows about dog walkers in NYC. However, I think there is a need for a charity organization who will help care for people's pets when they are hospitalized. Call it DOGGIE SOCIAL WORK, but there is definitely a need. I have heard of patients who actually will sign out of the hospital against medical advice if they are capable just because there is no one to care for their pet.
I did some research and there is now a federal law to hold communities to a standard in evacuating pets as well as people in the event of a disaster or major emergency, based on the Hurricane Katrina experience in Louisiana. I think a corollary should be that hospitals be required to arrange a pet sitter if someone is hospitalized on an emergency basis and cannot arrange such for themselves.
Saturday, April 19, 2008
Relating to an earlier post, a good colleague, nurse S mentioned the pocket informant as the BEST possible personal orgnaizer on the market, running the windows mobile platform. Soon, this summer, Sony Ericsson will be releasing the Xperia X1so I will be able to have organizer and phone all in one place, touchscreen, playing FM radio, camera, post to blog, RSS feeds, assisted gps (mapping), everything I need! Finally!
Tuesday, April 15, 2008
Was looking at my news feeds just now and noticed that on Al-Jazeera they are reporting Carter laying a wreath for Arafat and being refused entrance to the Gaza Strip, the BBC reports an Anti-EU gang attacks Irish MEP Proinsias De Rossa, and the Irish Times reports jobs moving to Northern Ireland. Each of these is ironic in it's own way.
Monday, April 14, 2008
Monday morning, 749 AM. Scramble out of bed to get the door as the doorbell rings. Even in a wired world, every month the doorbell rings early in the morning for the Con Edison meter person to check the meter. The meter maid shows up with an electronic record keeping device, wearing a walkie talkie and a speaker phone that chirps incessantly, but requires me to physically unlock the basement for her to check the meter. Even in a wired world, electric meters must be checked manually.
But how wired is our world? Well, judging by my wireless computer, extremely so!
This sorry state of affairs is due to the general lack of integration of the consumer electronics industry outside the land of mac users who can go from room to room in their house listening to their music on their Airport enabled speakers. My wireless connection doesn't seem to connect in my house, despite the fact that I can connect to my neighbors if I position my laptop in one corner of my room, my laptop battery goes dead after 1 hour, and I can't buy a USB FM transmitter to link my computer speakers to the home theater system (all the ones I can find in the store are powered by cigarette lighters).
I demand a widget. One that will let me connect my PC music output to my home theater, that will connect my paper calendar to my electronic computer, that I can download to my phone. My roommate says I should really stop thinking about a phone as a phone. He says it is an application on a handheld computer, as he sits in the living room and plays pacman on his phone.
Perhaps this is just my inadequacy in getting electronically linked? One of the attendings showed me her calendar on her phone, I asked her, can you really synchronize that with, for example, google calendars? She said she didn't know what that was. I am old school. My version of synchronization is scanning my wall calendar and printing it out, then cutting it to fit inside my leather pocket notepad.
Pocket notepad? Yeah, the other word is "pocket protector". What about a PDA? Nope. If I want to look up a drug dose I have a pocket PDR book. Why? Well, the batteries can't go out, if I drop it, I just pick it up, and if I lose it I just buy another. It costs 7 dollars. Plus, there is NO way that you can crash or stall a book, and once you know the book, you know where to find things fast.
Something tells me that as long as electric meters need to be checked every month by a person, the digital world will remain bound by paper, pen, and human. If that is the case, can't we switch suddenly once all the bugs get worked out? This transition from pen and paper to digital is absurd. It is complicated to remember fifty usernames and passwords in fifty different database/systems, entering the data manually in each, transferring the schedules of my life from bills/pdf/email/text message/verbal announcement/snail mail to my calendar, to carry with me.
I only have one written signature, why can't I have one electronic signature? I need ONE electronic information system to manage my affairs-financial, medical,social, recreational. For example, I should be able to log in to this system with one username and password, and conduct all the business I would do using my brain, eg, pay my bills (bank website/bank statements/atm machines), pay people (cash, check, credit card), keep up with friends (facebook, myspace, IM, cell phones), make travel plans (passport,airline reservation, hotel reservation, car reservation), take a picture (camera), read a book (libary, bookstore), listen to music (speakers, headphones, mp3 player, home theater), make a phone call (cell phone, skype), watch tv (slingbox, tv, dvr, cable box, home theater, remote control, dvd remote, cable remote, sound remote), schedule my week (calendar, phone, pda), compose a patient's medical record (computer, electronic medical record, HIPAA, fax, paper chart, written consents), review a patient's ekg from their private doctor's office (fax machine, photocopy), review their old echo reports (separate computer file), and so on. We do have the current technology to make this possible, we just need to do away with the idea that these are all separate activities.
They are all just information processing, and each has a separate device or technology or government regulation(in parentheses), to process that information, some are paper, some are electronic, some require some hardware, some do not. Everything from meter reading to buying a cheeseburger, it's all processing and exchanging information. We need some "urban planning", some "information architects" in this area. People in the IT world need to stop making LOLcats and facebook widgets and start doing something useful, like the folks who work hard at McD's every day.
In college, I learned about a theory of cultural evolution called the "costly information hypothesis" of Richerson and Boyd. This theory suggests that culture is transmitted easily because it is too costly from an evolutionary standpoint to evaluate each idea/bit of information for yourself, so we take the ideas and behaviors of people who appear to be successful (Britney Spears, Bill Gates), and these spread. This also means that bad ideas spread easily (lolcats).
In our current state of cultural evolution, we have fifty or so systems/classes/types of information exchange which all help us exchange information, yet each is not connected to the other, and each has many intraclass competing technologies. This so called "information sprawl", is a product of people making individual tested leaps in technology, yet no one has unified these technologies into something that simplifies life in a more adaptive way.
Any one technology is relatively low cost to develop and perfect, but the cost of failure in uniting all these classes of technology is so large and the economic benefit of consumers buying many things is so great that it is not adaptive for anyone to produce a unified technology that would simplify your life. Apple appears to be trying to convince us that their sleek machines do this, but in reality, it is just a big peripherals game with the same OS, it's not one unified system.
At the current pace, digital hasn't given us increased simplicity of living, it has made the world more complex because all these activities have a separate form of electronic information attached to them, and each has a separate operating interface and requires a manual backup and user dependent data synchronization. Thinking that the world is wired as it is now is like saying there is no glitch in the matrix. Right now, there is no matrix in the glitch.
Sunday, April 13, 2008
Have had some time to reorganize, rethink and regroup on vacation, and noticed the amount of time and money I put into things that don't always coincide with my long term goals. In the past, I have had a big problem with scrimping and saving and whined incessantly about this, mostly because it brought back painful memories of times when I was extremely poor, in which I had to scrimp and save to get through each month. For example in medical school and undergrad, I on occasion worked up to 30 hours a week in addition to my studies, just to afford rent and living expenses. I would sometimes be so poor that I had to live on bread and tea and potatoes for up to two weeks. I was constantly calculating how much money I had, where the next dollar was coming from and where it was going. I once walked home 12 miles because I did not have bus fare and my bike was broken.
The point is not to have a pity party, but instead to reflect on the fact that something which has such negative connotations (as per my previous post on negativity), can make financial planning unpleasant simply because it has always reminded you of how poor you are. I am now choosing to focus on the positive things that financial planning can do for me, by allowing me to align my expenditures of time and money with my long term goals.
For example, according to my netflix account I have watched 131 movies, which is about 13.1 movies per month, averaging at about 2.48 per movie. If we consider that each movie is approximately 2 hours long, then I have spent about 26 hours per month watching films. Had I used that time and money to workout instead, I would be able to work out more than 5 hours a week, and would be 325 dollars richer.
Take laundry for example. I just washed three loads of laundry which cost $12.50 and took 3 hours to gather, sort, wash, dry, transport, and fold. If I had chosen to drop it off, this would have cost me about $35.00 dollars, which saved me 20 dollars-which could equal a movie night out.
Just based on this analysis, I could think of several other activities and expenditures which could allow considerable flexibility in future goals. I am now resolving to stop drinking 3 cans of redbull on work days, which should save me about 9 dollars a workday, which is about 144 dollars a month.
Together by just washing my own clothes, not drinking redbull, and cancelling netflix, I could save 196.50 a month, which over a year is about 2400 dollars, or about as much as a vacation costs. In addition, this would prevent me from arguing with a significant other about the cost of a vacation, and allow me to spend 5 hours a week working out.
Saturday, April 12, 2008
OK. This site traffic thing I just put on here is interesting. Mostly it is my own visits, yeah, that Brooklyn tag is mostly me, but I wonder who the heck lives in Haskell, NJ and is reading this blog? Out with it. What's in Haskell anyways? It's way out there in Western Jersey in the sticks. , according to google maps anyways. Maybe it's an internet robot. I have few enough of you lot as it is... make a comment! My Cluster Map also shows there is someone in like Chicago somewhere? who like reads this a lot too. Where do you lot come from?
Friday, April 11, 2008
I got into a discussion on the attractiveness and natural beauty of cities and their occupants the other day, and the conclusion was that people in Europe are less uptight, and the cities are more beautiful, partly because their architecture is more historic.
However, I have to reconsider this, especially for example when riding the N, Q, R, B or D trains across the Manhattan bridge at dusk/dawn, that New York's beauty is mostly evident at night when the city is lit up, particularly from the water or in it's skyline views. The fact that NYC is surrounded by water should also theoretically make it a beautiful city for me, a California guy raised near the ocean.
In 2009, we are coming upon the 400th anniversary of Henry Hudson sailing up the Hudson river. I am going to make an effort to list all estuarine or river related activities in NYC, and make a resolution to attend some of them in the coming year.
Prime among these as a source of information is the Hudson River Park Trust.
I have NOT been to any of the following venues, that's why they are here. Actually, this is a great idea for a Meetup Group- nautical themed activities in NYC...
6th Annual Drums Along the Hudson Native American Festival and Shad Fest
Saturday, May 3, 2008 11:00 a.m. - 6:00 p.m. Inwood.
400th Anniversary of Henry Hudson
A listing of events to celebrate the 400th Anniversary, including a kayak trip between Quebec and Manhattan
A Dutch group which is participating in a transatlantic sailing race and the 2009 festivities.
Music on a barge in the east river
"River Rocks" at Hudson Piers
"River Flicks" at Hudson Piers
Running/Cycling/Rollerblading on the west side highway/FDR
Kayaking: free kayaking near west side highway at the Downtown Boathouse
Tennis: courts at West Side Highway
Schooners Adirondack and Imagine
The Boat Basin
The Ear Inn
Gigino at Wagner Park
Older (2005) listing of urban beach bars/dining
Downtown heliport with tours between $ 119-275 per person.
Thursday, April 10, 2008
Had the good fortune to be treated to dinner today, not by a pharmaceutical rep, not on a date, not even by a family member. I was treated to dinner today by a truly great physician, who gave me some insight into his career. We talked about the patients who influence us in choosing a practice environment. For example, in an ICU environment, one can invest a lot of emotional energy in caring for someone who is deathly ill, and still they may only have a 50% chance of living. And even in doing so, one may learn that despite one's best efforts, 50% of truly ill patients may die despite your best efforts, and 50% may live regardless of your care. Thus, you cannot have as your principle of motivation the percentage who live or die. Likewise, if you look at any emergency room, only a few patients look truly ill, surely it is no challenge to determine that they need care. Yet you cannot use "the patient appears well" as your criterion to determine whether they are hiding some grave disease, for in 24 hours they may look different.
As I was walking home, I began to think about life and the focus I place in my life on different things. I reflected on the fact that for example, when I am taking a test and I think it is hard, I could only remember the hardest questions, the 20 percent which I perhaps did not know the answers to. These 20% define how hard the test is, not the 80% which I correctly and perhaps easily answered.
Likewise, I was watching Memphis get beat by Kansas the other night in the final four, they appeared to be on the verge of winning the game, then lost on the basis of some missed free throws.
I was working a shift with a guy who I respect a great deal, and I heard him get off the phone, and I remarked, gosh you were nice on the phone. And he said, yes, it helps keep my calm, it keeps me thinking, and it prevents me from getting stressed out.
In life, relationships, work, it all comes down to percentages. And the outlook that you have can be determined by the percentages, or you can make your outlook change based on how you play the percentages.
For example, you can look at the 10% of your day that is marked by negativity, the computer crashes, you are having a fight with your girlfriend, the answering service puts you on hold, someone yells at you, you don't have enough money to go on that vacation. Those things that you don't like, those little pesky dark clouds, they sometimes turn into big black thunderheads. Something that is negative can have higher emotional tone, it draws attention to itself. And it magnifies itself into something bigger than it should be.
You mull over it. Gee, wouldn't it be ideal if such and such weren't this way? This is something I thought about while watching John Adams, the simpering man was complaining even after he was elected President of the US. After you mull over it, something which is a very very small thing takes up too much of your time. That little thing that strikes you as negative, which probably isn't even a big deal anyways, becomes a bigger thing because you are paying it heed.
This is a big problem for competitive people who for most of their lives have been driven to excel. They know the difference between 90 percent and 99%. It's not just 9%, it's everything, it's life, or death. It's the margin of success or failure.
So, that 9% negative in your day/life/relationship builds and builds until it becomes 20%, 40%, 60%, then finally it screams at you, this day just has to end. This relationship just has to end. This computer has to be rebooted.
It is at times like that, when the negatives pile up that you have to think of something positive. To remember that great time you had when you were sitting on the grass in the summer with your girl, to remember the time when you never wanted to leave her arms, to remember all the great things, because if you let the negatives take over you will be left with nothing, and that is not something you want to be left with.
Friday, March 21, 2008
Papa's in the swing
Monday, March 17, 2008
This St Patrick's Day marks the first time I got to see the NY St Patrick's Day Parade. I was expecting a lot of this- pro- Irish sentiment from the Derry crowd, who have had to endure their own version of Irish parading for so many years...
Instead, what I found was mostly an overwhelming show of POLICE and FIRE- what are essentially pro-authority GOVERNMENTAL groups. What happened to the traditional Irish distrust of authority, the Irish belief that power corrupts? When all the Irish moved to New York, did they become the authority that they had been unable to attain in their own country? It made me think about the original St Patrick, himself (like many Irish) a slave in his own homeland, brought to a new land, and became a saint.
Judging from today's turnout in the parade, if St Patrick were reincarnated as an Irish expatriate to New York he would have ended up as either a cop, fireman, or corrections officer.
This is all the more alarming when those claiming Irish ancestry are well represented in the police and fire and community service professions (where were all the Irish teachers in the parade?), yet most of their own countrymen in today's America are here illegally and live a hand to mouth existence. Why is it that there are so many Irish police in America, yet still Irish immigrants must live here illegally?
This was hilarious, I saw several counter-terrorism units scuttling around, with snipers on the roof of the Met where the parade ended. As if the entire parade wasn't full of law enforcement officers and their families.