Sun, Sea and Surf

Sun Sea Surf and Serious?

2011-03-05T15:58:00.002-05:00

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?

Physician Duties/Ethics in Public Health Emergencies

2010-05-11T01:24:00.003-04:00

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.

A hundred dead people in my truck

2010-01-19T00:56:00.004-05:00

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.

Coaster Tour of Coastal San Diego

2009-09-08T17:09:00.030-04:00

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.

AED needs of the mariner community

2009-08-13T17:01:00.002-04:00

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."

Every seat a window seat

2009-07-30T12:55:00.002-04:00

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?

Sell the freeways!

2009-07-23T02:20:00.013-04:00

Proposal to State Legislators, CalTrans and Governor Schwarzenegger

Objectives:
1. Create revenue for the State of California while maximizing use of State Controlled Land.
2. Pedestrianize, densify, and beautify the economically viable business micro-communities which have sprung up around California freeways by removing ugly, dirty and chemically hazardous gas stations from that business mix.
3. Decongest local traffic patterns adacent to freeway on/off ramps
4. Efficiently make use of land and reduce sprawl.

Background:

In many cities on the East Coast of the United States, highway development made use of eminent domain in which private land was seized to make space for highway development. As a result, many freeways and highways in dense cities on the East Coast directly abut residential and commercial areas, with the result that land is maximally used, in some cases with highways built on top of existing structures and real estate.

In these satellite photographs taken from google maps, you can see that highways in New York City are built right next to existing real estate developments with little to no buffer zone.

In Boston, freeways are so intertwined in the downtown area that the freeway goes underneath parts of the city, in the exorbitantly expensive public works project known as the “big dig”.

In England, motorways in the UK have service stations built almost directly near the roadway, practically abutting the same. An example is visible below, on the M5 motorway in the west of England, a fairly rural portion of the country.

In many parts of California, residential and commercial development ends within a buffer zone and in many cases this buffer zone is very wide at the on ramps and off ramps. In some cases, this space is large enough to allow for an alternative use of this space. In some cases, this space is already being used by park and ride spaces, demonstrating proof of concept that viable use of dead space surrounding freeways can be made useful in a safe way (safe to motorists and users of the space).

The proposal:

The State of California could lease this property to private companies, who would then be permitted to build gasoline stations on the land. This would be desirable to private companies because they would get enhanced visibility and traffic from motorists on the freeway, because the gas station would be very close to the highway.

It would also permit the small economic communities which flourish near highways to diversify their function and focus less on services provided to motorists and more on services for local communities.

This would reduce traffic from the freeway as motorists simply needing gas and or a coffee or soda or a place to stretch their legs would not have to really exit the freeway and thus have the effect of causing local traffic to flow more smoothly.

Proof of concept:

At Poinsettia Lane in Carlsbad, there is almost enough space in the southbound off ramp dead
space to fit the nearby structure of the Quality Inn which is the business directly next to the off ramp. There is clearly enough space here to safely construct a small gas station and integrate it into traffic flow. This could have a beneficial effect of possibly removing a gas station from the small mall which is nearby on Avenida Encinas, or decreasing the incredible number of gas stations at nearby Palomar Airport Road.

Palomar Airport Road is a particularly poignant example of poor integration of the freeway into local traffic patterns. At Palomar Airport road there are TWO southbound freeway on ramps, one of which uses an incredible amount of space.

Removing this leaf of the cloverleaf and placing a gas station on the land would reduce traffic exiting the freeway and reduce congestion to local traffic patterns. In addition, a gas station on this land and the existing southbound offramp could be integrated with the existing fast food establishments located west of the highway which would further reduce local traffic patterns and prevent congestion on the local roads which predominantly serve tourists to the upscale legoland park and nearby tourist attractions. This would remove unsightly gas stations from the business mix on the east side of the freeway and permit more up market businesses in keeping with the business mix in the local area.

A motorist exiting the southbound freeway here has the following views to the left and right. Imagine if that motorist could refuel their vehicle without having to fully exit the freeway, by stopping at a refilling station RIGHT on the offramp, and at the same time having access to the food options to the west of the freeway. This would safely reduce local traffic and improve efficiency, beautifying the local area, and providing revenue to the state.

In Sorrento Valley, elevated highways
clog the landscape. A small park and ride ekes out it’s survival in the shadow of these freeways, providing proof that a service station could be built somewhere in this complex and providing revenue to the state.

Another possible site is shown here at Encinitas Blvd.

Countless other examples abound within the state of California. We could generate a substantial amount of revenue, beautify local communities, decrease pedestrian exposure to pollutants, improve local traffic patterns, and increase efficiency of the freeway system by reducing overall transit times for drivers by reducing time spent waiting in congested and often complicated highway offramp business communities.

John Haughey

Images provided by Google Maps.

Union Square Clock

2009-03-12T07:14:00.000-04:00

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.

Emergency Medicine In Training Review

2008-12-28T15:34:00.005-05:00

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.

Awake Cardiac Bypass Surgery

2008-12-05T15:28:00.004-05:00

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.

Can you warm up that ultrasound gel for me?

2008-12-03T21:17:00.006-05:00

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!

New York Harbor Police

2008-11-22T18:34:00.005-05:00

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...

Bodegas and street cats

2008-11-22T18:26:00.003-05:00

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.

Shock

2008-11-19T06:13:00.002-05:00

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
class 1-
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.

class 2-
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.

class 3-
up to 2000 mL blood, pulse >120, decreased BP, decreased PP, RR 30-40, UO 5-15, anxious/confused, replace with crystalloid and blood.

class 4
>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)
http://bja.oxfordjournals.org/cgi/reprint/94/5/556

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

trauma activation
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
rollover
auto vs pedestrian >5 mph impact
motorcycle > 20 mph or separation of rider and bike.

flail chest
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
limb paralysis
pelvic fx
combo trauma plus burn
major burn

Empty Stretchers, Sunflowers and Waterfalls

2008-07-20T06:53:00.004-04:00

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?

Stepwise Sterility of Central Venous Access

2008-05-22T13:11:00.017-04:00

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.

get consent.
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.

Surfing, Ultrasound, Subclavian Placement, and "Del.icio.us for Docs"

2008-05-13T11:15:00.021-04:00

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!

References:
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

Kiss and Sail

2008-05-05T23:08:00.009-04:00

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!

Pets and Hospitals: An Observation about Doggie Social Work

2008-04-24T10:26:00.006-04:00

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.

IT integration

2008-04-19T09:04:00.003-04:00

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!

Topsy Turvy Spin of the News Media

2008-04-15T16:08:00.003-04:00

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.

Black Books - Bernard Avoids Doing His Tax Return

2008-04-15T15:45:00.002-04:00

Snatch Greatest Quotes

2008-04-14T14:09:00.002-04:00

Checking Electric Meters in a Widgetless Wired World

2008-04-14T09:00:00.001-04:00

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.

Resolutions and Opportunity Costs

2008-04-13T00:15:00.001-04:00

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.

site traffic

2008-04-12T21:15:00.000-04:00

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?

Drums Along the Hudson

2008-04-11T19:05:00.001-04:00

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
Music on a barge in the east river
"River Rocks" at Hudson Piers

Movies
"River Flicks" at Hudson Piers

Athletics
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

Ships/Cruises
Schooners Adirondack and Imagine

Bars/Dining
The Boat Basin
The Ear Inn
Gigino at Wagner Park
Older (2005) listing of urban beach bars/dining

Heliport
Downtown heliport with tours between $ 119-275 per person.

Playing the Percentages of Self Sabotage

2008-04-10T03:50:00.001-04:00

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.

Papa's gotta brand new bag

2008-03-21T19:02:00.001-04:00

So I recently brought my lunch bag to work on the one night a week I actually have the time to make a decent lunch/meal for work (see previous post on steak)... When I arrived at work, one of the male nurses who shall remain nameless told me my bag was gay, and offered to set me up with one of the other gay male nurses. Now, I had previously brought this bag to my ex girlfriend's apartment and been told by her female roommate who works at Prada that this bag was a "cool" bag. Perhaps that was the giveaway. I was just happy to find this vinyl bag at Trader Joe's and used it to carry my groceries home one rainy evening when paper would decompose somewhere between Manhattan and Brooklyn.

During my shift, I polled no less than 6 other males (half gay/half straight) whom I was working with, about 5 of whom said it was indeed a gay bag. I have to say in their defense, there are a lot of bright colors, however, the bag has a picture of a ship and an airplane on one side, which I will term the hetero side. However, the other side has a picture of a cock (ahem, rooster), in a car, with lots of fruits. This, fruity side, with the cock, I am terming the homo side.

I am thinking of writing a letter to Trader Joe's. Their other vinyl bag has lots of flowers on it.

I wonder what James Brown would think?

Come here sister.....
Papa's in the swing

He ain't too hip...

about that new breed babe

He ain't no drag

Papa's got a brand new bag

Come here mama....

and dig this crazy scene

He's not too fancy....

but his line is pretty clean

He ain't no drag.

Papa's got a brand new bag

He's doing the Jerk....

He's doing the Fly

Don't play him cheap 'cause you know he ain't shy

He's doing the Monkey, the Mashed Potatoes, Jump back Jack, See you later alligator.

Come here sister

Papa's in the swing

He ain't too hip now but I can dig that new breed babe;

He ain't no drag

He's got a brand new bag

Oh papa! He's doing the Jerk Papa...

he's doing the Jerk

He's doing the twist ...

just like this,

He's doing the Fly ev'ry day and ev'ry night

The thing's....like the Boomerang.

Hey....come on Hey!

Hey.....come on Hey!

Hey....he's pu tight...out of sight...

Come on.

Hey! Hey!

-James Brown.

St. Patrick's Day

2008-03-17T20:05:00.001-04:00

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.

Not even an illegal Irish person in New York can get a posh city job like these NY Sanitation Officers.

I wonder what Jasper Johns would have made of all these American flags passing by the Met Museum with his exhibit inside?

night shift in the mines ooops, um er.

2008-03-14T18:26:00.001-04:00

Two steaks from Costco, dethawed from freezer, marinate in Peter Luger Sauce with shallots, green onions and four strips of bacon, pan fry under high heat with marinade, serve half with mash potatoes, cranberries, insert half into bag and eat during night shift at the mines (oops.. um hospital).

Best of Snatch

2008-03-12T17:43:00.001-04:00

never trust a man who owns a pig farm

NEXT BLOG

2008-03-11T00:35:00.001-04:00

Totally random, and slightly inspired by the best weblogs of 2008 announced recently in Austin at sxsw (which legitimizes the growing LOL language practiced widely throughout the world with the inclusion of the "I can has cheezburger.com" blog as best photoblog).

My personal prediction, since I suck at picking teams for tournaments like march madness, is that stuff white people like is going to win a bloggie next year.

If you are ever bored, having a hard time coming up with an exciting morning case, have writer's block, or are stuck in a hotel room in Tokyo doing a whiskey ad promotion and want to learn a random thing about the world, log into blogger, go to that link for the next blog on the upper left corner, and just randomly read other people's blogs. I ran into this great one about a banker who doesn't balance his checkbook, in his words,

"Balancing Checkbooks is or are the random thoughts of a commercial banker who has never balanced his checkbook in over thirty years. This is something I should be doing regularly but life seems to interrupt me so often. As I said, life interrupts me so don't look for a posting every day."

He also had some things to say about residents and hospitals...

"Friday was the first time that I have been seen by a male oncology resident. I think the doctor needs to tone down his vocabulary somewhat. I don’t think that using terms like “fantastic” and “great” are necessarily the best choices when commenting on patient reactions to the medication.

I also think the young residents need to get a better grip on the time – space continuum concept. The resident said he would step for five minutes while he reviewed my file with the attending physician. Most of the other residents have had a poor concept of how much time would be necessary for a consultation with their supervising physician.

The resident returned twenty five minutes later."

Oink Oink

2008-03-06T20:34:00.001-05:00

There is a line in the movie Snatch, which states that you should never trust a man who owns a pig farm. (See related youtube blog post), this is because a pig can easily devour anything thrown it's way (including human bodies).

As reported in the NY Times, an artificial ingredient in heparin which is designed to look like heparin on drug quality tests but is not heparin. Heparin is a blood thinning drug used when someone has a heart attack, when someone has a life threatening blood clot in the lungs (pulmonary embolism) or deep venous thrombosis (DVT), in dialysis, in heart bypass surgery, and is the only powerful blood thinner that you can use in pregnancy. The benefit of heparin is that it can be reversed quickly and acts rapidly whereas coumadin (an alternative) is not as easy to reverse and takes a little longer to be effective.

The scary thing which has been revealed by the recent product recall and ban on multi-use vials of heparin is that most of the world's supply of Heparin comes from one place: Baxter Pharma, and is made in China, from a plant that was inappropriately inspected by the FDA because the name of the plant was confused for another plant.

Heparin is extracted from PIG intestines. I wonder how this news is going to go down with my devout Jewish patients when I tell them they are getting heparin, they probably didn't know this before but with this recent news I wonder how many will know now.

I have noticed a trend with the inability to use heparin boluses after the multi-dose heparin recall to use lovenox more often... Lovenox, made by Sanofi-Aventis, is going generic late this year, and it is surprising that the stock value has been more affected by that than the probably increase in sales which will come from the scare about heparin. Will be interesting to watch what happens here. Ironically, Baxter stock is not down as much as Sanofi-Aventis, although both are down.

This adds to the list of other "unusual" chemical additives which are not what they seem coming from China. In the past year we have seen melamine which is designed to fake protein content in pet food, and DEG (like antifreeze) in OTC products such as tainted toothpaste from China, tainted cough syrup in Panama, which led to the execution of the leader of the Chinese Food Safety Bureau last year, as well as many deaths due to these harmful agents.

And the scary thing is even if you are an educated consumer who reads labels and consults your doctor, you would never know, since these events made it past doctors and veterinarians, which shows the (misplaced?) trust we place in drug manufacturers and the regulatory agencies which govern them.

Snail Mail

2008-03-04T17:25:00.001-05:00

Am thinking about finally sending some thank you notes to catch up with the rest of the world. Found my stamps and realized I am not entirely sure how many stamps to use, partly since I haven't kept up with the price of postage and partly am still somewhat confused trying to adjust from the An Post mail system, in which one can mail things on Sunday and mail a package from virtually any corner store.

I have various stockpiles of stamp books which I purchase every time I have this problem, last time this snail mail problem was solved by the "Forever" stamp, which is apparently good, well, forever? A large number are going on sale now, until May 12th, when the USPS is changing the price of a standard stamp to 42 cents, yet the Forever Stamp will still work. Read about it here, but not here, because this full rate table will make it clear why FEDEX is superior.

Slide Guitar

2008-03-04T15:16:00.001-05:00

Cleaned my room and dusted my guitar off. Reminded me of seeing this guy play in Dublin, just a random busker, video sucks but this guy can play!!!

Future Generations, Parental Molding, and Online Dating

2008-03-03T00:13:00.001-05:00

I just finished my psych rotation in the ED. This experience, my current residency, and a relationship which ended a few months ago have led me to think about growing up and who I am as an adult.

Invariably this path of thinking leads back to how one was raised, and despite my mother sending me the book which she used to raise me, something called "Whole Child, Whole Parent", by Polly Berends, I still haven't worked out all the twists and turns of my own childhood.

The role of parents in my life today intrigues me. As I thought about my generation, and the impact of generational conflict, I did some googling. I came across an interesting set of authors- Howe and Strauss, who write about generational patterns and archetypes. As I define myself and who it is and what it is that I want, I thought about what I would like my children to be like, and wondered what I would impart to them.

As a 33 year old, I consider myself part of Generation X, my parents were Baby Boomers, and my grandparents part of the Greatest Generation, neither of which dated/had families in any way based on a set of principles or ideas, but merely formed marriages and children based on either the fact that they were pregnant (Greatest Generation), or the fact that they thought it was the right thing to do (Baby Boomers).

The generation now in early adulthood, at least in NYC, is what I like to call the Hipster Generation, raised by parents who grew up in the chaos of the fully developed swinging 70's, early 80's, drugs, the economic booms and recessions of the 80's, the cold war... They adopt the clothes of the swinging 70's, the cultural trends, yet seem apathetic and seem to want to make every artistic measure into an economic success, particularly the internet. Just as their parents experimented with drugs, they experiment with the internet.

They have a sentient knowledge of time before the internet, in other words they were born sometime after 1980 and before 1995, which is the approximate time between the earliest time the "internet" became part of common knowledge, and after the earliest generation X'ers were born.

The new Modern generation succeeds the Hipsters.. and it will be interesting to see what a generation raised by Generation X will look like.

Dubbed the "Quiet Generation" by Friedman , or the "Internet Generation" by Strauss and Howe, some place all children who were alive during the rise of the internet into this group, but I would argue that for the generation to be fully called the internet generation, they cannot have a sentient existence prior to it's creation. Therefore, the Internet generation must be those whose first words and activities were recorded in the internet age, those children who as babies heard their parents use the word "download", or "I-pod", or "PDF", or "email".

You know who these children are. You have read your married friends blog posts about their development in the womb, seen their cute baby pictures in mass emails.

These modern children will be raised by parents and grandparents who were born after humans had been to the moon (1969), birth control pill (1960), commercial jet travel (Boeing 707/DC-8-1961), the Cuban Missile Crisis (1962), the idealism of JFK (ask not what your country can do for you speech-1961), the civil rights era(I Have a Dream Speech 1963), after the conclusion of Vietnam (1959-1975), the rise of HIV/AIDS(1981), MTV (1981), PCR (1983), Chernobyl (1986), the fall of Eastern Europe and the end of the Cold War(1989), mobile phones (GSM standard 1991), reality TV (1991-MTV-Real World), forensic science/OJ Simpson trial(1995), human genome sequence(2001).

Whereas previous generations feared poverty, war, or discrimination, the new Modern Generation was born into a world around the time of a cataclysmic terrorist attack(2001- World Trade Center), and the fears of the cold war/nuclear war have been replaced by rogue terrorist fears such as the Unabomber 1978-1995, Iran Hostage Crisis (1979), Oklahoma City Bombings (1995), Washington Sniper (2002), and school shootings at Cleveland Elementary- "I hate Mondays-Boomtown Rats"- (1979) Columbine (1999), and Virginia Tech (2007), others.

As a Generation X'er, I lived through these events or heard about them from my parents. I have pretty much renounced the role of any external force in my life such as religion or parental wishes to make decisions about A. whether to start a family, and B. what kind of a family life I want, leaving the only significant deciding factor to be my wishes and those of my future spouse.

As I reflect about what I want in an ideal family and how I would raise my children in this modern world, I would hope that my family would be social, enjoying a good connection to the wider community, that they act according to ethical principles and in the interests of being good people, participate in the arts, and have access to a good education and a stable home environment, with access to green outdoors spaces and a safe community. As they grow up, I would hope that my children speak at least one other language and have the opportunity to live in another country and be immersed in another culture.

What will today's children will be like in the future, particularly those children born after 1995 who are now between 0-13? These children, born during the height of the internet revolution, during the dot com boom, have never known a non-technological time, and their parents are arguably the most technology dependent parental group ever.

In fact, it is likely that their parents met using the internet, perhaps arranging a date via either online dating agencies such as match.com, e-harmony, or jdate, or using various other online enabled communities- myspace/facebook/instant messenger/speed dating.

How interesting that we have come to this point, in which the characteristics of future families, future humans, could be determined by what happens on a date set up on the internet? And say, for example, that due to the increased options available in finding a mate, that one is able to find the theoretically "PERFECT" mate for them. Does that translate into a better family life, or a better chance for a happy lasting marriage? Or is the internet only useful in initially connecting people who could potentially be good life partners?

It will be interesting to see how the next generation turns out. It will be one of the first generations whose parents met using the internet- in which parents truly made a decision about each other, and their desire to design a family to their liking, the ability to choose partners from a wide range of society, and the ability to control when and where to have children. Perhaps this more reasoned mating will lead to a correction of the apparent problems of the technology age? Or perhaps this will never solve the most important question- toilet seat up or down?

Booze and Cigs- a Public Health Prevention Scheme

2008-02-28T10:50:00.001-05:00

Having this handy bottle opener around would help you monitor your alcohol consumption, eg, I can think of some patients I see every day who could use one of these as a gift to accompany their discharge papers from the ED. Or perhaps ambulances could stock them and hand them out as a public health initiative- sort of like the NYC Condom idea- thanks for riding with us. Maybe one end could have a cigarette lighter which would monitor your smoking too, and another little application would be a breathalyzer. Yes, another great idea for halfbakery.

Jarvik and Pfizer

2008-02-26T13:18:00.001-05:00

Apparently Pfizer has done something worse than overcharge(Gouge? Extort?) 80 year old ladies for off label use of viagra to treat their pulmonary hypertension. (Viagra costs about 10 dollars for 100 mg, whereas Revatio, which is the same thing (sildenafil), is marketed at 10 dollars for a 20 mg pill which is usually taken three times daily. Change the name, triple the cost, the old bait and switch...)

Pfizer, according to our duly elected representatives in the US Congress ( John Dingell and Bart Stupak), has gotten the inventor of the artificial heart, Dr. Robert Jarvik, who has degrees in both Engineering and Medicine, to speak for lipitor in between rowing sessions. This is supposedly misleading because he allegedly is not licensed to actually practice medicine, therefore his advice on an effective lipid lowering agent should not be trusted. hmmmm. This logic is somewhat tenable (more tenable is the idea that he is decidedly not an expert on lipid physiology), however the irony of what appears to be at face value an honest fairly conservative advertising campaign blowing up in Pfizer's face is more palpable than an atherosclerotic thrombus in the LAD.

in training review

2008-02-26T09:48:00.001-05:00

My peripheral brain for tomorrow's intraining exam, as modeled in House of God by the Ice Queen. However, the mnemonic for gravity and parity is conspicuous by its absence as pointed out by Dr. S, A G3P40089344 woman walks into the ED, huh? Read it if you dare...

good reads vs librarything

2008-02-24T22:54:00.001-05:00

I recently learned about goodreads.com, which compared to library thing is more slick, more social, and has neat features like author's lists, and the ability to sort into different types of "shelves",such as a "to buy", "to read", "to leave on a bench for bookcrossing"...

One problem on library thing is the lack of discrimination between books I have and books I wish to have... However, the geek in me likes librarythings taggability (is this a word?), and it's data-driven method- one can create "clouds", which suggest new avenues to go on from previously read books, as well as generate statistics such as "median/mean library obscurity", as well as generate a gallery of pictures of the authors in your library

While migrating my library to GoodReads, I stumbled on a prescient link from my 2005 blog to the NY Times best 100 books of 2005, which I had come across in December 2005 while doing a winter elective at the Mayo Clinic, elicited most likely by my friend Kat in Minnesota. As I looked over the titles picked as excellent in 2005 by the NY Times, I noticed one, Cormac McCarthy's, has since been made into an Oscar Winning movie- "No country for old men", (a nice addition to the 2007 Pulitzer Prize for "The Road" from this secretive author, and another is Friedman's "The World is Flat", "Glass Castle", "Freakonomics", Marquez's "Memories of My Melancholy Whores" were all in there.

In retrospect, I should have picked up Ian McEwan's "Saturday", a book about a day off in the life of a neurosurgeon...

Fast forward to this year's list, 2007 , and I noticed these ones which look good- "Matrimony" by Joshua Henkin, "Septembers of Shiraz" by Dalia Sofer, "Then we came to the end" by Joshua Ferris, and "How Doctors Think" by Jerome Groopman...

My only question now is where Oprah gets her list?

Class Divide in Brooklyn

2008-02-03T17:30:00.001-05:00

Today, Superbowl Sunday, I had off, and I took the morning to venture out to Coney Island which is at the end of my subway line. I found a surreal place, this picture with the seagull sums it up: some sea life, an aquarium, urban decay, the Verrazano Narrows bridge in the background, and some really ugly public housing.

As I ventured farther down the beach, I came to a fence that extended half way down the beach to a jetty, with a sign that said something to the effect of "this area is closely monitored by surveillance. Violators will be prosecuted". Violators of what exactly? The sign didn't expressly say that you could not walk down past the fence... I would have thought that if that was the case they would have put the fence into the water, or said, no trespassing, keep out, private property... instead it said, this area is being surveiled. This is apparently private beach, although it is unclear where the private property ends, clearly they don't own the water. There is some talk of building public jetties here to protect the private sand, without providing public access. I decided to do my own surveiling and take a picture, and it appears the moss is greener on the left, which is the private side, nicely juxtaposed against the fugly public housing on the right.

As you get up closer you realize the development on the left is Sea Gate, a private gated community, and the developments on the right consist of classy buildings such as "Mermaid Manor"

I was really only trying to get around Sea Gate to take a picture of the bridge, but the guards of Sea Gate and the scary environs of Coney Island deterred me from heading any further into the heart of this island. This was the best I managed to do
Now, I guess the mermaids that live on Coney Island year round are not the ones that participate in the annual mermaid festival, perhaps the mermaids of Mermaid Manor frequent this establishment?

On my way back from trying to get around the lovely development of Sea Gate to take an unobstructed picture of the bridge, I ran into some more citizens of Coney Island. First were the retirees and Russians of Brighton Beach getting their afternoon winter sun.
As I walked around, it began to dawn on me why the Russians love Coney Island. It's just like home! It's cold, with ugly public housing, which reminds them of the communist housing in Russia, and it has decayed burned out buildings reminding them of the fall of the Communists, and it has a large esplanade for them to parade around, sans high boot kicking, with their orange lipstick and heavy furs. It is perfect for the Russians.

As for me, they can have it. I wonder why Coney Island gets the bad rap. It has the same sand that Fire Island and the Hamptons have, same Atlantic Ocean, maybe it is the reach of government projects that spoiled it. I did see evidence that at least some happy people do enjoy the beach, the Polar Bear club came down with their American Flag in preparation for a cold midwinter swim. Seeing the American flag, it got me to thinking about the place as representative of what US government is good at and what US government is bad at, in fact, any sort of government.

Government is good at making fixed assets which require little maintenance, for example the boardwalk, the tennis courts, the public housing. These are victories for Coney Island. Lots of poor people have these resources. However, what government tends not to be very good at is high demand services like healthcare, education, or trash collection, or policing, or other services which require responsiveness from consumers/users to improve them or provide adequate service. There are too many levels of power/bureacracy/politics between the provider of the service and the user.

This became clear to me as I was walking back to get on the subway. I saw a sanitation enforcement officer parked in a Prius, as I was about to marvel at how efficient the NYC sanitation department is, I noticed the officer threw a cigarette butt out the window onto the street, still smoking. I had my camera with me, so I took a picture of the officer's car with the butt on the street, and as I started snapping pictures, she took off.
I did catch up with her a block or two up the street, as she was policing some businesses who had left their trash in bags out on the street. I asked her if she had thrown the cigarette butt out onto the street. She denied it.

On my way back on the subway, I stopped into another little suburb in Brooklyn, a development of houses which was meant to cater to wealthier folks. The subdivision has street names that are based on English place names... In any case, the subdivision is now surrounded entirely by projects and public housing. It is a bit odd to see these huge houses right next to public housing developments, and kind of makes you wonder if it contributes to class/ethnic tensions?But perhaps, like the parading Russian retirees, the midwinter swimmers, and the smoking sanitation worker, it's just life in Brooklyn.

Skills of Laryngoscopy

2007-12-24T05:11:00.001-05:00

Excellent vid on what I will call "goal directed laryngoscopy" by Dr Weingart at Elmhurst Crit Care..here

Costs and Efficacy

2007-10-02T12:58:00.001-04:00

The cost of iv antibiotics was a question raised recently in conference. Is cost a real consideration in deciding which antibiotic to give a patient? I thought this was interesting since a group of my colleagues was recently invited to a night of drinking at a bar in New York on the basis that we should prescribe levaquin (Ortho McNeil) instead of avelox (Bayer) for community acquired pneumonia.

I ran across some interesting
studies, including one, the European MOTIV study which compared avelox to levaquin head to head, showing outpatient use of avelox to be as effective as combined levaquine (twice daily iv) and ceftriaxone (2 grams iv).

There is some concern about quinolones, particularly in the elderly for risks of QT prolongation and tendon ruptures and muskuloskeletal effects(young, old, athletes), and oder quinolones such as cipro do not cover strep very well, and the risk for quinolone resistance due to widespread use for example in the treatment of UTI.

One of our pediatric attendings suggested that quinolones have been used in the pediatric age group in Europe, however I suggested that on the basis of my European experience these agents were often avoided in the young active or elderly patient due to the risks of Achilles Tendon rupture. http://www.jabfm.org/cgi/content/full/16/5/458

In my quiz last week I asked which antibiotic combination is most expensive, the winner for most expensive is TNT- tobramycin and timentin...narrowly beating out zosyn.. both at around 56$ per day from my cost source, this is somewhat old though, since cipro has since gone generic...

and the cheapest- amp-gent, comes in at less than 10 dollars per day.

Yet a better question, at least for those patients, for example with community acquired pneumonia, is probably who should be admitted, and who should be sent home, and what is the most efficient way of arriving at that decision in the emergency department...use of Pneumonia severity indices is one way of doing that, as shown. The AHRQ has a set of guidelinesfor treating pneumonia on an outpatient basis which are useful, in one estimate, the cost of treating an admitted patient for pneumonia is $3000, vs $300 for an outpatient treatment plan.

as follows- the base cost (drug only, not including IV or nurse) of giving a patient the following drugs for 24 hours, obtained from this site at Wisconsin Medical College. Note this is not what the hospital bills...

ampicillin- $ 8.80 (generic)
azithromycin- $19.19
bactrim-$17.64
unasyn- $36.66
ceftriaxone- $ 23.11
cipro- $ 33.88 not accurate- now generic.
clindamycin- $22.89
flagyl-$3.72
gentamicin $1.05(generic)
timentin $48.72
tobramycin-$7.77 (generic)
vancomycin $10.74 (generic)
Zosyn- $56.00

strange architecture

2007-10-01T13:08:00.002-04:00

Two swastikas on public supposedly non sectarian architecture- a US Naval base in Coronado, California and the layout of the Staten Island University Hospital in New York..kinda scary huh? What is it with buildings and terrorism?

Can I get a doctor's note?

2007-09-19T02:34:00.001-04:00

So, this is hilarious, recent Family Guy episode, Osama gets a note from his doctor because he does not want to do a suicide bombing.

Handicapped Trucker

2007-09-12T06:37:00.002-04:00

Handicapped Trucker, originally uploaded by johnsunseasurf.

The driver of this truck is polishing his bumper parked in a handicapped spot in Clearwater, Florida.

Yosemite

2007-09-10T02:40:00.001-04:00

Just back from Yosemite and California, took a few pics which are
here
, had an interesting wilderness adventure, capped off by the flight crew on my flight home
asking, "is there a doctor on board?", to which I did in fact respond in the affirmative.

It's kinda hard to use those crappy stethoscopes in the medical kit they give you on the plane when you are at 20,000 feet...and they give you the entire drug kit for the ACLS protocols, but no cardiac monitoring equipment other than a sphygmomanometer, thank heavens I didn't have to run a code at altitude...

CH CH CH CH Chia.... ....Horse.

2007-08-20T10:05:00.000-04:00

Yes, this is in fact a massive chia pet spotted on the stoop of a west village house. How it got there is a mystery. But it certainly one ups the Jones's... or is it someone's twist on stealing lawn gnomes?

Mind the Gap

2007-07-27T09:57:00.000-04:00

Elevated Anion Gap Acidoses: A summary of approach

A recent summary of a scheme for the evaluation of anion gap metabolic acidoses that I did while at the NYC Poison Control Center. Available at Google Docs- online here.

Ultimate anyone?

2007-07-26T16:18:00.000-04:00

So. just had the annual mandatory fun, resident's retreat at Fire Island and realized it has been so long since I played ultimate frisbee, I am SO sore... the last time I played ultimate was in 1999 when I went to Dublin for the first time, ended up tearing my hamstring and got a massive bruise.. No such luck this time. Now I am resolving to keep myself in better physical fitness, but alas, my frisbee got eaten by Dan Waxman's dog, URSA, or as we like to call her, MRSA. And the last sporting goods store I went to all the frisbees were sold out... but, NO shortage of useless Yankees, Mets, or Jets gear... I mean c'mon, it's not even football season!!!!

So, if anyone reads this and is in New York and knows of an ultimate team for out of shape medical residents, well sign me up. But I will need a frisbee. and lots of ice packs. I found one in Brooklyn... anyone down for that?

Click here to check out
The Bay Ridge Ultimate Frisbee Meetup Group!

EM Procedures - Central Line part 5

2007-02-20T17:59:00.001-05:00

This is a series of youtube videos on central lines which are pretty awesome... Thought I would post them here..

EM Procedures - Central Line part 4

2007-02-20T17:58:00.005-05:00

EM Procedures - Central Line part 3

2007-02-20T17:58:00.003-05:00

EM Procedures - Central Line part 2

2007-02-20T17:58:00.001-05:00

EM Procedures - Central Line Part 1

2007-02-20T17:57:00.001-05:00

ACED it!

2007-01-24T10:03:00.001-05:00

This post is inspired by the fresh rhythm of the posts over at protecttheairway.com...

The patient's chief complaint: ankle pain.

Patient was seen here one week ago and ran out of ACE bandages. Patient walked to the ED in 30 degree weather in the middle of the night in the icy cold, winter, to obtain ACE Bandages, risking slipping on cold icy sidewalks to do so. Patient is WEARING a perfectly good ACE bandage.

When patient is asked if they would like the ACE bandage applied by the doctor, patient states, no thanks, I will just take that and go... It was too expensive up at the pharmacy.

When questioned by the doctor if the patient went to their followup visit at the ortho clinic, patient states, I was never told to go there....

Net cost to taxpayer: 400 plus dollars for ED visit for ACE bandage which was also available free of charge at orthopedic follow up clinic.

Net cost to patient: nothing but a stern lecture in the middle of the night.

Dinosaur Orthopedics: Snow day at AMNH

2007-01-22T00:37:00.000-05:00

OK, so it snowed on Friday

here is a picture of the cemetery on my way to work (which reminds me to do a good job each day....) ! I was pretty excited, not because of all the bundling up New Yorkers have to do,

but because of the snow. WOW. It was cold. That's why special ear warmers were invented. Mostly, however, I went around wishing I had a balaclava on. So, the weather was cold enough that indoors activities were more appealing. So, the order of the day was to go up to the American Museum of Natural History and check out the dinosaurs!

Now,these dinosaurs got me thinking about orthopedics, of all things. Just have a look at the size of the head on this one, for example.
I began to wonder why there were so many varieties of neck and head and vertebral structural variation in the dinosaurs.Was variation in bony structure accompanied by variation in underlying neural structure?

Take for example the tortoise, which is a well adapted species, living hundreds of years. For example, one of the tortoises found by Darwin recently died in 2006. The tortoise has as it's main adaptation a bony armor, which forms the shell, basically preventing it from exposure to trauma, which is life threating in humans, for example, who have an expsoed cervical spinal cord and walk upright (making them liable to fall and undergo head trauma). Ironically, however, the cause of death in one 154 year old tortoise kept in a British Fort was an accidental fall! So much for that hypothesis!

So, I began to think, which dinosaur species was least likely to require a head or c spine CT? Is this a possible candidate?

The whole concept of the Ottawa Ankle rules was very intriguing when applied to dinosaurs and vertebrate skeletons. If you are evaluating a dinosaur in your ED, can it hop three steps unassisted before you scan it's massive ankle? How do you put a C collar on a beast of this size?

Take the camel or giraffe. They have the longest skinniest bones, highly vulnerable to long bone fractures, and a C spine which also places it at great risk. Cerebrovascular disease in a camel, therefore, would appear to make a camel fall down and injure many bones... How can this possibly be adaptive other than the whole reaching for high leaves and seeing your prey from far away arguments?

Altogether a very interesting afternoon, for anyone interested in orthopedics, the dinosaur exhibit is well worth your time.

New Year's Retrospective

2007-01-02T02:00:00.000-05:00

So, I was just looking through some pics, and thought I would put up some cool pics here that I snapped over the last 6 months in NYC. The first one (above) is of Santa riding the L train. It was a very festive Christmas holiday!

Next we have the shot taken from the roof of one of the hospital buildings, I think it is Fierman, in which John discovers the meaning of the word "ph" in an elevator... It stands for penthouse.

Every city has it's own peculiarities with respect to floors. In Ireland, I was constantly miffed by the fact that the ground floor was not the first floor, and what I thought should be the third was actually the second. Here in New York I have had to grasp a whole new vocabulary... mezzanine, lower level, and Sabbath elevators. I determined that it takes approximately 3 minutes to get to the top of one of the twelve story buildings in my hospital if you get stuck in the Sabbath Elevator.

In any case, one of the perks of New York is the rooftop scenery. New Yorkers love their rooftops! Here is an example of the rooftop at the Met, with art from confiscated sharps at the airline security checks...

I ventured north to Boston and saw some trauma backboards being used for a more relaxing purpose, a parkbench, and quite the ham that I am, had to take a photo op...

While in Boston, there was a competition to carve several thousand pumpkins on the Commons. Apparently there is a competition between towns in Mass. to have the most carved pumpkins. Jack o'Lantern turnout was an estimated 24,000 plus pumpkins! As well as some cool rowing on the Charles!

Thinking back to summer, it feels like just yesterday when I was hanging out on the piers on the Hudson...

And watching the sunset on Fire Island...

I even got to take a trip to California and catch a California sunset! and enjoy good times with the cat, grandmother, and fire...

pushing paper and drugs

2006-11-28T13:38:00.000-05:00

How come no one on Grey's Anatomy or scrubs ever has to write a chart? Or wait on hold on the phone? How come they never show the nurse saying, please put that order in the computer? Or, here is the form for that? Or, you have to fill out this paper to bring this patient to the CT? Or, no, you can't have that medication without filling out this form. How come when Dr. Mc Dreamy says, Did the patient get an MRI no one hands the intern ten papers to fill out to get the MRI, the MRI is magically done? Yes, we do see the doctors pushing the patients down the hallway, but do we see them doing their real job, which appears to be pushing paper?

At home, my mom asks me... do you know who the interns are on this show? Do you know the story? Grrrrr. Don't spoil it for me mom, if you talk during the show I won't know what happens at the end... I am waiting with baited breath for the paper pushing doctor to appear.

Post Turkey Tryptophan Toxicity

2006-11-28T13:30:00.000-05:00

The Journal of a Gypsy Doctor

Yesterday I came back from my first 9 day vacation away from the emergency department. It was turkey day, so my tryptophan levels must have been sky high.

I wasn't the only one with toxicity... My patient with digoxin toxicity: " Can you please gag the patient in the next gurney?"... Me: Gee, Attending, I think she might be a little altered, she wanted to gag the patient in the next bed... Attending... Maybe that's her baseline, maybe she's just cantankerous?

I guess I forgot how to be mean on my vacation, when I came back
yesterday, I was just like "oh you are standing in the emergency room
looking lost and you want to use the phone to call your cousin from
vermont? oh sure I can help you with that".... or.... " hi I am the
clueless surgery consult from upstairs and I can't find patient
booboohead can you show me where they are?, no problem, here they are,
let me drop what I am doing and log in to this computer terminal and
show you." Or the patient handing me a bottle of urine in the middle
of the chart writing area and smiling..grrr. several choice statements
and comebacks left my vocabulary for the past week... I felt aphasic,
I couldn't even name the peak flow meter to the nurse, I went looking
in the drawer for the puffer thing the patients blow into...I spent half my shift happily chatting to people instead of doing what I was supposed to do as an intern.... which is writing my notes, pushing paper, slipping x rays, calling primary doctors, calling the lab, waiting on hold.

I am arming myself with these for tonight... there is a public
telephone in the lobby... or... did you ask the charge nurse? did you
ask the consulting resident where the patient was? or... when you are
done with the urine, please hold on to it until I return...or.... this
is a chart writing area, although this counter looks like a desk in a
hotel lobby I am not your concierge nor will I be leaving a mint under
your pillow... or...in a more monty pythonesque vein (you have to see this movie to really understand this one) think of this counter more as a castle wall from
which I fart in your general direction.

I love the ploy where the ambulance brings in an unresponsive patient
and the third year resident says... ok, John do you want to
take this one, it will be a good experience for you, not quite a
stroke code but not much to do, just a bunch of stuff to get
cooking....Gee, I am kind of swamped... Oh we all are... we need
a stat CT Head, C spine, Portable chest, ABG, you need to talk to the
family, get those labs, check those labs, fill out that paper for the
CT, write the chart, consult the CCU and the MICU, and don't forget
about the other six patients you have.

Then there is attending number 1... Make sure you call that private attending and
discuss whether this man who walked here needs a stat MRI tonight or
whether he can wait till tomorrow. Why hasn't the radiologist called
back with the report? Radiologist.... Yes Call the sono lab, they are
reading the reports there. Lab... the patient is on the table still
getting the study which was ordered four hours ago... Sir, I am
sorrry, the report is not available because the patient is still
getting the study.
Then Attending number 2... I thought that patient was ready to go when
Attending number 1 signed out to me! I thought everything had been
arranged! Why is this patient still here?

Me. 10:30 pm, 14.5 hours after my shift began. Why am I still here?

Panaderia

2006-09-04T17:04:00.000-04:00

Today I had Labor day off and went into the city. I stopped at the Mexican grocery across from my local Halsey stop and found some Mexican Pan. It was comforting to see the brightly colored bread, sweet on the inside, with the aroma of Mexico. I was reminded of trips to the panaderia in Rosarito Beach halfway to my grandfather's house in Mexico. And I had a thick Limon ice, which was delicious as I waited for the L train. What a glorious day. Que bien.

Hospitals and Subways

2006-08-20T21:12:00.000-04:00

Is it just me or is it a little ridiculous for the NYU Joint Hospital to have a sign on a subway stop at First Avenue and 14th St... when that subway station doesn't have ANY handicapped access?

How exactly are the patients supposed to utilize that facility from the subway if they can't climb stairs?

Or that almost none of the subway stations in New York City have Automated External Defibrillators? And EMS personnel dread those calls to the subways. They have to lug three bags of equipment down to the subway when called to a cardiac arrest or medical emergency in the subway.

But far be it from me to comment... I am just a new to New York kinda guy.

Queen Square Patella Hammers

2006-04-24T14:47:00.000-04:00

As promised, the experience of my final medicine OSCE deserves a blog post. Or rather, my SOSCE, which stands for Subjective Objective Structured Clinical Examination. We all got gussied up in our suits, struggling to find a place to lodge those Queen Square Patella Hammers, stethoscopes and penlights without looking like we were construction workers with massive utility belts. Honestly, there is no justification for the design of these patella hammers. There is NO good way to carry them around apart from poking a hole in your pocket and having them protrude ridiculously from it. Hence the phenomenon of doctors checking reflexes with stethoscopes.

We all sighed with relief with the announcement that funduscopy would not be required. Come to think of it, I would rather have used my ophthalmoscope with the eyes not dilated in broad daylight using the largest diameter setting than my Queen Square Patella Hammer. Which says a lot. May Gordon Holmes turn over in his grave (did you know he was Irish?). Here is another interesting pre-exam fact which Brian Hayes pointed out to me. Apparently Abraham Colles, of RCSI and Colles Fracture fame, was succeeded by Smith, who, apart from describing the opposite fracture, also performed Colles autopsy. Also, thanks Brian for pointing out that the glabellar tap is performed by percussion whereas the jaw jerk is performed with the patellar hammer.

clustr map

2006-04-23T01:07:00.000-04:00

I am excited to have a clustr map on my myspace.

I was looking for people on myspace who live in far away and exotic places to add to my map, and I am disappointed most of you people who say you live in Greenland or Antarctica or Madagascar or the South Georgia Islands don't actually live there...if you know anyone who does, tell em to view my profile so I can get a dot from there.

According to Myspace there are 2308 inhabitants of South Georgia and the South Sandwich Islands between ages 18 and 100. I find that interesting considering that the South Georgia Islands and South Sandwich Islands (SGSSI) (further to the south-east) are a UK overseas territory see website. Continuous UK administration has been in place since 1908. At the height of the whaling period some 2,000 people lived on the island. Now there no permanent residents - but there are two British Antarctic Research Stations (Bird Island and King Edward Point), two Museum Curators and a Marine Officer and his wife.

Here is what it looks like ...

The Heard and McDonald Islands are also very far south... see website

If you are one of the 2039 estimated myspace residents of these places, you are just demonstrative of everything wrong with american culture. it's not an island so you can make a joke about big macs... currently there is no permanent resident population, and there are no ports or harbors... here is what really happened there: In the five years following the discovery of Heard Island in 1853, and of its reporting in newspapers around the world, more than 50 visits were made to land gangs on the island to kill elephant seals and render their oil.

Doesn't sound so cool anymore does it....

The killing and rendering of elephant seals at Heard Island commenced in 1854/55 and oil production peaked in 1857/58.

Following the near destruction of seals on the island by 1859, oil production continued until 1877. Up to this time more than 40 vessels, almost all from the north-eastern United States of America, had made over 100 voyages to the island.

The poor weather conditions at Heard Island and the lack of sheltered harbours along its coast meant that many vessels ran aground at the island, occasionally sinking in view of the sealing gangs that awaited their return.

There are few details of brief, sporadic visits to Heard Island by sealers and whalers in the early 20th century, and no records of sealing activities occurring on the McDonald Islands.

Now here is a little information about Christmas Island for the more than 3000 myspace residents of that Island who think it is a joke to say they are santa and live on Christmas Island (courtesy of wikipedia)

Since the late 1980s or early 1990s Christmas Island periodically received boatloads of refugees, mostly from Indonesia. These, and the occasional illegal fishing boat, were never a large issue, often welcomed by locals who looked forward to the exploding of the boats once the "boat people" had been processed. During 2001, Christmas Island received a large number of asylum seekers travelling by boat, most of them from the Middle East and intending to apply for asylum in Australia. The arrival of the Norwegian cargo vessel MV Tampa, which had rescued people from the sinking Indonesian fishing-boat Palapa in international waters nearby, precipitated a diplomatic standoff between Australia, Norway, and Indonesia. The vessel held 420 asylum seekers from Afghanistan, 13 from Sri Lanka, and five from Indonesia. The standoff eventually led to the asylum seekers being transported to Nauru for processing. Another boatload of asylum seekers was taken from Christmas Island to Papua New Guinea for processing, after it was claimed that many of the adult asylum seekers threw their children into the water, apparently in protest at being turned away. This was later proven to be false.

John Howard, the Australian Prime Minister, later passed legislation through the Australian Parliament which excised Christmas Island from Australia's migration zone, meaning that asylum seekers arriving there could not automatically apply for refugee status, allowing the Australian navy to relocate them to other countries as part of the Pacific Solution. As of 2005, the Department of Immigration has begun construction of an "Immigration Reception and Processing Centre", due for completion in late 2006. The facility is estimated to cost $210 million, and will contain 800 beds.

I don't think that's very cool.

As for the 1801 myspace residents of the Marshall Islands, I can only wonder why they want to live on a nuclear testing site.

Did you know that as of Dec 31 2005 there were more than 1.3 million US military personnel deployed in more than 100 countries? When you compare that to the estimated 10 million undocumented persons living in the US, I think it is silly to say for the US to say that there is a problem with undocumented people. I mean, for every armed American who is prepared to die to defend freedom and our way of life, there are 10 people who are living peacefully and just going about their business, living free in the USA. What's wrong with that? Just give em citizenship. Heck, give the whole world US citizenship. Why not. Whoever wants it should be able to get it, whoever doesn't want it doesn't have to have it.

I mean, seriously, if people on myspace can live wherever they want what's the big deal with a few immigrants?

Besides, most of the stuff we use in the USA is made somewhere else...

baby names and google

2006-04-20T14:49:00.000-04:00

names

apparently it is all that to name your kid funky names. gwyneth paltrow and apple, the new cruise kid suri, grier from brooke shields. and who ever heard of pilot inspektor for a kids name.

ok but although according to freakonomics your name has no impact on your life, in google suggest this is not the case. Try it and see what your "Google Suggest Number" is...

http://www.jerrykindall.com/2004/12/10_google_suggest_number.asp

http://www.google.com/webhp?complete=1&hl=en

apparently there is even a google suggest alphabet, which on launch day was:

a: amazon
b: best buy
c: cnn
d: dictionary
e: ebay
f: firefox
g: games
h: hotmail
i: ikea
j: jokes
k: kazaa
l: lyrics
m: mapquest
n: news
o: online dictionary
p: paris hilton
q: quotes
r: recipes
s: spybot
t: tara reid
u: ups
v: verizon
w: weather
x: xbox
y: yahoo
z: zip codes

census

2006-04-19T22:34:00.000-04:00

Sunday the 23rd is the Irish census. I filled out my section. According to it, I am Irish American, it asked me how far I travel to work and how, what my level of education is and if I volunteer. Quite comprehensive. And apparently you can be fined a substantial sum for refusing to participate. I wonder what happens if you tick the boxes wrong. Do the census police come after you?

The last push

2006-04-18T22:46:00.000-04:00

It is late April. Where did the time go? I thought it would never go this fast. I have had a busy few months, obviously, since February 1st. I knew I was not going to match on Match Day due to the impressively "unresponsive to my pleas" errors of my medical school and the ECFMG. So, I ended up flying to New York City to participate in the Scramble. I negotiated the Scramble from my laptop computer inside a Kinko's on the Avenue of the Americas. I used my SKYPE phone to make phone calls, all from my computer. Then, when I finally got my c.v. through to some programs, being on the ground in the city enabled me to interview in person for a position. I lucked out being there, but since most of the unfilled programs were in NYC, it was a good strategy move in retrospect. I would have regretted not going.

One highlight of my visit was getting to see my grandmother. For a woman in her 90's she gets on remarkably well, continuing to drive! To think that the state doesn't enforce a night driving restriction on her, she only does that herself, makes you realize just why they were the greatest generation. How many younger people would voluntarily restrain their activities like that?

After coming back to Dublin, it was time for more study in preparation for finals and Step 2 CK. When I took this exam, some of the questions were just very tiring. It seemed like every question told you the patient's BMI and a whole slough of useless information, where you had to read the stem for the one significant clue. Several gems of questions focused on AMS people being brought in by concerned spouses and significant others. It was so formulaic it was ridiculous, but I really had to giggle at one question in which I was asked to discriminate the toxidrome of the munchies to determine what drug of abuse the significant other who had recently run out of an illicit substance, and had been avoiding work had been using.

I took USMLE Step 2 CK in London, got a chance to sit on the footsteps of St.Paul's and think about the last twelve years since I sat there last. When I was there last time it was 1994, I was 19, and just there for a year of study abroad. Now I am almost done with school, and it made me think, being there sitting outside that cathedral. Cathedrals take a lifetime to build, they are impressive in that way. Similar in many ways to professional education. Yet, I hardly feel like a cathedral.

Ah well. Also got a chance to pop over to the British Museum and have a look at the drawings of Michelangelo. He was pretty good at representing anatomy, apparently he wanted to publish his own drawings as he did dissections (but never ended up doing so) to make sure he represented the muscles correctly. As I was looking at his sketches that he did for the sistine chapel and for other works such as David and the Pieta, I began to realize that he had to do several sketches in advance, to get the perspective and points of view right. It became interesting to me when I thought about it, very similar to reading an x ray or CT in terms of visualizing in 3 dimensions. He would do sketches from points of view never visible from the viewers perspective, just to get the dimensions and sculpture right. It was interesting.

Here are Michelangelo's thoughts before he died. He was a fascinating figure. While I was in the British Museum, I had a peek at the Rosetta stone. It was a stone which enabled translation of ancient hieroglyphics. Fascinatingly, it only came into the possession of the British through military conquest. Speaking of military conquest, apparently things don't change much. I saw several exhibits of the Assyrians and other civilizations in Iraq in the British Museum. One of the exhibits displays a bas relief of some soldiers in a conquest in Iraq. The caption is telling, things don't change much. I just saw in the news that SIX retired generals have come out stating that Rumsfeld should resign due to his mismanagement of the war in Iraq. One of the interesting points I saw in the argument was that the civilian control of the military remains paramount to our democracy, but perhaps is very irksome to the retired generals who view his conduct as arrogant. Interesting, because as Republicans arrogantly state big government is bad, and the role of the government should be limited, this obviously doesnt apply to the way they run things, from Cheney shooting hunters to Rumsfeld's micromanagement.

One last note. Recently two commercial airliners were diverted from landing in the Irish Republic due to bomb threats. British RAF Tornado jets were scrambled to escort the planes to landing facilities in the UK. I find it somewhat interesting that in 2006, 90 years after the uprising in Dublin in 1916, the sight of RAF jets over Irish airspace is handled so well by the public. Particularly in view of the recent Dublin riots and the military parade on Easter Sunday. Yet after talking about it with my Irish friends, I realize the Irish Air Force has NO fighter jets. It is inconceivable to many Americans to live in a country without that. But, looking at the Irish Air Force, they really don't boast too much apart from the only Learjets in Europe.

Back in Dublin

2006-02-01T08:20:00.000-05:00

Ok So I am back in Dublin and I have been back for like three weeks. It's nice being back in the hospitals, mostly, as in this picture, we medical students run around trying to find tutorials and read books and attend lectures that only half the time occur when or where they are suppposed to. Basically, its pretty stressful because you go in every day and you never know whether you are going to learn a lot or not. Some days you just want to stay at home and read, especially when you go in one day and only half your lecturers show up and half of the ones that do show up are a pile of crap. We are supposedly attached to teams but everyone is so busy that we dont really have any real responsibilities on the team. Its a pile of crap and its difficult to keep a good attitude. Anyways, apart from that, I met this girl on myspace who came to Dublin and she's pretty neat, I like her a lot, she lives in New York and I have been talking to her on skype, she's cool.

Back from Saginaw

2006-01-06T18:39:00.000-05:00

Went to Saginaw Michigan for an interview, stopped in Grand Rapids to say hello to my cousin Marie Claire and Victor. Saginaw is the home of Dow Chemical... and not too much else. But the interview was cool, I had a chance to sing the fight song of UC Davis, of which all I know is the first line, which is "We are sons of California...", and all the campuses use the same song, but I think there are some particular Aggie/Mustang lyrics in there. Thats random, but I have never been asked to sing a song in an interview before. The other thing I was asked was who my favorite superhero was. I did some research the night before and I was going to say Finn Mc Cool who ate the Salmon of Knowledge, but figured what with the toxicity of the Saginaw River I didn't want to go there.

The Saginaw ED is cool, they have a great program run by the president elect of CORD, and their ED is on the cover of ED Design Guide put out by AAEM. They even have a toy train in the pediatric procedure room, and each pediatric room has a fish tank! Not Level 1 Trauma, but they do have most every specialty, and one of the hospitals does site directed TPA for stroke. Seems like a good place to learn.

Drove across from Wisconsin via Chicago, Michigan is an empty state. Lots of flags at half mast, still, since I was there a month ago in Detroit, apparently this is because there are a lot of troops serving from Michigan who are quite young.

A New Year

2005-12-31T20:58:00.000-05:00

This is a list of notable new books by the New York Times for 2005, it is clear that I am home early on my New Year's Eve! It's still OK, because the Chinese New Year isn't till January 29th, and 2006 is the Year of the Dog!

Detroit

2005-12-25T19:30:00.000-05:00

Two weeks ago I went to Detroit to interview for a residency position there. Motor City is an interesting town. It's sprawled out like LA, but the traffic is nowhere near as bad. There are a lot of liquor stores on the inner city street corners, and not much happening. Despite the fact that the Super Bowl is coming this year, it's a shell of a city. Why can't US automakers start making small cars that are fuel efficient and make the city thrive? At the very least, the Saturn Sky looks promising!

On a completely unrelated note, I was at Wayne State for the interview, and had a chance to go down to the Shiffman medical library there. Upon entering, I noticed a plaque on the door, and was quite surprised to see my great grandfather's name on it. So, since I was there, I looked up some of my great grandfather's work in the bowels of this library that looks like a nuclear bomb shelter. As I sat there leafing through the pages of the journal that he edited for some time, the Journal of the Michigan State Medical Society, I had the chance to see another era of US medicine. In those post World War I years and into the Second World War, there was a definite fear of socialized medicine. The fear was that the US Public Health Service would take over the profession, leading to poor quality, and the erosion of physician independence to make decisions for patient care. At the time, Blue Cross and Blue Shield were started as prepaid health plans, some of the first ones in existence. It is interesting to see how this situation has changed over the years. Looking at the NHS in the UK, it is fair to say our health care in the US is of higher quality. However, one thing I notice about the US is that people get left behind. In the NHS, and in Ireland (a separate system), there is a safety net. At some stage here in the US, we will need to establish a safety net, and whether it is prepaid, or paid by the government matters not.

After my visit to the library, I wandered past the Detroit Insitute of the Arts, and paused in fronth of Rodin's Thinker. Actually, one of many. As it turns out, there are copies of this statue around the world,and the original is in Paris. I don't know why, but I have bad museum karma. Every time I visit a city with a cool museum, I end up going on the day it is closed! So, if you don't like museums, travel on Tuesdays, you are sure to find the museums closed...

Minnesota

2005-12-25T19:17:00.000-05:00

I have been here in Minnesota for three weeks now, doing an elective at the Mayo Clinic. It's pretty cold here, but it's Christmas Day today and the snow is starting to melt! Anyways, the place is huge, it's like a factory town for medicine, with the clinic being pretty much the only thing here. That said, it's an efficient well oiled machine for getting things done! Here I am sitting next to the Brothers Mayo on the steps.

There is an interesting professional ethos around here, something I haven't seen elsewhere, not even at Scripps Clinic in San Diego. Maybe it is the Mayo Model of Care, which I found engraved in the museum here. Certainly there is a lot of history around the place.

results are in

2005-12-01T22:25:00.000-05:00

Got the word today, passed peds, obs and psych. Had the ex-president of the Irish Medical Council in my Peds exam, and faced both external examiners in the Obs exam, one from Trinity and one from Dundee, so it means something to have passed these last ones, not easy were they (couldn't have said it better if I was Yoda). Now just have to pack the old bags and am off to Minnesota for an elective in Critical Care, with trips to Michigan for interviews. Called round to Mick's gaff tonight and saw his pics of him laying the wreath at his grand-uncle Patrick Kavanagh's grave in Monaghan, very feckin cool. Heard interesting stories from Daran about the Jameson Distillery where he is now working, evidently they allow a free bottle of the stuff every two weeks. If a bottle of whiskey is 30 units of alcohol, that just about does it for your alcohol for life if you work there. Today was World AIDS day, so I guess my post about the condoms previously should be taken to heart! Went to an HIV/AIDS conference earlier this year sponsored by Bill Powderley in the Mater and it was staggering to hear what the global burden of this epidemic is, particularly in Africa.

Christmas in Dublin

2005-11-30T17:00:00.000-05:00

Christmas Time!I managed to catch this shot of some buskers playing some music at the top of Grafton Street, with the Christmas Tree.

Then, while walking to my favorite cycle shop to pick up my bike with the broken spokes, I ran into a strange man who was promoting the idea that condoms are not what they seem to be. Rightly so, I suppose, as there was a recent condom scare in Dublin, in which several thousand fake condoms were distributed and sold in shops! More information available at Irish Medicines Board. Anyways, I escaped unscathed and the bike shop didn't even charge me for the repair! I think this is because I called my favorite Spanish bike mechanic "The Man", and he said not even his mother called him that. That made my day. Anyways, the exam results from peds, obs and psych come out tomorrow. Man I am sweating it! Ran into two people from the class walking across town, evidently the day to be out shopping for Christmas! Which reminds me...

Back from Sligo: Without a Fridge Named Saoirse

2005-10-15T04:02:00.000-04:00

Spent the last two weeks commuting back and forth from here to Sligo, on a psych attachment there. Sligo is a small little place, made liveable by the Sligo Higher Institute of Technology, affectionately known as SHIT. At least it's not shite! Lovely little roads to run around on leading to just about nowhere. Apparently however, a nice day in Sligo is a day it doesn't rain, as I was told it's a lovely day on two consecutive cloudy overcast gray days, which evidently were lovely by Sligo standards. It's all relative I suppose. And not to complain, but I am a little curious about the trains in Ireland. What is the story with a return fare costing the same as a single? And just what does the money go for? Is it the classy carriages? Why couldn't they put in some doors that you don't have to stick your hand outside the window to open? It makes me think I am in the wild west gettin off a train in Ireland, goin back 50 years to 1950... This is a little off topic, but my trip to Sligo did have two very interesting revelations about Ireland and roads.

First, I found out the meaning of the song about the N17. For those of you who haven't spent any time in an Irish country disco, the song says, wish I was on the N seventeen, etc etc. Now why would anyone write a song about a road? Well, turns out it's the road from Galway to Shannon, and it's a bit of an emigration anthem... ahem.

The second revelation came as I was gettin my hair cut by a barber on North Earl Street in Dublin, so not technically a Sligo based revelation. In any case, he was telling me about the emergency, during world war II. The government was so concerned about Germans landing here that all the road signs were taken down. Nowhere, anywhere had road signs, you simply had to know where you were going. This might explain why these days it is so bloody hard to find a road sign. I thought it was something to do with the U2 song "where the streets have no name"but it was all about the emergency in world war II.

Also finally found a place to live, nice place by the sea in Portmarnock. Will ride in to city, only 45 minutes cycle... All the looking around though. Spent ages on daft.ie... it really is daft. Got lost looking for a place in Beaumont area, some place called Ardmore with an housing estate with like five streets named Ardmore Drive, Place, Park, Grove, and Close. Of course, I have to walk down every single one because they are poorly signposted, and only three of the five have actual signposts... And this is an estate built post 1950, so the whole world war II explanation doesn't cut much slack for this oversight in roadway nomenclature. Speaking of which, I will have to devote another blog to the phenomenon of the Irish housing estate!

Video Blog

2005-10-14T23:16:00.000-04:00

Introducing the author of the post, check out my video (it's clean)...

Bluetooth

2005-10-14T20:12:00.000-04:00

Well, finally came into the 21st century and got a laptop, and even taught it to talk to my phone... This is all based on a technology which is named interestingly, after a Viking called Bluetooth, who was pretty sophisticated in his own time... I think he might have coined some money. So this whole bluetooth thing is very Monaaay!!!

The interesting part of all this is that now I can take photos with th e phone, which I have done, and some are here! If only I could figure out the panorama feature! The one above I took on a hike in Howth during September, when it was still warm enough to wear shorts. Some ladies were out riding their horses, and the flowers are nice. And the next one is of the view looking across Dublin bay towards Dun Laoghaire and Bray Head.

Stephen's Green

2005-09-28T14:04:00.000-04:00

First Post

2005-09-28T14:01:00.000-04:00

This is the first post to John's Journal of Irish living in Dublin etc. It is Wednesday Sept. 28th. This blog was inspired by Toby's blog about India. It will hopefully be better than my previous attempts.