Booze and Cigs- a Public Health Prevention Scheme

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

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

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

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

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

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

Costs and Efficacy

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

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?

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

Handicapped Trucker, originally uploaded by johnsunseasurf.

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

Yosemite

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.

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

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?

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

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

EM Procedures - Central Line part 3

EM Procedures - Central Line part 2

EM Procedures - Central Line Part 1

ACED it!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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...