Friday, October 31, 2008

The Redistribution of Education

Few things are more important to each individual's future success or to our nation's prosperity than education.Mark Kennedy

Education is the secret to success in the modern world. Sure, some will get lucky and win the lottery or develop Velcro or Liquid Paper, but overall a good education gets you ahead in this world. We would not know of Barak Obama had he not been a Harvard Law School graduate. Obama has seen great injustice because wealth in this country is disproportionately held. This seems logical to me because some work and some do not. Obama wants to provide a tax refund for those making less than $250,000 a year (although Biden is now saying those less than $150,000 a year). Heck, many of those making less than $150,000 a year don’t pay taxes. In fact, they profit from Earned Income Credits and other entitlements. I think Obama is wrong. Let me explain.

The secret to success is education. Education is too hard for some (you have to get up before the crack of noon). Thus, since so many are educationally-deprived, what needs to happen is a redistribution of education. We should draw the line somewhere in the community college setting. People who have Bachelor’s degrees should give 2 years of their education to the educationally unfortunate. Those of us with MDs, JDs, and PhDs should give up 4 years of education. I have a Master’s degree I don’t use often. I’ll donate it to the less fortunate among us. Then, after there has been a redistribution of education, the world will be right. I think nurses with 2 year degrees should give up a few months of education while nurses with 4 year degrees give up the basic 2 years. The more you benefit society, the more education you should share. Some paramedics don’t have degrees. But, they must do their part because of their medical knowledge. Thus, paramedics should have mandatory babysitting responsibilities so that the educationally-challenged can leave their five kids with a skilled provider so they can party at the local night club.

Thus, the secret to the current economic woes is not a redistribution of wealth, but a redistribution of education. John Edwards never got it (all right, he got some, but that is not what I mean). He spoke eloquently of the two Americas—the “haves” and “have nots.” Surely he could share his net worth of $29.5 million with the less fortunate (or move a gaggle of crack babies into his 28,200 square foot house). Edwards spoke of two worlds, yet lives extravagantly. Ted Kennedy champions energy independence, yet would not allow off-shore wind mills to obstruct the view from his family “compound” in Hyannisport. The rich politicians want everybody else to share, but not them.

So, I believe the “Voodoo Medicine Man Economic Recovery Plan” is the soundest advice out there. Let’s get to the root of the problem and share our education. It is the American thing to do. Give an inner city high-school drop out 2 years of your education and all will be well.

Wednesday, October 29, 2008

How To Know You're in the Wrong ER

Top 10 indicators that you have come to the wrong emergency room:

10. Paramedics are either laughing uncontrollably or shaking their head as they walk through the ER doors after dropping off a patient.

9. All of the nursing staff are wearing nursing caps reflective of the nursing school from which they graduated (including the male nurses).

8. Part of the waiting room is cordoned off by crime scene tape.

7. All of the waiting room toilets are filled with weapons-grade feces and have not been cleaned since Richard Nixon was President.

6. The housekeeping staff is selling crack in the waiting room.

5. The ER is equipped with a “take a number” dispenser but the sign that calls your number is out of service.

4. All of the emergency physicians wear turbans and have translators.

3. The nurses have a 10 minute fist fight amongst themselves inside the nursing station.

2. Emergency department techs have to sharpen needles daily for injections.

1. The man sitting next to you is wearing a Revolutionary War uniform and has a musket wound. 

Primum non nocere!

Tuesday, October 28, 2008

Where Civil Liberties and Personal Responsibility Meet

Every Emergency Department (ED) has its regular patients. We colloquially call them “frequent flyers.” They can certainly tax an already overburdened ED. Interestingly, in a 2001 article in Annals of Emergency Medicine, researchers in Oakland reported that a 46-year-old man had rung up more than 1,000 ED visits in less than 3 years. He was not just coming to the ED daily; he was coming on each shift. Interestingly, ED nurses either treated him with antipathy or sympathy. Interventions failed to change his behavior.

We had a “frequent flyer” who was an enigma. She first started to frequent our ED when she was 14-years old. Her initial complaints were vague and we would find that neither she nor her mother would follow our recommendations for treatment. Then, at age 14 she became pregnant. The hospital assured she got good prenatal care and that she was enrolled in Medicaid.

LaTonya was the victim of poverty and probably mild mental retardation. Soon, both she and her newborn were regular ED visitors. I remember, on many occasions, examining her baby girl while LaTonya sat next to the bed with a blank stare on her face. I would explain the diagnosis and proposed treatment and then she would pick up the baby and be prepared to leave. Sometimes, LaTonya’s mom would come along and would chide LaTonya for not following the doctor’s directions. Sometimes, LaTonya would show up to the ED with her child without reason. The triage nurse would ask LaTonya what was wrong with the child only to have LaTonya say, “I don’t know. My momma told me to bring her in.” Over the next 3-4 years LaTonya delivered another 3 children. By this point LaTonya was almost 200 pounds, but only 5 foot or so in height. She was obviously an easy target for the neighborhood boys. Love is blind, and has no sense of smell.

By now, LaTonya and one, or all, of her 4 children were regular fixtures in the ED. Once, one of the nurses thought she could make a difference. She decided to try and find out who the various fathers of LaTonya’s 4 children were and try and get child support for LaTonya. As you might imagine, LaTonya did not have a clue as to who fathered her children. Any attempt at DNA testing would have to include all males in the neighborhood as they all, at one time or another, had a poke at LaTonya. One day, after examining two of LaTonya’s kids with upper respiratory infections, I explained the simple treatment only to be met with a blank stare. At that point I developed a whole new respect for veterinarians. Their patients cannot talk.

Finally, at age 19 LaTonya was pregnant for a fifth time. The nurses again set out on a mission—helping LaTonya get her tubes tied. LaTonya didn’t want any more children (so, she said). When she came in to deliver her fifth child, all anticipated an end to her fertility. But, after she delivered, her scheduled post-partum tubal was cancelled. It seemed that LaTonya had missed several prenatal appointments and never signed the sterilization consent (they must sign at least 60 days before the procedure). She left the hospital with her 5th child and her fallopian tubes intact. Attempts to get LaTonya to take birth control pills were unsuccessful. She forgot, lost them, didn’t get the prescription filled, and similar excuses. By now, LaTonya, her 5 children, her mother and 2 adult brothers all lived in the same house—all receiving government subsidy and not a soul working.

At age 20, LaTonya was again pregnant for the sixth time. A local OB/GYN offered to do the post-partum tubal for free, but anesthesia would not and the whole plan died on the vine. Eventually, LaTonya and her family moved and she quit coming. Over the years she and her 5 children had well over 500 ED visits and nary an admission.

This begs the question. If government (meaning we, the people) is going to support a family for their entire life, does government have the right to deny benefits when health care and social recommendations are not followed? We would not transplant a liver in a patient who is still drinking. Yet, we will allow uncontrolled procreation in a patient who probably does not have the mental capacity to determine whether unprotected sex is in her or society’s best interest. The sad thing is that we are victims of our environment. The only life that LaTonya’s children will ever know is one of poverty and entitlements. Redistribution of wealth is not the answer. Personal responsibility, integrity, and a good work ethic is the answer. My grandparents survived the great depression and 2 world wars. They never depended on the government for anything. What will the millennium generation (the current generation who believes they deserve entitlements) add to society? However, wherever LaTonya is—I wish her well.

Monday, October 27, 2008

Gender and Racial Bias in Medicine

We are far from a homogeneous society. The recent discussion on gay marriage is certainly one example of that. Gene Roddenberry's Star Trek vision of a society where there is no system of currency, no religion, and no racial (or species) or gender bias will never occur in our generation. Even some of the most tolerant people will resort to racial and gender issues when their back is against a wall. I have certainly seen "macho" men, who typically are often critical of women, hire a female divorce attorney to better their odds in court. I have seen more racism in Asia than I have seen in much of the United States. Not only are many Asian countries extremely prejudiced against non-Asians, but equally prejudiced against other Asians of different nationalities. A Chinese-American medical student I once had rotate with me was ostracized by her family for marrying a Vietnamese man (Vietnamese are reportedly at the bottom of the Asian pecking order). I also know an Indian-American resident whose family cut off all contact with him after he married a non-Indian who was not pre-approved by his family. Just look at the way women are treated in Arab countries. America may not be as bad as some would think.

In medicine, gender, age, racial and sexual biases must be put aside. I can never ever remember seeing a patient as anything but a patient. In medicine, we learn to compartmentalize our feelings and emotions. It allows us to be objective and effective. It has to be--at least in emergency medicine. I have heard objectionable conversation in a hospital doctors' lounge only to see the same physicians respond to the pit and and work heroically to save the life someone of color. I have seen doctors cry when one of members of the hospital housekeeping staff (a gay, black male) finally died of the AIDS we all watched him suffer from for two years. I dare you to find a physician or nurse who does not have a bias. These are, for the most part, put away in the treatment room. Health care providers are human. Bias is something learned, usually from parents. Barbara Bush once said, "Bias has to be taught. If you hear your parents downgrading women or people of different backgrounds, why, you are going to do that."

Yet, I just read an article in a journal that detailed the fact that women are not getting as aggressive care as men for STEMI (heart attack). That is ridiculous. While certainly gender and race affect certain aspects of the health care decision making process (e.g., African-American hypertension is treated a little differently than that in whites and men are less likely than women to have endometriosis). Beyond that, there is no excuse for women not going to the cath lab with the same regularity as men. The medical literature contains many articles about racial, age and gender bias in pain control. A study in Atlanta showed that African-Americans were far less likely to get adequate analgesia for the injury (an isolated long-bone fracture) than their white counterparts in an urban emergency department. The same researcher went to Los Angeles and found that Hispanic patients were less likely to receive adequate analgesia for their injury than non-Hispanic whites. Women are less likely to receive adequate analgesia for their chest pain when compared to men. Children and the elderly are vastly undermedicated for pain. I really don't think these biases are overt--just a part of who we are. Yet, they must be changed.

We are all human. We all take risks. Some of us are obese and subsequently suffer from diabetes, hypertension and early death. People who choose to smoke must understand that smoking can shorten your life. Even sexual practices can be harmful when taken to the extreme. In medical school, we had to work at the local STD clinic one day a month. On many of those occasions we saw the same patients--back with another STD. Some were prostitutes (male and female) and some were not. There is nothing sadder than a 21-year-old male prostitute with anal condyloma who will have to wear a diaper for the rest of his life because his "job" has led to fecal incontinence. We all play a role in determining our medical destiny.

Medicine remains both an art and a science. Today, there is more science than art. More of us need to compartmentalize our biases in the clinical arena. Whether you believe health care is a right or a privilege, everybody who seeks health care should be treated equally.

P.S. Just read an article in the Journal of Trauma. Age and insurance status were two major predictors of who ultimately survives trauma. I won't touch that one for a while.

Sunday, October 26, 2008


The first time I was ever in Australia and New Zealand, I left the standard 10-15% tip on the table after a meal. As I was leaving, one of the locals came up to me and said, "You must be from the states mate. Pick that money up. We don't want to get that started here." So I did. As I traveled through Australasia I found it quite nice to not be expected to tip. It made sense and still does. Here in the US, if you don't tip you are snarled at or worse. Everything here, related to travel, requires 10-15% more just for tips--wait staff, concierge, valet parking, luggage help, and even the housekeeping staff. I think everybody should earn a fair wage and many in the service industry are underpaid. The solution? Just pay them a fair wage up front and charge accordingly for the service. The Department of Labor requires a minimum wage of $2.13 an hour for those receiving tips. That is ridiculous. Just price your food or service accordingly and I'll pay if I want. Requiring your customer to pay separately for your employees wages is a ridiculous practice. I have found service in Australia and Asia generally better overall than here.

Saturday, October 25, 2008

Call Me a Redneck Because I Just Don't Get It.

I think Thomas Jefferson clearly defined the theme of America’s future when he listed “Life, liberty and the pursuit of happiness” as one of the inalienable rights of man. Personally, I think personal liberties are part and parcel of what makes America great. But, where do we draw the line?

Recently, I was traveling in northern California. While listening to a clerk describe a wine to us, I looked over and saw two middle-aged men sampling wine. I looked back at the clerk helping us and overheard one of the men saying, “We just got married!” They proceeded to show the young woman working with them their new, shiny wedding bands. Not being from California, I looked around for their wives. Not seeing anybody else in the small room, I came to the sudden and uncomfortable realization that they had married each other. How could I forget I was only 60 miles from San Francisco—well into the twilight zone?

Men getting married to each other is something I have not personally seen (of course, I know that Elton John married his “lover” in a big ceremony—but that was in England). Likewise, women marrying women is something I have not seen (such as Ellen DeGeneres and whoever she married after that Ann Hecht girl quit switch hitting. Also, when Rosie O’Donnell married her “wife,” all heterosexual men let out a sigh of relief—for one of us might be forced to have sex with Rosie one day). But, now back to California. I was now fully distracted. Two things surprised me. First, the very attractive woman helping them said, “Congratulations you two. That is great.” It was not so much what she said as how quickly she replied—like it was an everyday occurrence. If that were to happen where I am from you would immediately have the whole room go immediately quiet followed by somebody in the back yelling. “Get a rope!” Following her compliment, one of the men then planted a sloppy wet kiss on the lips of the other. That made me uncomfortable. O.K., I’m lying….I was extremely uncomfortable—to the point of nausea and reaching for the rental car keys.

Some will look to Freud to describe my feelings of being uncomfortable around men swapping saliva as some suppressed homosexual tendencies because my mother breast fed me too long or some similar horse shit. That is not true. I am and will remain heterosexual. I have never had a desire to explore the world of homosexuality and never will. But, there is something about it that just does not sit right with me.

I truly believe that homosexuality is both genetic and learned (societal). Richard Simmons obviously got a weapons-grade dose of the gay gene. But, should it be flaunted? From a Darwinian standpoint, they certainly don’t reproduce (readily) and contribute little to the gene pool. Is it an illness? Interestingly, many years ago the American Psychiatric Association listed homosexuality as a mental disorder in their Diagnostic and Statistical Manual-II. However, in 1973 homosexuality per se was removed from the DSM-II classification system of mental disorders and replaced by the category “Sexual Orientation Disturbance.” This represented a compromise between the view that preferential homosexuality is invariably a mental disorder and the view that it is merely a normal sexual variant. In actuality, the percentage of psychiatrists who are gay is significantly higher than in the general physician population. Thus, they themselves could not have a DSM diagnosis and the category was changed. That is the dirty truth.

So, should we live and let live? I guess so. But, I am uncomfortable with the politically-correct mantra of “it is totally normal” and making kids read about Johnny having two daddies or Susie having two mommies. Should gay “couples” raise kids? Certainly some children have come out of gay households and done well. Others have not. I don’t know the answer. Should a court place an orphan with a gay family when there is an equally qualified non-gay family?

I was not aware of gay people until I was 16 or so. In those days we called them “theatrical.” I did not have a clue what they did sexually—I just assumed they participated in some sort of penile jousting. Obviously, homosexuality was more widespread than we thought. It all became apparent when Rock Hudson was "outed" as he wasted away from HIV.

I guess the solution is to live where your comfort level is tolerable. For me, I am really not comfortable with open expressions of homosexual affection (granted, heterosexual affection can be just as startling—but certainly more interesting.) So, to the newlywed couple, Jim and Dan, all I can say is, “Enjoy California.” For me, I’ll reside elsewhere.

P.S. Now I know why California is nearly bankrupt. They have so many politically-correct social programs that they cannot even support their own damn infrastructure. Their roads are horrible and taxes and gasoline higher than hell—but their Governor can kill robots.

Saturday, October 18, 2008

Weirdness in Las Vegas

I am used to the continuous weirdness of Las Vegas. The city attracts more riff-raff than a Mogen-David wine convention. But, there is always something that stands out. Today I saw a car with high-quality graphics all over it. I looked initially and did a doubletake. It was advertising a website and had New York license plates. It said " number 1 website for Christian Porn." Now that was weird. The worst thing is that I did not have my camera. I am afraid to visit the site and have not. But, one day curiosity may get to me and I will. But, in terms of weirdness, this was way up there. This makes Area 51 seem quite normal.

Tuesday, October 14, 2008

Predicting Hospital Philosophy and Affiliation by Observation of Emergency Department Waiting Room Television Programming: An Empiric Study

In order to help health care consumers determine the proper hospital for their needs, observation of emergency department waiting room television programming is an effective guide to hospital philosophy and affiliation.

• Catholic hospitals—Eternal World Television Network (ETWN) showing the classic reruns of Mother Angelica or "Father Thomas discusses the sin of masturbation."

• Episcopal hospitals (Catholic Light)—National Geographic Channel featuring “Shark Attacks in the Holy Land.”

• Methodist hospitals—local news and weather, followed by "Dancing with the Stars."

• Baptist hospitals—Christian Broadcasting Network (CBN) showing Pat Robertson or his son experiencing another psychotic break.

• Seventh Day Adventist hospitals—Home and Garden Network showing “Experiencing serenity through vegetarian diets.”

• Children’s hospitals—Cartoon Network showing "Sponge Bob, Square Pants" or "Teletubbies."

• Women’s hospitals—any of the estrogen networks (e.g., “Oh” or “Lifetime Movie Network”) featuring the episode where Ophrah learns about the “G spot” or some movie about how cruel husbands are to their wives.

• Boutique hospital—professionally produced and narrated biography of staff physician Phar Ting Mann, MD and his contribution to the silicone industry (running continuously).

• University Trauma Center—almost invisible television image, but appears to be “Jackass” or “America’s Best Police Chases.”

• County hospital—crude local production of patient education video entitled “Good Parents Don’t Put Their Children or Pets in the Microwave” alternating with "Los buenos padres no ponen sus bebés o animales domésticos en el horno microondas."

• Rural Hospital—analog television showing reruns of “Green Acres” or “Blue Collar Comedy Tour.”

• VA hospital—C-SPAN covering the riveting Senate vote on limiting Red Snapper fishing off the coast of Alabama.

• Inner City hospital—Repeated viewing of “Cribs” or “America’s Most Wanted” (before the television is stolen).

• Multi-Specialty Clinic hospitals—A&E Network showing the surgical separation of conjoined twins from Pakistan.

• Jewish hospitals—Bloomberg network with constant stock exchange ticker.

• Community hospital—40 inch plasma showing either “The Jerry Springer Show” or “Judge Alex.”

• Psychiatric hospitals
--A&E Television showing "Intervention."

• Military hospitals--TV Land showing reruns of "M*A*S*H" or "Hogan's Heroes."

This guide can be printed for patients (clients to nursing) to keep in their wallet as a handy reference. They make great stocking stuffers or Hanukah gifts!

Monday, October 13, 2008

Political Correctness is Politically Incorrect

I recently heard an interview with Dan Whitney about political correctness. Dan, like me, feels that we have gone way too far when it comes to being “politically correct.” If logic and political correctness were plotted on the same graph, the lines would have crossed many years ago. I certainly believe that public discourse and communications should be non-threatening. But, it has gotten to the point where it is just plain silly. 

Recently I was writing a piece that mentioned some historical dates. As I learned in my days at school, including fancy schools, dates in western society are generally represented by the Gregorian calendar.The usage of this calendar was decreed by Pope Gregory XIII and was based on the birth of Christ (no surprise here—he was a Catholic pope.) Standard Gregorian usage requires the use of BC for dates before the birth of Christ and AD for dates after the birth of Christ. A California editor, sitting in a little cubicle and eating tofu, told me that BC was politically incorrect. I learned that we are supposed to use BCE (Before the Common Era) for BC and CE (Common Era) for AD. What pointy head, Volvo-driving, Starbucks-drinking academic thought of this bullshit? Stunned, I asked why and was told that BC and AD were offensive to the Jews and Muslims (if that is the case, it is the first time these groups have agreed on anything other than total annihilation of the other). I have several good Jewish friends (who send be Hebrew jokes I don’t totally understand). So, I called two. One said, “I have never heard of such nonsense.” The other was more to the point. He said, “Horse shit.” Now, my Jewish friends may not represent the entire Judeo-Muslim world (in fact, they love barbecue pork ribs), but they know their culture. Who is the victim here?

Not long ago I was in California—specifically a hotel in Oakland near the airport (I have found that a hotel near the airport is the only place to be in Oakland). The City and County of San Francisco was having some sort of job fair in the hotel. As I was waiting in the hall I started looking at the application. It was clearly written by some ACLU nutcase with a BA from Cal-Berkley and a JD from Harvard who probably clerked for Ruth Bader Ginsburg. The application was nonsense with long statements about these rights and those rights. The thing that struck me was the place where you are usually asked to put your gender. Instead of male or female it said, “With which of the following genders do you most identify?” The answers were “masculine”, “feminine”, or “I don’t care to disclose.” This is about as ridiculous a statement as I have ever seen. I am not anti-gay by any means, but you either have an X and a Y chromosome or you have an X and X chromosome. There is no in between (and don’t start on the chimera crap). If you got your outdoor plumbing cut off by some Bangkok surgeon and are taking estrogen to grow breasts, you still have an X and a Y chromosome (and issues). If they clone you, your clone will have a penis and no breasts. Our society has drifted way too far into lala land when we start adjudicating the laws of nature.

Perhaps it is time to back off a little on the political correctness thing. I think it has, in many ways, hurt our productivity. Dan Whitney is certainly more eloquent than me in this regard. Who is Dan Whitney? He is better known as “Larry the Cable Guy.” When he gets out of character, which he rarely does, he is as sharp as Dennis Miller in pointing out the problems with modern American society--especially political correctness. Thus, “Get ‘er done.”

Sunday, October 12, 2008

Confessions of a "Wetback"

Before I get into this, I feel illegal immigration is one of the greatest threats to American sovereignty. And, I am not just talking about the influx from Mexico. I am talking about all illegal immigration. Through my federal and state taxes, I am supporting more needy people than Sally Struthers can shake a stick at. One thing that the federal government should do, I think, before becoming the world’s policeman, is to secure our own borders. I don’t care whether it is done with fences, walls, predator drones, or crocodiles. Illegal immigration needs to be stopped.

That said, there is the human side to immigration. Recently, I was running one of our cars through the local car wash (because I am too lazy to wash the damn thing). The people who do the final detailing are all of Mexican ethnicity. On the last trip, I was sitting outside (enjoying the beautiful weather) and watching how the workers continued to pick on one particular kid. To look at me, people would not think that I speak Spanish—but I do. The conversation amongst the workers became more heated. Suddenly, two of the workers started yelling at the young kid, “Pinche mojado.” There is no direct translation (pinche is an insult enhancer that literally means “f**king” while mojado means “wetback” in slang). In essence, they are calling the kid a “f**king wetback.” I watched as the kid walks angrily over to the soda machine, puts in a dollar, and gets a can of Sprite. For some reason, I walk over to him.

I will continue in English for brevity. I said to him, “Those guys don’t like you, do they?” He looked at me for a moment, a little unsure whether to trust me, the gabacho with blue eyes. Finally, he said, “No. I am the only wetback here. They are all wetbacks too, but they have their papers.” I asked him where he was from and he said, “A poor little town in Durango. It really does not have a name—it is just a colony.” A colony (colonia) in Mexico is usually a slum. I asked him how long he has been here. He thinks for a while and says, “Almost two years. I want to get home. I have not seen my wife and beautiful daughters in two years.” He goes on to explain the shortage of work in Mexico and says that the best job he can get in the agricultural fields in Durango pays maybe US$15.00 a day. He says, “I have to stay here for my family to live. I am a Mexican. My heart is Mexican. I don’t want to be here—but what are the choices? He says, “There is no help from the Mexican federal or Durango state government for the poor other than they provide electricity and will put a phone in certain houses in the colony. Only the [Catholic] church will help when they can and they usually can’t. So I am here.” I asked, “How do you like it here.” He thought carefully, clearly not wanting to offend me, and said, “It’s OK. Some North Americans treat us good, others don’t.” He details how he pays US$100.00 a week to sleep in a trailer house with 10-12 other men. Every day he walks more than a mile to the place where they wait for work, rarely eats, and sends 90% of his earnings home. He says that even the companies that wire money take advantage of him. He laments, “What can I do. I am a wetback.”

The young man is silent for a while and speaks, “I understand why you [white people] are upset about immigration. Many in my country abuse the United States and your generosity. I don’t. I am hoping the economy in Mexico gets better so I can go home. A whole colony could live on what you [Americans] throw away or put into a garage sale. Your country is wasteful….and lazy. If it were not for us wetbacks you would have little.” His voice drifted off and tears came to his eyes. He said, “I have a beautiful wife and beautiful daughters. A father should be with his children. Would you like to see a picture?” I said, “Sure.” He digs a wrinkled picture from his wallet, obviously taken at one of those cheap photo booths, and hands it to me with great pride. I knew that this picture was probably his most cherished possession and I treated it with respect—carefully holding the tattered edges. His wife, obviously of mestizo origin, is indeed attractive and his children are precious. I said, “I bet they miss you too.” He says, “Yes, they do. I am afraid they may not know me when I get home.”

About this time one of the workers yells, “Viene aqui mojado (come here wetback).” The kid takes his last drink of Sprite, gets up, grabs a dry towel, and walks to an old Lincoln and starts wiping the windows. He doesn’t say a word to me. His pride demands silence. I get into my fancy SUV and drive off. Our worlds will never meet again….and they are so different.

The solutions to illegal immigration have to be international. Mexico has one of the strongest economies in the Western hemisphere. They can provide jobs. Mexicans are a proud people. They do not want entitlements--they want jobs.The League of Nations and similar entities must push Mexico to take care of their own. If they do that, we may need fewer fences and the young kid at the car wash can again hold his wife and daughters.

Saturday, October 11, 2008

I'd Rather Not Know

As soon as humankind attained consciousness, we wanted to know the future. From a layman’s standpoint it seems fun. You could make a fortune betting on sports (or anything for that matter) and you might be able to see if the Chicago Cubs actually win the title again (unlikely). But, there is a much darker side of knowing the future. We would see our ultimate decline and death. Can we handle that? I am of the belief that humans would best not want to know their biological future.

A company in Mountain View, California called Complete Genomics will soon be providing a person’s complete genetic blueprint—sequencing and all—for $5,000. Will there be any takers? Do we really want to know what is hidden in our genes (not jeans)? What if you were 30 years old and your genome showed you were going to develop Huntington’s chorea, Alzheimer’s disease, multiple sclerosis, or amyotrophic lateral sclerosis (ALS)? Would you live life differently? Would you want to live? Would you reproduce?

I have seen more death than most people can imagine. Death is not to be feared. Sometimes in medicine we get so involved in worrying about electrolytes and fluid balance that we forget the patient will die regardless--often without dignity. There is a fine line between extending life and prolonging death. Death is not always the enemy. I don’t fear death for it will come to all of us in time. I do fear the years before death. I watched my father and paternal grandmother die from the ravages of Alzheimer’s disease. There is nothing dignified about Alzheimer’s disease for it steals the very soul. While I don’t fear death I fear that I have the Alzheimer’s gene. I don’t want to spend my final years in Last Chance Nursing Home thinking that the potted ficus plant in the corner is one of my children.

For me, I would rather be surprised as to what my genome holds. I am an optimist and a survivor. Until we can safely change our genome, knowing what it contains is worthless. I would rather spend the $5,000 enjoying my friends and family while I still have the consciousness to do so.

“I am not afraid of tomorrow, for I have seen yesterday and I love today.”
William Allen White

Friday, October 10, 2008

Survival of the Fittest?

There is an old saying in medicine” “Your ability to survive major trauma is inversely proportional to your value to society.” Way too many times I have seem two ambulances arrive from the same scene—one with a dead 17-year-old high school Valedictorian (with a scholarship to Notre Dame) and the other with a combative 27-year-old plumber’s helper with 3 DUI convictions and a BAC of 0.280. His only injury—broken teeth from hitting the dashboard unrestrained (I have learned that unrestrained drunks often consider the dashboard a favorite food group). The old adage is true.

Several years ago, while working in a community hospital, one of the local cops walks in and says, “The ambulance is on the way in with a guy who was shot in the head—probably a drug deal gone bad.” We headed to the trauma room and waited. In comes one of our best EMS crews with a 26-year-old guy, strapped to a backboard, with an entrance wound on the right temple and an exit wound on the left temple. My visual assessment started to tell me that his future was going to be limited to being an organ donor or a politician. A quick mental status exam revealed him to be alert, but certainly intoxicated. I looked in his eyes and ears and he tracked what I was doing with his eyes. Then, I said to the nurses, “I know what is going on here. I have seen this before. It must have been a low-energy round and it hit the skull, was deflected around the head under the galea, and exited on the other side.” I had really seen that many years ago. So, to prove my theory I had Mongo, the x-ray tech (a big hulking man with a great sense of humor), get an AP and lateral skull film (I know, skull x-rays are taboo—but this was a few years ago and I was trying to see if there was intracranial trauma before I ordered a CT). Much to my surprise there were bullet and bone fragments as well as free air in the cranial vault. Holy shit! This guy appeared totally neurologically intact (but, I would not want him balancing a check book). So the work-up began.

The shooting victim had significant intracranial trauma. The hospital did not have neurosurgical care so we had to send him to the University hospital (people who get shot in the head NEVER have health care insurance. I understand the United States Association of Dope Sellers [USADS] has been negotiating with Humana for years to no avail). The transfer was arranged and we were waiting on an ambulance. I am sitting at the desk finishing a chart. I look up and there is the shooting victim (a gauze turban on his noggin) watching me. He politely says, “I got a headache.” I looked at him dumbfounded. I said, “Man, you’ve been shot in the head.” He replied, “Is that bad.” I said, “Yes. Real bad.” He says, “Oh. OK. Can I have a Tylenol.” I got up and gave him some Tylenol.

The ambulance came and off he went to University hospital so that some neurosurgical resident can improve his skills (collateral surgical damage in this case would be impossible). Later, as the sun was coming up, the nurses called me to the phone. On the phone was a second-year neurosurgical resident (with an Ivy League accent) who seemed totally flabbergasted. I asked, “What did you find about our friend.” Much to my surprise, he said, “Nothing.” I said, “Are you sure we’re talking about the same patient?” Something is wrong here. The CT looked like somebody put a stick in his brain and twisted it around like a chimp probing an ant mound. The resident said, “No doctor. You don’t understand. This guy got mad and walked out of the pit—with an IV in his arm and wearing nothing put a hospital gown. We can’t find him and he has air in his brain.” What can you say to something like that? (Of course, putting a Foley in a patient is the best way I know of to tether a patient to the bed). I said, “I’ll let you know if he shows up here.” Believe it or not, he was never found and assumed to be alive (they kept an eye on the Medical Examiner’s Office for several weeks). But, I think I know where he is. He’s working for A.C.O.R.N. signing up voters.

Thursday, October 9, 2008

Paramedics for the Dead

Weirdness I ran into while looking for other weirdness:


We have an ongoing need for licensed paramedics and emergency medical technicians to join our network of Regional Transport Teams. Currently, our need is in California, Arizona, Florida, and Texas. Your participation would be on a contract basis. If selected, you will be given cryonics training that will enable you to participate in our rescue and patient transport cases. Licensed professionals do not have to be members to work with us. We welcome your expertise and interest. Applicants should email their resume to

EMTs and paramedics for dead people? Who is their medical director? Jack Kevorkian? Alcor? Aren't these the nuts that froze Ted Williams head (after he died) so they can bring him back in case the Boston Red Sox need a helping hand? I can hear the Fenway Park announcer now, "Now playing in left field is Ted Williams. Ted has humber 9 on the lobster pot containing his frozen head. He is hitless in 364 innings since his death. But, Manager Tony Francona feels Williams is on the cusp of a rally"

If I were an EMT, I would not touch this deal with a 10 foot pole covered with a bull's condom. I have seen some weird stuff in my day (like O.J. getting convicted), but this is way up there on my weird shit meter.

Entitlement Zones

I looked at the clock. It was only 4:30 AM. My back was killing me. Not sure what I did but I had somehow strained my back. I slowly got up, walked carefully to the kitchen and downed 800 mg of ibuprofen. Within an hour I was comfortable enough to sleep. By the time I awakened a few hours later, the back pain was almost gone. I am a big fan of early mobilization following muscular back injury so I set about my tasks. By 2:00 in the afternoon the pain was back and the repeat dose of ibuprofen was not as effective. But, stubborn and trying to practice what I preach, I pushed on.

Part of my day was a trip to the local Wal-Mart. I have a love/hate relationship with Wal-Mart. I hate how it results in the closure of multiple small businesses in town. But, I love going to one place for all the crap I need. Besides, if you are in the mood to see some weird shit, head right to your local Wal-Mart. Not long ago, I saw a family of 4 who collectively would have weighed in excess of 1,500 pounds, riding electric carts, and raiding the ice cream freezer. Now that’s quality entertainment. But, I digress.

Today, my list included bottled water, mouse traps (the little bastards moved in when the weather started to cool) and fabric softener (obviously, not my list). But, by this time my back was killing me. I was determined to keep going and refused to take anything stronger than ibuprofen. I pulled my truck into Wal-Mart and started looking for a parking place fairly close because I was now limping and walking slow. As I pulled through the parking lot I noticed that all of the close-up parking spots were for handicapped people and every one of them was filled. I never knew there were this many handicapped people in my town. I thought, “Gosh, the inside of Wal-Mart must look like a casting party from Doctor Zhivago.” As I circled the lot I saw two cars pull into handicap parking whereupon the owners threw the blue handicap card up on their mirror. They then jumped out of their car and skipped into the store like Michael Jackson entering a day care. I thought, “Handicapped my ass. These people are in better condition than I am.” I did not see one person that I, using my medical judgment skills, would consider handicapped. As I was entering I ran into a friend and commented on the handicap parking issue. He looked and said, “Those are not handicap parking spaces. Those are entitlement zones.” I thought, “Boy is he right.”

Many times emergency department patients have wanted me to sign one of those damn forms so they can get lifetime handicap parking. I always reply, “I’m sorry Mrs. Washington. You simply have an ingrown toenail. Now that I have wedged it you will be dancing in a matter of days.” They rarely see the humor in my comments.

I have never received entitlements. I was pretty much raised by my grandparents. They were simple folk who lived through the Great Depression and two World Wars. There was nobody to help them. Herbert Hoover sure as hell didn’t give them a handout. They fended for themselves. In medical school, we lived from student loan to student loan—raising a young family on $500 a month. I remember breaking the penny jar and sitting on the floor rolling pennies trying to get enough money to buy a box of diapers for our daughter. I would have gotten a job rather than asking for help.

Entitlements are a two-edged sword—they can help and hinder. Now, I am not talking about social security retirement or pensions. I am talking about a lifetime of Medicaid and welfare and food stamps. It breeds a culture of laziness. I have a relative-in-law (never married) who has three kids. All seem to have some disease process or condition that allows the family to receive three checks for social security monthly. As a result, the whole damn family would not know a job if it bit them on the ass.

My Wal-Mart story is not over. After I limped through the store and completed my list, I opted for a human (I think) to check me out. My back was not up to self-checkout (which never works). Ahead of me were two women and two young children. The oldest was obviously the mother of the other woman. They had enough groceries to choke a horse. And, they were all name brand crap like Del Monte, Campbell’s, and so on. The total surpassed $300.00. Without a blink, she whipped out her food stamps and paid. Then, for her daughter’s basket, she paid with a state welfare card. Then they whipped out cash (crisp twenties) for the beer and cigarettes. Finally, they asked for help to the car with their basket. I paid quickly and limped back to my truck. Low and behold there were the welfare queens—parked in handicapped parking. Furthermore, they were driving a fairly new Mazda SUV and one was talking on a cell phone. The poor souls! They barely have a pot to piss in. Right.

I have tried to take a stand against such abuse. For example, when I am treating a febrile baby when working in the pit, I will explain to the mother that the infection is viral and antibiotics are not needed. Then, I detail how to treat the fever with Motrin or Tylenol. After spending 5 good minutes explaining the situation I hear, “Aren’t you going to give me a prescription for Amoxil?” I look at her and quickly decide against trying to educate her on antibiotic abuse and superinfections. Anything more complicated than operating a vending machine would overwhelm her intellect. I explain, again, that the infection is viral and antibiotics don’t work against viruses. She gives me a blank look. Obviously, she only has three neurons: one is infected, the second is infarcted, and the third is inhibitory. Time to send in the nurse. Nurses can fix anything. Five minutes later here comes our best nurse--frustrated. She says, “She wants a prescription for Tylenol—she can’t afford it and if you write a prescription, Medicaid will pay for it.” I begin a slow burn and remember rolling pennies for diapers. So, I went in the room. Mrs. Gonzales is on the cell phone having an animated conversation about the most recent Matt Damon movie or some other critical issue. Her purse is open and therein I see a pack of cigarettes. She has a cell phone and a pack of cigarettes and can’t afford Walgreen’s brand acetaminophen for her rug rat? So, I lie. Medicaid says we can’t prescribe over-the-counter meds. Surprised, she says, “Dr. Sataranyanassayaty always gives me one.” She is describing an idiopathic condition. Her doctor is an idiot and she is pathetic. She says, “Well, if Angel gets worse, I’ll take him over to St. Elsewhere. They have better doctors.” I said cynically, “Yes they do—the best!” I think to myself, “Good. I hope at St. Elsewhere she ends up with a third-year medical student from a Caribbean medical school on his first rotation in the pit, all the time trying to get the his English verbs and nouns to agree. C'est la vie.”

We have banks failing and people are hurting. Entitlements lead to crime and societal degradation. They have decimated many communities. Interestingly, first generation immigrants and their children excel (just take a look at any medical school class). But, when the third generation is here, then they are in the same rut as many Americans—looking for the government to support them. While the US is dealing with a big financial crisis, I think the first act should be to stop foreign aid (turn it into American aid) and start culling the various entitlements. In my state, virtually anyone—chiropractors, optometrists, maybe even veterinarians—can sign those handicap parking forms. It needs to be better regulated. Perhaps if more people walked from the back of the Wal-Mart parking lot they would not need those electric carts or handicapped parking. Handicapped parking should be saved for the Christopher Reeve’s of this world, parents with kids who have spastic cerebral palsy—you know, real handicaps! It is high time to end “Entitlement Zones” But, this is just a blog so I am doing nothing more than pissing in the wind. My back hurts.

Wednesday, October 8, 2008

You Can't Make This Shit Up!

"Fiction is obliged to stick to possibilities. Truth isn't."

-Mark Twain

Man picks up 'dead' fox, wrecks after it revives

By TAVIA D. GREEN The Leaf-Chronicle

Tommy Fox was driving home from his job in Dover Wednesday at about 11 p.m. when a beautiful red fox dashed in front of his SUV. After he ran over the fox, he stopped his GMC Jimmy to get the fox to cut off its tail for a souvenir, and he put it in the back seat, said Dale Grandstaff, a Tennessee Wildlife Resources Agency wildlife officer.

"The tails are real bushy and pretty and thick this time of year," Grandstaff said.

Things took an odd turn when Fox heard a noise coming from his back seat and realized the fox was alive — and not happy. The driver desperately searched for something to hold the fox back and prevent him from climbing into the front seat and biting him, he told Grandstaff. As he looked in the back seat to get a blanket to block the fox, he took his attention from the road. The SUV crossed the center line and wrecked in a ditch, flipping once and landing upside down in the 3900 block of Lylewood Road, Grandstaff said.

Fox suffered minor injuries and bruises and was treated at the scene by Montgomery County Emergency Medical Service. The fox was found dead in the SUV. Grandstaff said it was not clear whether the fox died of injuries caused by being hit by the SUV or if it died in the wreck. It was also not known if Tommy Fox got to keep the tail.

Fox could not be located for comment, and the complete Tennessee Highway Patrol report was not available Thursday. His vehicle is registered in Beaumont, Miss., said Laura McPherson, Tennessee Highway Patrol spokeswoman.

The wreck was handled by Trooper Vincent Turocy.

Never cage a fox

Grandstaff said foxes can be found in many places in Montgomery County. "They're around — they're just really shy and reclusive animals," Grandstaff said. "They do get run over this time of year."

Grandstaff said there was nothing wrong with Tommy Fox taking the animal after striking it.But foxes don't like to be caged, especially when they are alive, he said.

"They are a wild animal — they don't want to be picked up or touched. They just want to be left alone," Grandstaff said.

I've seen some rednecks do some pretty stupid stuff. But, a guy named "Fox" hits a fox with his SUV and the fox attacks him causing him to wreck. PRICELESS!!!! And, Grandstaff is one sharp cookie when he states, "They are a wild animal--they don't want to be picked up or touched." With great wisdom he went on to state, "But foxes don't like to be caged, especially when they are alive." The gene pool in Tennessee is very shallow evidently.

Tuesday, October 7, 2008

What Would Darwin Do?

I threw the x-rays up on the view box. I thought to myself, “Moderate degenerative joint disease, nothing more." I walked into the ortho room and told the old man, “Nothing is broken, just a moderate sprain.” The patient, an old farmer who has spent much of his 76 years toiling on a farm not far from town, was relieved at the news. He had slipped stepping off of his tractor and turned his ankle. He said, “That’s good news. I still have several acres to plow." I replied, “The ortho tech will be here in a minute to put an air splint on your ankle.” As I was walking out the door the old man said, “Hey doc…. can ask you something kinda’ personal?” I thought to myself, “Okay, here comes the standard exit consult.” Out of respect for the old man I walked back into the room and sat on the stool. Then, he asked, “Doc, do you think I can get a prescription for some of that Viagra I have been seeing on TV?” I thought pensively for a moment and asked, “That's not a medicine we prescribe very often in the emergency room. Have you asked Dr. Williams (his family physician) about it?” He paused for a moment, looked down at his injured ankle and said, “Yeah I did, but he would not give me any.” I asked, “Why?” He slowly replied, “He said I can’t take it because of my chest pain.” I quickly asked, “Are you having chest pain?” He said, “Oh no, not now. I just have it when I work real hard or when I have relations.” I thought for moment and said, “I think Dr. Williams may be right. It sounds like you have what's called stable angina. It's dangerous to take these medicines when you have stable angina. Besides, we just don't prescribe these medications in the emergency department.” The old man looks down, takes a deep breath and says, “Thanks doc. I understand.” Later, he waves to me as the ortho tech pushes him out to the emergent apartment doors. Well, I started thinking.

Then, a thought came to me, “What would Darwin do?” For those of you who attended Christian schools, Charles Darwin was a 19th century scholar who described the science of evolution and the process of natural selection. Natural selection assures that only the strongest individuals breed to ensure continued strength and propagation of the species. That is, it assures that the offspring get the best possible genes in order to have the best possible chance of surviving a changing world and reality television. Thus, what would Darwin say about drugs like Viagra, Cialis, Levitra, fertility drugs, in-vitro fertilization, surrogate pregnancies, and similar practices that may seem to doom the species? Mother Nature went to great length to assure that Tony Randall, Hugh Hefner and Bob Dole no longer contribute to the gene pool by taking the lead out of their pencils. Now, along comes the pharmaceutical industry with television ads—the worst being yahoo Nashville studio musicians singing the nauseating, but catchy, “Viva Viagra.” In reality, they should be telling the truth. The real song should be the Rolling Stone’s “You Can’t Always Get What You Want.” But, in a somewhat altruistic way I really wonder if we are harming our species.

An infertile couple is certainly sad. We all have a natural need to propagate. But, if you have impotence because of diabetes, perhaps it is best not to have offspring who carry the gene and possibly threaten the species. Likewise, a woman with polycystic ovarian disease does her offspring a disservice by passing on a bad set of genes to her kids. Genetics is a crap shoot. If you get a bad set of genes, you obviously did not pick your parents well. Childless couples can be fulfilled through adoption. Many third world countries would love to have their orphans cared for in the United States (Romania, as of this writing, is having a 2 child for the price of 1 sale—no refunds, cash and carry). I have seen too many couples undergo $100,000 worth of fertility work only to have 13 miscarriages before they finally become pregnant with triplets. One dies, the other two are born at 23 weeks and spend 6 months in a NICU with a bill totaling a million dollars or more. What a life. Thus, I am proposing a new bracelet (magenta in color) emblazoned with “What Would Darwin Do?”

P.S. Right after I wrote this rant I ran into an article where geneticist Steve Jones has declared that human evolution is complete. He said, “Another factor [causing the end of evolution] is the weakening of natural selection.” This is distressing because, if evolution stops now, I will spend the remainder of my years listening to rap music, watching Paris Hilton and Brittney Spears show their cooch, and watch helplessly as Congress slowly takes every penny I have ever learned. So, all together: “What Would Darwin Do?"

Monday, October 6, 2008

Neonatal Screening

In medical school, some MD, PhD with a German accent spent two days lecturing on “inborn errors of metabolism.” He told us stories about some obscure clinic at Harvard where he had worked and was able to tell us an interesting tidbit about each of these diseases. For example, with a thick accent, he would say, “These patients have the disteeenct odor of tomcat urine.” For another condition (G6PD deficiency) he said, “Be sure to tell your patients never to eat fava beans.” I did not have a clue as to what a damn fava bean was and don’t think I have ever smelled tomcat urine. And, in over 20 years of clinical practice, I don’t think I’ve ever seen a true “inborn error of metabolism.” Likewise, I don’t think I have ever seen a newborn screening panel for these metabolic diseases come back positive for anything but sickle cell trait (granted, in the emergency department we don’t see many newborn panels—but we serve as the “family physician” for every urban outdoorsman and welfare recipient in the community—so we must stay up on this crap).

But, one day not too long ago, this whole thing became crystal clear. I was in a hurry to catch a plane. As I was trying to work my way through the first class TSA screening point I was called on the carpet because something terribly suspicious had showed up in my carry-on bag. The young wanna’ be cop TSA agent said, “You did not take your computer out of your bag. You’ll have to go through the line again.” I said, “That’s not right. My computer is right here.” He said, “Well then, there is another computer in your bag.” For a minute I was puzzled. The, I remembered my camera. I said, “That must be my camera.” He said, “I’ve never seen a camera that looked like that before.” I told him that it was a very sophisticated professional camera and must look like a computer because of circuit boards.” He ignored me and called for a “manual bag check.” Some woman, who evidently was doing something important like eating her lunch or talking on her cell phone, came over pissed off with an attitude (of course, “pissed off with an attitude” describes every TSA agent I have ever met). She took my bag and went through it taking particular care to be as rough as possible with my camera. Finally, after 5 minutes of fumbling she said, “It’s just a camera.” At this time, I heard the gate agent calling for final boarding for my flight to New York. With camera and bag in hand I started to run for the gate. But, the supervisor stopped me. “Now what”, I thought. He said, “Sir! Sir!” I replied tersely, “What? What?” Then, came THE question. He looked me in the eyes and said, “Did anybody put anything into your bag without your knowledge.” I looked at him and blew a gasket. I said, “How in the HELL would I know if somebody put something in my bag without my knowledge. I don’t know about here, but where I come from the phrase ‘without my knowledge’ means I do not know. So, there is no way I can know whether anybody put something into my bag without my knowledge.” Without cracking a smile or missing a beat he again looked me in the eyes and said, “That’s why we ask.” I was dumbfounded…..speechless. Had my plane not been immediately leaving, I would have loved to discuss this with him more (and probably got on some terrorist list).

I detailed the above to say this. While sitting on the airplane steaming I had a moment of clarity—similar to what supposedly happens to alcoholics. The neonatal screening conundrum was now clear. Of course, these screens will identify people with phenylketonuria so that they have an excuse not to drink diet drinks. But, the most important use of the neonatal screen is to identify cretins early so they can begin training for a TSA job. There is certainly no other explanation for where these people come from. Now, I wish I had’ve paid more attention to that professor from Harvard.

Presidential Politics

I have to admit that I have no interest in the current Presidential election. Choosing a candidate to vote for will be like choosing whether I want cancer or AIDS. Either way, you're going to get screwed. Just when I thought the system was as bad as it could get, along comes Green Party candidate Cynthia McKinney. McKinney is a former United States Congresswoman from Georgia (1993-2003). She is so far in left field she can't see the damn stadium. She was voted out of office (primarily by Republican crossover voters) after she said that President George Bush knew about the 9/11 attacks before they happened. Her career finally came to an end when she struck a United States Capitol Police officer in the chest after he tried to stop her from walking around a metal detector in the Capitol building.

Now this idiot is running for President of the United States. Granted, she has a snowball's chance in hell of winning. But, she is still crazier than a shit-house rat. Recently, she said that she has learned that the United States government "systematically killed" 5,000 prison inmates in Louisiana and "dumped their bodies in a swamp." Evidently, these people were mostly male and mostly "people of color." Following their "execution" data was reportedly entered "into a Pentagon computer."

Our forefathers, when they wrote Article II, Section 1 of the Constitution, forgot an important requirement for the office of President. All candidates for President should undergo a mental status exam and psychiatric assessment by a board-certified forensic psychiatrist. After 15 seconds into the interview with McKinney, most psychiatrists would start filling out the paperwork for an involuntary commitment. Perhaps, after she is properly medicated, she can help drain that Louisiana swamp and start showing us those 5,000 bodies.

One Small Step

After much persuasion, I have officially entered the blogosphere. I am not sure why I am here or where this will take me, but it will certainly be interesting.