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Potato Salad

The middle-aged woman seated in the eye room was moving nervously in her seat. Her right eye was quite injected and teary. I went in and introduced myself and asked her what happened. She replied, “I think I got something in my eye.” I asked, “When did it happen?” She answered, “I’m not sure, but it was several days ago.” I did a general external eye exam. I noticed that the woman had very pale, white skin. As I looked further I noted a few bruises on her face and arms. I made a mental note of these as they are often an indicator of domestic abuse.

I placed the slit lamp and had the tech darken the room. Upon magnification I saw that her conjunctiva was injected and swollen. There were several denuded areas on the cornea and these readily took up fluorescein and lit up under the blue light. I moved the slit lamp aside and said, “You have several nasty abrasions on your cornea. These need to be treated.”

I looked her in the eye and said, “I’m concerned about the bruises on your face and arms as well as the eye injury. Is there something you need to tell me?” The woman looked a little perplexed and shifted her weight in the seat. She said, “I’m not sure what you mean doctor?” I answered, “Well, these injuries often occur as a result of domestic abuse. Are you in an abusive relationship?” She answered, “Oh gosh no doctor. I’m not in a relationship at all.” I confronted her more directly and said, “State law requires me to report cases of suspected domestic abuse. It is for your own protection.” She carefully considered what I had told her and replied, “Potato salad.” I said, “Pardon me?” Again, she said, “Its potato salad.” I thought to myself that this woman was in a level of denial that I have never seen before. I asked, “How can potato salad cause these bruises?” She answered, “I like potato salad.” I answered, “I like potato salad too, but I am not sure what this has to do with this.” She answered, “You don’t understand. I really like potato salad.” I said, “Yes, me too—with mayonnaise—but you have to stopt beating around the bush.”

The woman stared at me for a bit and started to move around more anxiously in her chair. She said, “I really like potato salad.” I stared at her waiting for her to elaborate. Finally, she spoke, “I know it is kind of weird, but potato salad makes me frisky.” “Frisky?” I questioned? She said, “You know…frisky…horny.” Incredulously I asked, “Potato salad makes you horny?” She said, “I know that sounds weird, but yes, it makes me horny.” I asked, “Are the nurses playing a joke on me?” She got a serious look on her face and said, “No. It’s true. I guess it is some kind of a fetish.” I sat there totally perplexed. Finally, I said, “OK. So potato salad is your fetish. That doesn’t explain the bruising and the eye injury.” She sighed deeply and said, “I like to have the potato salad thrown at me.” I looked up from the chart and said, “What?”

It seems that Ms. Papa’s last marriage was somewhat kinky. Evidently she and her ex-husband liked to have sex in the kitchen and somehow potato salad got into the picture. The patient went on to say that when she gets comfortable with a man she gets out the potato salad. She takes a large sheet of plastic and tacks it to the wall and strips down. She then gets a tub of potato salad out of the refrigerator and has her current beau “chunk the potato salad” at her while she stands in the middle of the plastic sheet. The harder the potato salad is thrown and the more it hurts, the hornier she gets. Then, once she has been adequately exposed to potato salad, it’s off to the bedroom where, evidently, the encounter with the potato salad continues. Thus, the bruises and the corneal abrasions were due to high-velocity potato salad striking her during the throes of passion. I looked her in the eye for a minute and pondered what I had just heard. I said, “OK. I don’t really need to know more (although that little devil on my shoulder wanted to know the intricate details). I’m going to give you a prescription for eye drops and some pain medicine. Be sure to follow-up with the ophthalmologist in 48 hours.” I watched her walk out. She looked so normal I thought—almost frumpy. Since then I have never looked at potato salad and not thought of her.

Merry Christmas

All the streets are filled with laughter and light,
And the music of the season.
And the merchants' windows are all bright,
With the faces of the children.
And the families hurrying to their homes,
As the sky darkens and freezes.
They'll be gathering around the hearths and tables,
Giving thanks for all God's graces.
And the birth of the rebel Jesus.

Well they call him by the Prince of Peace,
And they call him by the savior.
And they pray to him upon the seas,
And in every bold endeavor.
As they fill his churches with their pride and gold,
And their faith in him increases.
But they've turned the nature that I worship in.
From a temple to a robber's den.
In the words of the rebel Jesus.

We guard our world with locks and guns,
And we guard our fine possessions.
And once a year when Christmas comes,
We give to our relations.
And perhaps we give a little to the poor,
If the generosity should seize us.
But if any one of us should interfere,
In the business of why they are poor.
They get the same as the rebel Jesus.

But please forgive me if I seem,
To take the tone of judgment.
For I've no wish to come between,
This day and your enjoyment.
In this life of hardship and of earthly toil,
We have need for anything that frees us.
So I bid you pleasure,
And I bid you cheer,
From a heathen and a pagan,
On the side of the rebel Jesus. 

The Rebel Jesus by Jackson Brown

On the Bastardization of Language

All countries will have variations in language. We typically call proper English “the Queen’s English” or we will call proper Spanish “Castilian Spanish” (although Latin American Spanish is certainly recognized in its own right). But, no nation like the United States has butchered language like we do. The United States is quickly becoming a Tower of Babel. But, in the United States, instead of correcting the problem, we romanticize it by giving it cutesy names like “Spanglish” or “Ebonics.” Children who attempt to enter the workforce using Spanglish or Ebonics are doomed to fail (or spend a career at McDonalds).

Language bastardization is a major problem—not as bad as the economy—but still a major problem. I can’t count the number of times I have heard a young Latina mother tell me, “Well, I was going to take him a bath.” Many African American patients use so much slang that I have a hard time understanding what they are saying. Noted minority figures who have risen above the fray; such as Collin Powel, Barak Obama, Condolezza Rice, Bill Cosby, and Henry Cisneros; have done so with mastery of the language. Bill Cosby was on the money when he told the NAACP, “I can't even talk the way these people talk. 'Why you ain't, where you is.' ... I blamed the kid until I heard the mother talk. Then I heard the father talk. This is all in the house.” I have a good surgeon friend who is Nigerian by birth (although educated in the United States). He is appalled at the language skills of African Americans in the United States (especially some of the chosen names). Who would trust a doctor who said, "Well, I is going to give you a prescription”? Who would trust a doctor who said, “Here drink these pills three times a day.” (Spanish does not distinguish between “take” and “drink” so the verb tomar is used for both).

I laughed once while watching a show about the islands off the coast of Scotland. The people who were interviewed had such a Scottish accent that they were very difficult to understand. So, the editors used English subtitles to translate the “English” being spoken by the Scots (which was actually only a thick accent). I have occasionally watched a show on A&E called the “First 48 Hours” that details real life murder investigations. The show is well done and contemporaneously details two murder investigations in two cities. Recently, two things struck me. The victims and suspects are almost always black or latino (this may be because they often shoot the segments in Memphis, Dallas, Miami, Detroit, and Phoenix). Certainly, the crime rate is higher in some minority communities. The other thing that struck me is that when they have African American people on camera, they almost always have to use subtitles. The English is so bad or the accent is so thick that they are hard to understand. Why has this evolved? This is the standard “chicken or the egg” argument. Did the language contribute to the poverty or did the poverty contribute to the language.

Believe me, I am not a racist (but, I will never buy another Dell computer because I will never attempt to get service help from a call center in India from a person named “Bill” with a very thick Indian accent). But, modern society depends on language. If you don’t have the language skills, you’ll never make it. I have chosen to speak two languages (with help from my mother and family). I think speaking more than one language is desired, but an option. Romanticizing the bastardization of language helps no one. So, the schools should not allow this crap to continue. Bilingual education is fine to help the young Spanish-speaking child transition to English. But, after a year or two, all need to speak English. The same holds true for so-called “ghetto-speak” or Ebonics. I would not move to Mexico and try and speak English to the locals. Yet, millions of people mover here and try and maintain Spanish as the language of choice. We Americans are just too gracious sometimes.

A Liberal Treatise From a Staunch Conservative

I’m no tree hugger. I hunt and I fish (not as often as I would like). But, I have my limits. I will not hunt anything I won’t eat or won’t be eaten by somebody. I have found that ardent hunters and fishermen are dedicated conservationists. Ducks Unlimited has done more to protect waterfowl than any liberal environmental movement. That said, I don’t think marine mammals have any significant food value. I would never consider eating a dolphin (porpoise) or a whale. In fact, just recently I was at a meeting on the southwest coast of Maui and spent hours watching humpback whales (and their calves) frolic in the Pacific. They were spectacular. Every time one of these leviathans hit the surface, a tour boat would approach. Finally, a group of jet skiers chased them off (these jet skiers could face large fines for approaching whales under Hawai’i wildlife laws). Life and let live I have always said.

The night after watching the whales off the Maui coast I caught a show about an activist environmental group called the Sea Shepherds. This was a group that broke from the Greenpeace people because the Sea Shepherds wanted to be more aggressive in stopping whaling and other animal abuses. I always thought the Greenpeace people were a little kooky. I have encountered them in Australia and they can be fairly militant. The Sea Shepherd people operate a boat called the “Steve Irwin” named after the Australian crocodile hunter who succumbed to a massive ray after the animal plunged the tip of his serrated tail into Steve’s heart. The Sea Shepherd boat had the usually suspects—twenty-first century hippies, vegans, and remittance men. Interestingly, everybody was from a first world country (there would be something ironic about an Ethiopian or Nigerian on the boat preventing the harvesting of food. Of course, if there were Nigerians on board nobody could access the internet because of the outgoing email scams). But, I digress.

I actually thought whaling was illegal with the exception of some Canadian and Alaskan aboriginals who hunt whales specifically for sustenance and actually respect the species. Thus, I have read quite a bit about whaling over the last few days. Whaling may be restricted in most waters, but the Southern Ocean appears to be a different story. The Japanese, who will eat anything that comes from the sea, still have an active whaling program. I read where the Japanese do not see any difference between pelagic mammals and fish--they all should be on the dinner plate. They harvest about 1,000 whales a year—primarily minke and finback whales. This year they are hunting the humpbacks as well—an endangered species. There are treaties in place that prevent whaling. The Japanese take advantage of a loophole in the treaties. The loophole allows whales taken for research to be subsequently butchered and sold. Thus, the Japanese take upwards of 1,000 whales a year for “tissue samples” and to monitor calving patterns and diet (supposedly). Every Japanese sailing vessel has the word “research” on the side. In one camera snap on the Animal Planet channel show they showed several Japanese fishermen butchering a whale while an idiot in a hard hat holds up a sign (in English) that says they are “taking tissue samples.” Horse shit!

If a people are dying and whale meat will save them, I’ll be the first son-of-a-bitch on the water looking for these critters. But, Japan has plenty of food. In fact, the demand for whale meat in Japan has fallen to a point where it is almost negligible. In fact, Japan has tons of whale meat from prior hunts in frozen storage. In order to support the archaic whaling industry, the Japanese government is trying to get schools to include whale meat in their school lunches. Why not serve Nemo as Sushi?

I have been to Japan several times. It is a curious, yet beautiful country. I cannot understand their adherence to traditions that result in whaling or the harvesting of shark fins (I like to catch and eat small black tip sharks—they are great. But, the Japanese cut the dorsal fin off the shark and throw it back in the sea where it dies immediately or becomes vulnerable to predation). I just can’t understand the Japanese way of thinking. I also can’t understand why Japanese women can’t walk in high-heel shoes—their gait is a continuous near fall. I am not sure I have a point here—just a concern.

By the way—the day I was watching the whales in Maui was Sunday, December 7, 2008. Seems as though the Japanese have struck again.

A Sad Case

Patient R. X., a 30-year-old white male surgical House Officer was admitted to the University Medical Center Emergency Room with depressed sensorium and focal seizure activity. The onset of symptoms occurred suddenly when the patient, present at a medical fraternity party, observed an inebriated female lab technician dancing naked on the piano. Those individuals present stated that the patient manifested an acute loss of reality contact, staring and fixed conjugate gaze, drooling and smacking of the lips, and pseudochoreiform movements of the fingers.

When first seen in the Emergency Room his blood pressure was 200/150, his pulse 160 and bounding, and he exhibited Kussmaul's Breathing (1). He was noted to have considerable proptosis (36/36 over 102).

The oculocephalic reflex was exaggerated. The tongue was protruding and deviated to the right. Auscultation over the precordium revealed an obscene murmur. There was rigidity of the abdominal musculature. The cremasteric reflexes were hyperactive, resulting in a gubernacular hernia on the left. The remainder of the physical examination was censored.

His past medical history was remarkable in that the patient had experienced several petit mal seizures when watching young women in mini-skirts. Reportedly he once suffered a grand mal seizure while on a beaver-shooting expedition in Focal Point, West Virginia.

Seizure activity was ameliorated by cooling 3 liters of saline to 5 degrees Centigrade and pouring it directly on the umbilicus.

He was admitted for observation and further diagnostic studies. Routine lab studies revealed a mild increase in Serum Porcelain (28.2 mg/L -normal 0 to 18) and a Horni titer of 1 :256. There was a ten-fold increase in delta-4-androstenedione as measured by immunoflourescent assay utilizing the seminal fluid from the Lithuanian Hairy-Necked Jackal (Lupus heavihungus horribilis).

Electroencephalography revealed paroxysmal three-per second spike and dome activity in the right temperoparietal leads when exposed to Playboy centerfolds. Brain scan utilizing labeled Acnesium240 (Acne244) demonstrated uptake only in the central facies. Cerebral angiography revealed a superior displacement of 3 capillaries of the right lenticulostriate system. Magnetic resonance imaging revealed impingement on the anterior horn of the right lateral ventricle.

Symptoms did not improve and on the 52nd hospital day, having been cancelled 38 consecutive times by the Anesthesia Department, he was taken to the operating room where a right temperoparietal craniotomy was performed. A cystic 4 x 6 centimeter mass was discovered adjacent to the amygdala in the Corpus Hornii. This was removed intact. Radioassay of the specimen with Low-Activity-Radio-Detection-Assay-Scintillating-Substance (LARD/ASS) revealed a weight-wet tissue Testosterone level 1,400 times normal. Tissue blocks were referred to the AFIP where microscopic exam revealed palisades of well-differentiated oxyphilic cells resembling abnormal Leydig cells. AFIP pathological diagnosis was "Functioning Ectopic Intracranial Testicular Adenoma." Histological diagnosis at this institution was "Normal Gallbladder."

The postoperative course was complicated by optic constipation leading to irreversible blindness. The patient was left with severe deterioration of intellectual function and was presented to the Department of Vocational Rehabilitation for disposition. As a result of extensive testing which revealed severe, generalized impairment of cerebral function he was given a scholarship to Law School, from which he graduated summa cum loudly. He is now gainfully employed as legal counsel for the Tip-Top Grill (2) where he spends his days reading the Kama Sutra in Braille and seeking olfactory ecstasy among the bar seats.
_____________________________________________________________________________
1- Seymour Kussmaul. a local "breather" well known to the Telephone Company and the County Pervert Patrol.
2- A local establishment frequented by randy ER nurses and tenured faculty.

Can Somebody ExplainThis To Me?

I'm no economist (I know, supply and demand). But, I'm no Forrest Gump either. Today, in my town, I found unleaded gasoline for $1.25 a gallon (don't forget the 9/10--the fraction used in gas pricing is more nonsense I have never understood). How can we go from what some naysayers were calling the "end of western civilization" when gas passed $4.00 a gallon to the current price which is almost $3.00 a gallon less in just a few months? I didn't understand why oil approached $140.00 a barrel (and don't give me the Gulf of Mexico hurricane crap). I don't understand why it is now significantly cheaper. Bush was blamed for the high gas prices several months ago. Will the Democrats give him credit for the current price? I doubt it. The credit will go to Lord Obama (unless the Governor of Illinois is caught selling oil futures). What about all the people who sold their gas guzzlers and now driving Cooper Minis and Toyota Prius hybrids. When gas was high, the difference in what it cost to fill the tank of my car was almost 30% higher than theirs. Now, the difference is minimal. I wave at them when I pass them on the roads as their car groans while trying to get up a simple rise in the road. Perhaps they need some Viagra in the car's gas tank.

A Reasonable Living Will

To my family physician, my lawyer, my friends, and all others to whom it may concern: 

I, _____________________, being of sound and disposing mind and memory, do hereby make, publish and declare this to be my LIVING WILL. If the time comes when I can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes and directions while I am still of sound mind.

If I suddenly begin to take an unexplained turn for the worse, before any drastic or irreversible decisions are made, it is my desire that someone first check to make sure my attending physician is not Dr. Jack Kevorkian.

Should my attending medical personnel determine that an organ transplant is necessary, it is my expressed wish that, if at all possible, the baboon be of the same faith as me.

If a kind soul takes it upon themself to read aloud to me, it is my fervent wish, as it was during my non-incapacitated life, that they skip directly to the dirty parts of the book, and then read those passages over and over and over again.

It is my expressed want that no family member, friend or acquaintance shall enter my hospital room bearing one of those tacky "Get Well Soon" helium balloons. Likewise, any get well card sporting Garfield the Cat shall immediately be returned to its sender.

I wish my TV set off whenever "Oprah" or “The View” are on.

If at all possible, I prefer "Depends" over "Serenity."

I would prefer that my visitors leave their small children home if all the kids are going to do is stare at me and play with my toes.

When it comes time to change my Foley catheter, I would prefer a nurse with untreated Parkinson’s disease perform the procedure while singing "Barnacle Bill the Sailor" to me.

At no time, even on the occasion of my birthday, do I desire to have a party hat placed on my head.

While I am not morally or ethically opposed to so-called “life sustaining equipment," I am vehemently opposed to the concept of hooking up such machinery to "The Clapper."

I agree to sponge baths only if given by a member of the opposite sex. Several members of the opposite sex at once is certainly acceptable and, in fact, preferred. Ditto for any "therapeutic Jacuzzis" that may be prescribed.

Please kill anybody trying to enroll me in Wii-Hab or similar nonsense.

It is my strong desire that in any and all elections that may take place, my absentee ballot be marked for the individual running opposite Barney Frank.

In the unfortunate event that the time comes to donate my vital organs, it is my wish that in all donations, a receipt be obtained for tax purposes. Also, do not give my organs to anybody associated with the IRS or the United States Postal Service—let those bastards die a slow and painful death.

No Jello or Ensure. Margaritas with Patron Tequila (preferably the Grand Platinum variety) will be acceptable.

When it comes time for me to give up the ghost, make sure the embalmer leaves a smile on my face.

This statement is made after careful consideration and is in accordance with my strong convictions and beliefs I want the wishes and directions here expressed carried out to the extent permitted by law. 

IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my LIVING WILL on this the ___ day of _______________, 20_______

THIS FORM MAY BE PRINTED FOR PATIENT USE.

The Gynecology Room (Redux)

In the house of medicine, we often give obstetrician/gynecologists a hard time. After all, it is the only medical specialty soley based upon a totally normal human event. We give them colloquial names such as “vaginicologists” or “spreaders of old wives’ tails.” Regardless, we in the emergency department usually despise the gynecology room. But, they provide memorable patients.

While a resident I was moonlighting at a fairly rural emergency department. A young Mexican woman came in complaining of contractions. I assessed her and sent her to the OB floor. During the night, a small dusting of snow paralyzed the town (people in my area start buying milk and break anytime snow is in the forecast). At 6:00 AM, 1 hour before my shift was about to end, I was called to assess Maria on the OB ward. The on-call obstetrician could not (reportedly) make it to town because of 2 millimeters of snow that supposedly made local roads impassable. I was literally beat. I had not slept in 36 hours and was not excited about delivering a rug rat. But, being the professional I am, I scrubbed and gowned up. Maria was a 19-year old Gravida 2, Para 1 (second pregnancy). I checked her and she was 10 cm dilated, 100% effaced and the head was at a +2 station. We were going to rock and roll. I sat on the stool and, in Spanish, talked her through the second stage of pregnancy. I readily delivered the baby girl, clamped and cut the cord and handed the baby off to the nurse. I took the curved Kelly clamps and wrapped the maternal segment of the umbilical cord several times around the clamps and waited for the placenta to separate. While I waited, I was so tired I dosed off while seated at Maria’s perineum. Suddenly, I was awakened by the sound of the placenta hitting the hard tile floor taking my clamps with it. This was a sound unlike any I had heard in my life. It scared the shit out of me. Suddenly, Maria started crying, “Mi hija. Mi hija. (My daughter. My daughter)." I realized that the mother thought I dropped her newborn baby. I reacted, although exhausted, by grabbing the placenta and picking it up to show the mother that I dropped the placenta—not the baby. I forgot that most people have never seen a placenta (it looks something like the alien larvae from the movie “Alien”). She took a look at the placenta and started screaming and saying Catholic prayers. I thought, “What the hell is going on with her.” Then, it hit me. She thought the placenta was her baby and that it was some sort of demon or alien. She began to scream and cry. Finally, I got the nurse to bring the baby to her side. For the life of me, I could not remember the Spanish word for placenta (it turned out it was a cognate—same word in English—just pronounced with Spanish vowels). Finally, I explained the situation and I think she understood. She was happy to see her baby girl was OK although she kept looking me with a look that would thaw a snowball.

Another memorable vaginicology patient was a 30-year-old female in the tuna pit. She had a “discharge.” Finally, I went into the room. The patient was pleasant enough, yet a few sandwiches short of a picnic. The nurse and I explained the procedure. I stuck my gloved finger into the vagina and struck a firm object. “That’s weird,” I thought to myself. I got the speculum and carefully inserted it. There was something solid in the vagina and it smelled like a morgue somewhere on the equator. The nurse handed me a pair of ring forceps and I removed a clump of pus that appeared to have some shape. I realized that it was a contraceptive sponge (these were popular contraceptive devices in the 1990s, except they led to some horrible pelvic infections). Then, I pulled another one out, and then another, and finally a fourth one. I looked up at the patient and said, “I see you are using the contraceptive sponge.” She said, “Yes, my boyfriend won’t wear a rubber.” I said, “You know you’re supposed to take them out when you are through with your sexual encounter.” She looked at me totally perplexed and said, “I thought they dissolved.” What amazed me even more is that she somehow managed to have sex with 4 contraceptive sponges in place.

Finally, one of the most memorable patients in the gyn room was a patient named Monique. She was a very pleasant black female who presented with a vaginal discharge. No big deal. This was the third patient with the same complaint during the shift. Monique was a big woman—in excess of 200 pounds. The young nurse (the young nurses are low on the totem pole and draw the tuna pit). The nurse put Monique up in stirrups. I explained to her what I was doing. My technique is to carefully insert a gloved finger into the vagina and put pressure on the posterior vaginal wall. Then, I tell the patient I will be inserting the speculum. I then turn the speculum sideways and insert it and then rotate to the upright position, spread the speculum and look for the cervix. At this point Monique started to move around and moan. I thought I had pinched her with the speculum. I released the speculum and reopened it. I was not pinching the vaginal mucosa. Monique started to move around more and moan. Her moans got louder. I looked and saw her vaginal muscles start to contract rhythmically and she pushed the speculum out into my lap. Immediately Monique apologized, “I’m so sorry doctor.” I still didn’t have a clue as to what was going on—-but the nurse did and started to smile. I asked Monique, “What happened? Did I hurt you?” Monique couldn’t speak. The nurse said, “Can’t you tell she had an orgasm?” I said, “What? Are you kidding me?” I looked and Monique was still twitching. I was perplexed. This had never happened before (at least in a medical examination room). Monique was very embarrassed (and apparently quite sensitive). I didn’t know what to do. I just sat there. Then, I had the urge to offer her a cigarette. In fact, I wanted a cigarette and I never smoked a day in my life. I was obviously the source of much teasing for months thereafter.

The Gynecology Room

Everyone who has had the pleasure of working in emergency medicine has had their share of memorable patients. I actually have memorable patients in various categories: funny ones, stupid ones, ones I liked, and ones I hated. An old attending physician told me something that I have come to believe is true. He said, "If the patient pisses you off in the first 15 seconds of the interview, they have a personality disorder." I have found that if the patient makes you laugh in the first 15 seconds, the shift will go much faster.

The following are some patients I remember fondly from the dreaded gynecology room (colloquially called the "tuna pit" by the staff):

#1 (20-year-old Jerry Springer Show reject). I had to inform this eloquent young lady that her abdominal pain was due to her heretofore undiagnosed pregnancy to which she responded, "I can't be pregnant because my husband had a hysterectomy." Sigh...

#2 (27-year old morbidly-obese frequent flyer). After delaying the pelvic exam as long as I could (I was hoping I could push it off on my partner at shift change), I went to the gyn room with a nurse. I asked the patient, "What's the matter today Donna?" With a straight face she said, "It feels like Dr. Chong (the local Medicaid OB/GYN) put my IUD in with a pogo stick. I can feel it moving around in my pussy." Sigh...

#3 (Young married couple--not the sharpest knives in the drawer). I went to gynecology room where I found the wife reading the National Enquirer and the husband (a big burley blue collar kind of guy) reading BASSMASTERmagazine. I kindly asked, "What brings you to the ER today?" The young woman, ever so polite, said, "Doctor, I hate to bother you, but I ran out of my pills and can't get a hold of my doctor." I said, "What pills?" She produced a birth control package that was empty (we don't refill birth control pills, but I played along). The prescription was for a six month supply (21-day regimen) and was issued only 2-3 months earlier. I said, "You got a six-month supply. You know that you are supposed to stop taking the pills for a week after each pack for your period to start." She said, "Really?" I said, "Really." She pondered what I said for a minute and said, "I wondered why I ain't got my period in several months." Then, I realized that even this did not explain why she was out of her pills. I said, "How do you take your pills?" She replied, "My husband works nights so we take them before he goes to work." I paused to carefully assure I heard her right and said, "Did you say 'we'?" She replied matter-of-factly, "Yes. I take mine and he takes his." Evidently, both the husband and wife were taking oral contraceptives. I look at the man reading the BASSMASTER magazine to see if he is growing breasts. Can't tell for sure. Time to send in the nurse. Sigh...

#4 (Very prim and proper looking 50ish female with a quasi-Pentecostal look). I saw this patient walk in. She walked beside the nurse looking around the ER. She was plainly-dressed with a blue jeans skirt and a Pentecostal bun--no makeup or jewelry. Such patients were not uncommon in our ER and were usually quite pleasant. She was placed in a minor medicine room and I went to see her promptly with a young female nursing student in tow. I introduced myself and sat on the stool. She said, "Well doctor, I got a bad headache and it won't go away after two BC powders." I listened intently going through my list of differential diagnoses. I asked, "What were you doing when the headache started." Without a pause she replied, "Well doctor, my husband and I were f**king. After several minutes of it I was about to go 'boom-boom' and my head started hurting." I sat there for a few minutes literally speechless. For clarification I asked, "What do you mean by 'boom-boom'?" Again, without a pause she said, "You know I was about to come...go 'boom-boom'. Isn't that what you call it?" The young nursing student, all professional in her white dress and smock, was trying to keep from laughing so hard I literally thought she would piss her pants. I excused myself and walked to the ambulance dock where I laughed my ass off for at least 10 minutes. Sigh... (P.S. Mrs. Boom-Boom's CT was negative and her headache went away with some Imetrex).

You gotta' love medicine...

A Picture is Worth a Thousand Words

Spinal immobilization over utilized in the United States? Never!

Nothing Says I Love You Like a Glock

I was in the local Bass Pro store (hey, they got great clothes!). As usual I spent some time looking at the guns and boats. I like both and wish I had more time for both. Interestingly, the gun counter was unusually busy. I think the uncertainty of hard economic times and a novice president is taking its toll. Several of the more popular guns were sold out. I watched a caring young man trying to select the perfect gun for his wife for Christmas. Certainly, nothing says I love you like a Glock.

But, the aura of modern day America is worrisome. It reminds me of the gas shortage of the 1970s and Black Monday in 1987. With the economy in the dumps and the stock market more labile than a fat diabetic's blood glucose level in a Krispy Kreme, the fear of the average Joe is real. People are stocking firewood and ammunition. Somali pirates have hijacked nearly 100 ships on the high seas. Las Vegas is so slow they are giving away rooms (and Chris Angel's MindFreak show at the Luxor is so bad it is stinking up the strip). Even American Airlines has some deeply discounted fares. Times they are a changing. But, are they changing for the better or for the worse?

Pondering this, I believe that many have lost confidence in America and are forgetting the American dream. The Drudge Report had a link that detailed the presumed demise of America as a world power. The recent elections demonstrated that we do not have a leader who can do for America what Lincoln, Roosevelt and Reagan did--lead us out of our despair. Until that leader comes, we must find solace in other things.

Well, I've put off seeing the Medicaid family of 4 with runny noses as long as I can. The nurse has put the charts in front of me 3 times now. It is amazing that an emergency department can look so busy it might be mistaken for a disaster, only to find that all of the patients are actully less sick than the staff working the department. It is hard to imagine the amount of money a small rhinovirus costs the welfare-paying public each Winter. Life sucks sometimes.

Round Up the Usual Suspects

In the classic epic Casablanca Captain Renault said, "Realizing the importance of the case, my men are rounding up twice the usual number of suspects." President-Elect Barak Obama must have taken this quote to heart. As a presidential candidate campaigning on the concept of change, it sure looks like the old Clinton White House. Soon, we will hear that Monica Lewinsky will be reappointed as "Special Asssistant to the President for Fellatio." Rham Emmanuel, Hillary Clinton, Bill Richardson, Tom Daschle, and Eric Holder are all Clinton insiders (although Daschle was in Congress--he still kowtowed to Bill and Hillary). Somewhere, inside of this, is the voice of Bill Clinton saying, "I'm still here. Where's that new intern with the hot little ass?"

"Change doesn't come from Washington. Change comes to Washington." (BARACK OBAMA, DNC speech, Aug. 28, 2008).

Horse Shit.

American Legacy Businesses Need to Learn a Hard Lesson

I fly a lot. When I say I fly a lot, I mean 80,000-100,000 miles a year. Some years a great deal of it is international. Some years, like 2008, it is primarily domestic. Most of my flights are on American Airlines where I hold elite status. But, this year I have flown Continental and United a few times. Overall, all legacy United States airlines suck. The planes are old. The employees are angry. Bags are lost. Nobody answers the phone. It is a miserable experience.

Recently, I flew Richard Branson's Virgin America between LAS (Las Vegas) and SFO (San Francisco). What a wonderful change. The new Airbus was clean and looked like the inside of a Lexus. The seats were leather and each had satellite television and games. The flight attendants and pilots wore simple black shirts and pants. The pilots walked into the cabin and gave the introductory talk instead of using the speaker system. There were flowers in the lavatories. Even the required flight instructions were fun. The recording said, "If you are one of the 0.001% of the population who have never used a seat belt, please watch the following..." The trip was actually fun.

I have flown on quality airlines like Cathay Pacific, Qantas, Air Tahiti Nui and others and actually been pampered. But, to be treated like a human being and a paying customer on a domestic airline was truly a treat. Why can't American and the others adapt? All have suffered the ill effects of fuel costs. It probably comes down to the unions.

Yesterday, the news was about the bailout of the United States auto industry. Ford, General Motors (GM) and Chrysler all want billions of dollars in loans from the government. Interestingly, Toyota, Honda, Mercedes, and Nissan have not asked for anything. Then, an interesting graphic appeared on television. The average cost of health care insurance for employees accounted for approximately $1,600.00 of new car costs for GM and Ford. The same costs for American-made Toyotas is approximately $300.00. Is it the unions?

I was recently in Mexico and passed numerous US-owned factories (e.g., GM, Westinghouse). They are solely there because of labor costs. I feel everybody deserves a fair wage and unions have made life easier for most. But, have unions outlived their usefulness? Are they killing American business?

I own 4 cars (Lexus, Acura, Chevrolet and Nissan). The Lexus and Acura have never required anything but service. The Nissan has 128,000 miles and runs well. The Chevrolet has 30,000 miles and has been to the shop for warranty work 5 times. Several years ago I had a GM Chevrolet Tahoe. I kept hearing a noise and took the car to the dealer 4 times. Finally, they took ff the driver's door panel and found a golf ball. Evidently the factory workers were playing with the golf ball and lost it in my car. In Japan, an auto worker would commit Hari Kariover such an event. Here, they get a raise.

Perhaps the government should let nature take its course. I say we give GM, Ford and Chrysler a "do not resuscitate" order. In the overall scheme of things, Darwinian logic would say only the strong will survive. Likewise, let Northwest airlines and some of the legacy carriers go as well. It is time to think outside the box. If they are going to bailout the auto industry, then they should bailout health care as well. But, it is only wishful thinking...

It's a Sad Day When a Fart's Not Funny Any More

Recently, I was flying home on a two-hour American Airlines flight. A middle-aged woman dressed professionally in a gray pinstriped pants suit sat in the window seat to my left. We made the usual small talk about how tired we are of flying and how shitty American Airlines has become. Then, as the flight was preparing to leave, we did the Blackberry ritual of checking our emails and then prepared for the flight. After the plane had reached a comfortable cruising altitude, I heard a strange noise that seemingly came from the business woman. I thought to myself, “That was a fart.” I know a fart when I hear it for I have been on both the donor and recipient end of the fart spectrum. Unsure whether it was really a fart or some weird noise coming from the aging MD-80, I sniffed like a puppy looking for a dog treat. It was a fart for sure. I am not sure what this woman ate, but something crawled up inside of her and died. But, then I started to smile. The smile turned to a laugh and the laugh almost became uncontrollable. I looked at the woman who was sleeping soundly and she let another one rip. I was trying to cover my mouth to keep people from seeing me laugh and my nose to keep from smelling the weapons-grade gas this attractive woman was eliminating. With the second fart the old woman across the aisle scowled at me. I thought she was giving me the “what are you doing in first class with jeans and a t-shirt look.” Suddenly, I understood that she thought I farted (I know men enjoy and good fart here and there) so I quickly pointed at the sleeping woman and laughed. The old woman gave me an indignant look and went back to reading her Deepak Chopra book. I continued to laugh.

I am a physician. I understand the pathophysiology of flatulence. But, a fart is still a funny thing. Have we come to the point in society where a fart is not funny anymore? In Geoffrey Chaucer’s The Canterbury Tales (written in the fourteenth century) he details the story of a miller trying to trick another man by farting on his face. In high school, we used to have farting contests. In medical school I farted just as four of us were getting out of the car at a restaurant. When we returned later, the fart was still in the car and we had to open the windows and doors for 5 minutes before we got in (the fart later became one of the great legends of our medical school class). Everybody farts. Farts are funny (especially in a bath tub).

But, have we come to a point in our politically correct society where we can’t laugh at a fart? Will the PC police ban “whoopee cushions.” Farting can be an art form. I used to work with a friend who could fart the first 8-10 bars of the southern hymn “Dixie”. Racist, probably not as my friend was black. I am not sure I want to live in a country where a fart is no longer considered funny. How about you?

Immigration, Part II

I recently spent a week in central Mexico. Even though I was far removed from the United States/Mexico border, I clearly saw how important the United States is to Mexico. The U.S. elections almost overshadowed the deaths of several high-ranking Mexican federal officials in a plane crash. But, conversations with everyday Mexicans revealed how much they envy life in the United States.

Jorge was an affable young man. He preferred we speak in English because he doesn't get much chance to practice his English (which is quite good). Jorge had previously lived in Chicago and married a Mexican-American woman with whom he has a daughter. He left Chicago almost 9 months ago and returned to central Mexico because his mother was dying. However, when he attempted to return to the U.S., he was unsuccessful. He said, "President Bush doesn't want us in America and he has certainly made it very hard for us." Meanwhile, Jorge works as a valet parking attendant at an upscale hotel. He earns about 4,000 pesos a month (about US$360.00). Jorge said that he wants to stay in Mexico but the Mexican government won't allow his family to emigrate and he cannot return.

Rico is a gas station attendant at a Pemex station along the autopisto. Despite my best Spanish, he recognized the American accent and asked where I was from. After some small talk, Rico told me that he lived in San Diego for many years. He had been deported more than 6 times (he thinks) and now cannot return because he is "in the migra computer." Unlike Jorge, I did not have a good feeling about Rico. But, he went on to say, "The Americans and President Bush have made it very hard to cross. The coyotes (human traffickers) will charge you US$1,000 to take you across. But, they will leave you in the mountains in the desert without food or water. It is very dangerous." He went on to say that he had to wait 10 years before he could cross again (there is a rumor in Mexico that U.S. ICE files are purged of names after 10 years--not sure whether that is true or not).

But, I can say, after several conversations with Mexicans of different social groups, the Bush policies on immigration are working. They may not be perfect and people still cross, but the numbers are down and the word is out that America is very difficult to now enter. Also, the lack of jobs for Mexicans in the United States are down due to the economic downturn and that is widely known. Thus, like him or hate him, Bush has made a difference in immigration and that relates directly to our national security. For that, I am thankful.

Antidepressant Advertising a Major Source of Depression

I do not think it is a good idea for the pharmaceutical industry to advertise directly to the public. Would you trust the advice of the big pharmaceutical companies in regard to medications they manufacture? As an analogy, would you continue to see a doctor who only orders the drugs advertised on the pen with which he writes the prescription? How many times have we heard a patient ask for Viagra or Cialis after seeing an ad on television. We reply, "Oh, do you have erectile dysfunction?" The patient answers, "Gosh no doc. I can get it up OK. I just want an erection like I used to have when I was 16." Or, there is the patient too stupid to even understand the message in the television ads. The mother looks me in the eye and asks, "Do you think my child should get that there vaccination called Gardasil?" I think for a moment and decide to give a simple answer. I say, "No." She goes on, "Well on TV they say it prevents many types of cancer. I don't want my child to get cancer." I take off my glasses and look the mother in the eye and say, "Until your son grows a uterus, his chances of cervical cancer are quite low and I really don't think he needs Gardasil." Missing my humor (alright, frank sarcasm) she says, "Thank goodness. That is one less thing to worry about." I sigh and wish I had gotten a business degree instead.

One of the biggest issues I have, at present, is the advertising for antidepressants. Hell, the advertisements depress me and I am usually as happy as a clam. Last night I saw an ad for Cymbalta. The ad was dark and the music sad. The people were virtually catatonic. Before I knew it I was in the kitchen looking at knives and trying to determine which was sharpest and would be the least painful when I cut my own wrists. Later, I saw an ad for Abilify. It was equally depressing. What is most disconcerting is the fact that I have never heard of Abilify. Thus, the patients may be more informed than me. But, I am just an emergency doc and don't prescribe antidepressants and rarely diagnose depression.

Is it me or is depression the diagnosis de jour? Feel bad, here, take a pill. I think the problem of depression is related to modern television. Today the people watch too much television and the programs on television are as depressing as the antidepressant ads (except House and Boston Legal). When I was a kid I watched the Three Stooges, Tom and Jerry, Felix the Cat and similar epics. We never got depressed (besides, we rode our bikes so much we slept like rocks). I think the major reason we have so much depression is because of the 24 hour media and the fact that too few children now grow up seeing the exploits of Curly Howard. Instead of writing a prescription for some SSRI, just tell the patient to go to Wal-Mart and buy Three Stooges DVDs and watch them for one hour before retiring for the night. That is a much safer, less expensive, greener, and more appropriate treatment. To quote the great philosopher Curly, "I'm a victim of circumstance!"

Mentally Ill?

When I was much younger, I was interested in all things weird. Once, near our town, there were several sightings of a "goat monster." So, for several weeks, the adventure de jour was to go in search of the "goat monster." As we drove to the area where the monster was seen, we started trying to scare our friends. When we got to the area, we became convinced we heard sounds and saw evidence of the monster. It was fun.

Now, to 2008. Not long ago I was flipping through the channels and came across a "marathon" of a show calledHaunting Evidence. Two people, featured on the show, are "forensic paranormal investigators." These people traveled to Colorado and stomped around the house where Jon Benet Ramsey was killed. In another show, they went to Aruba and investigated the death of Natalee Holloway. The segments are always shot at night and these people, the investigators, seem to be on the cusp of overt mental illness. It is interesting, yet sad to watch--like a train wreck.

Bullshit, masquerading as science, is entertaining. But, this is nothing but entertainment--much like Sylvia Brown and John Edwards (the psychic, not the North Carolina shyster). Unfortunately, desperate people will do desperate things in times of grief. And, these people are profiting off the loss of others.

But, I have a few questions:

1. Why does ghost hunting and paranormal crap happen only at night? Well, it goes back to our fear of the darkness. Available light camera shots and muffled speech are part and parcel of the show.

2. Why is it faces are all that are often seen? The identification of faces is an evolutionary remnant. In days of ole, face recognition often meant the difference between life and death. Thus, we humans tend to see faces on the moon, on trees, and in other situations. A whole flock of people came to worship the image of Jesus on a flour tortilla. Could heaven be nothing more than a good burrito?

3. Why are snakes often seen? Seeing snakes is an evolutionary remnant as well. Snakes can kill. Even puppies know to stay away from snakes. Our mind, as a defense, will look for patterns that appear to be a snake (e.g., a piece of rope, a belt on the floor) and we will immediately, and subconsciously, stop in our steps. It is in the primitive brain.

Back to the television show. These two researchers go through great emotional displays as they retrace the last steps of deceased persons and then come up with "scientific" conclusions about the deaths. Much of what they find can be explained by pure chance, coincidence, or just the excitement of the hunt. Their emotional displays and behavior certainly make you wonder about their mental health. How different are they from those who wear tin foil hats or get cryptic messages from their televisions? How different are they from those who let religosity impair their activities of daily living? Certainly, each to their own. But, I was just somewhat saddened to see these people paraded on television when their issues seem to be deeper. Most of us have outgrown the search for monsters and ghosts--but, we need our television and we have to watch an occasional train wreck to see how lucky most of us really are. James Randi has done a great job of debunking these myths and actually has amillion dollar challenge for anybody if they can prove the paranormal. Despite being available for years, the challenge is untouched.

Kind of Speaks for Itself....

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.

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!

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.

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.

Tipping

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.

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.