Tried to get off of work today--sore back and neck are no good at all when you're looking at a 12 hour Saturday night shift at St.D's. No luck--this is a business, not a fraternity. Maybe it's because I'm in pain and in a sour mood, but I'm letting the wellfare crap really get to me. Two people have come in from the local Indian casino (a monopoly awarded on the basis of race, by the way) with chest pain. Neither has health insurance. How do you have money to gamble if you can't pay for your health insurance? Answer: I pay for it. Me and all the responsible tax payers of California get taxed to pay for the healthcare of these people who have decided gambling is a higher priority. Crazy. From my observations the following is a rough list of the top things people on wellfare spend money on instead of health insurance: 1)Cell phones--usually one for mom and one for dad and one for sister, but the baby daughter lives off of wellfare. 2)Cigarettes. 3)Tattoos 4)Motorcycles 5)Alcohol 6)Etc....aud infinitum Back to work U-561

Wow. Almost a high mortality day for me in the ED. Well, not the ED, but a lonely stretch of the 60 freeway at 0130. I got off work late. Driving home, fast, on a bare stretch of highway. All of a sudden some guy on a motorcycle swerved from the left lanes right in front of me. Christ! Braked, swerved, hit him, lost control, spun, crashed into barrier, came to stop. Stunning. It does not escape my notice that this was day 8 in a row and it was 1:30 in the morning after a 12 hour shift. Did fatigue and overwork contribute to my almost killing another man? Hmmm.... By the grace of God the guy was okay. Poor guy is shaken up, but walking, talking, breathing, perfusing. In the fractions of seconds this crash took to resolve I had clear thoughts--just fragments of thoughts banging stacato like in the moment. I'm going to hit him. Try avoid. No. Hit. Not too bad. Spinning. I'm out of control. I might be killed. I hope not. Will I hit the barrier? Will I be hit by someone else? Is the guy okay? Was I at fault? Hit barrier. Okay, survived that I think, will reassess in a second. That's my airbag. Slowing. Lower risk of serious injury. Less risk of being hit. Stopped. Feel okay. Not hit yet. Okay. Okay. Really okay? I think so. As a resident I had the least possible auto insurance so I think I am probably SOL. But, being alive is something to be thankful for and I am. God knows I have seen what can happen at 80 miles an hour. Downside: Pain, loss of car, inflated insurance premiums (can you blame them?). I have a braod red abrasion to my left forearm (airbag?), a painful abrasion on my left anterior tibia (under the steering column?), and a red painful abrasion to my left neck (seatbelt! Wear'em kids!). Upside: May have to buy a Ford Mustang GT sooner than I thought. Convertible? Also, I did an amazing reduction last night. Soccer player with a nasty tib/fib fracture. His posterior tibia portion was a jagged shard of bone posteriorly displaced and shifted proximally. Ugly! I put this guy down with Propofol (200 mg!), braced mysefl and cranked on his freaky angled leg. Pulled, jerked upward and then flexed forward and...click. Splinted (sugar tong plus long leg) and post redux films were F'ing flawless! Flaw-less! Booo-ya! I wrote "Flawless reduction by ED doc" on the films and told him to take it to the Orthopod in the morning. Sweet! How you like that overpaid bone jockey! Ha, ha, ha! U-561

Wow. High mortality day in the ED. Was working at about two-thirds speed through the beginning of the day, and then a patient bomb exploded. We had two full arrests come in at the same time. I was rushing to room 13 (bad sign) for the first when I saw goggle-eyed medics wheeling in the second. Nothing for it---stabilize the first and see the second when I can. Ah, California, you're carefully designed public safety net in action. Look ye upon it and rejoice! This first guy was young, fifty, and a complete cipher. No pulse, no breathing, and idio-ventricular (Latin for WTF) rhythm. We coded him up. The medics thought they might have seen a peaked T-wave or two before the guy dropped out, and he had a dialysis shunt, so hyperkalemia seemed like a reasonable bet so we treated for that. As I was tubing the guy--almost a cluster, but salvaged it at the last minute--I was calling out orders. Epi, Atropine, 2 of Bicarb, 2 of Mag, 2 of Calcium Chloride, Insulin 10 units IV, D50.....and when I lifted me head up to check on the nurses they hadn't missed a beat. What a team! So, so, strong! We had a trainee EMT with us and he got to see an eyeful--from the convenient perspective of doing chest compressions. I put in a central line--bloody, bloody mess that i had to apologize for afterwards--and we reassessed the guy. I'll be damned if he didn't have a rhythm and a pulse. Bolused Lidocaine, hung a drip, and moved to phase 2--Consolidation. Ahhhhh....not so fast young Dr.U! I checked on the second Code--thank God! Paleo had been called from ED2 to run it (F'ing STUD this Pableo guy). Then my guy dropped again and we had to code him back up. He just slipped from a booming sinus tach with robust 130/74 pulse to an indetectable dribble of QRS complexes at about 20 per minute. The only thing keeping this guy alive was IV epi. And over the course of fifty minutes we gave a lot of it. Pressors were hung, labs were sent...and I went to see the family. Young daughter who speaks English and wife who doesn't. I was direct, not quite as gentle as I would have liked, and left no room for misunderstanding the fatal severity of the issue at hand. We called them in to see the patient....just as he dropped out again. We were an hour and fifteen minutes in, and I'll go pretty deep into reserves to pull out a 51 year old, but I was increasingly confident that we were no longer working towards a medical or moral good outcome. I called it. Poor guy. The next guy was almost called in the filed, but freakishly we got a (questionable) return of pulses and the guy lived just long enough to be subjected to a mediocre five minute code before I called that as well. Another guy would have been coded, but was a DNR and another guy (Pableo's) lived through the first resuscitation effort and hung on for three hours before dying on the hands of my evening shift replacement. A whole lot of dying going on. In happier news...I may have made a briliant diagnosis! Listen to this! A very sweet Muslim girl comes in with an odd rash on face, palms, soles. I won't be coy and tease you through the medical investigation but suffice it to say: INH, fasting because of Ramadan, and unusual rash on her palms and soles--am I seeing a case of Pelagra? I treated her per the standard Pelagra regimen (for those of you not in the medical field, this "standard Pelagra regimen" is a bit of a joke) and arranged follow up with Family Medicine. You could almost here the stupified disbelief in the FM attedning's voice. Not that Pelagra had been found in 21st century America, but that a grunting Er doc had 1)been able to consider such a non-obvious diagnosis and b)been able to pronounce the word. Home early. Two days down, six days to go.

At work I had a sweet little lady come in, 50 years old, and walking into her room I knew she was not going to make it to 51. She was flourescent yellow. Painless. Abdominal distension,discomfort, decreased appetite, weakness...a grim litany of maladies that could only signify cancer. I sent the labs and ordered the ultrasound and CAT scan, but really this was a stalling maneuver to buy myself time to rally myself for the "You have cancer" conversation. When the CT was done I wet read it and her liver was enormous and riddled with golfball size mets. I went to her bedside and broached the subject directly, but gently. You never know how this is going to go, telling a stranger she has this dread disease, this monster living within her. In the non-privacy of a bed curtained off in the the ED no less. Typical for cancer patients she was sweet and stoic and took it with grace and tremedous courage. I hope she gets a good doc. The Biscuit and I have hit a bump en route to the wedding. Two bumps--the gift registry and the total wedding cost. For the registry we have different tastes--my distaste at spending money on fashion presents something of a chasm between what I enjopy buying (even by proxy) and what the Biscuit might. I am happy to pay for quality, but fashion and name-brand cachet have no appeal for me. And as for the wedding we have butted up against our $15,000 budget. Wedding for 150 for $15,000--that seemed pretty reasonable in the halcyon days of being newly engaged. Alas, we are 13,800 in and we have no photographer and no wedding dress. Both, I have to admit, seem like a good idea at a wedding. The Biscuit's solution is (get this!) for her to work as a waitress for twenty nights through the holidays to make the money to buy a $3,000 wedding dress. To hell with the money--we are miles apart philosophically on this one! U-561

Went for a ride this morning. Drove home after dropping the Biscuit off at her Marine Corps weekend drill and decided that the weather for riding just wasn't going to get any better. I'm still coughing and congested--there didn't seem much point on going out if I was just going to be hacking and gasping after a few minutes out--but after a few tuberculous hacking coughs the lungs felt pretty good. Certainly the lungs were good enough to put the legs in a hole and I was able to put some burn in these new flabby legs. It actually felt great. Cool weather, empty roads, and a nice steady slope that required work, but wasn't agonizing. Finished off with a brief grunting climb up a short hill and then coasted home. Want to put in a quick plug for my bike: Scattante CFR. Scattante is the SuperGo house brand and the rumor is that the S-CFR frame is just the Kestrel 3000 frame in mufti. Regardless, it's light and rigid and responsive. I've got almost 3,000 miles on it in 2 years and it's been rock solid for me. Sure, I baby it, but God Damn it's a good bike! At work--well, I haven't been working. I've been studying for Boards. Ah, misery......I alternate between feeling anxious about the coming Boards and feeling apathetic. Fortunately its interesting stuff to study, but I just can't bring forth that superb endurance for eight hour studying marathons that got me through college and into med school to start with. The Biscuit really had a phenomenal day yesterday. She does what other people just talk about and wish they had the courage to do. She's remarkable. Something about her is magical. Ride: 17.3mph 22.7mi 1:18 U-561

Lousy days at work. I went in to work sick on Saturday. Over the course of the ten hour shift I went from just a small niggling sense that my body wasn't quite right, to sneezing and chills, to a throat that felt like I had swallowed broken glass. I was miserable and could barely hold on. Didn't do any of my paperwork and went home to crash. The Biscuit was there. I took Tylenol, Motrin, Phenergan with codeine, and slept for twelve hours. Awoke feeling sick and congested and had to go back in. Then, to top it off, my boss came to talk to me about a pediatric hyperglycemia case I mismanaged. No harm, but he's right--I didn't do a very good job. Shit. U-561

I rode yesterday and it felt pretty good. Obviously the legs are the same, so that's not the difference. I think I just was ready for the pain. The first day out after so long off the bike--well, I had just forgotten how much pain was involved and the shock of it was demoralizing. But going out the second day my mind was ready for it, and it's so much easier to accept the pain with equanimity when you have steeled yourself for it. That is what appeals to me so much about the pro cyclists--it's not that they don't feel the pain, its just that they have developed such a phenomenal ability to endure and embrace the pain. Today I had a free day to ride--no deadlines to race to meet--so I went out at 3:30 and knew I could push myself a little further. The legs felt decent. I went out along the same canyon road; today the Devil Winds ahd died down and in ten minutes I covered the miles it had taken twenty minutes to do the day before. The canyon has a long uphill road. Only one real hill, but a long stretch of grade just steep enough to be a pleasant challenge. It's not pretty. Nor is it cool and shady. It's just a long stretch of asphalt bordered by brown dirt and broiled under a miserable sun. I rode until the uphill disappeared and then turned around and cruised back into town. Nice ride. 1:05 18.0 16.6

I went out for a bike ride today. I love being on the bike, but I have been off it for months. Probably five or six weeks since I rode at all, and probably three or four months since I put down any serious miles. But yesterday in the shower before work, feeling tired before my 6am shift, I shaved my legs for the first time in months. It just felt like it was time to get back on the bike. I spent all day yesterday knowing that I'd be riding today and it felt good to have that before me. The actual riding was not idylic. Put air in the tires and went out. I used to ride on the PCH (magnificent!) but now that I've moved I have the Godforsaken Hwy outside my porch. The first turns of the crank felt wonderful and smooth. But the legs weren't right and it was dismaying. After a half mile I knew that I had put myself into a deep hole. It's going to take while to crawl back to decent physical shape. I had known it would be like this; harbingers of doom had been all about me for months: my heart pumping too hard after racing up to a code on the fourth floor, my calves no longer filling out the legs of my jeans, catching my reflection in the window and wondering "Whose chicken legs are those." It was bad, and embarrasing, but so be it. It felt like these weren't my legs, like I had borrowed them from someone who had spent a large part of his life sitting on a couch drinking beer and watching his ass widen. I only put thirty minutes in. I think riding here will be okay: there are hills, and a few long desolate stretches to burn miles on. It will be okay.

The boss took me aside last night for a parley. I was a little anxious because even though I was pretty sure I hadn't done anything wrong it's just never nice to have the guy who signs your paychecks say "Can i talk to you out here for a moment." And, the fact remains, I work in a job where people die on a fairly regular basis and that leaves the door to grim professional conversations always open. Turns out a complaint from the nurses had reached him. I have been called to account for my......dirty white coat!!!!!! Are you fucking kidding me. The Departmental Chief has been contacted regarding my grimey coat? Give me a fucking break! How chicken shit and ridiculous is that? On the other hand...they have a point. It's a ridiculously filthy garment that can be cleaned, but immediately reverts to its disgusting ways within a few wearings. It's atrocious. Really, really horrendous and they're right....it shouldn't be brought to the work place, much less paraded around in front of people with compromised immune systems and incipient nausea. There's no excuse--the coat has to go. No one wants to be known as the slovnly doc with the disgusting white (grey/yellow) coat. I plan to kill this reputation while it lies newborn. I'll buy some new coats, get them monogrammed, and develop a reputation as a F'ing popinjay. U-561

The next day I went to work and the patient was still there. They had gotten consent from the family for withdrawal of care. As a non-surivable he had lowest priority for the ICU so the chronic bed shortage left him lying in the ED for 24 hours. I was asked to pronounce him. His dad was at the bedside, we remembered each other from the tense moments we had shared the night before. I told him I was sorry iot had come to this and he said "He was a good son." I pronounced him and he was dead. His father left.