Shoe Money Tonight

Occasional ramblings by an anesthesiologist/mother (and sometimes her husband).

Sunday, August 27, 2006

Quiz time again

Gakked from KLT

You scored as Euterpe. You are Euterpe, the muse of music. You are an inventor, and you constantly come up with new ideas. You are happy when everyone else is happy.



















Which of the Greek Muses are you?
created with

Thursday, August 24, 2006

Assessing Driving Ability

Yesterday, my husband and I were out shopping at the local Wegmans. While we were walking into the store, we observed an elderly gentleman (probably in his 70s) backing out of a parking spot. As we were watching, we knew he was going to back right into a car parked across the way. Now this is a wide lane - wide enough for two Hummers to drive side by side. As predicted, he hit the car. There was NO evidence in his face that he even realized that he hit another vehicle and he proceeded to drive off . The car he hit was a mid 80s Cadillac and he hit it hard enough to make it rock. Just knowing this guy was out on the road made me very nervous. He was so unaware of his surroundings that he hit a large parked car without even noticing it.

I come home today and read on Drudge that an 89 year old man drove his car into an open air market injuring 10 people. Not to mention the incident in Santa Monica in 2003 that killed 10 people.

There are more and more elderly drivers on the roads today. I can't even begin to count the number of times I have nearly been hit by an elderly driver. Especially in dusk or at night. This probably happens to me three or four times a week. It is only going to get worse as the Baby Boomer generation (the one that includes my parents) gets older.

One of my grandfathers (my dad's dad) voluntarily took himself off the road at night because he realized he wasn't able to drive safely after dark . My other grandfather always insisted on driving and had a few near misses. When I was living at my parents, our next door neighbor was in her 80s and still driving. We almost got hit by her a few times.
Assessing driving ability

It has been well established that teenagers have a high rate of automobile accidents, mostly related to reckless behavior. It is also clear that as we age our eyesight and reflexes dull. In order to be a safe driver you need good reflexes. Although I'm sure that the AARP would lobby heavily against it, I truly believe that we need to retest drivers to reassess their abilities. I think this should happen from the moment you first start driving, with the frequency of retesting increasing with increasing age. I'm sure I'll hear from people telling me that the elderly need the freedom and mobility that come with driving. This article was recently in the news. It showed that there was a relationship between an elderly persons functional status and their mobility via car. They recommended looking at driving ability as part of the ADLs (activities of daily living) that are assessed by physical therapists. Now does stopping driving decrease functional status or does poor functional status decrease ability to drive? I don't have an answer for this, but I believe it's the latter.

It is important for those of us with older parents to constantly assess their ability to drive. We also need to have the fortitude to insist that they stop when they become a danger to others. This means inconveniencing ourselves to help them run errands, go to doctors appointments, etc. But in the long run, isn't a little personal inconvenience worth saving lives?

See my other half's earlier post for more on this.

Wednesday, August 16, 2006

It's amazing how far we've come.

I've been on my cardiac anesthesia rotation for the last month and a half. It has been my most interesting anesthesia rotation to date (not that it's saying much since all I did before was basic anesthesia). I'll admit that I did not think I would like it nearly as much as I did. Most days we do on pump (using the cardiopulmonary bypass machine) CABG (coronary artery bypass grafting). Every once in a while we do a MAZE procedure (freezing part of the heart to stop an irregular rhythm called atrial fibrillation) or a valve replacement/repair.

Today we did something completely different, a pericardectomy. The pericardium is the layer of tissue that surrounds the heart. There is a small amount of fluid between the heart and the pericardium that allows for free movement of the heart. Sometimes, the pericardium can become stiff and less flexible, preventing the heart from beating freely. It makes it harder for the heart to fill with blood and pump it out. To fix this, the surgeon removes the pericardium from around the heart, removing the restriction.

The patient today also had an implanted defibrillator. The wikipedia article can be found here . In it there's a pretty good description of why a person might need one and the types of devices that are used. Now, to get a defibrillator placed, everything is done through the large veins in the upper chest/neck. We don't even put the patient to sleep, most times they just get a little sedation and some local at the incision site. But as recently as 14 years ago, it was a much more complicated process. They used to open up the heart and apply a patch directly to the heart's surface. Since the original one was placed in this patient, another more modern device was implanted to replace it. So the surgeon actually took out the patch.

Today was one of those days where I realized how far we've come in medicine. Especially in the last few years. Things that were once major surgical procedures that took days of in hospital recovery can be done as same day surgeries due to new surgical and anesthetic techniques. I can't wait to see what the future holds.

More on organ donation

In the comments on a previous post , a commenter included an email conversation between herself and a friend. They were having a discussion on donating organs to someone with an alcohol or drug use. As her friend put it "I personally don't want my organs to go to some alcoholic who has ruined his own liver and I don't want my lungs going to anyone who needs a lung transplant who has a 20 a day habit." She wanted to hear other thoughts on this. I've never actually replied directly to a comment before but here goes.

I'm not sure how things are in the UK, but here in the States there is an evaluation process that someone goes through before they can be placed on the list. The severity of their illness is only one of the things taken into account. Also looked at are length of time on the list, geography. The Mayo Clinic has a good page on organ transplantation. On it they talk about the fact that being a smoker can disqualify a person from being a recipient. At least in this country, people who abuse alcohol and drugs are not considered good candidates for an organ. Even a person's compliance with their physicians orders in the past is looked at. I would presume that in the UK, like here, they have some sort of vetting process. That is not to say that people don't slip through.

George Best was a British soccer player with a long history of alcohol abuse. He got a brand new liver in 2002. In 2004 he had one of many DUI arrests. He subsequently died in 2005.

That is not to say that someone who has a history of substance abuse would not ever get an organ. If they are clean and sober, and show that they have changed their life, a new liver/kidney/heart could be on the positive reinforcement they need to keep on the right path.

I'm of the opinion that you shouldn't let a concern about who is getting your organs to dictate your willingness to donate. The people running the list do their best to make sure the recipient is someone who will recognize the donation for what it is. The ultimate gift someone can give to another - a second chance at life.

In my area we have UNYTS (Upstate New York Transplant Services) who do a great deal of outreach in the area. One of the pages on their website is Facts and Figures . I am particularly proud that in my area we have a 65% donation rate. The nationwide average is 50%. I would love to see that number get higher.

Monday, August 14, 2006

Big & Rich at the Erie County Fair

ES1 was able to finangle for herself a rare vacation day. We first slept in (8:30 is an accomplishment for us). Then, we went down to the fair. We had tickets for Big & Rich, and decided to spend the day enjoying the fair.

For those who are not Aware, "America's Fair" (aka the Hamburg Fair, aka the Erie County Fair, aka the Western Spiral Arm Fair, aka the Universe Fair...) is the second largest annual fair in the country. Over the last few years it has just plain gotten huge. We spent the day there seeing the sights.

Unfortunately, we were halfway there when we realized that we had forgotten the camera. We decided to just suck it up and use the cameras on our Treo 650s. The pictures aren't great, but they're manageable (for the most part).

Pictures here.

Comic book form here.

The fair is still ongoing, so I highly recommend going. For now, just a few highlights.

Fries - Just outside the Bazaar was a fry stand, called Jim's Fries. They make fresh fries, as well as sweet potato fries. When I say fresh, I mean that you can watch Jim in the back of the stand, placing a potato in the slicer, and then dropping the fresh cut fries into a frier. In the immortal words of Alton Brown, that's the only way they should be made. As far as condiments - sweet potato fries require honey only. Don't use ketchup. It's tacky.

Pop (no, not soda) - there was a booth which sold fresh homemade selections such as root beer, birch beer, sasparilla, etc. Also, each booth carries collector's cups that are not only insulated, but also can be refilled at any stand for $2. By far your best deal.

Food - too much to mention. Make sure you walk around and check out prices before you buy. One stand, for example, sold deep fried Oreos at the rate of 4 for $5. Another sold 5 for $3. Take a walk. You'll be better off.

Sure, there were lots of games and rides - but you can do those anywhere. At the fair you have local animal exhibits of many types. You'll get a lot more out of those.

Well, we did play one game. ES1 & I took part in the squirt gun race (in which contestants have squirt guns, aim them at a target, and the constant stream of water propels their racer). As is usual, she won and I took a close second. But the point is that we got a very nice (and very large) gift for our goddaughter.

There's too much else at the fair to be able to go into properly; suffice it to say that if you have the opportunity to go, take it.

Finally, time came for the concert.

We discovered Big & Rich about a year ago. We were familiar with their big hit, "Save a Horse, Ride a Cowboy," and decided to check out the rest of their catalog. Needless to say we were hooked.

As far as the show itself, it was something to behold. From the introduction by 2 Foot Fred, to the Finale with Cowboy Troy and a massive fireworks display, it was unqualified fun throughout.

During their heartfelt "Eighth of November" they brought out a veteran to wave a flag. After the song they introduced the man, and told of the several times he was wounded in combat. It was a moment for us all to appreciate the sacrifices that were, and still are, made for our freedom. It is a sad commentary on today's society that there are so many who do not appreciate that; that so many are so mind-numbingly stupid as to think that if we got rid of our armed services that suddenly the world would be peaceful and happy.

Big & Rich's music is inclusive in the greatest sense of the word. They have a consortium, known as the Muzik Mafia which is dedicated to music without boundaries and hard classifications. There is a hard bias towards country music, but much of what was played crosses the boundaries into rock, and occasionally hip-hop. But the basic premise was that at their concert we are all Americans and music lovers. We're just here to have a good time.

The good time didn't stop there. They announced several times that they would be heading down to the Bucking Buffalo Saloon, downtown on Franklin near Chippewa. The concert promoted (ad nauseam) the line from their song "Coming to Your City", which says "Chippewa's where we go, when we're up in Buffalo, don't you know those yankees drink enough to drown!" If ES1 didn't have to get up at 5:00 the next morning, we probably would have tried to make an appearance. One of her coworkers did go there. Not only did they show up, but they bought a round of drinks for the entire bar. Granted, their accountants probably write it off under the budget for marketing. Still, it would've been fun.

In any case, a great time was had by all. The Fair, as well as Big & Rich, are things not to be missed.

Limitations of Wikipedia

One of Wikipedia's biggest weaknesses has always been its greatest asset - the fact that it can be edited by anyone.

In some cases this is a very good thing. Try looking for Harry Potter or Lord of the Rings info. You will find massive amounts of information, linked to pages about specific characters and events. The model has been extended for Star Wars in the Wookiepedia. While not technically a part of Wikipedia, it uses the user editable model to provide a source for massive amounts of info from the expanded universe.

The fact that any user can edit it, however, means that any user can edit it. This means that pages can be fraught with errors, especially those on controversial subjects. On such subjects it makes a good jumping-off point for further research. It should never be your sole source on anything controversial.

I used to think that technical and computer related articles were relatively immune from this. Well, it turns out that "relative" is a relative term. I stumbled across this blog post by the former lead engineer on the OS 9 team about his attempts to correct a mistake in an article about OS 9. I highly suggest reading it.

The problem, of course, is that people love their conspiracies. If you can go about your life believing that some big boogey man is holding you back, it gives you a convenient excuse for your own basic failures. The problem is that we used to leave the tin-foil hat brigade to shout at the wind by themselves, especially during wartime. Nowadays we hear "the charges are so serious that they must be investigated." Now every "the government brought down the WTC" or "it's a zionist conspiracy!" nutjob gets front page coverage.

At least the conspiracies in The X-Files were understood (by most) to be entertainment.

Sunday, August 13, 2006

Congratulations are in order

Everyone go to my friend's website and go congratulate her. She just got engaged!

Friday, August 11, 2006

Another random quiz

I'm tired and sore from the Erie County Fair and the Big and Rich concert yesterday. More on that later. I need a good long soak in a warm bathtub. Meanwhile, for your amusement:

Which of the X-men do you resemble most?

You are Beast of the X-men!With all that knowledge upstairs it's hard to relate to people. Sometimes you just find yourself enjoying a lab expeiriements. you are an adventurer anda great friend!
Take this quiz!

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Thursday, August 10, 2006

Crying wolf or making sure you need someone before paging them stat overhead.

I was on call Tuesday night and it was one of those calls that made me question the intelligence of my colleagues. There is a resident in the department of medicine who came very close to getting a loud earful from me on the inappropriateness of their behavior. The reason they didn't is because the incident in question happened around 8pm, not 2 or 3 am.

In anesthesia you don't really get many pages. Usually they're from the OR telling you the room is ready or the coordinator telling you what your next assignment is. If you're on call, you will get paged by the ICUs or floors for an elective intubation on your personal pager. But you almost never hear an overhead page unless its a code or something similarly urgent. So when I hear the "Anesthesia STAT MICU B pod" page go off overhead, I was on the elevator with the code box in hand before my pager even went off. Because an overhead page indicates that they want you there so fast you don't have the time to actually return the page - you are needed NOW. So I go charging into the room, put the code box down in the nearest flat surface and start getting my stuff ready for an intubation. As I'm doing these (getting my tube out, the CO2 tester, syringes, gloves on, taking a quick history to know what drugs to use) I'm told (not by the resident who had me paged but by another one in the room) to "hold my horses." See, even though I was paged overhead, they weren't actually sure if they needed to intubate this patient. The oxygen saturation monitor wasn't really reading well, they hadn't sent off a blood gas yet, and the pt was lethargic but responding to things. In addition to me running over, respiratory therapy heard the overhead page and also came running, figuring that they needed to get a ventilator set up ASAP. After hanging around for about 10 minutes, while I tried to get someone to tell my if they definitively wanted me to intubate the patient or not, I was finally told, "I guess we'll just page you after we get the blood gas back if we need you." It turns out, I wasn't needed at that point or anytime during the night for this patient. In fact, their blood gas showed no need for intubation.

So why does this bother me so much? First off, I was called to what I felt was going to be an emergency situation only to be essentially told I was not needed. Second, at the time, I was preparing for an emergency surgery and the arrival of that patient. The only anesthesia personnel in house were myself and my attending. This means that there could have been a delay in the start of the surgical case. Third, I am responsible for all intubations needed in the entire hospital outside of the ER. If, God forbid, there was a code elsewhere in the building, my arrival could have been delayed because I couldn't get an answer out of this team as to whether I was needed or not. And if it had been 2 or 3 am and they woke me up only for me to got there and find out they didn't actually need me, believe me they would have heard about it. When I went back to the ICU to check on the patient after my case got out, the nurse who had the patient apologized to me for the fact I was called before.

Here's the deal, I don't mind running up to the ICU or a floor for that matter if I'm actually needed, no matter what time of day it is. But let me tell you, incidents like this one and others like it, make me very frustrated. I can't begin to count the time I've been called to intubate someone who is a DNR/DNI, a patient who is struggling to breathe but is telling the team he/she does not want to be intubated as I'm walking into the room, or just showing up and being told that they've changed their minds and they don't need me. Sometimes I (and some of my fellow anesthesia residents) have been called by the ICU team to assess if we think someone needs to be intubated. Unfortunately, that's not what we're supposed to be doing. We really can't come in and eyeball someone and tell you yes or no, we are not their primary physician, you are. Use some clinical judgement and actually assess the patient. Please make sure you need us before you call.

Sunday, August 06, 2006


A few days ago, via BlackFive, ES1 & I were made aware of a current blog project under way, the 2996 Project.

The idea is to have each of the victims of September 11th remembered in a blog. Bloggers from all over the internet are signing up. I made a special request for the person I will be remembering (for reasons that will become clear when I post). Anyone, however, can sign up and receive the name of a person to remember in blog form. On September 11th, the 5th anniversary, all these bloggers will post their remembrances.

Tuesday, August 01, 2006

Distracted Driving?

Reading this post over at Aaron Adams' webpage brought to mind a number of driving related issues that should be on everyone's mind, since everyone's safety is involved.

A few years ago, New York State instituted a ban on the use of cell phones while driving. The only exception was if you used a hands-free set. The day the ban was passed, I watched a televised debate between a representative on AAA and a New York State legislator. The legislator brought along a cellular phone, and attempted to demonstrate the distraction caused by using the device. Being a typical NYS legislator, he was completely incapable of comprehending basic logic, and therefore was oblivious to what the AAA representative was attempting to tell him.

The distraction of cellular phones is not caused by holding the unit. It is caused by having to divert your attention to conversing with someone else who is outside of your current situation. Your situational awareness is reduced. Conversing with someone in your vehicle means your attention is still contained entirely in your current location. Since holding the unit was not the distraction, every single study that had so far been conducted showed absolutely no difference between using a hands free unit or holding the phone.

This knowledge has been readily available for some time. No state or locality has, to my knowledge, instituted a general ban on the use of cell phones while driving. They all include exceptions for hands-free units. The obvious conclusion is that Cell phone driving bans are about public perception, not reality.

The greater danger comes in general from people who operate motor vehicles without the capacity to properly control them. It has long been established that operating a motor vehicle on a public road is not a right, but a privilege. This privilege is predicated upon the person's ability to safely operate the vehicle.

One of the most obvious detriments to one's ability to successfully operate a vehicle is alcohol. I know of no person who would defend a person for driving while drunk. The definition of 'drunk,' however is being constantly defined down.

Groups like MADD, ostensibly founded to combat drunk driving, have proven themselves to be nothing more than neo-prohibitionist groups. They constantly push to have the legal limit pushed downwards. They parade around people whose loved ones have been killed by people with BAC's of .08, expecting us to assume that the alcohol caused the fatal accident, though giving us no evidence of such. At the same time, I have yet to hear a single one of these groups complain about lax enforcement. All the attention is about grabbing people off the road. No attention is paid to what happens afterwards. People are often given nothing more than a legal slap on the wrist, and allowed to drive drunk again and again. People who have 2 beers after work risk being thrown in jail, while binge drinkers are sent out to kill again and again.

Next, we have the elephant in the room - elderly drivers. Modern medicine has allowed people to basically be middle aged at a time when a few centuries ago they would be dead. When you begin to reach a certain age, your strength, reflexes, and general mental faculties begin to deteriorate. There is simply no getting around this. You can't react as quickly as you used to.

Many elderly drivers compensate for this in a number of ways. Some refuse to drive on highways or at night. Many simply drive slower without noticing it. This is precisely the problem - not noticing. The amount of care you have to exercise while driving is proportional to your speed - the faster you go, the more attention you have to pay. The fastest person on the road has to take the most care. By driving below the speed limit, you are putting everyone else in the position of being the faster driver, but without informing them. I have always believed, therefore, that driving slow is actually more dangerous than driving fast. This is why laws require the use of flashers on slow moving vehicles.

Elderly drivers who don't notice this also often don't notice that they are weaving between lanes, straddling the line, or nearly ramming people. One of my particular pet peeves is vehicles parked in handicapped spots which straddle the lines, or are nearly orthogonal to the spot. If your handicap prevents you from being able to park your vehicle properly, then you are not in control and have no business driving. Period.

My right to swing my fist ends at your nose. One person's "right to mobility" ends when it endangers other people. Whether by distraction, chemicals, or age the problem is a general one - people who are not in control of their vehicles. The solution, I therefore submit, should be a general one.

If a person is found to be driving erratically due to not being in control of their vehicle, a mandatory suspension of the license and a testing of their driving abilities needs to be imposed. If a person drives on the suspended license - permanent revocation and jail time. If the person drives on the revoked license - life imprisonment.

Harsh, you say? The next time you drive to the grocery store, count the number of people you pass, whether in cars or walking. You'll probably pass a few hundered at least. Consider the fact that you are operating a vehicle which is capable of killing any one of them. If you are not in control of your vehicle, you have just committed that many counts of reckless endangerment and attempted manslaughter. In any other context, you would be lucky to not get the electric chair.

The problem with bans on specific items, like cell phones or a single beer, is that they miss the point. Some people can handle them, others can't. While we focus on the items, instead of the people, police end up being forced to look for cell phones instead of truly dangerous drivers. Police have better things to do then spend their time enforcing the latest nanny-state pet project of some moron in Albany while people who shouldn't be operating an electric can opener are driving a ton of steel at 12 mph in the wrong direction.