That escalated quickly. Now, watch Russia

And just like that, we BLEW through 10,000 cases.  I started writing this yesterday morning (Friday). Thursday morning we were at ~9,000 cases. We smashed through 10k, and actually landed at 15k by the time I got lunch yesterday. This morning, we're at almost 20k.  That's some explosive amplification.
https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

Lower right hand corner is that daily count graph. I actually don't think we can do stats just on the US or a specific state. I'll let the first paragraph above speak for itself. We went up by 50% in 24 hours, doubled in 48 hours... Boom

For you Plague Inc. fans, Madagascar has reported the first three cases (This is not me saying the end is nigh!).  It looks like there are no reported cases in Botswana, Mali, Libya, Yemen, Turkmenistan... I'm going to emphasize the word "Reported" there.

OK, if you look at that map, and zoom out, so you can see the whole world, something sticks out.
Nope...  Not that.  Nope... Not that. Yes, amigo, the ocean is HUGE, and we should go there.

Nope, I'm talking about Russia. Weeks ago it was a bit of a joke that Russia had two cases.  Two cases.  Two cases.  Day in and day out, despite having a fair amount of cross border traffic and a far east border condition that would make Trump shit himself (Hint, Russia says there are ~30,000 Chinese living in the Russian Far East. In reality, pretty much everyone agrees that the number is at least 10x higher). To say that border is porous would be an understatement.

Russia publicly started their quarantine program in February:
https://www.reuters.com/article/us-china-health-russia-evacuation/russians-start-two-week-virus-quarantine-after-return-from-wuhan-idUSKBN1ZZ112
Hey, comrade, look!  TASS:
https://tass.com/society/1117121
I love the headline: Coronavirus can't spread beyond quarantined health camp...
Oooookay!

This Google Search is kind of hysterical:
https://www.google.com/search?q=russian+quarantine+rumors&rlz=1C1CHBF_enUS849US849&sxsrf=ALeKk00HCMISgCWsP-zyJNAJvV6OxhfmYg%3A1584797075244&source=lnt&tbs=cdr%3A1%2Ccd_min%3A3%2F1%2F2020%2Ccd_max%3A1%2F1%2F2020&tbm=
OK, hysterical is the wrong word.  This one is tragic. Imagine finding out you are pregnant, in quarantine, in a country that is denying you exist:
https://apnews.com/0f0d815ef0be8eb6809babd542620ff4
Very interesting, there is literally no mention of the number of people quarantined, sick, or otherwise within Russia.

This article, two weeks later, talks about violently deporting 88 people who were quarantined but violating that quarantine (If you have to conduct a raid to get your deportee, I'm going to classify that as violent. Unfortunately, I have some experience in that. #NeverAgain).
https://www.reuters.com/article/us-china-health-moscow-deportation/russia-to-deport-88-foreigners-for-violating-coronavirus-quarantine-idUSKCN20M252
The article does talk about three Russian nationals receiving treatment, after contracting the 'Rona on a cruise ship, and two recovered Chinese nationals who had previously recovered.

Now, I find it highly implausible that the millions of people in Russia, living with a porous border to the epicenter of the outbreak, have a quantity of cases that you can count on one hand. But perhaps they're subscribing to the theory that if you don't acknowledge the cases they can't hurt you.

All humor aside, denying the problem won't work. Russia may be playing the numbers game, accepting the single digit percentage loss (That's a million people), for a strong image and ability to completely skip the outbreak response. Their population is more isolated than ours, and they'll have a better capability to infringe the rights of that population. It's unpleasant, but a possibility.

Keep an eye on 'em

Brushin' the dust off- Coronavirus is here

Wow.  It's been 6 years since I posted here, and an insane amount has happened. It crushes me a bit, but I'm not going to go into it here (But I should have, and for that, babe, I'm sorry).

But we have some important comments to get out.

First, Coronavirus (COVID-19, Novel Coronavirus) is here. As of this morning, it's in all 50 states. We had a bet going on whether it would be reported in WV first, or Madagascar. WV popped today. If you want an entertaining way to learn about pandemics, I would recommend Plague Inc. available on your app store.
If you're looking for a decent, raw stats visualization of COVID-19 spread:
https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

If you take a look in the lower right hand corner, you can see that we're in an almost explosive amplification phase of the virus. You can also see that China appears to have done a good job blunting the spread there, which is an interesting topic of disucssion.

OK, the main reason I brushed the dust off this page:
https://www.sciencealert.com/who-recommends-to-avoid-taking-ibuprofen-for-covid-19-symptoms
specifically:
https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30116-8/fulltext


This study was actually released several days ago, but has some good content. The crux is: try to avoid NSAIDs (Ibuprofen, Naproxyn) if you think you may have been exposed to COVID-19. Additionally, as a general rule, you don't want to use aspirin in kids for fever/viral illness due to the risk of Reye's syndrome:
https://www.nhs.uk/conditions/reyes-syndrome/

So, we're primarily looking at acetaminophen (Tylenol) for aches and pains. This comes with an additional warning to keep an eye out for what's in all of your meds.  Acetaminophen is in a ton of cold/flu/cough/allergy medications. Taking too much of it will damage your liver (A particular concern with my family, being the connoisseurs that they are...).

OK, that's the short post for today.  As always, shoot me questions, comments, and concerns. Throw links up to your own sources, when you have them.  Be safe out there.

A quiet thought over here in my corner of the internet

As healers we find ourselves plunged in the misery and sorrow of others.  We take great pride and pleasure in our work.  Not from the misery and sorrow, but from the alleviation of infirmity.  Not just in body, but most of all in spirit.  It is there that our own pain can find relief.

Ultrasound Phantoms: War were declared

The ultrasound phantoms work.  They have a few limitations, but for certain applications, these cheap DIY phantoms are going to be far superior to expensive commercial phantoms.  In fact, part of their DIY nature makes them inherently superior.  Creating a phantom for a special purpose, such as vessel cannulation, foreign body identification, or needle procedures, is simple.

One of the big issues that has come up is bacterial/fungal growth on the phantom.  This should be expected, as the phantom is constructed of gelatin and sugar-free psyllium.  The system is essentially a giant petri dish.  I needed to find a way to inhibit microbial growth.  Not just inhibit, but stop.  Completely and totally.

I lucked out in a couple of ways.  I tried mixing some bleach into the material when it was on the stovetop.  The mixture foamed up a fair amount.  This wasn't a big issue with the first two layers, as pouring the next layer seemed to dissolve the previously settled foam.  The final layer settled with a very large amount of foam.  This foam is a random mixture of air and gelatin, and almost completely sono-opaque.

This is the external surface of the simulant, and represented a major problem for the phantom.  It was impossible to image past this interfering layer.  I tried scraping the surface foam off, but to no avail.
I spent three shifts at the hospital trying to find a way to make the system workable.  At this point I had intentionally inoculated the surface with dust and dirt to attempt encourage microbial growth. At the three day point, no growth, but no apparent solution.

Ending my shift one morning, I had my "Eureka" moment.  One of the workmen was removing floor tiles by heating them with a propane torch.  Between my broken Spanish and his broken English, I was able to convey that I wanted to borrow his propane torch.  I quickly heated the surface of the phantom, melting the top foam layer.  It liquified and appeared to completely remove the foam layer.

I waited ten anxious minutes, visibly bouncing.  I placed the ultrasound transducer and was rewarded with two easily visible vessel simulants.  Cannulation was almost exactly the same (the new material seems somewhat more friable).

Six weeks later, the phantom was still visibly free of microbial growth (I don't have the patience or material to actually test for microbial growth beyond naked eye visualization).

I'm stuck at the next step.  I'm either casting a human arm and making a mould, or I'm developing some method to snake the vessels through the simulant to increase the difficulty in cannulation.

DIY Ultrasound Phantoms: Recipes, Part 1

I'm now on the fourth generation homemade ultrasound phantom. The recipe is pretty simple and low cost. I'm using store bought Knox gelatin, generic sugar-free psyllium fiber (Metamucil), and vein simulators (5mm Penrose drains). Before I link to the articles I used, I'm going to shoot the authors a quick email (The idea of using the above recipe is not my original idea). Right now I'm building the phantoms in cheap, flat food containers (ultra cheap tupperware clones). Each phantom is currently constructed of three "pours". Each pour uses the following recipe: 250-300cc's of boiling water 3 packets of Knox gelatin 1-2 tablespoons of sugar free psyllium fiber With the water at a boil, add the packets of Knox gelatin slowly. Some will probably clump up (This isn't a big deal. I'll go into that in a bit). While adding the gelatin, watch the boil, as it may boil over. Stir continuously. Once the gelatin is added, slowly add the psyllium fiber, again watching carefully and stirring continuously. If the mixture clumps a little bit, don't worry too much. If you are looking to create a relatively clear ultrasound phantom, pour the mixture into the mold (in my case, the cheap food storage container) through a strainer. This will catch most of the lumps. If you are looking to create a "Dirty" looking phantom, leave the clumps in. These clumps will sonographically appear as areas of varying tissue density. These inclusions mimic the appearance of real tissue. Our goal (at my hospital) is to create a better arm simulation for US guided IV insertion techniques. These inclusion bodies mimic scar tissue, varying tissue densities/types, and present a sonographic picture that is not as "cut and dried" as other vascular simulators. The cheap food containers that I am using hold 3-4 gelatin "pours". I have been using three pours for my prototypes. After each pour, I'm allowing the gelatin to firm up in the fridge for two hours, before pouring the next layer. After the first pour has firmed up, but before pouring the second pour, I'm putting down two penrose drains, filled with water/saline, to simulate vessels. One of the vessels I'm overfilling/pressurizing with 30% more fluid, to simulate an artery. My vessel simulators occasionally leak, so I'm not having tremendous success with the arterial simulation. Still, with the slight pressurization, the vessel does have a slightly different appearance when visualized sonographically. This is a practice, that once perfected, will enable students to differentiate between arteries and veins. I'm working on a method to create an automated pulse, so that the vessel is maintained under pressure and appears to pulsate.

DIY Ultrasound Phantoms

I've got a lot of projects kicking around. This one kinda got pushed to the front because one of my colleagues said "We need to be able to perform this skill, but we don't have the resources to develop our techniques". Ordinarily, this would warrant some kind of project, slow and methodical like. However, I'm now one of the guys that responsible for fixing problems like this. It's not just an issue, it's "my" issue. The glove was thrown down, so to speak. The issue is that we need to place IV (intravenous) lines in our patients. It seems pretty simple: you come to the ER, sick/broken/in pain, and we need to take care of you. One of the ways that we address this is by starting an IV line and drawing blood. If you are going to do either of those things, you can do them both (in theory). Most of the time, this is a simple matter of getting a skilled provider, with the right equipment, to the bedside. Veins are typically pretty easy to find (it helps if you have sensitive fingertips, not sensitive eyes), and then it's just a matter of a quick poke. The complicating factor is the condition of the patient. Some folks don't have great veins (for that matter, some folks don't have shallow veins, demonstrated sonographically). If you can't find a shallow vein, you need to find a deep one. Beyond a few millimeters, you simply can't feel a deep vein. You need some way to visualize those deep veins. Enter in the bedside ultrasound system. We use these during traumas to examine patients for internal bleeding. Occasionally we use it to check on pregnant women and the health of the fetus. Other than that (this comprises maybe an hour or two a day, at most) our bedside sono units are dormant. They're like any other medical imager: not cheap. A couple of docs figured out that we can use these things to visualize deeper veins (and arteries). From there it was a simple trick to guide an angiocath (an IV needle) into one of these veins. It's a pretty cool solution. It's not as invasive as a PICC Line (Peripherally Inserted Central Catheter), or other central line (subclavian, femoral, etc), and it's more comfortable than a jugular line. It's also a guided solution. No blind sticking, and you can see the structures in the patient's arm to avoid complications (inadvertent arterial puncture). However, it's also a bigger deal than a simple IV stick. You're taking an angiocath that you would normally poke a couple of millimeters down, and going 10-20 millimeters down into someone's arm. You're asking more of your patient. More to the point, if all you have done, to date, is a standard IV placement, you're asking a lot of yourself. I know that the folks that I work with care for their patients. Or they're crazy. No one would work under these conditions (low pay, constant threat of bodily harm, verbally abusive clients, incredible work loads) for years. They all seem highly functional, so I'm going to stick with "Compassionate". I think my colleagues generally care for their patients, like they would care for their own family. So it's a lot to ask them to jam a needle two to three inches into someone's arm, using a technique they're uncertain of. In fact, it's just wrong. We have ultrasound simulators, called phantoms, that we borrow from the medical school. They're around $300-$400 dollars, and they're simple blocks of gel (silicone? dunno) with vessels suspended within them. The sonographic image looks pretty nice: a couple of straight vessels a couple of centimeters deep. It's not what a patient's arm looks like: vessels that are all over the place, twisting and turning, with various inclusions scattered through the arm. We needed to come up with a way to transition from the perfection of the standard ultrasound phantom to the reality of patient care. Oh yeah, one more thing: No budget. Solutions will start in the next post. (I'm going to try out a cliffhanger ending for this one)

Sick and tired

I didn't understand what this meant until recently.

I've been tired before. I've had some times where I've been exhausted. Seventy-two hours on the job will do that. Insane tactical medicine evolutions will tax you as well.

I've always measured how tired I was by my ability to keep going, should I absolutely have to. Sure, I've been sick. I've been tired, but push comes to shove, I can still get my butt in gear.

A couple of weeks ago, I just got sick. It started out pretty subtle, no big deal. A little abdominal pain and some GI symptoms. Then it accelerated like a bullet, and just chopped my legs out from under me.

I was exhausted, and sore. Muscle and body aches plagued me in waves, as did this incredible lethargy. People who know me, know that I'm typically pretty gung-ho, and type A. I'm always doing something. Hell, when I'm not feeling well, I typically get involved with a project to keep my mind off of things.

Not this time. It was an effort just to sit up, and at times I'd just collapse in on myself, I was so tired.

It did give me new understanding though. I can better appreciate when a patient tells me they're so tired that it's an effort just to get water.

Hydration and eating were a constant issue for me. I just couldn't get the energy to keep going to the fridge, and I had no desire to eat (To the tune of 15lbs of weight loss).

All this, and we really didn't know what was going on. Sure, we had the symptoms pinned down pretty well (I really like my doc and her medical team, they cut right to the chase), but the differential diagnoses were legion.

This was really bizarre to me. Sure I knew the process in the back of my head, but I've never personally experienced that. When I've been sick before, it's been a sore throat, or the flu, or pneumonia (all of which were child's play compared to this). This time, I was just sick, really bad, and I had no idea what the real cause was.

I had occasional fevers that seemed to only underline that I was sick. I went whole days without them (I think). I actually got work done with the fevers. I wrote several hundred lines of code to get the basis of one of my projects done. Probably at the cost of a day's rest


A couple of weeks into it, I had a mini-freak out. What if this was forever? What if I'd gotten some bizarre chronic condition that wasn't going to go away? Holy crap! I still didn't know what was wrong with me! Three weeks?!

Wiser heads prevailed, and I was talked down from my lethargic hysterics. I'm really thankful for my family, and especially my girlfriend, Angel. She was incredibly helpful in keeping me fed and watered. Pretty much like one of the animals, actually. At least I felt that way at times. It was pretty depressing at times, but mostly incredibly comforting.

Thankfully, my panic only lasted about two days. At that point I went the whole day without having one of those bouts of exhaustion. The next day, I felt practically energetic. My joints weren't really hurting, and I felt like I could do things.

I wanted to get back to work. Bad. Real bad.
Three weeks was a really long time to be away from the department, and three weeks of cabin fever had jumped on me like a rabid elephant.


Turns out it takes more to get back to work than to call in sick. I spent three days on the phone trying to arrange a return to work. Drove me crazy. A week later, and I'm still making phone calls. GRRRR

But I am thankful now for the increased understanding. I never really contemplated being that exhausted, that lethargic, that out of it. I get it now.

New Year's Resolution (And why I don't like them)

It's a couple of days before Christmas. A full 10 days before New Year's Eve (Which I'm not working, thank God).

So I'm going to make a resolution. Which is bizarre, because I hate New Year's Resolutions. Not from others. I love self improvement, and if it takes a certain day of the year for people to adopt better habits, I'm all for it. No, I don't like them because I don't see a need to wait for a certain day to make improvements.

So I guess I'm not really making a New Year's Resolution, because I'm not waiting.

I'm going to try to keep up with this blog. That's it. Simple. Small. I should be able to do this.

I've got some incentive, and some reasons to keep writing. First, it's been a rough couple of months. Not just for me, I know, but I can really only write for myself. Money, friends, family, school, even work (and I love work).

But there is also some great good happening. Friends, family, school, even work (You see what I did there?).

So, we're going to start with the good. The pic above is my new family member, Ruffian (Ruff for short). Angel (My girlfriend, who is all sorts of good news) gave him to me for Christmas. Yeah, I know, you should never give pets for presents during Christmas. I'm going to amend that, and say you should never give pets as surprises for Christmas (Or Hanukkah, or any other big holiday). We've now been prepping for this puppy for two months (Well, I think Angel has been prepping for at least six months, maybe more than that).

I'm going to rant and rave about Ruff in another post. Maybe after I've had some sleep. He's been here for two nights, and has only given us a couple of hours (maybe 4-5 over the two nights) of sleep. We're trying to crate train him (he already goes into it voluntarily), but at night he just starts howling. Last night we scheduled potty breaks, but he still didn't sleep more than an hour or two. I finally went over and stroked him till he fell asleep. I know, probably not a good idea, but we're seriously bent right now from sleep deprivation. Tonight, Angel will get some sleep, as I'm up all night for my work cycle change.

Other great news: I'm working at an emergency room again (totally not saying which one, and I'd appreciate it if any commenters kept that information out). After Haiti, I realized how much I needed to continue working in medicine. I know I feel better, all around (lost 20lbs from running around over there).

Med school applications are in! I'm currently working on secondaries (and trying to afford the fees for it). I'm just applying to DO schools this year. I really just like their philosophy better. I'm going to keep writing about that experience.

I'd like to dedicate this post to one other thing, the enabler of this post, if you will.

Yesterday a surprise package came UPS. It's Christmas, so I wasn't sure what it was (I'm so sleep deprived that I wasn't sure it was something that I ordered). I opened the box, and inside was another box that screamed "Laptop".
I got a little nervous. I didn't order a laptop. No one would send me a laptop. I checked the box again. Angel needs a new laptop... Nope. My name.

I opened the box. Yep. It's a laptop! Very matte black finish, on the smallish side. Very thin. Light. And the first piece of paper that I see (one of three, single pieces of paper, one of which is a business card) has a chrome label and emblem on it.

Could it be....?

Yeah, it totally is.
For the less geeky of you (and I'm probably the geekiest guy you know), it's a Cr-48.
http://www.google.com/chromeos/
Google has created a pilot program showcasing their reference platform (the Cr-48), and their Chrome Operating system (Chrome OS). The whole concept behind the program is a web based OS. No downloading or installing tons of software onto your system. Google has everything hosted on their servers. In fact, go one step further. Store the majority of your personal files on their servers. That way, wherever you go, whichever computer you're using, you have access to your files. Even cooler: Sign on as a guest on someone else's Cr-48, and the computer will behave just like your computer.

So the laptop arrived on my door, unannounced. I have to admit, the effect was striking. I wandered around for a full ten minutes, just saying "Wow". Early Christmas, for a little kid... I already got a puppy this Christmas, so an unexpected, cutting edge laptop..... Wow.

Cutting edge... OK, I'm going to bet that this thing doesn't have an unlocked Core i7 in it's guts, or a multi-GPU setup to drive insane graphics. What it does have is an always on web link (I don't know what deal Google and Verizon worked out, but thank you Verizon for helping make this piece of tech happen. If you're not on WiFi, then a 3G modem kicks in, and you have 100MB of data transfer a month, free, from Verizon. OK, not exactly cutting edge, as other laptops have been doing that for years.
Turn the thing on, and it boots in seconds. Yes, truly, in seconds. Less than 10. From a cold start. That's cutting edge. My current laptop has a Seagate Momentus Hybrid Drive, and it's fast into Windows 7, but not that fast. I'm pretty sure that this thing is using a solid state drive (SSD), but I don't have the details.
No, what's cutting edge is the whole overall product. Everything is coming together in one package, in a novel beta-test (Free laptop! Really?!), in an incredible design.

Let me talk about the design. First, the battery is a Li-Ion pack that is removable. It takes up a full half of the bottom of the computer. Yeah, it's still removable. People, get with the program, and start doing this.... always. Its ridiculous that companies still make non-user changeable batteries.
The laptop itself is completely matte black, in a sexy, good feel rubberized plastic.
This chassis just feels really good in your hands. On the left is a VGA output port (Here, I wish for an HDMI port, just because that's a port that is going to be on every display technology for the foreseeable future). On the right, a power jack, USB port (USB 2? I think), an audio port (single) and an SD card slot. That's it. Simple. I'm sure people will argue that there are not enough USB ports. Maybe... I don't know. This laptop isn't about huge numbers of external devices. It's the internet, everywhere. Already it has an infinite increase in connectivity over an iPad.
The keyboard is great. This is important to me. My number one piece of advice for people looking at netbooks is to demo the keyboard first. In my experience, the keyboard is the make or break factor for netbooks (this thing feels like a really nice netbook). Chicklet style keys, with a great feel to them. Properly spaced, and easy to type with (Oh yeah, this whole post is written on this thing).
The keyboard has some changes. No, the shift keys are in the proper places, no bizarre punctuation keys. Google has made one significant change to the keyboard, that I'm hoping revolutionizes the keyboard as we know it: No CAPSLOCK. That's right. It's gone, been replaced with a "Search Key". I'm just glad that people who use this thing are going to, by default, have to use proper capitalization. Google, if you're listening, please don't ever change this feature. You hit this one out of the park.
Oh yeah, the function keys are gone, and have been replaced with internet keys (reload, forward, backward), screen keys (Brightness), and audio control (Volume, but no "Next Track" feature.... Can't really comment on it yet, I haven't tried audio yet). I can't see a "Screen Capture" key, but it may be in the shortcuts (Control-Alt-?).

So the keyboard kicks ass.

The mouse pad is huge. I mean really big. It's multi-touch enabled, so it allows for two fingered scrolling. It's a clickpad, which I'm not a huge fan of, but I can learn to enjoy. The "clickyness" feels good, I just keep moving my finger slightly when I use it.
However, there isn't a "Right-Click" button. In order to right-click, you have to press with two fingers. So far this has been a major hit-or-miss proposition for me (and my friend who has tried it out). This is a major change for me, and I'm having a fair amount of problems with the right-click interface. BUT, I'll get it.
In their defense, Google has provided all sorts of customization features for the controls. I just haven't had a chance to use them. I'll post on that at a later date.

As I've said, startup is fast. Really fast. When you first boot up, the system asks for your Gmail information (or allows you to create a new account). It takes a picture (I was so excited, I let the thing take my picture. I look like crap. It'll be interesting to see how many geeks, like me, are too excited to groom themselves for their pictures, upon receiving this thing). Then, you're onto the internet.

Security seems to be decent, though I'll admit I haven't delved into it. You have to sign into your Gmail account to gain access to the laptop. I typically have a different password on my computer than on my email accounts, so that hacking one doesn't give you access to the other, but this is how Google set it up.

The screen looks exactly like a Chrome browser window, with some very minor changes. No task bar at the bottom, a bug report button to the right of the "omni-bar", time, signal strength and battery indicator in the upper right. That's it.

Browsing around is easy, and just like Chrome (and pretty much just like every other browser). Open up a new window (Control-N for a new window or Control-T for a new tab) and you get access to your apps, including a small web store. The game "Entanglement" is pretty cool.

However, it's here, that I have a small problem with the whole system. There doesn't appear to be a way to split the screen. You can't consult notes on one side of the screen, while you are working on another screen. This is a great innovation of Windows that I love. Hell, I have a multi-monitor setup downstairs, and I use it continuously. Google, please find a way to do this. If you can set it up so I can split the screen, left/right and/or top/bottom, that would really upgrade my usability for this.

My only other gripe so far is the inability to code Python on this platform. I'm in the middle of a major project, so I need to be able to use a computer that lets me code (And test the code). For this reason, the Cr-48 is in use next to my other computers.

However, the Cr-48 is going to be by my side for the foreseeable future. I'll be posting up my further impressions, as I get them.

Thanks Google, I hope to give you the info you need!

Kind of a rational post about weed

Quick, to the point. A good, realistic viewpoint.

Though I seem to get my cognition changes through concussions and sleepless nights...

Yeah, for the record, Charlotte International SUCKS. Not the place to do a ten hour layover.

Oh yeah, also: Credit Card Companies! Please! If you think a hotel room is a suspicious charge, let it go, and arrest the guy when he gets there, if it isn't me.

If it is me, you can let me go.

If it is really me, and you deny the charge, I'm probably screwed due to my poor financial planning, and PayPal's withholding of funds.

I think I'm going to be seeing how friendly the Turks and Caicos is to free-range camping.

Seven days to go

I feel like I'm getting ready for a shuttle launch, or something of that magnitude. Something big is coming. I know it is going to be more of the same, completely different patients (something an ER guru once told me).

In seven days I take off, but that won't be the real change. That will simply be me, leaving what is comfortable behind. Leaving my friends, family, and numerous supporters (Nova Scotia? I also got a contribution from a Belgian, but I think he was only 100 miles away when he did it. My family has done a great effort on the West Coast, and I think they have the true distance award so far).

After that great takeoff, down the runway (I love taking off in planes. I wish they'd let me listen to my music), I'll coast for a bit. Actually, a couple of days. Getting further and further away from my home. Sure, I'll have an electronic link (thank god for the internet), but that's not the same.

Then the big change. Weightlessness. I wish. I'd love to go into space.

No, my big change will be Haiti. Cap Haitien, then Milot. Then a series of days at the hospital, hopefully in the ER, where I'll at least be comfortable in my work, if not my surroundings.

And I'll have a team. This is where the real draw is. I love working with a good team. There's nothing else like it. I pick my friends based on how well I can "work" with them. They're the greatest people in the world...

Hopefully I'll find new ones in Haiti.

We had our fund raiser dinner last night. The local restaurant bailed kinda at the last minute, so we hosted a shin-dig at the house. Good friends, old friends, even surprise guests showed up. It was a great time, with plenty of depth that I found surprising. I only had to do my Haiti "Song and Dance" twice (don't think I completed it at all, to be honest).

We talked all night. About everything. A couple of times the controversy regarding the Haiti relief efforts came up. I heard numerous opinions about who was screwing things up, and why. Why things were screwed up. How it could be done better. How the Haitians needed to do better. It kind struck me on numerous levels.

The Haitians just didn't have much before the quake. Then a huge chunk of their world fell apart. The world is coming in to help them, but how are they going to react? Are they going to ask us to build them new tin shacks? Are they going to ask us to build brand new houses? State of the art infrastructure? Build some new hospitals?

These poor people had next to nothing, and they really worked hard to make it better for themselves (I'm not going to believe that a whole, independent nation is nothing but lay-abouts). Now, as a nation, they're in a rough place (no matter how you slice it). Do they embrace the help, and profit from their disaster? Do they stoically, and pridefully turn away the help, and try to rebuild their status quo? I really hope not, but some of the things I've heard have made me think that this option is something that people want.

The other thing that has struck me is the number of people who know exactly what is wrong with any given problem/solution/situation. Wow, it's simply incredible. What's horrifying is the level to which we elevate some of these people. Celebrities, news personalities, pop icons. What the hell are we doing listening to them? (I won't get started about the Vaccine debate. It looks like Jenny McCarthy may try to shut up. Possibly too little too late. Amanda Peet, there's someone I could listen to).

Sure we arm-chair quarterback. All of us do. However, I'm beginning to see that there is a segment of the population that simply delights in that. No matter what is going on in front of them, they're going to accentuate the negative. No matter that your efforts are bearing fruit, they'll decry your mistakes, your inability to save everyone. They'll do this while you sweat, bleed, and succeed. They'll sit in their chairs and drag you down, while you do the best that you can.

And when you're done, they'll let out a sigh. Then roll over, and take a nap. Cynicism is exhausting. Or idle cynicism is exhausting. I'll be the first to admit, I'm pretty cynical. However, I'm cynical as I'm sweatin' bullets trying to fix the problem.

And finally, I was struck by the problems I'm leaving here at home. I apologize for this downer of an ending to the entry, but it's on my mind (and it's my blog!).

I'm not looking to save the world. I know I can't. I know I can try, and I know that sometimes, despite everything I throw at it, bad things will happen. However, there are times, where I just wish I could save something beautiful. Something that I see is going wrong, and that I just don't have the power to fix.

I'm leaving the virtual paradise of the US for Haiti. I'm leaving problems here that need fixing. Problems that I probably can't fix, but that are near and dear to my heart.

I'm hoping people get better about taking care of each other.

Some Milot Facts of Life

First, I found out that I'm the only emergency medicine guy on the team going to Milot. Seeing my name on the list was a bit of a thrill. I guess I'm getting too cynical, but it didn't seem real until I saw it in print.

So I got a little additional thrill this morning. Then I read the rest of the email. A frequently asked questions (FAQ) attached to it was pretty sobering.

The good news: I can take one change of clothes with me. The rest of the time I'll be in hospital provided scrubs. This is going to be the first time I've been practicing medicine in the field, in scrubs! Hot showers are available. Also pretty nice.

Unfortunately, that's the good news.

There are specific warnings about tetanus. They've already had patients succumb to tetanus. There are docs in the US who will never see a case of tetanus in their lives. It's a vaccine we (should) all get as children, and updated as a matter of course every 5 to 10 years. The Haitians may survive being crushed under a building, only to die from a completely preventable disease. It's chilling.

We're advised to make sure we eat, and get 5-6 hours of sleep a night. This is going to be good practice for medical school and residency!

The hospital has a 6-8 bed ICU. Ventilators will probably be available by the time I get there. Once again, something that we take for granted in the US, simply doesn't exist down there. In the US, if you need a vent, we get you one. If this hospital doesn't have one, they'll rent one, or transport you to a hospital that does.

Think about all those hospital TV dramas you watch. The ones where the hero (or mom, or dad, the son or daughter) is hooked up to the scary looking machines, while the loved one holds their hand, and tells them to come back. We won't get to that scene, in this drama. The realities will end the show (the season, the show) much earlier.

This is also a safety net that just isn't there. Miss something early on, and you won't have the option of intubating the patient, and supporting their breathing until they heal enough to breathe on their own. You have to stay completely on the ball, and not miss anything.

This is made all the more scary by the numerous times the FAQ says "You need to time manage", or "You need to hurry". Those aren't the exact words, but that is the impression. We're going to be seeing a ton of patients. We're not going to have enough time for the numbers of patients (Do you ever?), but the consequences for missing those subtle, crucial signs, will be dire. I'll be saying that most famous prayer, "Dear God, please don't let me screw up"

The lab sounds better and worse than I expected. Most conventional blood and urine tests will be available. That's good news. Apparently everyone is anemic, so H&H's are getting run continuously. However, no cultures are done at the hospital. None. Something in my mind made me think: If they have a lab, they must be running cultures. Assigning antibiotics to challenging patients is going to be another challenge.

Most patients arrive by helicopter. In the States, this would be a very ominous sign, as typically only the critically ill arrive by helicopter. Now I'm worried that the sick are arriving by the helicopter load (You can fit a literal ton of people into a Blackhawk). However, this is the beautiful thing about emergency medicine: The sick show up, and you start working. You keep going until everyone is taken care of. You'll always have work, and it will always change and surprise you.

The skills of local personnel appear to be highly variable. There are definite cultural, educational, and experiential differences. It sounds like there are problems with night shift workers making sure that patients are getting care throughout the night. IV's are running dry, and clotting off over night. It looks like I may be spending some nights in the ER tent... I haven't done that in a while, but those were good nights too.

Pain medication is in short supply. To top it off, the recommendations are to "Be prepared and willing to give more pain medication than you are accustomed to prescribing". I heard that before in certain operational medicine seminars, but I've never been in a situation where there was such a need, with nothing to give. This is going to be hard, really hard. Our hospitals have tremendous amounts and types of pain medication. Our job is to alleviate suffering. Pain control is so pivotal to medicine, and a patient's perception of their care. I think this is going to be where my limits will be tested. A minute in severe pain is a lifetime to a sufferer.

There are two principal sets of rounds. Morning and night. This is similar to US practices. However, evening rounds may not happen till after midnight, or even 4am. These are some really long days.

Deep Vein Thrombosis is a common complication. For those that aren't big time medical people, I'll run this down. Clotting is a fantastic adaption that we have. If we get a cut, our blood (hopefully) gums up, plugs the hole, and begins the healing process. However, through disease, injury, or loss of homeostatic control, we can develop clots within our body. When these clots form in our veins (typically the large, deep veins in the legs), it's called Deep Vein Thrombosis (DVT). There are a large number of complications that can arise from this, so it is something that we want to prevent. In the US, this is typically done with specific doses of heparin (a blood thinner). In Milot, they're looking at using aspirin. It's quicker to administer, and may be just as effective. Everyone gets assessed for DVT.

Lessons learned, and I haven't even set foot on the island.

I had a nice talk with one of my sponsor's last night. They're working on my travel arrangements. With that taken care of, it makes the deployment even more "Real". I'm hoping they'll let me name names. Too often these quiet benefactors remain in the shadows. I gotta be honest, this trip wouldn't be happening without their support. I'm a poor college student (I'm not starving, but only through the benevolence of others, and occasional honest work), there's no way I could afford to fund this on my own.

I've got to go beg more supplies from businesses. It looks like Casual Adventure is going to be able to get some of our needs (One of greatest local businesses. I really love those guys). I need to hit Home Depot, Microcenter, maybe even Best Buy.

It's going to be a busy day. I'm probably going to take the weekend off from blogging. I'm hoping to get out and see my horse. My girlfriend and I are going to spend the weekend at her place, something we haven't done for a month (though the weekends I've spent at my sister's house have been fantastic), it'll be nice to get away and relax.

Deployment to Haiti

It's official. Sometime around March 12th, I leave to volunteer at the Sacred Heart Hospital, in Milot, Haiti. The hospital is approximately 70 miles north of Port Au Prince, so it was not directly affected by the earthquake. However, they have surged in capacity to handle the massive patient influx from the disaster region. What started as a small local hospital has exploded in size to a massive medical center. The emergency room started out as a tarp over the concrete courtyard. It has since been replace/augmented by massive tents, capable of holding dozens of patients.

These patients look like they come any way they can. The hospital has "borrowed" one of the local school's soccer fields, and turned it into a helicopter landing zone. From the blogs and online photo galleries, it looks like the tent gets emptied, only to fill up completely in minutes.

Looks like my old ER, maybe a little worse :)

Another unfortunate staple of the postings from Milot is the number of amputations that are occurring. This is a tragic fact of life in austere medical conditions, particularly with the crush injuries that are common in natural disasters. Even more tragic is the lack of physical therapists. With the scarcity of resources (They're lucky to have x-ray capability, forget a CAT Scan or C-Arm), the surgeons have to operate to save lives, not limbs. It looks like they're doing a tremendous job, in difficult circumstances.

It looks like incredible work. The kind of work that I really miss. The downtime pictures show teams that looked tired, but happy. Caregivers are frequently seen with convalescing patients, with smiles on all their faces.

It looks like most deployments last a week. The folks that I've talked to have said it's an exhausting week. I'm hoping I can last more than a week. I've got the time, and I miss the work. Still, I think this is one of those things that you won't be able to judge until you see the conditions.

I'm running around now. Studying topics relevant to the conditions. There are a number of tropical diseases that I've never seen, but will be incredibly common there (Filariasis is a fact of life down there, and I've heard the mosquitoes are a sight to be seen). I'm also trying to learn a little bit of creole. My sister picked up a great book for healthcare providers, English/Haitian Creole Medical Dictionary, By Heurtelou and Vilsaint. The book looks like a kid's coloring book, but the simplicity of it will make it incredibly easy to use. Despite the simplicity, it provides significant depth in medical terminology. This was a great find.

I need gear. I haven't heard how the ER operates. I think I'm going to need to find a nice, adjustable headlamp for night shifts.

Also, while the hospital has filtered water capability, I imagine if the generator stops, so does the water... I need to find a decent portable water filter.

Malaria prevention is a big deal (at least to me). I just found out that one friend who deployed without taking anti-malarials is now laid up with malaria. Yeah, one guy is not a good statistical sample. Still, I'm a preventative medicine kind of guy. I'm going to work pretty hard not to get nailed with that little bug. So, I need to find mosquito netting, or even one of those combined hammocks. That would come in handy up in Canada as well.

Anti-malarials aren't cheap. In fact, the newer generation ones are insanely expensive. That's going to be a significant expense.

I'm only allowed 50lbs of personal gear. I'm hoping to find a cheap netbook. The hospital has occasional internet, and I should be able to upload things (like this blog). Hell, I wish I'd kicked my butt in gear awhile ago, and built that USB EKG box. That would be pretty useful right now.

I'll try to keep this updated. I guess I'll have to make sure I keep it clean and on topic, since I don't know who will be showing up. So if you read my earlier posts, I guess I have to change those rules. If there is information that you need, let me know. I'll try to get it on here.

People I'd like to be like

OK, this guy is really cool:

http://www.wftv.com/health/18373816/detail.html

A Crisis of Faith

First, I'll start with a typically weak excuse:  It's been a rough year.  It's been a rough two years.

OK, pathetic.  Really, no excuse when I compare with how rough it could be.

I "volunteer" at a local business that is putting in a new bar in my neighborhood.  The place serves around a dozen beers on draft, none of which I have ever seen advertised during the Super Bowl.  The food is excellent, and the owners have a knack for picking out some of the most personable staff it has ever been my pleasure to work with/for.  Finally, it is within walking distance of my house.

In short, an aweseome project to devote some of my spare time towards.  I won't even get in to the owners of the establishment, who are two of the coolest people around.

Anyway, I fixed a computer glitch the other day, and I wanted to stop by and check on it later that night.  I'm walking up to the door, when I see one of the server's around the back.  I wandered over and found him and a co-worker smoking.

Damn

I really like the guy.  He's young, smart, seems like a decent guy.  Always pitching in, never complaining, perfect "laid back" guy that you'd hang out with.  Honestly, he seemed smarter than a smoker.  

I know!  I've got a long way to go to overcome my preconceptions.  At least I know I have them, and I try to keep them in check.

So I started my bitching and moaning about his smoking.  It wasn't a real bitch and moan session.  It was more of a "Man, I can't believe you're doing that", and my complaining that I've seen too many people get nailed by smoking.

The two of them tossed it back at me (They don't know what I did for a "real living", before taking up the college student lifestyle).  I just talked about the handful of friends and acquaintances that had died in the last couple of years.  These were people their age who clearly died to young, and clearly not from a car wreck or bizarre drive-by shooting.  Could I say the cigarettes killed them?  No, but I could say that each one smoked.

I wound up BS'ing with them for a little bit longer before heading in to check the computers and talking to the owner.  I walked home without paying it a second thought.

This is the moment that chills me, and I'll get to it in a bit.

Two days later I'm back at the restaurant (I'm a computer guy, but I'll be the first to claim that I'm not a computer expert), and my friend starts his shift.  He pulls me aside and drops a bomb on me.

He's quit smoking.  Cold turkey.  Done.

Ordinarily, this would be enough to make me tear up.  He goes on to tell me that I really struck him the other night.  My coming over, and telling him how I honestly feel made him reconsider exactly what he was doing. 

His words "I just needed someone else to give a shit to show me that this is worth it."

Whoa

OK, I tried real hard not to visibly tear up.  I don't know how well I succeeded.

I've got a fair number of friends and family who smoke or have smoked.  I've seen all of them try to give up with varying levels of success.  Universally I've seen that it's a trial to do it.  The habit is not hard to kick.

I've heard people compare it to heroin or crack-cocaine addicition.  I'm not sure how valid that is, but I can tell you why cigarettes can be harder:

Social acceptance

This hits on so many levels.

First, a smoker has their "Gang", their friends that go out to the corner of the building and smoke.  You see them, they're the social outcasts now, who have formed their own rebel enclave.  They have secret meeting times, even special "gang signs" to indicate when to head out to the "Butt Hut".  The get together just to smoke.  Not what I would call a great support group.  Certainly not a group that is going to help you kick the habit.

Second, you can smoke in public.  On the street, at the bar, on your porch, in the majority of places you can light up.  No one is going to see you smoking and call the cops.  The next couple of fill-ups at the gas station, see how many people are smoking.  Easier, look for tossed out cigarette butts.  I'm going to bet that people don't carry them around just to toss them on the ground at the gas station.

Third, you can buy them anywhere.  With all the jokes about the invasion of Starbucks across the country (yeah, another addiction, but it's different) you'd think someone would notice that you can buy cigarettes almost anywhere.  Hell, in some places it's easier to find cigarettes for sale than a public bathroom, water fountain or pay phone.

I guess if smoking were as anti-social as heroin or crack-cocaine use, it might be easier to kick.  I don't know.  

I do know that if my buddy calls me at 2am, needing a gum fix, I'll be there.  If he can kick it, he can help someone else do the same.

So the reason that this chilled me so much:

I had almost gotten to the point of not caring.  I'd delivered my canned speech so many times that it was almost stale.  A year ago I would have walked away from the encounter bothered that this guy was engaged in such a self-destructive behavior (to call it anything less is just candy-coating it).   It took him listening, reacting, and feeding it back to me to realize where I was.

I'm really thankful that he grabbed it with such enthusiasm and vigor.  Even more so that he decided to turn around and share it back with me.  He may have saved my enthusiasm.

Speak your mind, share your thoughts.  You never know when it may change someone's life.  You never know when it may make living your life that much more rewarding.

A special shout-out to my best friend, who did quit smoking, has staying off, and vocally advocating others to quit.  I don't always agree with his methodology, but I'm really happy about his success.

Vaccinations

OK, before I start to rant and rave, you might want to just take a quick glance at this article:

http://www.clarionledger.com/article/20081012/NEWS/810120373/1001/news

This is a topic that was tiring before it even got to this point.  In 1998, Andrew Wakefield (A gastroenterologist, a bowel doctor) and his colleagues looked at 12 children who had bowel disease and developmental disorders, who had all recently had a vaccination of some sort.  All of these children had been referred to him as patients.  They were not blindly chosen for the purposes of a research study.  These patients had been selected (on some level) for care, specifically for their bowel problems.

For some reason, the daft Dr. Wakefield decided that he saw a trend, and published a "study" (this is in quotes because this is a study only in the most limited sense.  An article would be a better term).  The fact that this "study" made it into Lancet (a peer reviewed, and somewhat prestigious medical journal) only makes this story all the more tragic.

The media picked up the story, and before long an international scare burned across the globe.  Parents were petrified of giving their child something that could cause brain damage.  Media generated statistics (read: lies, half-truths, and misintepretations) were thrown into the mix.  Before long, people acted with what was felt to be justified outrage.  In their minds, the medical community was posioning their children.

By 2006, the majority of the authors of the "Wakefield Study" had issued statements of retraction, condemning the study.  The limitations of the study far outweighed any relevance to the practice of medicine, or the safeguarding of children.

The year is 2008, and we see children dying of a preventable disease.  Diseases which have been mostly conquered for decades.  Why?  Because parents remember the media feeding frenzy of 1998, and not th quiet retractions that have happened since then.  No real press has been given to the clarification that, in FACT, there is no proven link between vaccinations and autism spectrum disorders.

Correlation does not equal causation.  If you give a child a vaccine, and months later the child develops mental disorders (or any disorder) that does not mean that the vaccine is the culprit.  Think about it.  In the intervening months the child: ate, fell down (at least I did as a child), learned a new skill, breathed, had a band-aid applied (again, at least I did as a child), played in the dirt, etc.  Any one of these things could be just as guilty (or contributory) as the vaccine.  Or it may have no role at all in the child's developing condition.

Now, another chain of events.  Your child gets Measles (or mumps, or rubella), and now has a chance of dying, suffering from neural damage, or losing their sight.  The child also has a chance of spreading these diseases to others.  Pregnant women may spontaneously abort their unborn child due to rubella infections.  We know for a fact that this happens (if you want to discuss Disease Theory, I'll give it a short try, but this is pretty well established).

Please vaccinate your children.

But now that I've said that, we have to respect a parent's right to bring up their child.  There may be reasons to not vaccinate their children (though none of the above appear to be valid to me).  Strict religious reasons may prevent a parent from vaccinating their children (Not what I believe in, but a patient's beliefs should be recognized and respected.  It is one of those big reasons that life is so sacred).

I don't believe that the government should mandate immunizations in any but the direst circumstances (smallpox containment is an example).  Parents should be able to opt out of immunizations.  However, I believe that the default position should be one of immunization.  Require some level of energy expenditure to prevent the immunization, even if it is simply requiring a simple signature on a simple form.  This way, apathy will still result in protection of the child from potentially fatal illnesses, and help reinforce herd immunity.

Education should also be taking place.  Every flyer discussing immunization should list some of the relevant facts regarding the immunization/autism controversy.  Point out the level of discredit that Wakefield has suffered.  Point out the incidence of diseases of concern (not just MMR, but Autism as well).

The vehemence surrounding this is astonishing at times.  I know parents want the best for their children, and I know that I will never be able to assess "Best" for every parent in every situation.  However, the logic behind some of these decisions, and the numbers that are making these decisions is just baffling.

Stay safe, folks, and take care of each other.