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..as the philosopher Jagger once said, You can't always get what you want.

Jul. 2nd, 2011

Have you ever forgotten to do something really important? What was it?

Now if I remembered that it wouldn't be forgotten now would it?

Probably has something to do with the scalpel I left up someone's ass..

That's Doctor Asshole to you. I didn't spend all those years getting my doctorate in dickishness so people could call me 'Mister'.

..as the philosopher Jagger once said, You can't always get what you want.
This Valentine's Day, instead of "I love you", say "You raise the vasopressin in my dorsolateral middle frontal gyrus."

It probably won't win you any brownie points with your loved ones, but it just sounds like you're all kinds of educated.

..as the philosopher Jagger once said, You can't always get what you want.
This entry is simply an update so that LJ doesn't think this journal is abandoned. Please reply

..as the philosopher Jagger once said, You can't always get what you want.
What's your favorite cult film of all time, and why? What are the essential ingredients for a cult classic?

Dirty Harry,and don't ask me why unless you're prepared to make my day. Ingredients? What, is this home ec? How about cardamon, two whole salsify roots, minced, and a stick of butter.

Hey, Cam, look! A lolcat.

..as the philosopher Jagger once said, You can't always get what you want.

bonebreak fever

Jossei viina, terva tai sauna auta, on tauti kuolemaks.
{{Finnish. Translation:
If vodka, tar and sauna don't help, the dis-ease leads to death.

In my first year at PPTH, a nurse once said, "I don't know how you do it. You walk into the room of someone with an infected toenail and you come out doing a scan for a chest tumour and it's there. How do you do that?"

I do it by addressing the unspoken. The unspoken hangs in a room like a cloud. I can't see it but it is as if there is a giant floating cloud hanging above the person. It is often crying, pressing to be named. I don't even know I'm doing it, sometimes, asking just another question and another. We aren't on the template for the infected toenail anymore, we have wandered far afield. Fuck the template, that's fine for the coders and the insurance and the billers, but it really isn't about good medicine.

Sometimes you just need to say to yourself: All right, I'm God now. How the fuck do I get out of this mess?

If you can figure that one out, give yourself a pat on the head, and your patient a lolly {or boot their healthy ass out, as they've ceased to be anyone's problem but their own}. If not, rinse and repeat until you've sorted it all out. You wins teh internet. And a dirty old town gets marginally cleaner.

When a patient shows some sign or symptom that just might point to a serious condition, you pretty much must decide whether to perform more tests, or let it go. If tests are not performed, a problem can be missed. Maybe that shadow is really cancer; maybe that blood pressure reading reflects hyperaldosteronism, and maybe that fall caused a subdural haematoma.

But if they are performed, a problem can be created. Every time a test is run, we may activate the Iatrogenic Cascade. Every test and every treatment has risks, and those can snowball. In an extreme form: a patient has a cough, so we get a chest x-ray. A vague shadow is seen, so we get a Chest CT for a better picture. That CT shows that the shadow was nothing, but that the liver contains a cyst. So we aspirate the cyst, and it turns out to be nothing, but in aspirating it we caused an infection.


Questions will be asked..AND DESTROYED! BY ANSWERS!!!1!! Oh yes.

..as the philosopher Jagger once said, You can't always get what you want.
Do you believe in the concept of a soulmate? Do you think you've met him or her? Do you ever worry that "the one" got away?

I have a journal where I write emo stufff. It's covered in blood.

..as the philosopher Jagger once said, You can't always get what you want.
When you need to make a difficult decision, what kind of resources do you consult for guidance?

Well that's easy. I have a foolproof method. Seriously, you all should try it. First, I gorge myself stupid on bearclaws. Once I have an altogether radical sugarbuzz on, I stand on my bad leg only until the pain is enough that my mind shuts down and pushes me into a nirvanic state. At this point I have several scantily clad nurses get up all around me, each of which has an index card inserted in her hoohaw, on which I had printed several possible solutions before the process began. Now in my mad delirium I decide which of these babes strikes me as the most hot. Please keep in mind I am out of my gourd during this part of the experiment. The girl I choose now may not be the sort I'd take home if I had enough money and a sound enough mind to actual purchase a hooker. In fact at times I put my hand over my eyes at this point and determine the girl du jour by my sense of smell alone. Whichever one has the poontang juices that smell the least rank is the one who I select, you see.

I have the others lay me out in a suitably comfortable position on an already prepared setee, and then the chosen one circles me, doing a really stupid looking seductive dance that has been passed down through the ages. Finally, when she is finished she squats over me, and passes me the selected card by exposing herself and allowing me to extract the card with my teeth.

At this point my eyes are watering pretty badly, so I call in Dr.Cameron to assist me, in her alternate roll as Little Jugs, the passive Indian guide.

Little Jugs, I call out in a faux accented, theatric voice, please reveal the divine answer to the ultimate question.

At this point I have her shake off the dripping card and, holding her nose, read to me what she can read of it. Did I mention I write these answers in washable magic marker? This usually means a goodly portion of the letters have long since been smeared or washed away by sweat and booji juice. Still. It's an impressive floor show, and usually my staff are pretty impressed. I've been working up a more dramatic version of it I intend to take on an extended road show to various venues throughout the country, including a fall production we're going to do in Vegas.

By the way, this fasinated me.. did you know that more doctors smoke Camel cigarettes than any other brand?

Good luck with that lung cancer, other doctors..

..as the philosopher Jagger once said, You can't always get what you want.


..as the philosopher Jagger once said, You can't always get what you want.
..an angel gets his wings.

According to It's a Wonderful Life, this happens every time a bell rings. According to the hospital director Cam and I worked for,this happens every time I actually do something nice and put in clinic hours. Of course, neither theory addresses the question of what a wingless angel is and what they do all day.

If a fly has no wings, does that make it a walk?

In the late 70s and early 80s, heroin was in short supply due to conflict in and around Afghanistan and Turkey. Demand was still high -- this is heroin we're talking about, after all -- so the underground supply chain turned to synthetic opioids as a substitute. Fentanyl was popular; while its synthesis was expensive and difficult, as a common OR anesthetic it could be "diverted" from most any hospital. Morphine and the rest of the common opiates were [as always] popular too. Meperidine {Demerol}, a synthetic opioid, could also be used when nothing else was available, but its effect was shorter lived and produced worse side effects than the alternatives.

Still with me, kiddies?

Sometime in 1983, a chemist happened upon an analogue of meperidine with the chemical name 1-methyl-4-phenyl-4-propionpiperidine, commonly abbreviated MPPP. Known by some as "Super Demerol", MPPP's duration and feel were comparable to heroin, and it was an immediate success on the street. Unfortunately its synthesis was extremely sensitive, and by-products that would be impossible to find without a multi-thousand dollar GC-MS rig. Since clandestine drug chemists don't generally have access to such cool toys, they had no idea the reactions had produced anything but the desired product. One of the most common side-products of MPPP synthesis was MPTP, 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine, and batches of "synthetic heroin" containing it hit the street in force.

And addicts started dropping off like flies.

Or, if they didn't have any wings, probably more like walks.

Hours, days, or weeks after first shooting MPTP contaminated product, symptoms
started appearing: inability to move properly, tremors, stiffness of the limbs, difficulty speaking.

In other words the exact same symptoms as in advanced Parkinson's Disease, showing up in users of ages starting from their late teens. PET scans and autopsy revealed damage to the same area, too -- the MPPP/MPTP users had in every way come down with acute Parkinson's.

As it turned out, the MPTP was being converted to MPP+ {1-methyl-4-phenypyridinium} by monoamine oxidase, and MPP+ is extremely toxic to the dopaminergic neurons in the substantia nigra. Those neurons stimulate the basal ganglia which in turn are responsible for conscious control of movement -- when they're knocked out, the person can no longer move his body properly. Doctors figured this out by examining effects of MPP+ on animals, and correlated the damage to natural dopamine neuron death in Parkinson's sufferers, which they hadn't understood before. Either way the cell death happened, though, it was permanent and the deterioration would eventually build up enough to cause death. In short, both the junkies and the Parkinson's patients were screwed.

What has any of this scientific claptrap I've just subjected you to got to do with anything?

What indeed?

..as the philosopher Jagger once said, You can't always get what you want.