Behind the White Coat

SE Asia Tsunamis

The initial death toll was predicted at 10,000.  The next morning they expected it to be over 20,000... Now they are confirming over 30,000, and are predicting a death toll of 60,000 people.   60K people!!! That is unbelievable.  This has probably got to be the worst natural disaster of our time.  An earthquake registering 9.0 on the Richter, which is the fourth strongest earthquake recorded since they began recording back in the 1800s, combined with the massive Tsunami waves it spread out to the neighboring nations. It is something like 10 countries that have been affected by this tragedy.  Hundreds of thousands left homeless with nothing, millions of people without utilities and resources, it is going to be the greatest relief effort ever for a natural disasater.  The UN was even complaining that countries need to dig deeper into their pockets for this one... Especially the U.S.  I heard initially the U.S. was offering something in the 100,000 range?  That is ridiculous.  We have uncles who could dish out more than that.  Well hopefully that really isn't the case, because if you watch CNN or BBC and take a look at some of these pictures, it is frightening.  I pray for all those affected by this.  I even have a friend visiting Malaysia! Lets hope she is well.  CNN has a page where you can inquire about friends or loved ones who may have been in the area:

http://www.cnn.com/2004/WORLD/asiapcf/12/28/email.appeals/index.html

Aside from the death and destruction and flooding thas has already ensued, the death roll could even get worse from disease.  The tsunamis pretty much have altered the whole environment of certain areas of these nations, and now the big concern is things like malaria, cholera, disease from the rotting bodies, all kinds of bacterial and water borne illnesses, who knows possibly even plague.  So the clean up effort is even more important to help prevent further illness and death could really cause problems.

If you want to help with the relief efforts, a tremendous amount of help is clearly needed.  There are some websites that can facilitate this...

For international relief efforts, please consider donating to the Red Cross through their
International Response Fund:

https://www.redcross.org/donate/donation-form.asp

1-800-HELP NOW

American Red Cross International Response Fund
P.O. Box 37243
Washington, DC 20013

For donating relief efforts in India, try: https://www.aidindia.org

CNN has a big list of organizations you can donate to: http://www.cnn.com/2004/WORLD/asiapcf/12/27/quake.aidsites/

Merry Christmas

Merry Christmas Everyone.   Or should I say "Happy Holidays" or "Seasons Greetings."  I guess that developed as the more politically correct way to wish people well for the holiday season.  Though apparently some guys in the south feel this is an outrage because of the fact that Christ has been taken out of the picture of Christmas.  I guess it is part of its evolution into its more industrialized and capitalistic holiday for people, rather than its more traditional deeply religous celebration.  Well for me, not being christian, it's just another holiday, but with a little more room for festivity.  Sure I recognize that Christ was born on this day, but I have grown up with it meaning more of a recognition of time to be with friends and family, be happy, to give gifts and wishes, and to celebrate the happier and festive parts of life.  Though I can't say today was very festive... My parents were at a christmas party, so I didn't even cross the bridge to go home to NJ.. (Though probably tomorrow I will).  So I went with my friend and watched the Shaq and the Heat beatdown Kobe and the Lakers at a bar in NYC and then watched Ocean's 12 at the theatre.  Let me tell you the city was dead today!  It took us forever to find a bar that was even open! Cold as hell, but pretty easy to find a cab, but where the hell to go? Christmas really is the day that everything is shut down... Except take-out chinese and movie theatres... I mean shit, the Jews gotta do something!!

Today also happens to be several other birthdays I realized.  One random friend of mine who alwyas says she gets jipped because her bday coincides with that of Jesus.  Fair enough reason to complain since her gifts are probably always "combined."  Muhammad Ali Jinnah, the founder of Pakistan, also happens to be born on this very day.  And as I just learned, my uncle, Air Commodore Sajjad Haider, was too born on this day, and turns a young 72.  (Father of my cousin Zohare).

Today is supposed to markk the day I begin studying for Step 2... We'll see how successful that really is.

Laptops and Sperm Count

So at dinner the other night, my friend who is going into urology brought up a recent study that looked at the frequent use of laptops and sperm count.  Turns out some UK researchers looked at males between 21 and 35 yrs of age and tested their scrotal temperatures after frequent use of laptops.  Apparently, because of the heat given off the laptops, and the closed legged posture requireed when laptops are used in a specific position, the scrotal temperature can be raised 3 deg celsius.  Since a cooler temperature must be maintained for adequate sperm production, this would deem the user infertile.. At least temporarily.  Now this happens even in when someone sits in a hot tub for a while.  The inc in temperature will halt sperm production for something like 48-72 hours, if you are in there long enough.  So I suppose laptop usage will cause reversible infertility.  Though the researcher postulated frequent enough use may cause irrversible infertility.  I don't necessarily agree with that, unless of course you spend all day with your laptop on your lap. 

So next time you use your laptop literally on your lap--use a pillow or something man!  Unless.... you see the consequences as beneficial in your personal life for the immediate future... Which may very well be the case!

North Shore University Hospital

On another note. I had my North Shore interview yesterday.  A very private-oriented hospital, which I didn't like much, though I guess it has pros and cons.  Their theory was that the 'service' patients would not get the appropriate level of care or "backup," and they wanted an attending to be assigned to everyone to avoid that.  Even the residents said that if the intern or resident won't do anything for the patient, the attending would come and do it.  So basically they said you could do nothing and still get by!  That seemed kind of odd to me.  But nevertheless, it does havet a great cardiology program, and they do take a lot of their own.  The guy who interviwed me, this nice Paki doctor, was trying to sell the program to me.  It's not the greatest of programs, but it seemed like one of the better community-affiliate hospital programs (as opposed to the large primary academic centers).  The residents seem happy and match decently well.  (Even though they got a few DOs in there--nothing against DOs though, just a snobby measure of 'competitivness' if you will).  One huge plus was that it has the highest paid salary for residents in the U.S. !!  Almost 52K for PGY-1 residents, and 56K for 3rd years.  Plus free housing.  Now THAT is quite amazing.

Now Im sitting at home. Sick as a dog. Sore throat, cough, and body aches. Great. All I can do is down some dayquil, chicken soup, and chai.  Damn the temperature drop into the single digits. I always get sick during the holiday season!!  Guess I'll sit at home and watch crap TV in bed all day.

Old Friend?

We were out and about in the meatpacking this weekend for a bday party at Rhone.  A pretty cool place, with good music and stiff drinks, though a slightly older crowd.  Regardless, with our large group we had a good time getting the bday girl drunk.

So afterwards we are strolling the streets of the meatpacking, and I run into two friends of mine who are with two other peeps.  So after the introductions, the other guy, some random asian dude who is kinda drunk,  is like "Holy shit!! Ali!!! Yo man whatsup!!!"  I thought to myself: damn, do I know this guy?  I mean there have been many instances when I run into random asian people I have met through my asian friends who I can never remember, so I assumed I must have met the guy.  So I played along.  "Whatsup man!! Yea I remember you! Long time no see bro!!"  I responded.  He was quite ecstatic, like old college buddies separated for years.  But I could still not pinpoint where the hell I met him.  Then he continued on.  "Yo man, you remember xxxx , how is he doing??"  So now he takes it one step further.  He drops a name that I blankly stare at.  He looks dissapointed.  "Yo man! Don't tell me you don't remember him?? From Babson man!!"  Oh dear.  It's over.  I definitely don't know him.  But I''ve commited already. I've gone too far. There is no going back now. It's like when you hang out with someone the 3rd time and you still don't know their name, but there is no way you can ask them their name that late into the game!  So I was like... "Oh yea.. Thats right, when I was in Boston."  But he sensed the hesitation and skethciness.  So my friend Vinny looks at both of us, and is like, "Dude.  You don't know him do you!!!  When were you up there!?  You went to Wesleyan!!"  He was right. The jig was up.  Then I just broke it down... "Wait a minute.. You know.. I don't think I ever met you before.. It  musta been another Ali! It is a popular name you know." I guess just as the asians "all look alike,"  so must us desis look alike to them!  In the end, we all had a big laugh, and it was quite a funny encounter.  Now everytime I meet that guy, it's gonna be like we were friends from back in the day.

Random Fact of the Day

So as we were eating our salad, of which the main ingredient was watercress, my friend brought up an interesting fact.  It just so happens (though I have yet to confirm this) that watercress competes for the same enzyme in the liver that breaksdown alcohol in the body.  So basically that means that if you eat watercress, your body will be slower in clearing the alcohol, and get you more drunk.  Though I wonder how much watercress it will really take to do that!  So next time you go out on a date, make sure to insist on sharing a watercress salad as you sip your wine!  Or better yet, you can cook her dinner, and make sure to include some watercress.  Perhaps it will lead to a more enjoyable and cheaper evening! Hehe...

Too Young to be So Sick

"Please doctor, I don't want to live like this."
"We are going to do everything we can to help you.... Don't give up."
"Why is this happening? Please help me.  Please."
"Hang in there you hear?"

GB, a 22 year old girl, was speaking with tears, locked into Dr. S's eyes 12 inches away from hers as he leaned down over her unit bed.  A swan ganz catheter in her left jugular vein, several IV poles running diuretics and pressors, a vertical bandage over her sternum, dark, black spots on her arms and legs, oxygen mask, with light shallow breathing.  Only 22 years old, and she is here at the Sinai CCU for heart transplantation evaluation... Which isn't even the worrisome part of her condition.  Why is such a young girl on the verge of death here in the CCU?  What could have caused this?  She was a perfectly healthy woman her whole life... Until a horrible complication of her pregnancy.

The baby was born normally 4 months ago.  However, after her pregnancy, GB developed a post-partum cardiomyopathy--A rare but potentially severe complication of pregnancy where the heart dialates, and fails to pump sufficiently after a baby is born.  The reasons for this are not entirely clear, but it often necessitates a heart transplant.  However, GB's story gets worse.

Upon assessment of her heart by an echocardiogram, the doctors noticed something in the left ventricle.  A mass like structure connected to the apex of the heart on a stalk, about 3x2cm in size. Now when someone has a dialated heart that doesn't pump good, there is a tendency for the formation of a thrombus because of blood stasis, which can later shoot off emboli into the brain, organs, and periphery causing substantial, often irreversible damage.  In her case, for reasons unkwown to us at an outside hospital, the CT surgeons were worried about a mass in the left ventricle.  So they took her to the OR and opened up her chest.

After the operation, pathology showed the mass to be a thrombus instead of a mass (more on that below).  However, during and after the operation, she received heparin, which is a blood thinning agent utilized to anticoagulate the blood--a very common hospital medication.  However, some people can develop antibodies towards it, and develop a phenomenon known has HIT (Heparin Induced Thrombocytopenia), which causes arterial thromboses causing various arteries to clot, and cause body tissues to die. She happened to be one of those susceptible.

Now she has blockages in her right radial artery, leaving her thumb almost dead with no blood flow, in her right tibial artery supplying the first three toes , and in the right poplietal artery, which supplies her whole leg below the mid shin.  Now, as she sits here awaiting the workup for a heart transplant, it may be necessary to amputate her thumb, toes, and right leg below the knee.  How much more terrible can you get?  A 22 year old girl, and her only crime was to have a baby.  Today is also GB's 23rd birthday.

This is truly one of the saddest cases I've seen throughout medical school.  We asked ourselves in rounds, could have this been prevented?  Again, this is difficult since we don't really know every detail of what happened.  But if the echo showed that pedunculated structure, why did they think it was a mass and not a thrombus?  An LV thrombus is commonly treated by anti-coagulation with coumadin.  If that was the main suspicion, she could have been put on coumadin, and avoided the complicatoins of the surgery, and would not have needed heparin, and her limbs could have been saved.  She may have still required a transplant, but with much less complications and probably a better prognosis. 

But again, I'm no CT surgeon... Maybe they still would have to gone to operate? Who knows.  But medicine is not a clear cut field.  Every patient is different, every case varied, every complication unpredictable.  There is always the question of balancing aggressive vs. conservative treatments, which is the riskier path, and from what wil the patient benefit most.  We must talk to our patients, communicate and consult with each other, ask questions, be thorough, and learn from our experiences.

Morning code in the CCU

8:30am sharp, rounds in the Cardiac Care Unit begin.  We pull together the team, take our last few sips of coffee, and start at Bed #1 and begin to go through all 14 beds to check the daily status of the very sick patients in the CCU.  Things usually go slow and easy, each patient followed by discussion and teaching.  Today was different.  The intern starts presenting the first patient, and then we see two nurses run into tend to the Russian in room 5, Mr. K.  We hear some yelling, and the next thing you know we are all running in to the room.  Mr. K came to the CCU after getting stents put into his left main and circumflex coronary arteries the night before.  He is awaiting stem transplantation in order to treat his multiple myeloma, and due to his coronary artery disease, he needed some "unclogging" to procede with the surgery that could save his life.  But now, his heart has stopped working.  It is 8:31am.

On the monitor, his heart was in ventricular fibrillation.  The crash cart is ready, a central line is on its way in, the patient is being bagged.   "Charging 200 Joules.  Clear!"  He gets a shock.  We see a rhythm. 8:40am. He has some heart activity.   No pulse.  We start chest compressions.  Then we look at the monitors... Asystole.  Flatline.  "Get the Epi and the atropine!"  He gets 2 doses of epi, and goes into ventricular tachycardia.  "300 Joules charging!  Clear!"  A second shock, and we get a rhythm.  He has a pressure and a pulse.  Suddenly he starts to move.  He's awake!  A minute ago his heart had stopped.  Now he is talking.  Amazing.  "I can't breath.  Give me a minute.  Back away! I want to sit up!"  Chill out man.  We just broke your ribs, pounded your chest, and shocked you twice!   Go easy buddy.  But he's not out of the woods yet...

His oxygen saturation was low despite the 100% O2 mask.  He wasn't ventilating well.  We needed to intubate him.  Anesthesia was paged.  Two of versed and he was sedated, and ready to be tubed.  "V-Tach!!"  The monitor showed he went back into ventricular tachycardia. 8:45am. "360 Joules! Clear!"  The shock does nothing.  Asystole again. Chest compressions resume. He's finally intubated, and he is being oxygenated. The interns rotate on the chest--it does a number on the lower back I tell you. 4mg of Epi has been given, as well as Atropine and bicarbonate.  8:50am. No change. Not giving up yet. He was awake!! He spoke to us after being revived! We are not gonna lose this one.... Some activity, maybe a weak carotid pulse?  Push amiodarone, a potent anti-arrythmic. 9am. No change.  Fluids are going.  Meds are going.  Oxygen is going... We are watching closely...

At about 9:15am, he was pronounced expired. 62 year old guy who came in to get a catherization to clear him for his stem cell transplant.  He didn't even have anginal symptoms.  What happened? Why did this happen to him?  You just can't predict it.  I realized today if you code in the CCU versus the general floor, there aint much different.  There is a lot of manpower, movement, confusion, yelling, and commotion.  Everyone has a job, and needs to do it quickly and efficiently.  The crash cart supplies, the speed of the nurses, the efficiency of the team, and the guy calling the shots is what ultimately will determine if the protcol is undertaken in an appropriate and timely fashion.  The code was efficient, but after 10-15 min, when you've gone through your ACLS protocol, you are going on your gut, and you can just hope.  That's the first time I saw someone wake up and speak 2 min after being in asystole and being shocked twice.  Though out of the 6 codes I've seen, he joined the other 5 who didn't make it.

After the commotion we came to the poor 22 year old lady who needs a heart transplant... And all she did was have a baby.

More Anger

The onslaught continues.  Beth Israel Deaconess rejection came out today.  I guess I also expected it given the rejections I have already received fired at me left and right, like I'm a dummy at a shooting range. Despite my emails, phone calls, and pleading, no interivew offered.  All that remains is Cornell and Yale (guranteed rejections) and then I can have final closure.  I am still pissed.  Oh so angry.

Refer to my prior post that sparked all that controversy, I am once again as riled up as I was then.  You know what pisses me off the most? The fact that people who are way less qualified and able than me are interviewing at better places and will match at a better place than me.  It is just not fair.  I was talkin to my friend yesterday who is a pretty similar candidate to me.  Same board scores, and he honored medicine and one other.  I had 3 but not medicine.  He is getting interviews at columbia, cornell, BI Deaconess, UPenn, and ALL these places that straight up negged me.  Once again the evidence points to the overemphasis on the arbitrary grade of one clerkship.  I mean if you ask me, it should be the subinternship that matters most, who wouldnt want someone who is said to "possess clinical accumen unseen at his level of training."  Apparently everyone.  So much hard work over these years, and if I had the luck of having one different attending in my medicine clerkship, or if a certain "incident" didn't occur (I will extrapolate on that on another day), perhaps things would be different.  Sad how someone's life can be so determined on such a trivial and random thing.  If I had known Internal Medicine was gonna be so competitive, there is no way  I would have applied.. I woulda gone for radiology, or even something like ENT!  With my surgery honors, I woulda been a superstar!  Furthermore, I don't mean to be racist, but if I was a woman, or Jewish, I'd probably have a better shot.  I think being South Asian or Asian this day in age applying for residency actually works against you--I shit you not.

So what would my life be like if I ended up in Cleveland or St. Louis?  I know nothing about these cities, only that they are definitely not the cream of the crop of the midwest.  And the midwest alone is hardly the highlight of the continental U.S.  I mean shit, I'm a New Yorker man.  If anyone has read my blog over the months, could I survive in Cleveland or St. Louis?  Is Washington University that good that I would make such a big sacrafice?  Though what is my alternative?  Montefiore Medical Center.  I mean not only is that in the Bronx, but I'm farther north in the ghetto than I already am!!  If I wanted to live in Manhattan, I'd have to wake up at 5am on call days to get up there.  Now that is just gay.

Rant of the Day

One thing about commuting on the subway--despite having to wake up mad early and drudge to the bus, switch to the subway station, and walk it through rain or wind or snow to your ultimate destination--you do get a lot of daily time to sit and read a book.  I just finished reading 'Life of Pi', and I gotta say it was a great book.  You all should grab a copy and read this, it is one of those books that is fun to read, thought provoking, and makes you want to talk to someone else who read it too.  Truly an inspiring story. 

In reference to one of my older posts on the subject of wingwomen.com, This story shows that its coming into the mainstream deserving front page of cnn.com!  I'm telling you this has big bucks franchise opportunities written all over it.  Any ladies out there willing to be a wingwoman for 50$ an hour?  I'm damn sure there is! We could make a deal with the hotels to help out all those visiting Europeans and Persians get their game on in nyc.  Hmmm.. E-mail me for further discussion...

Last week for my Mount Sinai cardiology elective.  Still no word from Yale, Beth Israel Deaconess, or Cornell.  I wish they would just send out their rejection letters already so that I could at least have some closure, and seal my inevitable fate of being at Montefiore Medical Center in the Bronx for the next 3 years. 

So I have finally joined the modern world and bought myself a digital camera.  The canon SD300.  It's almost the size of my phone.  Damn I hope I don't lose this thing.