Behind the White Coat

Complications...

It was Thursday afternoon.  I spent the morning in the cath lab, and now it was time for my half day clinic session once a week where all the fellows see cardiology outpatients (those with medicaid or uninsured).  Although I love the cath lab, it is definitely refreshing to be able to talk to patients, see some follow-ups, do some clinical medicine, and hang up the lead for a bit while my back pain stabilizes.  Anyway, a few hours into my clinic, I hear an overhead announcement:  "Anesthesia Stat to the CCU"  That usually meant someone is having severe respiratory distress and needs to be urgently intubated by an Anesthesiologist.  But hey it happens, especially in the CCU, so no big deal. I continue my work.  A few min later I here "Code Blue, CCU"  That meant a cardiac arrest.  But usually the docs and staff could handle that in the CCU, they don't need the "Code Team" to come and help.  That probably meant that they had some MSD's (Multiple Simulatenous Disasters) and needed some man power.  I begin to get slightly curious, but eh no biggie.  Then a few minutes later, I hear "Code Fusion".   Ok now I'm definitely curious, and even slightly concerned.  No it doesn't mean there is some nuclear reaction going on, it is short for transfusion.  It means that someone is hemorrhaging and bleeding to death, and there is no time for blood typing, so come STAT with O- blood (the universal donor)!  You don't hear that everyday in the CCU, and it could mean someone is bleeding out from anywhere, most likely from the groin, specifically the femoral artery--which is our common site of entry when we "perc" to obtain vascular access when performing a cardiac catheterization.  I had cath'd a couple of patients that morning, and  got a tad worried.   Was it one of the patients I had perc'd?  Did I screw something up?  But the chances of that are low right?  I did 2 cases that morning, and everything was clean, smooth and uneventful... So I thought... I finished what I was doing and called to inquire.  

Earlier that day, I cath'd a patient with one of the private attendings.  Some 80 year old lady who was super nervous about the procedure.  She had a mild heart attack, and the angiogram revealed a very stenotic, 90% blockage of her Left Anterior Descending artery right where anther artery branch arises.  We call it a "bifurcation lesion".  Usually more challenging and tricky and higher risk.  The lady was so uncomfortable and nervous she wouldn't stop moving.  So we decided to stop for now, and defer the angioplasty of the blockage until a later day.   When we do a catheterization, the way we get to the heart arteries is by accessing the common femoral artery (which is right below the crease of the groin).  We palpate the pulse, insert a needle, and pass a wire through that needle, and then introduce a sheath over the wire, which gives us "access" to the artery.  From there we put our catheters up the aorta and into the coronary arteries.  Obviously one has to be careful.  Going into the femoral artery means ur puncturing a hole 2 to 3mm in diameter into the artery, which is enough to make someone bleed to death!  When you are done with the procedure, the hole has to be either "closed" by one of many devices, or pulled and compressed manually by brute force for about 15 minutes until the blood vessel can form a clot at the site of entry.  One of the complications that can occur from this procedure is obviously bleeding.  Occasionally this bleeding can be very severe.  If the "stick" is too high, they can bleed into the retroperitoneum, or the space in the back of the lower abdomem.  Or if the stick is lower, they can bleed right into the thigh.  The bleeding can be even worse if they get anti-coagulation--which are blood thinning medications we use when we are performing an angioplasty or stent, in order to prevent the blood from forming clots on the equipment.  Lucky for us we didn't "fix" anything in this lady, because if we gave her blood thinners--She would be dead.

She had her sheath removed, and was rolled back into the CCU. Things looked ok.  The nurses check the groin site frequently for the first hour or two.  Although sometime all it takes is a few minutes. In this case, she looked fine when she arrived, however when the nurse returned 15 min later, she didn't look to hot.  The patient was still so sedated from the procedure, she didnt' even have the state of mind to call for help.  By the time the nurse arrived for a check, there was a giant hematoma the size of a half volleyball in her thigh. She was bleeding--a lot and fast.  You can probably dump something like 1 liter of blood in the thigh of a big person before you notice it, so she must have had like a good 2 to 3 liters by then.  She was unresposnive, her blood pressure was about 70, and her heart rate was in the 130's.  Immediately my awesome co-fellow who was in the unit, and another one of our co-fellows, the girl on consult, dug their fists into her groin trying to stop the bleeding. She secreamed in pain, but we had no choice.  Could not give pain meds because of the blood pressure.  Anesthesia was called and intubated her, the code fusion was called to pump her full of blood, and she was put on medications to support her blood pressure, because she was in severe hemorrhagic shock.  Fuck.  What the hell happened?  The stick was "clean" I am sure of it! (Meaning I got it one shot, and there should not be multiple holes in the artery).  Did she move around too much afterwards and it popped open? Did they not hold it properly? I started to sweat and get real nervous.  This is the first time I have had a serious complication from one of my cases. (Minor ones yes, but this is considered life threatening!) ... They subsequently called the vascular surgeons, and given the amoutn of bleeding and her instability, they rushed her to the operating room...

In the O.R., the vascular surgeon sliced open her thigh and visualized the artery.  The femoral artery (which again is where we stick to get the access) had an arteriotomy site (hole in the vessel) that looked healed and closed.  There were no other holes in the artery, so the stick was clean.  However, there was a branch coming off the femoral artery that was completely transected.  Cut through and through. And blood was just pouring out of it!  Somehow, probably a combination of the anatomy of her blood vessels, and the angle of my needle insertion, I managed to sever a branch of an artery.  The sheath that was in the artery during the cases probably sealed off that branch, and when it came out, it just opened up and started pumping out blood!  Thought it looked like we had gotten her to the OR in time, and she was stable.  

Even the seemingly simple and routine part of a procedure can be very humbling.  This is not the first time--and definitely not the last--that a severe bleeding complication can occur from a cardiac cath, even if there is no stent placed and no anti-coagulation given.  The rate of a serious bleed such as this is probably under 0.5%.  But that means after every 200 procedures, you statistically may be due for a bad bleed.  Granted there are worse things that can happen.  I've seen them all: stroke, heart attack, caridiac arrest, allergic reactions, dissecting a blood vessel, cardiac tamponade requiring emergent surgery, and plenty of others, including death.  High risk.  High reward.  Sometimes it doesnt matter how good you are,how much you know, and how much experience you have.  Complications happen.  But you cannot approach things differently than you know or were trained.  You must accept this rate of complications.  People will want to sue you0-- no matter what consent was signed and what complications reviewed.  It is something that doctors deal with.  I just hope that the way things are going in the world of medicine, people don't change the way they practice, or veer off the "right way" of doing things, simply out of fear of liability.  Complications. Simply another reality of medicine.  Another sobering aspect that comes with that great responsibility of putting yourself out there and putting yourself--and sometimes the patient--at risk, in order to try and save lives.

Why Can't We Save Everyone?

Why can't we save everyone?  Yes it is a rhetorical question, because obviously everyone cannot be saved. But I'm not talking about the patient with stage 4 lung cancer diagnosed too late, or revealing to someone a diagnosis of ALS for which there is no treatment, only a terminal course. As physicians, there is a certain degree of complacency when it comes to these situations when someone has an end stage disease that sobers us into realizing that nature is stronger than our drugs and tools.  But there are some acute life threatening problems that we can save people from. We know so much more, have so many more advanced medications and therapies that we have managed to markedly decrease mortality, to improve outcomes, and to preserve people's quality of life across the spectrum of medical diseases--from HIV to heart disease.  But despite this, nothing is ever perfect.

Lets take a heart attack.  A big one.

30 years ago when someone had a heart attack (where an artery supplying the heart muscle becomes blocked), the treatment was aspirin, and watching them closely, while treating their pain, and letting them "ride it out".  Of course not "fixing" the problem caused many people to die.  A few years later we developed medications to unclog the blocked artery, and a few years after that we developed invasive procedures (i.e. angioplasty) to go inside the heart artery and mechanically open up the blockage.  Now opening a blocked artery is almost like another day at the office.  We know the problem, and we can fix the problem, and sometimes save lives--even when people are really sick and sometimes when they are half dead.  We can pretty much bring some people back from the dead now (If they die in front of us at least...) But you know, we can't save everyone... 

Last week we had a 37 year old Indian man come in with a massive heart attack.  Now for heart disease, that is extremely young.  It is usually people over 50 and 60 that have heart attacks.  You would be unlikely to even suspect a heart attack in someone so young--and neither did he which is why he waited 5 days to seek medical help.  Unfortunately crazy things can happen to almost anyone.  If this guy was in his 70's, he would have died well before making it to the hospital, let alone lasting 5 days at home with his symptoms.  His age kept him alive until he decided to come in to seek help.  Though when he did arrive, he was super sick.  He had the coronary blood vessels of an 80 year old smoker--terribly diseased and clogged.  He was a smoker, he was a diabetic, and he was South Asian. Unfortunately many South Asians have bad genetics when it comes to cholesterol and atherosclerosis (blockages in the arteries) .  He came in with a 100%  blocked artery in his heart--the LAD (left anterior descending) artery, the largest one of three heart arteries, he also had a 99% blockages of his RCA (right coronary artery).  His heart had suffered major damage and his Ejection Fraction was down to 15% (normal is 65%).  We had to use stents to fix the vessels, and help support his heart function, since it was barely pumping.  We used a new device called the Impella.  It is a small cylindrical motor that sits half in the heart, half in the aorta and helps suck blood out of the heart and into the body.  We insert it in the cath lab through the femoral artery.  It helped keep him alive and allowed us to fix the vessels.  Over the next few days his condition stabilized.  He remained on the respirator though.  After a few days however, we realized he wasnt moving his right side.  A head CT (catscan) was done revealing he had suffered a massive stroke.  He was not waking up and showed no sign of purposeful brain function.  The family was not ready to let him go, and decided to put a feeding tube in and a tracheostomy for a permanent ventilator.  Even though medically it was unlikely he would recover, sometimes you need to give the family some time.  Three days later, he suffered a cardiac arrest and died.

Sometimes, despite all our knowledge, skills and advanced technology, we still can't fix everything.  We can always hypothesize what if's: Should we have done this... or that differently?  Then again maybe the patient is to blame for not seeking help earlier? Or his family for not forcing him to go? And so forth... But the reality is, sometimes people just die.  Sometimes it is just your time.  You can't save everyone.  The lady I spoke of last time was 87 and survived despite the odds, but this poor 37 year old didn't fair as well.  We always wonder how some of these old people can sometimes live through anything. They will never die on you!  But on the other end a completely healthy 30 year old comes in and can just die no matter what you do. You just never know... Once you accept this reality, get past the improbable and the unfortunate, and continue treating the next patient no different than the last, you are one step closer to becoming the experienced doctor that people need.

 

 

Everyone has their time...

During my fellowship, I have seen the sickest of the sick who die, and the sickest of the sick who survive. I've seen the mildly sick and seemingly stable patients walk out of the hospital good as new, and I have seen similar patients suddenly drop dead out of the blue.  We are always anticipating certain outcomes, and prognosticating patients based on data from years of research and observational studies on various conditions--Where person A may have a 10% chance of dying, and person B may have a 80% chance of dying based on their diagnosis, age, co-morbidities, and how sick they are... But you never REALLY know do you?  There is always that little bit of unknowingness about every person and their condition. Because nothing in medicine or in life is 100%.  I think what it comes down to is that everyone has their time... And nobody really knows when that may be--except perhaps God, and often times, the patient themselves...

Take the lady I met 2 days ago.  She is 87 (yes, she is pretty old...), but a very functional 87 year old lady who cares for herself, goes grocery shopping, cleans the house, etc.  She came to the hospital by ambulance one week prior with severe sudden onset shortness of breath. She was found to be in pulmonary edema (her lungs filled with fluid) and ended up having to get intubated and put on a respirator to help her breathing.  An echocardiogram (heart sonogram) revealed a very weak heart--pumping with an Ejection Fraction of 20%, where normal is 65%.  We also saw a very leaky mitral valve (meaning half the blood was going back to her lungs and not forward), and her blood tests and ECG suggested she was amidst a heart attack which was complicated by severe heart failure (hence the fluid in the lungs).  She was too sick to take to the cardiac catheterization laboratory to try and fix anything blockages, so we tried to "tune her up" with medications in the CCU.  We managed to stabilize her over a few days, and then took her to the cath lab to see her coronary arteries.  We found severe blockages in all 3 of her arteries--one chronically occluded arter, and two others that we could potentially fix.  So over the course of two days we put stents in the two 95% blockages that she had to try and restore some blood flow so that her heart muscle could improve, and perhaps even the leaky valve.  Unfortunately her kidneys failed as a result of the dye we used, and she ended up needing dialysis for several days--not good.  Yet remarkably her kidneys recovered over the next 3 days, and she came off dialysis.  We did another echocardiogram showing a little bit of recovery of both her heart function and the leaky valve.  So all in all it looked like things were getting better.  So this 87 year lady survived acute heart failure, a major heart attack, and the need for acute dialysis all within one week.  I think each of those situations in themselves probably carried a 50% mortality rate in this lady!  She just refused to die.  She looked so good by the next day or two, she was ready to be shipped off to rehab.  Well, until....

She was all set to go.  She was sitting in a chair for half the morning. Then she went to have a bowel movement, and after that she suddenly didn't look so hot.  She became pale, and sweaty, and complained of nausea and her heart rate dropped and blood pressure dropped.  It all seemed like a vaso-vagal reaction, (which is a reaction that is caused by nerves innervating the heart and blood vessels that can cause someone to faint, and can be precipitated by a variety of emotional and physiological triggers--one of which could be a bowel movement) ... She recovered after some atropine, but about 20 min later it happened again for no apparent reason.  But this time, she didnt' perk up so quickly. In fact she lost her pulse and blood pressure and essentially went into a brief cardiac arrest.  We urgently intubated her, had done about 2 min of CPR and dosed her with some medications to try and revive her heart and blood pressure, and we were able to do so... But what the heck had happened?  In our heads we were thinking of the most likely culprits that could be causing this:  Could her heart wall have ruptured? Could a stent have closed off? Could she be bleeding internally? Something else? We did a quick bedside echo of the heart which showed no rupture or fluid around the heart, and her blood count didn't suggest bleeding.  We rushed her back to the cardiac cath lab and saw both her stents were open. We placed an intra-aortic balloon pump to try and support her blood pressure.  Before our eyes her blood pressure plummeted even more.  We then inserted a swan-ganz catheter into her pulmonary artery, to look at the pressures and output readings in the right side of her heart.  They were bizarre. The saturations in her pulmoary artery were 15%, where normal is 70%-- which suggested there was almost no forward pumping function of the heart.. But why??  Finally we did an urgent Transesophageal Echocardiogram right there in the lab to look at her heart closer.  We then saw two things.  One was that the right side of her heart was essentially not moving, it was "blown" -- but it was fine 1 hour earlier.  The only thing that could do that so quickly was a giant blood clot in the pulmonary artery--a pulmonary embolism.  Luckily with our TEE snogram we saw the pulmonary artery, and it was filled with a gigantic blood clot!  At this point she was near death on multiple medications for blood pressure.  We urgently called the cardiac surgeon, and he rushed her to the operating room...

We had low hopes at this point.  An 87 year old who just had a heart attack, and now has a massive pulmonary embolism causing cardiac arrest.  The mortality for this is probably upwards of 60 or 70% in this lady.  But the only lucky thing for her is that it happened exactly at the moment it did -- during the day, right in the CCU, with the cath lab available within minutes. 

She was in surgery for only about 2 hours.  They put her on bypass, cracked her chest open, and cut into her pulmonary artery.  this is what they pulled out of both her pulmonary arteries:

This was by far the largest clot I had ever seen!  Most of the time, if you have a clot this big, you are dead.  But this lady didn't die. She recovered from the surgery within 3 days! She is now talking, sitting in a chair, and almost back to heself.  She is going to be discharged tomorrow.

It is amazing sometimes what people can survive. And it is always the old peopel! This lady was 87 and survived a huge heart attack with heart failure and severe mitral regurgitation, kidney failure needing dialysis, and a giant pulmonary embolism with cardiac arrest.  She refused to die.  If this happened in the middle of the night or on a weekend, or outside the hospital, she would not be alive.  She is one lucky lady.  Everyone has their time, and it just was not her time to go...

Like I said, you can never know for sure.  And in some cases, we may say someone's chances of dying are 80% to 90... But a 10 to 20% chance of survival is not nothing.  That is the beauty of cardiology. You can literally bring people back from the dead.  And let them live their life until their true time has come....

 

 

 

How Old is Your Heart?

Exercise. Eat healthy. Lose weight. Avoid high cholesterol foods.  Avoid trans-fats. Stop smoking. Drink in moderation. Avoid salt. Don't snort cocaine. Don't get diabetes or hypertension-- If you do get them, treat them.  Don't get fat. Dont get old. Exercise some more. No seriously, eat healthy.  And this time really stop smoking.....

The list goes on. What are the things we can do to stay heart healthy?  We've heard all the preaching from our doctors, from our loved ones, from the media and so on.  Everyone theoretically "knows" what are the healthy does and don'ts.  Half the time we try to consciously forget them, or simply ignore them, because hey... I feel just fine.  Why should I give up my post meal cigarette?  Why should I stop eating McDonalds? And you know what, Im just too lazy to go to the gym.  Because it's true, most of the time you can get away with it and be just fine... But sometimes, bad things can happen. Like a heart attack. Because hey, you never really know how old your heart is.

The funny things about risk factors for something like heart disease, is that they are not causative in everyone.  If you took 100 people, and half of them were smokers.  You would by virtue of what we know, see more heart attacks in the smokers than the non smokers.  But, if you compared all the smokers amongst each other, some of them would get coronary artery disease and heart attacks, but others would be just fine.  One guy smokes half a pack a day for 20 years and the other, 2 packs a day, and the lighter smoker may have a heart attack, or lung cancer, and the heavier smoker may not.  Why one and not the other? (Assuming there is an equal amount of other major coronary risk factors--which include diabetes, hypertension, age, male sex, high cholesterol, and family history)

So questions do arise.  One of them is: Hey do I take my chances and just screw it and live how I want to live?  The other more intelligent question is: Hey is there something else that will clue me in on whether or not I am going to be one of those people at risk for getting a heart attack?  The answer is probably yes there is, but the reality is we have no idea what it is.  But I can venture a guess....

Genetics.  It must be right? Actually it has to be. From personal experience, family history of early heart attacks is probably one of the most important risk factors for heart disease.  (That and probably diabetes..). But family history means your genetic line has some predisposition towards heart disease.  By medical standards, a family history is defined as a first degree relative who has a heart attack before 55 (for men), and before 65 (for women).  But it grows beyond that... Not everyone whose dad had a bypass surgery at age 48 will have heart disease, then again the guy whose parents had no heart disease may have a heart attack at age 45!  Obviously this is not common, and we have to treat populations based on probabilities and risk stratification, we cant just go looking for heart disease in every human being... But again, perhaps certain families, and even certain populations and ethnicities have a higher incidence of disease.  This I can tell you is certainly true.  There really have not been enough large scale studies across all the different ethnicities for the guidelines to tell us "hey, if you are Pakistani or from Trinidad, then you are at higher risk than the white folk".  But from my anecdotal experiences, I certainly to some degree take ethnicity into mind....

Let me give you an example from personal experience.  A decent chunk of the population I treat at one of my hospitals happen to be minorities, as we have a large territory of Queens that we treat..  Everything from hispanic, to a good chunk of South Asians and people of Indian decent.  One particularly prominent group we see are of Guyanese decent. I don't know if more Guyanese people just happen to come to my hospital and the Asians more often go to neighboring hospital, but I can tell you that I have seen so many patients of Guaynese decent who have terrible coronary disease, often at a very early age. I have seen people not only in their 40's, but in their 30's with heart attacks.  The youngest one I remember was 2 years back, when a 29 year old kid came in with a huge myocardial infarction.  Anyway, the reason I started on this topic to begin was because just today we saw a 36 year old pleasant lady from Guyana.  She had some chest pressure 3 days before while playing with her 1 year old daughter, and thought it was just some head cold. She finally saw the doctor today, and they saw an abnormal electrocardiogram suggesting she may have had a heart attack.  It must be just some false positive right? I mean she is 37 years old, how could she have a heart attack?  We performed a cardiac angiogram, and found a 99% blockage of her right coronary artery, and we found she definitely had damage to her heart muscle -- i.e. she had a heart attack.  Crazy!  She is only 4 years older than me, she has a new baby, but was otherwise healthy.  She had no family history of coronary disease.  But she was Guyanese, and from my 3 years working here, although I was certainly surprised, and upset by it, I was not shocked, because it's not the first time I seen it in a Guyanese person.  I told her she had a near total blockage of her artery and had a heart attack, and we had to put a stent in to fix it. But she would be fine, but would have to be on medicines for the rest of her life.  All she asked me was "Can I still have another baby"?   That is something we don't usually here in cardiology given the average age of our population....

There is something in the genetics of certain people.  People of certain lineages and families.  But often of certain ethnicities as well, including South Asians, and especially those of Guyana and Trinidad.  Of course my view is biased.  I am in cardiology, and I only see those that have suspicion of or have true disease.  Maybe our population of Guyanese are somehow all related! There are probably tons of Guyanese and Indian families out there who never get heart disease... But there is certainly those that do.  Some of these cases we find a problem, like a certain type of cholesterol abnormality, or a strong family history.  Usually we talk about High LDL cholesterol (or bad cholesterol) .. But many times we see patients of Indian descent and Guyanese as well who have not so bad LDL's, but very low HDL's (or good cholesterol).  This may be worse than having high bad cholesterol. And of course a lot of these patients end up getting diabetes and hypertension at younger ages too.   So there are sometimes different things to look at and to target in terms of one's health and risk factors.  But occasionally, (albeit not commonly) like this lady today, you have someone who has no family history, a slightly low HDL, and if I saw her in the office, by guidelines, I would just recommend dietary modifications and no other meds, not even an aspirin.  However she came in with a heart attack. All I could think of was her ethnic descent as an explanation...  She may have ben 36, but her heart was more like 76.

So what does this mean for you? What can one do?  I am not saying if you are Guyanese, then get an angiogram at age 30.  It was just an example (probably of many potential others) to illustrate that genetics are important, and we can't control everything.  So, the only thing we can really do is what I said before.... Which is live healthy, eat healthy, get your cholesterol and sugar and blood pressure checked at least yearly to screen, don't smoke, if you drink--drink in moderation, and exercise regularly. This should start early, even in your late 20's and early 30's.. Because getting into these habits early on will stick to you later on after you pass age 45, which is when age itself becomes a risk factor and it never hurts to get a head start.  And I will say if you have a true family history of early heart disease, take things even more seriously.  Because genetics you can do nothing about.  All you can do is control the things you really have control of... And you can never truly know hold old your heart is....

The girl did fine by the way.. We put a stent into her right coronary artery, and she will have to be on medications for a while, but she will still be able to have her second baby.  However she will maintain a 35% risk of heart failure in the future, and a 6% of chance of dying suddently.  Though she is lucky, because a small portion of heart attacks end with a fatal arrhythmia, causing sudden death.

Nice people in NYC?

Say you were reversing your car on a side street in New York City and you hear a thud.  Crap.  You just hit a parked car.  You walk out and check out the damage.  It's not horrible, but significant enough.  You look around.  No cars on the streets, no pedestrians in range who could have seen your deed.  Now, do you think to yourself:  "Wow.  I am lucky.  No witnesses, I will drive away scott free!  I mean come on, this is NYC.  If you park on the street, you know there is always that chance of getting hit.  Deal with it buddy!"  Or, do you say to yourself "Nobody saw me, but I saw me.  And this is wrong.  If I don't leave a note, I will feel guilty."  What would you do?  Would you leave a note??

To be honest. If it were me. I would probably just drive off!  I would think that 90% of people would do the same.  But lucky for me, the guy who hit my parked car had a conscience, and he left a note on my windshield!  It read something like "Hi.  I accidently hit your car. I am very sorry.  Please call me and we can arrange reimbursment for your damages.  Again I am so sorry!"  He left his phone number.  I called him, and arranged his insurance to pay for it.  My first thought was that there is no way this guy is from New York.  I mean he must have been raised in the midwest or something right?  Such is the cynicism of us New Yorkers who cannot believe a decent conscience can actually exist in the city.  I think if you are TOO nice, you may not make it in New York, at least not for more than a couple of years.  In order to deal with the grumpy ones and asshles in New York, you gotta have the ability to dish out on occasion as well.  But the few who really are just too nice, probably just move to California.

No seriously, I think they do.  I was in San Diego for a Conference last week with some coworkers, and  and no matter where we went, everyone was so nice.  I don't think we found one asshole or even a rude or angry person anywhere.  It was almost eerie.  How can this be?  How can everyone be happy and smiling all the time?   At one point we even tried to instigate a little bit of negative emotion, like maybe some road rage by trying to make a turn on the road to block someone, or cut someone off.  But that didn't even work, they just waved and apologized like it was on them.  I felt like we were in some made up movie, like the Truman Show.  Or maybe cities populated with a majority of genuinenly nice and happy people really do eixst!  It was certainly refreshing dealing with all the positive energy in San Diego.  Though I'll admit, when I arrived back in NYC and hoped into a yellow cab as the driver cursed off and abused the cabbie behind him, it brought a smile to my face.  Home sweet home.

But it is nice to see that even amidst the city of NYC, filled with assholes, some nice people do exist-- like the guy who hit my car and left a note.  It was probably just a lucky break this time.  Because the guy who was driving the truck that sideswiped my parked car on first avenue a year or so back, causing about $3500 of damage did not leave a note on my car--only the remnants of my sideview mirror and door handle.  Don't think he's moving to San Diego anytime soon...

 

 

 

 

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