$

reviewing my timesheets and realizing the client has been underpaying me for 3 months.

Reading list

Currently intaking:

The Lexus & the Olive Tree. (T. Friedman)
The World is Flat (T. Friedman)
The New Paradigm (G.Soros)
A Briefer History of Time (S. Hawking)
Getting it Done (R. Fisher)

endless UpToDate articles
AASLD HCV Tx guidelines

Latest tunes:
Linkin Park. New Divide.
Mogwai. Autorock.
Global Deejays. One Night in Bangkok.
Nina Simone w/ Felix da cat. Sinnerman.

Sports:
Monday Night Football. NFL
Thursday Night Football. NCAA
Saturday Football. NCAA
Sunday Football. NFL
NBA preseason.
MLB playoffs.

Food:
PF Chang's
Sesame Chicken
Mongolian Beef
Panda Express
Orange Chicken
Beijing Beef
Ruth's Chris
Filet mignon
Prison Kitchen
Swiss on Sourdough grilled cheese w/ crispy fries

Firsts
Swore about a patient's care.

Uptime: 0400
Downtime: 2000

over & out

NCAA Football

Today was an all college football day. Great games. Thanks to justin.tv I could watch any game in real time for free. While watching I could IM friends thanks to Yahoo mail and e-mail others concurrently. All this while listening to Stephen Hawking's audio book, A Briefer History of Time.

Life is good.

The potential bleed out at work ended up being an error by the nurse making the lab draw Friday afternoon. The patient has a port-a-cath and the nurse sent the first draw to the lab instead of the second. This resulted in my ordering Vitamin K that could have killed the patient. Luckily, it is standard practice to recheck abnormal labs. (And thankfully, the ER nurse completed a physical assessment which she called in as normal without petechaie or ecchymosis.)

My Gators came through and beat LSU much to the dismay of my Cayenne loving friend in the central valley. He may have gotten his Arkansas victory but Beamer at VT chalked up another win. I hope Beamer passes Bowden, that academic cheating supporter. I wonder if the NCAA would accept dementia as an excuse. Or maybe that academic honesty hadn't been invented when Bobby was in school.

The SNL Obama skit about doing nothing was more humorous since he won the Nobel Peace Prize. The humor increased when the Daily Show led with the story that Obama delayed meeting with the Dalai Lama, another Peace Prize winner, in order not to anger the Chinese. I wonder if the Chinese are angered that a Guantanamo maintaining, Afghanistan war escalating, trade protectionist, Olympic bid losing President will meet with the Lama at all. (For the written record, I am pro-Obama.)

Tomorrow I go gun shopping since I can now basically by a firearm the same day.

Pew-pew.

bleeding out

I'm taking call for Friday night for a medical staff member who is deciding whether he has appendicitis or not. Doctors make the worst patients. Instead of going straight to an ER, he is monitoring the evolution of his symptoms over 16 hours. (I've done the same.) For no medical professional wants to be the one to misdiagnose him or herself with the false "hot abdomen." (Needing emergent surgery.) I wonder if bartenders ever avoid drinking in excess in public places to avoid having the server tell them, "Sir, I think you;ve had your limit."

At 0400 I receive a stat lab result, INR 17.
This is one of those "Huh?!" results where one asks the nurse to repeat what she says three times during the conversation.
"Okay, when was his last dose? When and what was his previous INR? And what was that INR today again?"
As if hoping to catch the nurse in misreporting. Wistfully wanting a, "Oh, doctor, I'm sorry. I misread the lab. His PT was 17!"

A PT of 17 needs more coumadin. An INR of 17 needs less.

I've been thinking of getting an online fax service so the nurses can fax me the reports so I can see them myself. (How untrusting you may think.)
That's what I'm thinking, "How untrusting."

This early call better not interfere with my early Panda Express run.

transpo

So after getting up at 0030 to drive O to prison, I slept in and was able to awaken to the sun rising over the mountains...

I arrive at work and have an e-mail waiting from O's Iphone...

The initial plan called for O to accompany an oxygen dependent inmate on a 14 hour transport...

The transport ended up being for two inmates, the original to the south and a psych/crazy inmate to midstate...

Each transport vehicle only has two cells...

O rode with the psych inmate in the middle.

He said fought to stay awake all morning...

not wanting to fall asleep locked in a cage with a Level 4 psych patient.

also...

there were no bathroom breaks for the entire trip.

So 14 hours later, the officers dismount the vehicle and go back and unlock his cage...

allowing him out to see his wife, who is the Chief Medical Officer.

He earned 3 thousand dollars.

Which he is going to spend on his mother-in-law.

Who forgot to pay her electric bill and had her power shut off.

PG&E came to the home but the electric box was very old and rusty.

The utility men stated it would need to be replaced before they could turn the power back on.

Estimated cost: 3,000 dollars.

Biggest fear on the trip:

(that we all shared at work)

There would be a car accident where the officers would be knocked out and the responding law enforcement would think O an inmate.

And he would be hauled of to jail for processing.

With the other inmates who know he's staff.

His ass would be worth a pack of cigarettes exchanged in under 5 minutes.

Chase Car

Today I receive the call from admin asking if I would be willing to follow a colleague to the airport to drop of his rental and drive him back to work. I would be paid full pay for the drive time.

The state is transferring a patient 14 hours away. The patient uses oxygen and would need an ambulance with paramedics to transport. This is expensive, so the state realized a normal transportation vehicle could be used if a medical provider traveled along.

So I followed the provider to the airport, we went to PF Changs and returned back all on the state's dime. This saved the state around 10,000 dollars. That's a win-win.

new hire

so i was invited back 0800 Friday am.
my lay-off lasted < 20h

now back on call until tuesday.

You've been terminated

Received the call to stop seeing patients today around 1200.
The Chief Medical Officer called to say she wasn't sure she could keep paying the registry staff and we were to stop providing care.
So tonight I'm packing up and going to do a little road trip.
Been wanting to travel.

Emergently status quo

tada, another night survived! here's the call of the night:

"Doctor, I have a suicide attempt. An overdose. I need you to come in."
me: "What did he take?"
RN: "He is in c-spine precautions."
me: "Why is he in c-spine precautions?"
RN: "He was found hanging in his cell unresponsive."
me: "What did he OD on?"
RN: "He didn't OD." (aargh!!!)
me: "Is he breathing?"
RN: "Yes, he's fine now. He was found unresponsive but was talking we picked him up. He complains of numbness and tingling on his left side."
me: "So there is suspected cervical damage."
RN: "Well, he had a stroke and he normally can't feel or move his left side."
me: "So he's baseline."
RN: "Well his neck hurts."
"So he was found hanging in the cell, but he can only use one arm?"
"He had shoelaces tied around his neck."
"And he was hanging from the light fixture or something?"
"Well they broke, but he had tried to tie them to the bunk."
"With one hand. And now he has neck pain & baseline numbness. How bad is his beck pain?"
"10/10. he takes methadone for his chronic neck pain."
"He has CHRONIC neck pain?"
"Yes, he also takes neurontin and tylenol for his neck pain."

At this point I ended the call with: "I'm coming in. Get suction ready and maintain his airway."

GARGH!

an example of my nightly calls.

CP

I survived the 8pm fake chest pain deluge! Day 5 of call. At every prison there is a time when the inmates who are scared present to the ER for evaluation hoping to be sent to an outside hospital. At this prison, its 2000hours.

When I'm on call for many days in a row, I begin to hear the call phone ring even intermittently. To account for this, the on-call phone has 20 available rings as well as the capacity to record a small sound clip. For my fourth ring I recorded the Senor Chang intro from Community the TV show. Now I smile whenever I get the call.

uncertainty

I am still on call. Normally call runs Fri-Sun or Mon-Thurs. Earlier admin decided that registry staff should not work more than 975 hours/year. This results in warnings to all registry staff that we would all be fired when we reached those hours. Understanding that there was no one to replace us. I volunteered to take as much call as possible while others avoided call because it racks up the hours quickly. So I have been billing since Friday 0700. It is Monday 2230. I think I am on until Wednesday afternoon, but the time runs together after so much time at the beck of the nurses.

Tonight we had a fake seizure, a fake chest pain, and a patient who returns from open ab surgery after multiple stab wounds. In prisons in this state there are two types of inmate yards. General Population and SNY, Special Needs Yards. The SNY yards are made up prisoners who would have safety concerns in a GP yard: gang drop-outs, pedophiles, former law enforcement personnel, etc. Recently the SNY prisoners have decided that even they cannot stand pedophiles and have begun a "clean-up" effort. Through stabbings, throat slashings and fake suicide attempts, these SNY hope to eliminate the undesirables. Note that all the SNY inmates are greenlit on GP yards.

Pedophiles ARE the worst inmate-patients. The level of psychological entitlement and lack of empathy needed to rape children leads to incredibly difficult patients who are unable to engage in a reciprocal doctor-patient relationship. Being more intelligent than the average inmate, the pedophiles use their literacy and criminal minds to push the bureaucratic buttons of the state to better their interests, or at least minimally make sure other people's lives are no better than theirs.

Inmate are, on average, undereducated and of low intelligence. This results in all prison announcements and workings to be made at a fourth grade level or below. This makes the rules easy to manipulate by reasonable people. Of course this does not include many union members. People who come to the state gifted, intelligent, motivated and over years of state-operating friction become petty, small-minded workers who spend every free moment, and some moments where they should be working, reading union contract books to find the next lophole to be exploited for vacation time, better work assignments, and punishment to their perceived offenders.

Tonight I joined a local gym to get back in shape. Working with the state is soul-searing. I think the subconscious Thanotos begins to win and the body/mind/spirit begins to die. A person can only survive so much incompetent management, ungrateful patients, and disapproving voters before one becomes a permanently defensive, injured psychic shell of one's former self.

State workers remind me of animal predators locked in small zoos with small budgets. Those dirty cages and empty eyes looking nowhere in particular because there is nothing to see.

Advanced Directives

Today a Hungarian doctor came from Headquarters to teach us about Advanced Directives. Usually the state overreacts to any error in medical judgment by any provider statewide with some gigantic, costly program that involves retraining everyone but the offending clinician who is usually suspended or let go.

A few months back a patient with an Advanced Directive for Do Not Resuscitate committed intentional suicide. The patient was found and potentially could have been brought back but the nursing and medical staff followed his wishes. Well, lo and behold, the court judged that a suicidal patient cannot have his Advanced Directive honored. So the state was in error. Therefore the state is implementing a giant education program for all medical staff to learn how to complete an advanced directive and then when NOT to honor it.

A beautiful program including powerpoint, Q&A and draft forms for us to practice. (Yes, we were required to complete out own advanced directives in order to show we understood how to complete the forms.) Of note, the forms we were given are not the actual forms we will use as those were not approved or ready for distribution by the time of the scheduled class. So we all evidenced we are capable of completing the forms we will NOT be using with patients. Pure genius!

I spent the meeting reading Standard & Poors "Movies & Entertainment" industry report. Basically, CDs are dying, mail-order is alive and online streaming/downloading is the growth engine of tomorrow. I purchased 300 shares of VTI and VEU today on limit orders that purchased at the bottom drop. I was just lucky that the market went back up at the end of the day. Though it matters little. The market will likely drop more in the next week but I am aiming for a holding period of around 12 months as I get my asset allocation set. I have been increasing my foreign equities. After the global equity balance is correct, I will liquidate some ETF holdings and purchase individual stocks.

The MAR committee went well. This committee reviews selected specialty care referrals by having the ordering provider defend why they want the requested service. Usually their is a selection bias where an Utilization Management nurse has preselected the weakest Requests For Service and then attempts to facilitate us publicly humiliating ourselves to our peers. Unfortunately for her, the medical staff find this meeting comical and sarcastically deny our own specialty requests and then write the denial is per MAR committee. This usually results in the Administrators reviewing it themselves and approving the requests as they are fearful the client's attorneys will attribute MAR committee decisions to the bosses.

I found out today that the inmates in the kitchen have been recently fired for putting feces in the chili, spitting in the soup and urinating in the cheese sauce. The kitchen inmates recently had their unit searched for contraband which results in their catharting pent up aggression on the unfortunate customers of the PK (Prison Kitchen.)

I'm watching South Carolina make Ole Miss look weak. Before this game I would have said Steve Spurrier is done, retired in less than 3 years. Maybe all he needed was a quarterback with an arm and some eyes.

Over and out.

The State Blinked

"The State Blinked" was the opening line of an e-mail from the Chief Medical Officer. Over the past few months, admin has been saying registry staff are doomed and we all needed to sign on to state service or be let go.

Staying strong the registry staff agreed to stay independent. At the last meeting I told the CMO that if the state wants to play chicken with its medical providers, I'm comfortable riding to the edge.

Well much sooner than I expected, the maximum hour limit has been removed. My job hunt was for naught. Though I enjoyed the job search. The imagining myself working in a more supportive environment where I arrive excited about anything other than money. Though like I've told many, I sleep like a baby on a pile of money, no matter how lumpy it is.

My move to Nevada is complete with Driver's License and Press plates on my car. Guns and tax savings here I come. Now if I could only afford a Panda Express franchise. (Oh no! I just went to the website and Panda does not franchise.)

---
I wonder if there exists a group of people who find Consumer Reports as engrossing as I do. It's like porn for the thrifty-minded.

I was reading back issues at the library today. (And the current one!)
The library is ordering new subscriptions so I had to put in a good word for the Economist, Car & Driver and Esquire.
Keeping my fingers crossed.

---
The new episode of The Mentalist is on http://www.free-tv-video-online.info/player/smotri.php?id=u13166039237. Woo-hoo.

Pain Management

Yesterday the medical providers at work were given a chance to present their difficult pain patients to the "Pain Management Committee." This group is composed of representatives from lab, pharmacy, nursing, psychiatry, custody and medical. Aiming to improve patient care through interdisciplinary review, I requested to present. So today I come to work with a full line scheduled. Knock out 8 patient visits including an acute chest pain in 90minutes and head over to the administration building eager to share and learn about my difficult cases.

As is the case with most state meetings, key stakeholders were absent. The Chief Pharmacist is on vacation. No one knows the whereabouts of the Director of Nurses. Psychiatry doesn't show. The Lieutenant is out sick. So the interdisciplinary committee is the Chief Medical Officer (medical), the Chief Physician (medical), lab, a nurse, a secretary and me.

The difficult patients in pain management aren't patients with radical deformities or intractable cancer. For those individuals, the accepted protocol is just ramp up the prescribed medications that hold street value. The challenges are the patients who have negative million-dollar work-ups and request more drugs at every visit.

So I presented three patients. Being very excited to hear a better way to deal with potential drug-seekers or people whose lives are so empty and miserable that they entertain themselves or find meaning in drugs of abuse, I gave a great case presentation. While reviewing the file on the patients with normal x-rays, MRIs, CTs, emg/ncs's and PT consults, I was surprised to see a Pain Management Consult note in the chart.

Pain Management is a specialty service that basically exists to absorb patients whose need for medication surpasses primary care and specialty care providers ability to justify high doses to the DEA reviewers. While cardiology treats objective findings like blood pressures and nephrology may focus on GFRs, Pain Management focuses on the "objective" 5th vital sign of the Pain Scale. This "useful" tool allows patients to rate their pain from 0-10. Higher numbers being worse. For the numerically challenged or children, there is a pain scale that uses faces becoming progressively miserable for smiling (0) to crying (10).

So Pain Management doctors make their money treating patients self-report as equivalent to blood pressure. If a patient says he's an 8, well then treat the 8. I'm hoping any individual who passed public elementary school can see the potential for abuse. (Also almost every medical provider has experienced numerous patients when asked to rate their pain from 0-10, say "12.")

There is no end to the lack of cooperation patients will show their treaters. Maybe this reflects the deep seated rebellion against parents and others in positions of greater power/knowledge but in no real position of authority.

Back to my great presentation. The Pain Management consultant recommends high-dose polypharmacy to narc the patients up. And... wait for it... he documents a essentially normal exam! With no justification other than patient self-report, this "specialist" deals drugs at a discount (subsidized by insurance companies paid for my regular people) to addicts and potential addicts.

A Yale study evidenced that 25% of patients prescribed opioids will develop addictive behavior within 4 weeks. So even sweet grandma will be jonesing for a fix.

I consider Pain Management as a field to be the equivalent of Rebirthing in psychiatry. Yes some people are helped, but at a humongous resource cost and downside.

So my presentation tanks when the discussion turns to the overprescribing of controlled substances and the "middle way" of reason becomes low dose narcotics. Even though I was tapering these patients off and wanted approval for no addictive substances.

---

So back to my yard to finish my patient line. Ugh, two of my most hated patients. A man I completely healed from disability by documenting his ability to walk, run and jump without his cane, walker (yes both), and disability payments. Losing his free cash has resulted in this man repeatedly stopping his blood pressure medications and presenting to the clinic with acute chest pain. By interrupting my treatment of potentially real problems, he hopes to guide me down the easier road of giving him an assessment resulting in a lifetime of free toys and money from the government. He's my personal version of the American corn farmer.

The second patient is a habitual manipulator who happens to have the IQ of a 1.5 grader. (Yes, we test education levels to make sure are medical instructions are understandable.) This man feels he is a master of human manipulation. When I don't give him what he wants he makes me repeat everything I say as if he doesn't comprehend. Then he laughs, repeats what I tell him back and states his same request again. Maybe he is a student of Lao Tzu and he knows that water eventually wears down the rock. Though in this case its urine and he is micturating on my clinical goals and patience.

---
Went to Round Table because I am too exhausted after work to cook. And subconsciously I likely hope to end my work life with clogged arteries. The overstuffing of the gut also is sedating and reduces the vehemence of my prayers for the LA fires to come north and engulf my jobsite.

I'm listening to "The Long Tail" which is an incredibly wordy audiotape that basically states more choices result in more sales to more people. Probably a great idea when it came out, the business populism of empowered masses buying non-blockbusters just doesn't seem surprising.

---
Read Standard & Poors weekly market advisor letter. When I first began investing, S&P seemed like a secret text from the Vatican vault that would guide me to St. Peter's financial mother-of-pearl gates. Now it reads like a marketing add for investment ideas from the 80's. (The ideas are probably even earlier than the 80's reflecting my still-immense ignorance of private asset deployment in capital markets.)

Vanguard is still preaching indexing as if they represented the Dewey Decimal Company. There's a successory in the nursing station that reads: "Meetings: because none of us are as dumb as all of us." Ahhh, indexing. (Don't hate, I have >50% of my portfolio in VTI and VEU.) I just don't believe indexing is the end of the story.

---
Limewire is great.
As is my neighbor's free internet.
Best quote:
"Come on guys, cut the President some slack." - when Obama is recorded calling Kanye West a jackass on CNN.
Barack is still THE MAN! (though i didn't vote for him.)

Electronic Communication Act

Per request and contemplation I aim to keep a record of the ideas I work with and the work I idealize.

Today I have been wondering about the Electronic Communications Privacy Act, 18 U.S.C. Sections 2510-2521 as it relates to free e-mail services such as yahoo, gmail, etc. Many attorney e-mails end with a threatening footer such as

---

Information contained in this e-mail transmission may be privileged, confidential and covered by the Electronic Communications Privacy Act, 18 U.S.C. Sections 2510-2521. If you are not the addressee, note that any disclosure, copying, distribution, or use of the contents of this message is prohibited. If you have received this transmission in error, please destroy it and notify us immediately at *****.

Is this just pompous posturing when attached to a free e-mail service? I located the following article "A User's Guide to the Stored Communications Act" by Kerr (http://papers.ssrn.com/sol3/papers.cfm?abstract_id=421860) that seems to touch on many of my concerns.

Originally I began researching this issue when confronted when I received e-mails with footers such as above and the content was entirely unrelated to legal work product. I wonder how much more we could get done if people focused less on appearing powerful/important and more on being powerful/important.