Let's say, just for the sake of argument that the following events had transpired;

April 2003: Following the spectacular celebration in Al Firdos square, and the electrifying images that accompanied it, Rush Limbaugh takes to the airwaves and circulates the idea that George Bush should be eligible to be president for unlimited terms. At this point in time, GWBs approval rating is close to 70%.

May 2003: Having sparked a huge debate in America regarding the wisdom of keeping Presidents for more terms due to the long nature of insurgency warfare, senior members of the GOP suggest that a non-binding referendum should be held on changing the constitution to allow George Bush to be President for multiple terms. The results will be tabulated only amongst state legislators as 'a representative sample.' The US Congress issues a law making it illegal for non-binding ballots to be printed for such a referendum, fearing that it could be used, should the results favor the President, to retrospectively declare a constitutional ammendment.

Early June 2003: Right wing factions from Europe and Israel ship ballots for this referendum to the United States. Upon hearing of this, the Governor of Virginia, where the boat containing the ballots is docked, activates the Virginia National Guard and seizes the ship and its cargo. 

Late June 2003: Right wing groups begin mass demonstrations and acts of civil disobedience, stating that the freedom of speach is being threatened and that they are being disenfranchised. George Bush starts taking to the airwaves along with Hannity and Rush proclaiming that Freedom is at stake, and making thinly veiled threats that there will be civil unrest and blood in the streets if the vote is not permitted.

July Fourth, 2003:  In an emergency session in congress, President George Bush is impeached and removed from office. Dick Cheney then issues orders to the FBI, in conjunction with the US Special Operations command, to arrest George Bush and fly him out of the country.

 The Prime Minister of Israel, along with Right wing factions in Europe demand that George Bush be reappointed as the President of the United States.

____________________________________________________________________________________

Now, imagine that instead of this happening in the US, it is happening in Honduras, and instead of it being a head of state from the right wing, imagine the head of state is from the left wing. Well, you don't really have to imagine it, because that is what is happening. If George Bush were to try to undermine the constitution in order to become President for life, and he was stopped only at gunpoint (but with the full backing of the law guiding those guns), how the Hell would you feel if the UN demanded he be put back in power? This is precisely the situation that Honduras is in now. This is not a military coup. This is a tyrant in the making who has been stopped by people, even from his own party, who believe in the rule of law more than they do the man. 

I find it disgusting for Obama to be relatively okay with a theocratic fascist state gunning down people in the street who desire democracy, but incensed that a man, legally relieved of power because he is trying to undermine the constitution of his nation in order to become head of what will become a totalitarian state, is removed from office. 

To Honduras, Israel, and all the other nations who find themselves scorned by the current US President; do the right thing. Obama rewards the recalcitrant despot, and abandons the people who yearn to be free. 

Respectfully Submitted,
-doc Russia

So, I went into my last shift as a resident just kind of knowing that things would suck, and boy, was I right. Please remember that I wore my cowboy boots for my last shift. Right after I arrived, the lab's electronic resulting went down. It means that lab results had to be delivered by hand. With a large hospital like mine, this means that the lab techs slow down as they have to split their time between doing their job, and physically writing down the demographics and results of each test, which slows the lab waaaay down. So, urine results, which normally take about 40 minutes from send to resulted took 6 hours. Cardiac panels were out for 8 hours before we got them back. I ended up changing my workup to rely more on imaging than labs. Made a *lot* of decisions based on clinical acumen. They worked out pretty well. I did press the lab once to call me with the results of one patient's labs STAT, and I got them back in fifteen minutes (TYhis is one of the few times when being an emergency medicine physician and saying STAT means that the tech running the lab stops whatever the f--- he is doing, and focuses on what you want to make happen). the two values I wanted were for the patients INR (a measure of how nuch they bleed) and the hemoglobin (a measure of how much blood they have). The guy had fallen and broken his hip. His INR was twice the normal value, and the hemoglobin was half the normal value. The ortho resident told me she was amazed at how nonchalant I was after I had relayed the case to her. I just smiled chuckled and walked off with my boot heels marking time. I didn't say what I was thinking; "I'm emergency medicine, sweetheart; I don't get spooked." Of course, her reaction was the opposite of the idiot senior surgical resident's reaction. I had relayed through their intern the facts of the same case.  When I talked with the senior he said that the GI bleed was a deductive leap of faith based on the guaiac. "you don't know that he has a GI bleed! The guy could have eaten a steak for dinner!' he said (rare cooked steak is a cause for false positive guaiac results). My retort was short. "The guy's Hemoglobin is 6.6. His INR is 2.1 I don't think that the positive guaiac is because he had a steak." I turned my back on him and walked out. Idiot.

I *almost* got to do a Burr hole on a gal. Almost except for the fact that the Nuerosurgeon got wind of the case, and was present. He took her to do it in the OR. *THAT* would have been a spectacular way to end the residency. As it is, my Residency is over. I have a lot more to say on that later, but for right now, I am going to go to bed.

...and the alarm clock be damned.

Respectfully submitted,
-doc Russia

I swear to God; the drug seekers were dripping off the rafters tonight. I had one who got pissed that I gave him morphine instead. If I may diverge slightly; I preferentially give morphine for pain control despite its side effect profile because it is cheaper, and field units are more likely to be equipped with it, so I want to be comfortable with dosing it. Anyway, he said that he didn't like me, and that he 'felt threatened' by me (and no, I never drew down on him) and that he wanted a different doc. This ain't burger king and you do not get it your way. You want to see 'your' doctors, then go ahead and see the resident clinic during their hours. Don't roll into an ER on Friday night looking for narcotic score for what is obviously a poorly concocted story. Don't then take photos of me with your cell phone. Makes me think that you and maybe some of your friends are going to be waiting to ambush me in the doctor's parking lot.

I had another one who I had to settle his butt down. After getting a shot of pharmaceutical grade liquid joy (prescribed by the previous physician, who signed the patient out to me), he then pulled out some of his own stash of prescription pills and chased it down. He could barely  stand, and was trying to get behind the wheel. I told him he had to have someone come pick him up. Nobody was coming, so I told him that he had to wait for a few hours before we could release him. He got belligerent, He got vulgar. He got loud. He got abusive to the staff. He got Haldol. He got some rest.

Lots of patients with scores of visits for chronic pain issues asking for dilaudid. 

Just a few more shifts.....

Respectfully Submitted,
-doc Russia

If I can just keep my hands steady enough to type... If I can keep it together enough not to start running down the street, swinging my shirt around, and screaming at traffic, I might just be able to get this posted.

But right now it's hard. Everything is humming and electric, and my eyes are bleary with tears, and I can't seem to get myself to settle down. I'm incoherent and jabbering on. I am delirious with hope and love and fear. 

The same word keeps going on and on in my head, like some sort of loop tape that I can't stop.

TWINS.

Respectfully Submitted,
-doc Russia

Fair warning: assume that links are graphic unless specified otherwise

Not kidding.

So, coming home from work, reviewing the days news, I see that my previous post was accurate. We see unarmed people being shot and killed in the streets. Looks like the lady took a GSW high in the chest, and managed to hit the great vessels which appear to have bled (quickly) into the esophagus.

I wonder if it was a gun-free zone.

So, remind me again why Obama, as the leader of the free world cannot make sort of strong, but general statement about tyranny being bad, and freedom being good? If he were to come out and call a spade a spade, then he would leave the IRanian Mullahs with nowhere to go. You tell them that there needs to be redo of the election, and that there needs to be international observers. He should simply say that the US will not be able to effectively negotiate with Iran if there is such serious questions about the leaddership being the reflection of the will of the people. You do that, and then Iran is stuck because they either have to cave in to the reformers, or you have undermined any future hard line position they may try. 

Then again, I guess Obama is a reflection of the United States.

I remember when we not only knew who the badguys were, we were not afraid to tell them they were. 

Obama's relative silence is aqcuiesence. If this revolution fails, he will have had a hand in it. If it succeeds, it will be no thanks to him. What a crappy position to be in. He will either let us be the bogeyman for the hardliners, should they prevail, or a bunch of hippocrites to the reformers should they prevail.

I simply do not buy the argument that if the US were to strongly support the revolution it would somehow quench the fire of revolution. If that were the case, then we should start publicly backing the Mullahs. We must then oppose the revolution in order to support it. Stop and read that last sentence to understand the complete mental gymnastics that one must go through to not support the revolution, and not be aiding the tyrants that run the place.

Hopefully the Iranians will be able to overthrow their tyrants. If they do, it will be costly. "the gutters will scab over in blood" kind of costly.

There's lots more I would like to say on this, and perhaps later I shall.

For right now, all I can say to the uprising is:

Good luck. 

You *are* going to need it.

Respectfully Submitted,
-doc Russia

Unlike in V for vendetta , there is usually an abrupt and bloody outcome when "people without guns stand up to people with guns .(Start watching at 4:40)" *link fixed*

I am afraid that this is what we shall see in Iran. I believe that the shooing off of international press is a prelude to some particular nastiness which the perpetrators of which wish to leave no witnesses. 

Unlike the movie, reality has this startling problem. The men with the guns, in resorting to brutality, have made a deal with the devil. They are already linked to the regime which they serve. Now, if they had done nothing wrong, and there were no secret police, and there was no fear of government reprisal, then they would not open fire on civilians. OTOH, if they had been complicit in the crime of the regime, then they are linked to it's future, and if the regime were to fall , all they can hope for at best is eeking out some squalid existence for the rest of their lives, and at worst, punishment for their crimes. As you can see, this leaves jackbooted thugs, already accustomed to dishing out mindless brutality with little incentive for anything besides to keep doing the same, but only more urgently.  The fierce urgency of now, indeed.

Here, now, is a very good opportunity for a number of birds to be killed with  one stone. First, we owe the Iranian regime payback for their actions against our troops. Second,it would be nice if a more western friendly regime were to take over. They may not be ideal, but turning a theocracy into a true democracy is not by necessity must be handled in a single step.

In short, this is an opportunity on a silver platter for us, and I do not see our government exploiting it, when we have every right and reason to do so. I do not know if this is because of some innate reluctance to action, a lack of leadership, an unwillingness to be the one who stands up and makes a decision, or a shabby political tack focused on ensuring that the previous administration is in no way tied to a successful policy that dramatically reshaped the middle east (and this last one is the one that is most doubtful and would be most worrisome).

Whatever the reason, we have here an opportunity to assist a people in the triumph of the individual over the state. Of liberty over theocracy. Of nationalism over tribalism. We have here this opportunity, and it appears that we are squandering it.

Perhaps I am wrong, and the messiah is secretly and frantically using covert assets to assist and ensure that the mad mullahs of Iran are overthrown, and people not bent on nuking our ally Israel to glass come into power. I hope I am, but I am concerned and saddened that there will transpire a vast horror while we stood impotent only by our own self-doubt.

We are better than to just let these people get chopped up.

Well, at least we were.

Respectfully Submitted,
-doc Russia

So far, the one thing I note is that there are a lot of vague promises.

"You shouldn't have to tell your doctor your medications" ...I'm sorry, are you saying that I don't need to get a complete H&P to get paid? Or, are you encouraging for people to not take responsibility for their own healthcare?

 "It will take doctors telling us what risk factors we need to avoid..." ...Yes, but how do you get people to follow advice? You can lead a horse to water, and all that. How do you get people to monitor their diabetes? Just the other day, I had a patient who got admitted to the ICU for Diabetic ketoacidosis, racking up tens of thousands of dollars in care, which got passed on to the insured and the taxpayer because when her glucometer broke, she didn't want to spend the fifty bucks to replace it.

"Healers, not bean-counters" Nice vague statements. 

"Paid.... well.... for how you treat the overall disease"   ...and how do you treat willful ignorance?

I have a problem with this idea that a national healthcare system "injects competition." How competitive is a plan which draws it's premiums forcibly from the subscribers of it's competition, requires treatment by doctor by fiat, yet is not obligated to pay for it? The answer is:ultra-competitive. 

 Looks like he is currying favor by beating up on insurance companies.

Will the imagined trillions of dollars more that inaction will cost us, similar to the imagined jobs lost had we not acted with the stimulus spending?

"20% re-admitted within a month" ...I see this causing people to be kept in the hospital longer, or to be readmitted for a different diagnosis.

"paying less to hospitals for the uninsured" ...WTF?!?!?!?! A *CORE* problem we have is the unfunded mandate incurring costs which we then must pass along to the insured. Now he wants to exacerbate it?!?!?! 

...So, to wrap up, there is a lot of vagaries, but that last point, where he states that he will decrease payments for an unfunded mandate, a problem I see everyday, shows a stunning lack of understanding of the scope and nature of the problem. If this is how little he understands that portion, I shudder to think how ignorant he is of the rest of it.

In the end, I see costs outpacing projections, and healthcare rationing at the same time. The response to this by proponents will be that the costs would have been higher otherwise, and the rationing would have been more extreme.

Respectfully Submitted,
-doc Russia

One of the readerrs had asked about information regarding crossfit.

While it is not for everybody (because nothing ever is), I have been pretty impressed with what I have seen and experienced through it. 

Now, to declare my ignorance on the subject, let me first say that I am not certified by, affiliated with, or trained in the particulars of crossift. I came across it by accident while going through a tactical medicine course. If there are any readers out there who are, and would like to have me publish something more accurate or detailed on the program, then feel free to post something to comments (I am lousy about checking my messages), and I would be more than happy to allow the use of this site for further education on the subject.

One of the subjects covered was the health and fitness of tactical teams, and what kind of programs you should consider to help your team to be physically prepared for the demands of the profession, especially including how to avoid training injuries, which are a constant -and I mean constant- danger to operators.

Well, as it would turn out, the guy sitting next to me was a former Corpsman with Force Recon and in absolutely incredible shape. We ended up talking about fitness routines, and he *is* a certified trainer, and after hearing him describe things, I decided to give it a try, and I have been pretty impressed with the results.

Like all fitness programs, you will only get out of it what you put into it. 

This should definitely not be a suprise.

Generally speaking, Crossfit starts with the understanding that fitness entails a wided number of attributes, like strentgh, endurance, flexibility, balance, etc., etc. The way that you improve all of these elementsis not through muscle regimens which "isolate" and "target" muscles, but use more complex motions to produce work. Large body movements are the norm. There is also a lot of body weight exercises like push-ups and pull-ups.

What is most remarkable, IMHO, though, is the variation. During a session, you will often be doing multiple different tasks, at speed in a circuit. Not always, but often. There are a modest number of "maximum effort" sessions, but most routines are set up where you will do a circuit of three to five complex  exercises, of varying reptitions. the number of reps is usually influenced by you roverall fitness level. SO, you will do 5 of exercise A, 10 of exercise B, ten of exercise C, and 15 of exercise D, and you will repeat thisthree to five times.

So, what I have found is that first, you do not get bored. This is probably the greatest advantage of crossfit. There is such variabilty that each day is a challenge, and not a routine. 

You also will always be sore since the variation impairs your body's ability to develop a tolerance to specific tasks.

But it's agood kind of hurt.

The exercises are also scalable, so that by increasing the complexity, resistance or repitions involved, you will get a workout without being defeated by an insurmountable obstacle. btw, the exercises for beginners may look like childs play, but then you get this funny look on your face about a third of the way through it when you realize that it is *not* as easy as you had imagined it in your mind. This look turns into something like panic when you are two thirds done, and you are realizing that this workout you took so nonchalantly is going to *waste* you.

So, Here are a couple of links.

First there is a link to what is a forum for daily workouts:

In it, you will see the daily workout posted. I recommend that you wait a couple of days to see what the scalings are, and to get a fee for the points of the workout by seeing what others posted. Please remember that this is a free forum to access, and the people who are putting it up are doing so out of the goodness of their heart, and their desire to see the program succeed.

Here is the main crossft site .
  This has a lot of information, but most useful is the list of "exercises and demos " which comes in real handy when you do not know what a sumo deadlift high pull is.

I use this in conjunction with Krav Maga (also known for it's emphasis on physical fitness).

Together, these two things form the foundation of my physical fitness routine.

As always, YMMV.

Respectfully Submitted,
-doc Russia

I saw this article through Gruntdoc .

It is a pretty quick read, and I think that this encapsuulates the problems that we are facing in medicine regarding the coming of universal care.

There is a incredibly precise line about how we already have socialized healthcare because *anybody* can call 911 and get a free ride to the EC and a free workup, and never pay a dime, regardless of how they fail to follow-up and take their meds and do all those things which would keep them healthy.

"Overwhelmosis" seems very appropriate, too.

Respectfully Submitted,
-doc Russia

After doing that tactical medicine course in California, I saw that I had let myself get out of shape. Badly. Well, one of the fellow classmates was a former Navy Corpsman who had been in Marine Recon. He was, naturally, in phenomenal shape. Since I was sitting next to him, at some point, our conversations turned to fitness. He described a program I had never heard of called Crossfit. After the class was over, I was looking at my gut and decided that I would give Crossfit a try for 90 days. Well, while I have not been a very strict adherent to it's schedule, I have lost about twenty pounds, dropped down to a 38 waist, and gotten into much better shape. I still need to drop another twenty pounds. I was 270 (:O !!), and am now 250. I should get down to an ideal of about 230 pounds. While this still puts me into the obese range, I have really slimmed down. So, while I wear a 38" trouser, I am also 6'1," I have gotten into *much* better shape. I can now do five dead hang pull-ups, even though I weigh 250. I also just hit a personal record and did a deadlift of 330 pounds. I also am running 10mph quarter mile sprints as part of my warm-up. 

When I was in Chicago, the obviously homosexual guy at the perfume counter started flirting with me (in front of my wife, who was the reason we were there) and asked "So what do you do for a living, lift weights?." I have never before been hit on by a gay man before (and hope I never will be again), so I am guessing that I look pretty buff. 

As I started to get into better shape, I also have noticed a few things in my work environment. First, I noticed that nobody gives me $hit. Not to my face. On the phone, the surgical residents are rude, but when I am towering over them, they get polite. More interesting is to note that patients react differently to me. When a drug-seeker (and we seemed to have a lot of them last night) comes in, and I present them with an itemized list of their abuses of the system, and tell them that not only will I not give them narcotics, and reward their behavior, but I will dictate a note stating that I advise other physicians not give them narcotics, they just say "okay," and then depart without a fight. Last night, I saw a patient who had visited a couple of weeks ago, and gave one of the polite female attendings a hard time. The patient was abbusive, disruptive, demanding, and generally a pain in the a$$. When I went in and told her "SIT. DOWN." She would shut up, sit down, and behave. When male patients come in and start becoming abusive of my nurses, they settle down quick when I start standing behind that same sweet little nurse and stare at them like they owe me money.

As much as we like to talk about hhow cerebral and enlightened medicine is, when it comes down to the actual practice of medicine in the trenches, the fact of the matter is that size really does matter. 

Anyway, I have to get to my next shift, where the size works against me. I am working in pediatrics, and my sheer size is enough to make children start crying. I try to be non-threatening to them, but when somebody who looks like a possible prison convict comes in, and starts reaching for them with strange looking instruments in their hands, they get terrified, and then they start screaming and crying.

Respectfully Submitted,
-doc Russia

Holy Catfish!!!!

I just sent out the cash and affidavit for my temporary Texas license. I also have been in contact with someone about doing some per diem work as an ER doc in some remote areas of Texas for some *very* lucrative pay. Texas has a problem with underserved, rural areas, and there is often a lot of money thrown at docs to come to those areas. Unfortunately for rural areas, docs who likely have trained in major urban centers tend to acquire a taste for big-city benefits, and rarely want to stay in small towns. I am one of those. I like having stuff around like good restaurants, NHL games to go to, a major airport as a gateway to exotic locations, and other things like that. Anyway, I am looking at working a bit in order to get some cash because of some domestic medical expenses (D-6 and I are trying to conceive). I am still going John Galt, jr, but it is really cool being able to make a lot of money in a short amount of time almost at will. This is a very fortunate position to be in, especially given the current economy. 

Anyway, getting back to the point of the post....

I will be working the next 16 out of 17 days, so I will be very busy. A little less than two weeks after that is my graduation dinner. Ten days after that is my last shift. I really am almost done. I think, in fact that I can see the light at the end of the tunnel. 

Yes, I am sure of it.

I am wrestling with what to do with this blog at that time. Should I go public? Should I fade away? Should I just carry on as anonymously as ever?

You know, despite the issues that I am facing (and yes, there are issues that I have been struggling with that I have deliberately kept off the blog because they are family matters, and nunya bidness), I really do have a great life. I have been getting into great shape recently by doing crossift , and feel healthier than I have in a long time.  I have this absolutely knockout of a wife who loves me dearly, and who I am absolutely madly in Love with. I mean, after almost eight years of marriage, my-heart-still-does-backflips-when-she-smiles-at-me in love with her. I have a really cool job lined up doing what I absolutely love, and I am in a position where I do not need to worry about money because I can make more should the need arise.

I see my end date approaching, and it's like the last breathless yards of a long run. That time in the Marine Corps when the platoon would have been taken on a smoker of a run, and you are turning the corner into the barracks parking lot. That ladst little bit where you know that no matter how much it hurt, no matter how long you wanted to give up and fall out, you *know* that you are going to make it, and how it diminishes all the pain.

Alright, I have to go and get ready. I ain't done yet, and I have a shift ahead.

Respectfully Submitted,
-doc Russia

TV newscaster [set to dramatic music in a fear-mongering voice]: "This is little Molly... She's only three years old, but has already had surgery for kidney stones. Find out in our newscast why doctors are seeing this and why you might be at risk.."

doc Russia [looks closely at video of child]: "Looks like FLK."

Domestic-6: "You mean Phenylketonuria?"

doc Russia [in flat monotone]: "No..... Funny Lookin' Kid."

Respectfully Submitted,
-doc Russia

D-6 and I will be absent this weekend. We are taking a weekender to Chicago. We figure that since we will be moving back to Texas soon, we might as well visit some of the close-by cities while we can. Six months from now, we won't be able to hop in a car and drive to Chicago in a few hours, so we might as well do it now.

Respectfully Submitted,
-doc Russia

So, as I had mentioned in THIS post, I lamented the poorly run bureaucracy that is public health. Well, as it turns out, it turns out that that little five year old did, in fact, have swine flu, or as I like to call it, "The Mexican Bugaloo."

It turns out that once a swab is positive, it goes through testing reflexively. It also turns out that two other residents -so far- have been exposed to confirmed cases.  So, I am not the index case at my hospital. Naturally, I had given *many* reassurances to the worried mother that it was NOT swine flu.

oops.

At least now I will be able to cut in line for stuff by going "*cough* damned swine flu *cough* *cough*"

The only thing that really worries me is that when I went to the gym two nights ago, I felt kind of weak, and my endurance was flat, so I quit early. Otherwise, I have felt fine. Now, while I am glad that I did not push myself, I hope that it was just an off night, and not a symptom of the Mexican Bugaloos incubation period.

I was exposed on a sunday afternoon, and, according to the CDC, the incubation time is likely to be from 1-7 days with 1-4 days being most likely . So, I am hitting the 4 day mark right now, and other than that episode at the gym (which was a late session, and my fatigue may have been a normal manifestation of that), I have felt fine. Okay, I did get a headache after sparring in Krav maga, but you get punched in the head, and having a headache is not unanticipated.

Alright, I am off to pick up a srip for Tamiflu for myself, and one for my Domestic-6.

Respectfully Submitted,
-doc Russia

So, suddenly Obama decides to reverse himself, and *not* release more photos that would be used to paint the defenders of America with the worst brush, going against ACLU marching orders. I mean, it's like someone well and truly did smack the Obamatuer with a cluebat something good and hard. There was nothing to gain and much to lose by releasing them.

Why the sudden change of heart? Forgive me if I do not scratch it up to Obama temporarily forgetting his likelihood to do whatever is calculated to do the exact most harm to the country. No, I have a sneaking suspicion that a few of his top Generals, (or maybe just Petraus) threatened to resign. I have nothing to back this up. Nothing at all. But, until I hear a more self-serving reason for him to do this, I will keep my suspicions.

-R/S,

doc