When Are You Going To Die? There's An App For That.

Have you always wondered when you are going to die? Down to the last second? Now there is an app that will tell you. The Deadline app uses the iPhone's new Health app to collect your daily activities and calculates your life expectancy. It will even display your time left on Earth in the Notification Center. That way every time you pull down the screen to check your text messages you can also see how many days left you have to live. Isn't that information worth 99 cents?

All About That Bass? What About All That Diabetes And Cardiac Disease?

Yeah, my mama she told me don't worry about your size
She says, "Boys like a little more booty to hold at night."
"All About That Bass" by Meghan Trainor

From the Centers for Disease Control:

• Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.^{1, 2}
• The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.^{1, 2}
• In 2012, more than one third of children and adolescents were overweight or obese.¹
• Overweight is defined as having excess body weight for a particular height from fat, muscle, bone, water, or a combination of these factors.³ Obesity is defined as having excess body fat.⁴

• Overweight and obesity are the result of “caloric imbalance”—too few calories expended for the amount of calories consumed—and are affected by various genetic, behavioral, and environmental factors.

 

What's wrong with having a little more junk in the trunk? Again from the CDC:
 
Immediate health effects:

• Obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. In a population-based sample of 5- to 17-year-olds, 70% of obese youth had at least one risk factor for cardiovascular disease.⁷
• Obese adolescents are more likely to have prediabetes, a condition in which blood glucose levels indicate a high risk for development of diabetes.^8,9
• Children and adolescents who are obese are at greater risk for bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem.^5,6,10

Long-term health effects:

• Children and adolescents who are obese are likely to be obese as adults^11-14 and are therefore more at risk for adult health problems such as heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis.⁶  One study showed that children who became obese as early as age 2 were more likely to be obese as adults.¹²
• Overweight and obesity are associated with increased risk for many types of cancer, including cancer of the breast, colon, endometrium, esophagus, kidney, pancreas, gall bladder, thyroid, ovary, cervix, and prostate, as well as multiple myeloma and Hodgkin’s lymphoma.

So yes your mama should be worrying about your size and watching your diet. Besides if you want to sing about having an oversized booty, this song is much better and will always be a classic:

The Ebola Hysteria. Where Is The Next Ryan White?

The New York Times reports that the medical staff at Bellevue hospital who are treating Dr. Craig Spencer, the physician who contracted the Ebola virus while working in Africa for Doctors Without Borders, have been shunned and discriminated against throughout the city, even within their own hospital. Businesses have asked them to leave when they find out they are employees of Bellevue. Some nurses who moonlight at other facilities have been told their services would no longer be needed.

Unfortunately, this panic among the general population, and even within the medical community, has been promulgated by the clumsy handling of the issue by the government and specifically the Centers for Disease Control. On their very own website, the CDC states the Ebola virus can only be spread by direct contact. It is transmitted through body fluids or a needle puncture with a contaminated needle. It is NOT spread through the air, by water, or with handling of food. Yet this important information has not been aggressively emphasized as the government has pursued people all over the country who may have flown on a plane that on a previous flight had carried an Ebola positive patient with a very low grade fever. Their mandatory 21 day quarantine also reenforces in people's minds that Ebola is so easily transmittable and so deadly that even people who have tested negative for the virus need to be isolated even though they show no evidence of being infected.

If all of this sounds familiar, then you are right. Back in the early 1980's, America was caught up in another viral disease panic. Its name was HIV. Like Ebola, HIV is not spread through the air or drinking out of the same water fountain. It is now well known that HIV is only transmitted by body fluids or contaminated needles. But at that time, the government's mishandling of the situation led to massive discrimination against HIV patients.

HIV remained in the public conscious as a disease of the damned: the homosexuals, IV drug abusers, and the prostitutes. It was not until a young Ryan White from Indiana came along that put a personal face on the disease. Ryan was a boy with hemophilia. He caught the virus through a blood transfusion at a time when blood wasn't tested for HIV. He faced horrible and ignorant intolerance from children and adults alike. He was banned from attending school. Their family car was vandalized. Store clerks would throw change at his mother to avoid coming in contact with her hands.

Back then, HIV was much more prevalent than Ebola is now. People were familiar with the images of skeletonized HIV patients. There were hundreds of HIV patients in the big cities, making them easy fodder for the major TV news operations of the country. Yet it took the courage of one young man to finally make the country understand that a person who has contracted a disease should be treated with compassion, not as a pariah. With the help of the medical community and the government, people got educated on how HIV is really spread, not just basing their fears and rumors and hearsay.

Ebola is currently in that same early stage of awareness as HIV where people are more fearful of the unknown than the reality. Heaven forbid Ebola will one day reach the same prevalence as HIV. But if it does, we will at least have experienced a similar teaching moment to fall back on and not make the same mistakes all over again.

Why Nurses Have Bigger Cojones Than Doctors

Physicians can be such wimps. You would think that a group of people as smart as doctors would be natural leaders in society when it comes to making medical decisions. Yet we are pushed around by lawyers and politicians with nary a complaint even though we furtively grouse about our predicaments behind the closed doors of doctors lounges. Meanwhile, when nurses feel they have been wronged, they let everybody know about it.

The latest example is Kaci Hickox, the nurse in Maine who had just returned from Sierra Leone after taking care of Ebola infected patients. The state wants her under "voluntary" quarantine for three weeks even though she has tested negative for the virus and exhibits no fever or other signs associated with the disease. Like a good New England rebel, she has defiantly resisted this rule, even riding her bicycle out in public. She claims it is unconstitutional for the state to keep her locked up in her home out of fear and without any evidence.

This follows the defiance of nurses at Brigham and Women's hospital in Boston (must be something about New England that breeds dissenters) who are suing the hospital over forced flu vaccinations. The hospital has called for termination of their jobs if they don't get the shot. The hospital is demanding the vaccinations despite the fact that there is little evidence the vaccine actually prevents the flu or that it is necessary for healthy young people. Besides the lack of efficacy, the vaccine has real potential complications that can lead to a lifetime of disability, like Guillain Barre.

Meanwhile doctors just complain to each other about how difficult our professional lives have become because our decisions are being made by others, usually not even in the medical field.  Instead of doing something about it, we, and our professional societies, continue to kowtow to sharper legal and political minds as we trudge through our daily grind.

Doctors should be leading the charge against mandatory quarantines where there is no evidence of illness. Physicians should be educating the public about why the flu vaccine may not actually prevent the flu and can lead to crippling illnesses. But we don't. How pathetic is that?

What Are The Most Common Anesthesia Complications?

Pardon the profusion of lists on this post but there are some really fascinating data here that every anesthesiologist should read. The Doctors Company, a national medical malpractice insurer, compiled a list of anesthesia claims between 2007 to 2012. A total of 607 cases were identified. Their most common anesthesia complications leading to claims were:

1. Teeth damage-20.8%
2. Death-18.3%
3. Nerve damage-13.5%
4. Organ damage-12.7%
5. Pain-10.9%
6. Cardiac arrest-10.7%

The most common allegations of malpractice against anesthesiologists were:

1. Improper performance of anesthesia procedure-25%
2. Tooth damage related to intubation and extubation-24%
3. Improper management of patient under anesthesia-19%
4. Failure to monitor patient's physiologic status-3%
5. Positioning-related-3%

And what are the improper performance of anesthesia procedures that people are suing for?

1. Injection of anesthesia into the spinal canal-37%
2. Intubation of respiratory tract-35%
3. Injection of anesthesia-peripheral nerve-20%
4. Injection of anesthesia-sympathetic nerve-3%
5. Nasopharyngeal intubation-2%

The average payout for anesthesia related complications was $309,066. That compares poorly with the average for all other physicians, which was only $291,000. However anesthesiologists are right in the middle of the pack in a list of other specialties. Pediatrics had the highest indemnity with well over $1 million while ENT had the least with under $200,000.

There is a lot more information from The Doctors Company study than is presented here.

Our Hospital's First Ebola (Computer) Virus Scare

Our hospital recorded its first ebola scare today. A woman came in for a routine outpatient procedure. She has been coming to us regularly for months so nobody was especially on guard about any potential health hazard with this lady.

When we opened her electronic medical record, a stunning display popped out. Right at the top of the page, in bold red background lettering, the computer had declared she was positive for the ebola virus. A minor panic nearly ensued as everybody started scrambling for protective gear and wondering how we would all get along as roommates for the next 21 days in quarantine.

Then cooler heads prevailed. A quick call to the IT department confirmed that this was an error. In fact, if we had looked up every patient that was in the hospital at the moment, they all had the same ebola warning. The department was inserting new programming into the system for the diagnosis of ebola, which didn't exist before. Somehow it had crossed over into the live system and infected every patient's chart (pun intended).

After that we all gave a big sigh of relief and laughed at the stupidity of IT. Now we can go back to ignoring the big bold warnings about our patients with MRSA, VRE, MDRO, etc...

Anesthesiologists Need To Work Out These Muscles

You know that tired feeling you get after a long day of intubating patients? That sore aching sensation in your lanryngoscope lifting arm that has you popping Advils by the mouthful by the afternoon? Well now somebody has gone ahead and determined which muscles are causing you so much grief.

A study in the British Journal of Anaesthesia has determined which muscle groups an anesthesiologist uses the most rigorously during intubations. They used a surface electormyograph to compare the muscle activity of ten anesthesiologists as they intubated a mannequin using either a Glidescope or a regular Macintosh blade.

Glidescope

 

They found that the Glidescope allowed for less muscle exertion compared to a Macintosh overall. But it was most significant in the anterior deltoid, posterior deltoid, upper trapezius, and brachioradialis.

So before the next time you start having tender and aching left sided upper body pain, you may want to ask your department to invest in a video intubation system. Or risk having an anesthesiologist file a disability claim against the group for not providing adequate equipment to do his job. Or maybe you just need to hit the gym more often you girlie man. Yah.

GI Doctors Want To Make Their Patients Less Safe During Procedures

This is pretty freaking unbelievable. Despite the fiasco of the death of Joan Rivers during a routine endoscopic procedure under sedation, some gastroenterologists want to provide even less monitoring of their patients. Some GI doctors are resentful of ASA guidelines to improve patient safety during a procedure. The ASA has declared that all patients under sedation, even "only" moderate sedation, must have their end tidal CO2 monitored.

Apparently even this minor inconvenience is too burdensome for some GI to take. A paper was presented recently at the American College of Gastroenterology Scientific Meeting that tries to refute the necessity of capnography for ASA 1 or 2 patients under moderate sedation for colonoscopy. The study claims that there is no benefit to capnography for this patient population.

According to Dr. Paresh Mehta, the author of the study, the ASA has "mandated something without any evidence of benefit with moderate sedation. Yet capnography increases the cost of colonoscopy because all endoscopy centers have to purchase these devices and specialized nasal cannulas. You have to train your staff how to use the device because not everybody is familiar with looking at wave forms and making decisions off that."

You can practically hear the derision of the ASA from the statement. But Dr. Mehta's so called evidence based practice is so short sighted it's almost malpractice. Anybody with any experience with oximetry and capnography knows that the two instruments work best when done in tandem. Pulse oxes are great for detecting hypoxia before the patient becomes cyanotic. But they also have a lag in their reading. Depending on a patient's pulmonary status, a patient can be apneic anywhere from 30 seconds to two minutes before the pulse ox starts trending downward. Once the numbers start dropping and resuscitation is begun, there is a very scary period where the numbers continue to drop as the pulse ox lag starts to catch up with the real oxygen saturation. It is during this frantic hypoxic episode that a patient can suffer a cardiac arrest or stroke. If capnography is present, a patient's apnea can be detected and corrected immediately. Isn't preventing these potential complications alone worth the price of having a another monitor in an endoscopy center?

GI docs may also be lulled into thinking ASA 1 and 2 patients are chip shots to sedate. Anesthesiologists know that any patient can have respiratory distress regardless of ASA status. Maybe the patient has an undiagnosed sleep apnea. Perhaps they are taking medications at home that make them more susceptible to sedatives but they didn't disclose that information to the doctor. Just because somebody is an ASA 1 doesn't make them immune from an anesthetic catastrophe.

Finally it doesn't seem right that not all patients are getting the same level of care when it comes to safety precautions. The endoscopy center already owns capnography monitors for their other procedures. Why not use them on all patients getting sedation? Why discriminate one group of patients from another? Imagine how a GI will respond to a malpractice lawyer asking him why a patient died from respiratory distress because the patient went apneic for too long before being detected and capnography was available but not used, "But I read a study that said capnography is not necessary during a colonoscopy." Better whip out that checkbook right then and there.

Obviously the main reason GI doesn't want to use capnography is mentioned in Dr. Mehta's statement; they don't want to spend the money. They don't want to have to buy the equipment. They don't want to have to train people on how to use it (though today's equipment is as simple hooking it up to the patient and turning it on. Not rocket science). Surgery centers are all about cash flow and profits. That's why they don't want any anesthesiologists or their pesky safety equipment to keep them from their assembly line of endoscopic examinations.

The AGA should be ashamed of presenting a study like this that advocates expediency and profits over patient safety.

The California Medical Association Is A Tool Of The State's Liberal Politicians

I was sitting at home trying to be a good citizen and fill out my mail in ballot for next week's general election. The process can be overwhelming. With literally dozens of races to decide on, I thought I should seek some professional advice. After all, I'm not a political wonk that knows the ins and outs of all these different candidates and proposals.

I first turned to the California Society of Anesthesiologists for their voting guide. I figured they of all people would have my professional well being as a top priority. Well they were no help. Their main issue is a screaming denunciation of the much hated trial lawyer sponsored Proposition 46. As far as assistance with state legislative candidates or any other propositions, they were conspicuously silent. While the website presented all the information for me to read,  I would still have to sift through it all by myself. They make no endorsements for me to follow. I needed somebody who was familiar with the people and the bills to give me educated guidance.

Next I surfed to the California Medical Association's web page. Now we're talking. This group actually does have endorsements of the dozens of different candidates running for office. Upon closer inspection of their recommendations however, the names all looked awfully familiar. To confirm my suspicions, I turned to the California State Assembly website to find the list of all the state's assembly members. My hunch was right. Nearly all the candidates the CMA has endorsed are incumbents. Candidates approved by the CMA and who are not currently in the Assembly are usually running for an open seat, and a Democrat.

So what's going on? Is the CMA so caught up in Sacramento's power games that they can only recommend candidates who they have shared lunch and drinks with these past few years? Are they so beholden to the politicians that they cannot fathom anybody else who is more qualified to represent the will of the people?

It's ironic that the CMA would want to keep in place the supermajority of liberal Democrats that have a stranglehold on California politics. I suspect that most of the CMA's members, and doctors in general, are more conservative than the majority of the political hacks running our state government. Yet the organization would have its members vote for candidates who are usually in bed with the trial lawyers--the same lawyers who wrote Prop 46 and its weakening of the cap on medical malpractice judgements. Does nobody at the CMA recognize their error in judgement by putting back the same liberal politicians year after year? These are the same elected officials who are derailing the state economy by approving high taxes and antibusiness legislation. Yet the CMA would have us believe that these representatives are the best people we can find to run our state. CMA, this is an epic FAIL.

This Food Can Make Your Brain 30 Years Younger

Remember when you could devour volumes of medical textbooks at a time and actually retain the information? No? You tell me you don't even remember what you had for dinner last night? Well new research has discovered a food that can help your brain retain memories like your 30 year younger self and it may be as close as your local pharmacy.

A study in Nature Neuroscience asked 37 participants between 50 and 69 years old to consume cocoa flavanols. One took 900 mg flavanols daily for three months while the other group only had 10 mg. At the end of the study period the high flavanol group scored memory tests equivalent to people 20 to 30 years younger while the low flavanol group didn't perform as well. Radiographic imaging of the brain showed that the high flavanol group had increased blood flow and function in the hippocampus and specifically the dentate gyrus.

One caveat is that the study was funded by the chocolate company Mars. While one wouldn't won't to eat seven chocolate bars per day to get the equivalent quantities of flavanol, Mars does conveniently sell a cocoa extract called CocoaVia. Each tablet contains 250 mg of flavanol. A box of 60 costs $25 at your local pharmacy. So a box will last you two weeks to achieve the high flavanol quantities necessary to show any effect. That's not a bad investment to get your youthful brain back.

Now if somebody can combine flavanol and Viagra together, that would be the ultimate fountain of youth in a pill. That's my next billion dollar idea.

Ebola 101 For Anesthesiologists. Bring Duct Tape.

The American Society of Anesthesiologists has released its recommendations for anesthesiologists who might come in contact with the much feared ebola virus. It starts out with a quick FAQ on the nature of the virus. For instance, did you know that even though the virus can be easily eliminated on a dry surface with household bleach, it can live on your skin for up to 6 days? If you live long enough it can survive in breast milk for two weeks, urine and stool for a month, and semen for over 100 days.

The diagnostic criteria for ebola infection is a fever of at least 38.6 C. That partly explains why that one nurse from Texas was allowed to board an airplane after treating an ebola patient; she had a low grade temperature of less than 38 C at the time of her cross country trip. Initial symptoms include headache, GI symptoms, and easy bruising. This eventually leads to DIC and multisystem organ failure. The only treatment is symptomatic and possibly some experimental vaccines and serums. 

The ASA's suggestions for doctors who are treating ebola patients is simple--wear personal protective equipment (PPE) religiously. That means training in how to safely don and doff (their words) the astronaut suits precisely without contaminating yourself or anyone around you. The space suits that we sometimes see orthopedic surgeons wear are not good enough. They circulate air inside the suit with simple fans on the top of the head. These fans blow unfiltered air directly on the operator's face, thereby actually concentrating the amount of virus that the wearer might come in contact with. It's also a good idea to use duct tape to seal off all open spaces between clothing.

Patients will be in isolation for the duration of the illness. They should not be transported anywhere in the hospital. All equipment and personnel will come to the bedside, including anesthesia and surgical equipment in the unlikely event a patient needs an emergency operation. Once in a PPE, the doctor must stay in the suit until the procedure is finished. So don't have that last cup of vente Starbucks before donning the PPE. 

The anesthesiologist in an ebola procedure room will have to be self sufficient. Nobody is going to run in and out of the room because the correct size intubation blade is not present. The anesthesia cart will be taken out of the room and a bare supply cart with the minimum amount of equipment and drugs will be made available. No anesthesia machine either so better get used to using total IV anesthesia. If a patient is coding, no crash team will be able to quickly put on their PPE's to assist with resuscitation. If a patient needs an emergency intubation, personnel may not be able to put on a PPE fast enough before he suffers anoxic brain injury.

These are just some of the issues that all doctors and patients in the future will have to confront in this small cross contaminated world of ours.

The Most Important Question To Ask Before Surgery

Today's issue of the Wall Street Journal has a nice little article advising patients how they should discuss their anesthetic care with their anesthesiologist. Since it's in the WSJ, you know every anesthesiologist in the country has already read it this morning. So we're well prepared for the onslaught of questions by the well to do patients and readership of the paper. It goes into the some statistics about the safety of today's anesthesia: 3 deaths per 10,000 procedures and a 4.8% anesthesia complication rate according to one study.Those numbers seem high to me but that's the conclusion they reached.

Naturally they have to bring up the death of Joan Rivers. What they failed to mention, but which I already have, is that no anesthesiologist was involved in her care immediately before she went into respiratory and cardiac arrest. The article's best suggestion may have been this blurb, "Find out who will monitor you during the procedure—the surgeon, a nurse or an anesthesiologist. Only a medical professional specifically trained to administer anesthesia and monitor patients should care for you throughout a procedure." Presumably the surgeon has not been formally trained in administering anesthesia. So unless he is double boarded in surgery and anesthesiology and he tells you he will give instructions to the nurse on what drugs to push for sedation, get ready to run the hell out the door. I wonder how the morbidity and mortality figures from that study would have changed if only anesthesiologist provided care was used to calculate its results?

We anesthesiologists don't presume to understand how other doctors do their jobs. We don't want to know how to perform an endoscopy or a cardiac cath. Yet these non anesthesia trained doctors are so arrogant as to assume they know how to provide dangerous anesthetic drugs while performing their procedures at the same time. So Dr. Murray, Dr. Cohen, and all you other procedurists out there who are putting your patients to sleep out of expeditiousness and greed without any anesthesia training, I hope you start getting a lot of hard questions about why you're not using an anesthesiologist for this most risky portion of a case.

What The Deaths Of Michael Jackson And Joan Rivers Have In Common

Following the unexpected death of Joan Rivers, I am once again inundated daily with questions from concerned patients about the safety of anesthesia. Everybody comes in with wide eyed fears while family members produce a list of questions about how likely their loved one will die during a routine outpatient procedure.

This hysteria is similar to the events five years ago when Michael Jackson was found dead in his rented mansion after being sedated by an inattentive cardiologist. At that time patient anxiety was actually far more intense because of Mr. Jackson's notoriety and the widespread news of propofol's involvement.

However, my answer to questions about both Mr. Jackson's and Ms. Rivers's deaths are quite similar--in both cases an anesthesiologist was not present to give the sedation. We know for a fact that MJ was overseen by Dr. Murray in a private bedroom with absolutely no evidence of any anesthesia resuscitation equipment available, not even oxygen. Ms. Rivers's case is still under investigation so we only have gossip and heresay to tell her story. However all evidence point to Dr. Cohen, her gastroenterologist, as the primary procedurist in the room. He has strongly voiced his opinion that the use of propofol by a non-anesthesiologist is just as safe as when an anesthesiologist is giving the sedation. With such a strong advocate of DIY anesthesia as Dr. Cohen, it is unlikely that he let any anesthesiologist sedate his patients, especially for a procedure as "benign" as an EGD.

As you can see, in both tragic cases there was no anesthesiologist in the room when a crucial airway emergency occurred. When patients ask about these sensational events, they must be firmly told that an anesthesiologist would most likely have prevented the untimely deaths of these two celebrities. No amount of PR material from the ASA about physician anesthesiologists (how I hate that term) can compare to a face to face bedside education that an anesthesiologist can give to his patient about the safety of our craft. This is another golden opportunity to inform our patients about the frequently misunderstood practice of anesthesiology. Out of tragedy anesthesiologists can really shine and demonstrate to the public the indispensable skills we possess to safely guide a patient through his most vulnerable period.

The Scariest Doctors I Work With

I've worked with angry doctors. I've worked with slow doctors. I've worked with funny doctors. But do you know which physicians worry me the most? No it's not the psychopath surgeon whose mother never taught him how to talk with his inside voice. Nor is it the befuddled old coot of a surgeon who meticulously labors through a case that would take half the time in the hands of a more competent physician. No the procedurists that worry me the most in a procedure room are...first year GI fellows.

Why do these young innocent physicians scare the crap out of me? It really is no fault of their own. Every doctor has a steep learning curve that has to be traversed before they can be the experts they will eventually become. Unfortunately for me, new GI fellows are acquiring their craft by obstructing the part of the patient I am most responsible for safeguarding, the patient's airway.

When these young doctors first grab hold of an endoscope, they literally don't understand the ups and downs of the instrument. They'll fiddle with the myriad of knobs and locks to try to understand how to aim the scope in all directions. They'll play with the various valves and buttons to determine how to suction or insufflate. It makes my sphincters tighten just anticipating what is about to happen.

Then the dreaded procedure begins. The fellow will sort of bend the end of the scope to what he thinks is the approximate curvature of the tongue and the oropharynx. He will pass the scope through the lips then...get completely lost. All he'll see on the monitor is a red or orange monochromatic screen. Unless he pushes really hard into the soft tissue in the mouth in which case he may see white as all blood under the mucosa is pushed away from the end of the instrument.

In the meantime my job is to preserve the patient's airway while sedating her well enough so that she doesn't jump off the table as the neophyte continues his lesson. If the patient starts coughing or moving, I'll get the much despised, "Anesthesia, patient's waking up!" and it will be my responsibility to keep the patient still with more drugs while the fellow continues to meander his way down the mouth.

Eventually he will advance far enough past the tongue to actually see the vocal cords. It is at this point, when the greatest danger to the patient is present, that most of them decide to pause to admire the view, as if they think they are ENT surgeons. They may blow air directly on the cords to keep open the space around the tip of the scope, which of course causes the cords to become irritated and the patient to cough. Once again I'll have to respond to "Anesthesia, patient's waking up!" as if it is my fault. Or worse, the tip of the endoscope may become smeared with saliva and the fellow decides he needs to wash it with a squirt of water, which again leads to coughing, or worse, laryngospasm. All of these reactions the patient is suffering somehow have to be mitigated by me or the doctor won't be able to continue.

Once he's had a good look at the cords, he will then proceed to enter the esophagus. He will try to enter through that tiny little space right below the arytenoids and through the upper esophageal sphincter. Here is where most of them baffle me. They will tell the patient to swallow the scope to open up the sphincter. How quickly they forget that I have to sedate the patient so deeply for them to get to this point that the patient is not able to cooperate to verbal commands. This step may take awhile as there is usually a slight bend in the UES before the scope will enter the esophagus properly. Once they have passed this point I can finally let out a quick sigh of relief as the airway is now at less risk of obstruction once the scope has passed.

I know they have to learn their trade somehow. And after a few thousand endoscopies under their belts, they will be one of the highest paid physicians in the country. But in the meantime I don't think patients understand what risks they are taking when they have GI fellows practicing their procedures on them. Maybe this is one of those times where a model simulation of an endoscopy, like simulations of airway intubation, can be both safe and effective. I'm sure getting tired of pushing more propofol just so the fellow can get the endoscope past the patient's uvula.

Rich People Doing Stupid Things

I've seen some pretty ignorant driving behavior here in Southern California. There are the women who put their mascara on while going down the road at thirty miles per hour, the applicator just millimeters from their eyeballs. Or the girls who decided they just needed to braid their hair with both hands at that moment while steering their vehicles with their knees. Texting while driving is practically ubiquitous these days. But when I saw this car on the freeway I had to do a double take.

People were all driving 50 mph+ when this BMW M6 convertible came zooming past. Now that isn't unusual for a car with an excess of 550 horsepower under the hood. But what shocked me were the three teenage passengers sitting in the back seat. They weren't really sitting in it so much as squatting on it. As you can see their heads and shoulder are way above the headrests. That's probably because this car's knee room is so cramped that they couldn't fit their legs back there. This car is more of a 2+2 touring vehicle, not a family transportation hauler. BMW calls it a 4+1 seating configuration, meaning the person in the middle of the back bench had better be tiny and willing to straddle a huge center tunnel running down the middle of the car.

Of course when you aren't sitting in the seats properly, you can't wear the seat belts either, which none of these three kids were doing. If this car ever got into an accident, those kids would become living breathing flying missiles shooting out of the vehicle at fatal speed. So now you have three children squatting in the back with their heads above the headrests and none of them wearing seat belts in an open top convertible. The potential for disaster is mind boggling. This just goes to show that just because somebody has lots of money, the retail price of this car is almost $120,000, doesn't mean they have much common sense, or any sense. I hope somebody recognizes this car and tells the driver to stop this insanely reckless behavior before innocent people are killed.

Binge Drinking Is Another Reason Why Children Shouldn't Copy The Behavior Of Their Sports Heroes

Here's another case of a professional athlete setting a bad example for their young admirers. While the child abuse case of Adrian Peterson and the spousal abuse by Ray Rice are worse, this binge drinking by San Francisco Giants pitcher Madison Bumgarner is potentially more dangerous. Most of us can't contemplate the violent behavior of the aforementioned football stars, but the Giants player's binge drinking will certainly be admired by many young adults, maybe even impressionable high school students. In this video clip, Mr. Bumgarner is seen chugging FIVE cans of beer simultaneously while his teammates cheer him on in the aftermath of their win in the National League Division Series. Is this celebration of a baseball game excessive? Will Mr. Bumgarner want to be remembered as the man who can drink five cans of beer at a time? How will he feel when his own children and other young family members watch this on YouTube, up there on the internet for all time? Will he be embarrassed? Or will he be like the hypocritical pot smoking parents who tell their kids not to do what they see their elders doing?

Excessive alcohol consumption is a serious issue in our country. Its economic cost is estimated to be over $200 billion per year in medical care and lost productivity. Seventy-five percent of that is directly related to binge drinking. Binge drinking is defined in men as taking five or more drinks within a two hour span. In the video, Mr. Bumgarner is doing it all in thirty seconds.

According to the CDC, ninety percent of alcohol consumed by young adults under the age of 21 are done by binge drinking. Think of the fraternity weekend parties, postgame keggers, and Greek nights on campus. But it's not confined to just college campuses. Ten percent of high school drinkers have binge drinked. These are precisely the fans who will be admiring the beer guzzling performance of Mr. Bumgarner.

For the same reason these young fans buy the shoes and other products endorsed by athletes, they will also try to emulate their actions on and off the field. At that youthful age they don't have the judgement to discern what's wrong and what's right. I don't have to go through the long list of potential complications from excessive alcohol use, including injury or death to oneself or others from drunk driving, hepatitis, pancreatitis, unwanted pregnancy and sexually transmitted diseases. This sort of behavior should not be an example of a celebratory display after a hard won game. Spraying each other with champagne is one thing. Drinking alcohol so quickly that it is running out the sides of your mouth and down your clothes should not be condoned by any athlete or their professional organization lest they want their own children to do the same thing.

Everything You've Always Wanted To Know About The Female Sex Organs And Were Afraid To Ask

This extremely clinical description of the female genitalia will surely take any romance out of the mystery of female orgasms. Hmm, required reading for high school sex ed and college fraternities everywhere?