Memorial Day – A Celebration of Life.


As we celebrate Memorial Day lets us all take a deep breath and look at those around us. Celebrate with remembrance. I would like to suggest that we continue to remember those who are struggling as much as we celebrate the fallen. The fallen are a reminder of how terrible we can be to each other and a caution to us all. Let us not lose focus, we celebrate because some were taken before their time.

Let us celebrate life and work to preserve our essential freedoms without the need for the loss of life. Let us celebrate nature and the circle of life. Happy Memorial Day to all.

SUDDENLY THE ROOM WENT DARK.


Bang! Bang! I was awoken from a deep sleep and jumped up from bed. My head collided with something hard and I fell back into bed. I felt an intense pain race down my neck and into my lower back. My face felt as if I was walking under a sprinkler. Immediately I knew what was coming next. I could taste the viscus liquid on my lips, I was bleeding. I looked up and  noticed the nail on the bottom of the upper bunk. I had not slept in a bunk bed in many decades and the bed had taken its revenge on my head. The pain became more intense and I grabbed the blanket and applied pressure to my head, but the flow of blood was stead and unrelenting. I felt as if I could not breathe. I tried to open my eyes fully but my sight was being obscured by the red flow.  I called for Paul, but there was no answer. I more carefully stood from the lower bunk.

I tried to move forward but did not get far. I was pulled  toward the floor by an unseen force at my left ankle.  I used my hands to cushion my fall and let go of the blanket and the stream of blood became a torrent. I heard the scrapping of metal against concrete and felt the coolness of the concrete floor under my elbows. The impact was painful and I screamed from its intensity.  I thought the pain in my elbows would be the worst, then my chin meet the concrete floor. My jaw was on fire. I pulled at my left leg but it was not going anywhere.

Bang! Bang! Bang! I had forgotten about what had awoken me. It was gun fire. I was certain of it. I shouted for Paul again, but there was still no answer. Suddenly there was an intense beam of light. The door slammed into the wall with a loud bang and the intensity of the light made me realize how dark the room was. I heard a loud voice in a strange language. Suddenly the room went dark again. There was a bag over my head.

WAKE THE FUCK UP AMERICA!


As a parent I want the best for my children. I want them to achieve more than I have. I want them to be fully equipped to take on the challenges ahead. The only lasting thing I can give them is an opportunity to get an education. The education they get will determine their ability to make a living and be productive citizens. Their education will help them avoid the pervasive scams in our society. The education I fight for them to attain will improve their ability to survive. I will continue to fight for their right to be given a competitive education. As such, I am proud to support the goals of common core. It seems I am among the minority of persons who believe that common core is a good thing for the American K-12 system.

The continued attempts to disparage the goals set reflects a fundamental misunderstanding of what education means. It is a reflection of how urgent the need for better education is. The problem is that most Americans know enough to complaint but not enough to assist in the fix. We are a very poorly educated society in spite of the graduated masses. We are a society that prefers quick answers rather than long processes. The truth is that getting the correct answer is less important that understanding how you arrive at it. Every time I see a story decrying the ills of common core I see another example of a parent or teacher who lacks the fundamental understanding of what education means. Our education is lacking and we cannot compete, but we want to go back to the old ways. The old ways have not worked. The old ways have created people who oppose change not because the change is bad, but because they are so poorly educated they do not understand the change.

 
Someone suggested to me a novel solution. The parents who do not want their children learning in the common core “way” should be allowed to go to their own schools and the rest of us learn a common core based education. That sounds great to me, but the truth is that the educated will continue to suffer at the hands of the stupid. Do not be stupid and destroy your kids ability to compete. If you want to disadvantage your child let me thank you now. Thanks for removing my childs competition.

Can we please wake the fuck up America.

WE ARE WITHOUT SANCTUARY.


I am happy to be living in a country that affords me the opportunity to succeed. As a parent I am happy that my children will have more opportunities open to them than I did. My job is to guide them into success. As I look around America I am worried for my children in spite of all the opportunity that exists. The recent string of killings of men and women of color has helped to refocus my attention on the details. I, like many people of color in this great country have been lolled into a false sense of achievement. Worst is that we have allowed the wider society to accept the fallacy that racial justice as arrived. We have failed in teaching our children the important details.

As a parent of girls of color I have focused on making sure they are confident and well-educated, that is not enough. Over the last few months I have had to re-evaluate everything I have come to believe about equity in America. The history of people of color in this country is one of brutality and subjugation. There has not been enough change in our situation. In the last several month several studies have shown the depth and pervasiveness of our disenfranchisement. Our girls are 6 times more likely to be harshly punished in school compared to white girls. Americans of African heritage with master degrees are paid the same as whites with bachelors degrees and even doctors of African heritage are paid about 10 % less than similarly educated white doctors. Why is this so? I have come a conclusion, that question is not relevant. It is not relevant because those in power do not care to fix the problem. I have given up on the idea of equity in my country. The continued inequity makes me angry and concerns me for the future of my girls. I am angry but I will not be deceived into violence. Protesting does no good. Voting does almost as little.

So, in my quest to find a better answer I have looked around and think I have found the only viable route in the Jewish experience of World War 2. No one is allowed to forget the Jewish Holocaust and so too no one should be allowed to forget American Slavery and Jim Crow. The end of the Jewish Holocaust is celebrated but the brutality of it is what is referenced most often. This is what we all are reminded of daily. As people of color we need to teach our children about the brutality of the American enslavement of out ancestors and the continued brutality of Jim Crow America and the current discrimination. We need to have them understand that the current celebration of Martin Luther King Jr is fake and serves only to assuage the guilty. It is not a sign of contrition, it is hollow and designed to distract from the ever-present and pervasive discrimination against people of color. Our children need to know about the Martin Luther King Jr struggle before they can appreciated his success. They need to know and see the pictures of America brutality to their ancestors. They need to know the name Emmet Louis TIll along with Martin Luther King Jr. The goal is not anger, it is empowerment. Our children need to understand that things have changed and that we have many opportunities, but they also need to understand that they need to succeed in spite of the many race based road blocks. They need to succeed to honor their ancestors.

Violence is not the answer, it is only a way to continue to enslave us in the prison complex which is designed to strip us of the rights our ancestor died to attain. Our children need to understand the context of their lives in this land of opportunity. We need them to take the opportunities and make progress while making sure no one forgets the brutal treatment of our ancestors. We should honor our ancestors for their willingness to stand up for their rights and we should build on their success by taking the opportunities available and making the most of them. We know that we will not be treated fairly nor paid equitably because this is the current state of America. There is no real hope of progress beyond the eventual death of the merchants of death. As parents of children of color we need to prepare them to survive and thrive until that day of Martin Luther King Jr’s dream arrives. Don’t get violent, get angry and achieve.

EXAMINE YOUR LIFESTYLE.


The new year is here and I still cannot believe it. 2014 came and went at a seemly quicker pace. The truth is that the speed of time as not changed. What has changed is how we experience it. We continue to allowed procrastination to decrease how much we achieve. We over think and neglect to take the actions that would allow us to attain more of our goals. As we second guess our decisions the universe continues forward at the same pace we found it. We are achieving less and the feeling that time is going by faster is just a reflection of our lack of focus on the important things.

For the new year we all should stop thinking and start doing. I am a parent and want to leave a better planet for my children. What are you planing to leave to your children? The discussion about climate change is just one of those issues where we could improve the world for our children. The facts are not in dispute, the climate of earth is changing. I do not dispute that human activity is the cause. If you dispute that I hope we can at least agree that the climate is changing.

With that in mind I would ask you, how do you think climate change will affect your children or grand children? I would suggest that the most likely direct effect will be on the quality and quantity of food and water available. The current estimate of people around the world going hungry is about one billion annually. Concurrent with that is the fact that some of the most productive agricultural areas are in regions whose water supply is dependent on seasonal rain and snow falls. It is already evident from current objective measurable data that these regions are close to breaking point in their water balance. The drought in California, which is the current bread basket of the United States is worrying. The gravity of the danger is not being addressed. But if the level of the water in Lake Mead Nevada is any example we should all be much more concerned.

Our water usage patterns are unsustainable and more forthrightly has led us to a very dangerous place. Agriculture is the primary user of water both for plant and animal production. Animal production is an especially egregious drain on our every decreasing available water sources. The continuing willful deafness of many of our leaders to the coming and already present crisis is criminal. The low intelligence of many of the people on mass media discussing the topic is genocidal in their effect. As we continue to neglect the obvious the problem worsens and the solutions become evermore burdensome. The unfortunate consequence is that the poor all around the world are already experiencing the trauma of food and water insecurity. Even the wealthier among us are being affected. The difference is that most of us can afford the increasing cost of our basic supplies. The larger question needs to be asked, what will happen when the squeeze truly gets to the richer among us?

I am of the scientific persuasion and believe that all the evidence points to mans central impact in leading to climate change. However, I will acquiesce to those who have not attain that clarity. I need only you agree that no matter the cause climate change is occurring and that we need to act to protect our global society.

I would suggest that we start by examining our consumption patterns. Change your lifestyle and change the world. We are all apart of the change that we need.

AMERICAN SWEAT SHOP.


There is a curse that inhabits the American work place. We have become slaves to profitability and not to best outcomes. The primacy of profits has led us to misunderstand the nature of work and the importance of worker satisfaction. Making ever-increasing profits is the goal but how we get there makes a difference. Some employers have lost their focus. Sustained profitability is about worker satisfaction. In many fields lip service is paid to the worker, while they are trapped under inhumane work conditions. Fortunately work conditions in the developed world are better than they were. However, we still have a way to go before we can claim victory over poor working conditions. The severity of the impact of poor conditions is dependent on your industry. In health care the impact can be life threatening.

Our culture for too long as valued hard work over smart work. We seem to believe that the worker that workers longer hours is more noble and deserving of praise. This misplaced praise has led to continued poor choices and has led to the misery and burn out of the American middle class. The depth of the problem continues to go unnoticed and unacknowledged. Poor outcomes continue to be placed at the feet of poor training and individuals are blamed. I too have a tendency to blame the individual. The truth is that sometimes the individual is to be blamed, but we too often neglect to evaluated the conditions under which mistakes are made. The systems under which most of us work are archaic, inefficient and are undermining our ability to be the best we can be.

I will be attacked for my stand but the truth needs be told. I love my work because it gives me the opportunity to help my fellow humans at a time when they are most in need. From my limited experience that help is best delivered when I am well rested. Some may consider me weak for insisting that adequate rest is required for best productivity and patient safety. I, however, would rather follow the evidence that suggests that efficiency and safety are best attained with a well rested and optimally trained work force. The conditions of many operating rooms where staff can work full daytime shift and take overnight call then work a full day shift is putting our patients at risk.

The unfortunate problem is that when a staff member makes a mistake that harms a patient she alone is blamed. The idea that she needs to take personal responsibility for her mistake is commendable , but essentially is a cop-out. Her bosses are just as culpable, because they have put in place a system that does not allow her to work at her best. The continued scapegoating of individuals is a sickness in our system that needs to be driven into the grave. Our success is dependent on the balance and efficiency of the systems we construct. Spending money on technology is commendable and necessary but alone will not improve patient outcomes.

Better pay is a great place to start, but is a poor quality band-aid when one works under mentally oppressive conditions. Improving the system starts by focusing on the best assets of the system. Our human capital is our best asset and must be treated as such. We are not robots, we are better. We may not be able to work as long hours and we get bored easily; but until robots can think intuitively and problem solve on the fly we will continue to be the best part of the workflow equation. Functioning at maximum efficiency must be out foremost goal. For humans to be focused and efficient we must have adequate rest and distraction. If we would focus on those areas many of our problems would be resolved without the need for expensive investments in equipment.

Let us invest in our best and most productive assets, our people.

THE NEW YEAR IS COMING.


This is the time for resolutions. It is almost the new year. Have you met your goals this year? If you have not, there is nothing to be worried about. There is still time. If you have run out of time you are not alone. Most of us are too busy living life to focus on our resolutions. I would suggest that we all use this time to look back over our year and be thankful for all that we have accomplished. We all have come a long way and are on the brink of a new year. Let us be happy.

The new year will bring new challenges that will give us more opportunities to grow. Let us take hold of our challenges and continue to succeed in spite of the opposition. All our challenges should be viewed as a means to success. It is only by confronting and overcoming that we can advance. Wipe clean the slate, start anew and conquer. The only person standing in our path is ourselves. Set that goal, make a plan, hold yourself accountable and make it so.

Have a wonderful and successful 2015.

POSTOPERATIVE DELIRIUM


Life expectancy in the USA as of the most recent data is 78.61 years. Along with longer life span we have a every increasing number of surgery. With out-patient surgery rapidly growing year over year. The population over 65 years are living a more active life still and are requiring more surgical intervention. Our peri operative technologies have improved to allow us to provide safer care to those at the extremes expectancy range. WIth this improvement and comes many additional questions. The question of post op delirium continues to be a problem and will increase as the populations ages and more surgical procedures are available.

How the older patient is cared for in the peri operative time frame is and will continue to be of special concern to themselves, families and increasingly to payors. The process of getting from diagnosis to the surgical suite is basically divide in 2 routes, either via he emergency room or the physician office. The peri operative preparation is as import as the intra operative care and involves many, however as an Anesthesiologist i will present the process from my vantage point.
The care of any patient starts with the basics, taking a good history. For all patients under the care of an anesthesia provider taking a focused and directed history is vital to the safe delivery of appropriate care. For the older patient extra attentions should be placed on history of delirium in the post operative period which i would suggest should be considered to include the first 24 hours post PACU discharge. Other vital components to evaluate include vision impairment and hearing loss. For the visually impair consider how soon after arrival in PACU to return glasses. For the hearing impaired do they use hearing aids, can they be left in for the procedure. Does the patient lip read. Even for those that do on lip read, looking directly at them, speaking clearly with proper enunciation without shouting works very well to transmitted data.

Carefully look over medications for hints to treatment for early dementia. Ask about early dementia. What happened after last surgery. Who will be present in the post operative period?

There is no clear evidence that anesthesia specifically is the cause of post operative delirium. The choice of anesthesia should be based on what intervention will provide for the safest working conditions and facilitate a rapid low pain recovery.  For those with dementia the suggestion that regional alone maybe advantageous is not as clear to me as it maybe to others. From my experience regional as the sole anesthetic in a demented even for very minor procedures will be a challenge because of the lack of circumstantial awareness from the patient. The lack of awareness can and often leads to lost of cooperation and increased risk of morbidity to the patient. The primary anesthetic must provide the appropriate working conditions firstly. The demented patient like all patient must first be in optimal surgical condition. General anesthesia is often the most optimal choice. General anesthesia is not one thing but many varied combination of drugs and this is where the judgement of the anesthesia provider can be very helpful. From my vantage point the goal is to provide the most advantageous conditions using the lowest dose of the fewest drugs required. A monitor that was dependable in the judgement of anesthetic depth would be of great utility in the older patient. The BIS monitor is claimed by some to be such a monitor, but many others find it inconsistent and unreliable. I have not seen any evidence that convinces me that it provides and advantage. It may provide some advantage but that advantage is not clear to me. The traditional monitoring of anesthetic depth includes observation of changes in vitals and direct observation of the patient may be insufficient to guarantee adequate depth but is still the best we have. A vigilant provider is still the best monitor. I hope that one day soon we will have an even better monitor. Without that monitor the provider needs to be conscious to balance depth with risks of post operative delirium. The drugs that we use to maintain anesthesia are important potential risk point and one area that is especially concerning are the anticholinesterases. These drugs are used as apart of the cocktail for reversal of paralysis and can cause delirium and should be used with caution. The optimal situation would be to not need them, meaning if necessary we should avoid paralysis. However, if paralysis is needed full reversal should be used because incomplete reversal could make the post operative situation worse. Additionally making sure all our anesthetic if below therapeutic levels before going to the PACU is beneficial.

Once the optimal condition for surgery have been meet and the anesthetic is optimized to decrease the risk of post operative delirium the patient needs to be cared for in a PACU that continues to  optimize recovery. The environment needs to the at an appropriate temperature with appropriate lighting and quiet. Use the minimum required monitors to get the job done. The nurse in the PACU is a vital partner, she needs to orient the patient to date time and location. Orient, orient and orient again. Assurance of adequate hydration, pain control, empty bladder, treatment of nausea if present, prevent hypoxia are all vital. If delirium occurs, low dose benzodiazepine and family at bedside should be considered. The use of regional anesthesia is a great tool to assist the post operative period. I find the most utility of regional in the patient with dementia or at risk of delirium is in its ability to provide significant long-lasting pain control that decreases the amount of opioids needed in the recovery period.
Special attention to the needs of the older patient at risk for post operative delirium is a worthy goal. However, we must not be lead from first principles. We must provide a safe environment for the procedure. With careful planning and attention to detail we may be able to decrease the risks, but we should not lose site of the facts. Fundamentally, there is no good evidence that the type of anesthetic correlates with risk of post operative delirium. The only consistent fact is that the patient has had surgery. Teasing out the specific component of the peri operative environment that increases risk is still some way off. What anesthesia providers need to provide safe conditions that decrease risks based on the evidence we have.

DO NOT GIVE THEM AN EXCUSE TO KILL YOU.


Once more our country is focused on the aftermath of the death of a young black man. The frequency with which this scenario occurs is alarming, disgraceful and is not likely to change in my life time. I am a 40-year-old physician without a criminal record. I have a brother who is a Veterinarian and another an Airline pilot. Neither has a criminal record, but we all have experienced the brutality of American racism. We do not often talk about it. We live it and pray that our children will have a better experience. We want them to get a good education and not be killed by the police. That is our American dream.

The truth of what happened in Ferguson is irreverent to us because we live the brutally of knowing that at any moment we could be killed for no reason. As black Americans we have come a far way, but the fundamental problem for us has changed very little. We are not seen as humans, we are seen as murderers waiting for an opportunity. We are determined to survive so we try standing up for ourselves. However, standing up for yourself as a black man is seen as threatening. Success for us is about surviving the constant attempt to institutional us. If that can be avoided material success is possible, but only if you are not convinced to give up before you have had a chance to try. Material success is about picking your battles.

As a Physician I see the contempt patients show towards me at times, I swallow and still provide them the best care possible. I love taking care of patients and that care is not about anything but my pride in doing the best job I can. Because I provide you with care supported by the best evidence I am comfortable. In spite of providing excellent care I am challenged but nurses and patients. I often wonder what I am doing wrong, but it does not matter. I am of the wrong completion, so my care is subject to review. I need to justify my decisions with evidence, while others provide poor care and are not challenged. This is my life as a black physician.

I am strong enough because I was brought up in a culture that expected me to succeed. My early years in Jamaica has given me a belief in myself that is difficult to shake. It has been shaken, but I have recovered. Unfortunately my girls are growing up in a society that does not expect them to succeed. I will push them hard because their mistakes, no matter how insignificant, will be judged and punished harshly. I need to build in them confidence that is based on competence because our country will not give them the chances they deserve. I will teach them about how not to get killed.

The sad story is that my girls and my nieces and nephews will be at risk from violence from all sides. There is more violence in black communities both from cops and criminals alike. There is nowhere to hide, there is only learning how to manage the risk. Our treatment as black Americans is dependent on the complexion of our company. While out with my brothers and nephews we are treated like predators and undesirables. The excuses for treating us like monsters are varied but none are credible. In spite of the despicable treatment I often experience, I will still treat you well. I will still give you the best health care, although I will not be given the same treatment.

Rioting will not help nor will talking. Sorry Martin, I no longer have a dream, just a reality, ” Do Not Give Them an Excuse To Kill You”.

Be safe America.

GET YOUR MUSIC RIGHT.


Does music make you happy? I think we all get great enjoyment from music. Not just from the words, but from the whole composition. The ability to be transported to worlds unknown is open to us all if we just allow it. Music will make us think and sway. Music will change or mood and can make every day better. Make your day better by putting together the correct mix. With the advent of music streaming services we all have great options. First things first. If you want to hear your music like you have never before please discard the ear buds that came with your cellphone. Most cellphones will do a pretty good job of bring the content to you but the headphones are a disgrace. Do some research and invest in a good quality headphone. That does not mean BEATS.

Headphones: This is my short list.
Audio-Technica ATH-M50X
Monoprice 108323
BeoPlay H6 Natural Leather
Sony MDR10RBT

What streaming service: This is my short list.
Nokia Mix radio
Spotify
Songza
Jamendo
Soundcloud
cmd.fm

Go explore and let the music move you.