In keeping with a concise entry, the following is a list of some tasks I accomplished today. You can decide which ones are reasonable or outright ludicrous:

• Emptied my garbage can into the dumpster: a patient threw a banana peel and apple core in it at 9am–I did not want my exam room to smell like banana the entire day
• Checked my patient’s vision, dilated, them, and filled out a driver’s license renewal form.
• Refused to fill out a disability application for a free Metrocard on an otherwise healthy 33 year-old guy who supposedly had a back injury before he moved to this country. He also had 20/15 acuity.
• Called a primary care physician’s office for records.
• Faxed physical exam requisitions to physician’s office.
• Cleaned the computer keyboard with alcohol swabs.
• Faxed forms to schedule my surgical cases.
• Asked surgical scheduler why he did not fax my surgical cases.
• Spent 2 hrs entering clinic notes on our broken EHR.
• Glared at technician who bypassed my exam lane 3 times while attempting to “find” me to place a patient chart. I was the only physician examining patients in the entire hallway of lanes.
• Called patient to remind her for surgery for tomorrow.
• Performed forced ductions on a STAT 9pm consult in the operating room for someone s/p orbital floor fracture repair. ENT had already closed up the incisions.

Yes, plumbing. Sort of like cath-lab work and stenting vessels, right? Nothing like cataract surgery.

One of the plumbing jobs I encountered this year involved this:

This is a 1.5gpf Mansfield #160 toilet. The flushing mechanism is a vertical flush valve without a plunger. Over the past few months, the toilet became more difficult to flush (via the trip lever). There was no leakage into the bowl. It turns out that this is a typical problem with the system, when the flush valve seal (red ring at the tank-bowl junction shown with red arrow) becomes corroded.

As you can see, the ring edges decay with time. The ring actually maintains a watertight seal and vacuum–hence, the difficulty in flushing. With time, the seal will likely decompose and result in a continuous flow into the bowl.

This ring costs around $2.00 at Lowe’s, and can be replaced relatively easily. I found a video of this online, after I had replaced them in two toilets. No equipment was needed in the repairs, although a vise or wrench may have come in handy.

]]> http://ophthosurgery.com/2010/12/replacing-mansfield-flush-valves/feed/ 0 http://ophthosurgery.com/2010/04/gambling-as-a-profession/ http://ophthosurgery.com/2010/04/gambling-as-a-profession/#comments Wed, 28 Apr 2010 02:27:10 +0000 admin http://ophthosurgery.com/?p=1023 I have always been fascinated by playing card manipulation, partly because there is an analytical component to card games. For the masses,  Hollywood has  been responsible for publicizing card gaming, through Rounders and 21.

However, the appeal of gambling as a profession is attributed to Jon Chang, who spearheaded the MIT card club into a lucrative business. “Lucrative” is certainly not exactly an accurate description of the profession anymore, but much can be gleaned from gaming history nonetheless.

The game of choice at the time was Blackjack, which was simple enough at the time produce a probabilistic advantage to the player. The fundamental premise behind winning in Blackjack is to keep count of which cards have been cycled out, and increase your bet when there is a higher chance of obtaining face cards (table is hot).  Casinos have since implemented strategies to discourage card counting. One frequent finding in casinos is simply shoe recycling. Dealers and pit bosses have much lower thresholds to reshuffling the shoe even after about 50 cards in a 6-deck shoe. In Vegas, the tables with more lenient shuffling policies tend to have a higher minimum bet. Overall, winning in Blackjack consistently is more of a chore.

That said, I have seen a handful of people hit the card tables routinely for weekend Blackjack sessions twice a month with relative success. The gains come mostly in the form of “comp’s”; Blackjack is one of the highest compensating table games at the casino. Your “comp” status depends on the duration you spend at the tables, as well as the betting amounts you put down. The casinos keep track of your earnings/losses through their member cards at the table.

In Vegas, the standard tables are mostly located downtown. These casinos keep the cards unshuffled until over half of the shoe has been cycled through. I suspect that this is a marketing gimmick to attract business. On the Strip, most tables have horrible card movement. The $5/$10 tables at Excalibur, Luxor, MGM, Tropicana, and NYNY all keep the player’s winning percentage at a minimum. Mandalay, as I recall, has a few tables during the early hours that allow a more systematic gaming system, although they mostly require  $10/$15 minimum bets. Aria, Bellagio, Caesar’s, Wynn, and Venetian all have strict shuffling policies on all under-$25 tables. Overall, winning conditions are generally unfavorable in Vegas.

Where are the best tables? Sound out in the comments below!

Several weeks ago, I noticed that a few of the hospital maintenance workers were digging around the “locked” bin. Since then, I’ve acquired a cheap-o-shredder for shredding purposes.

What I’ve discovered is that the standard 6-8 page vertical shredders are junk. You can’t aggressively shred anything thicker than 5 pages without jamming the grinder. In addition, the papers shreds could actually be reconstructed without too much difficulty if all the pieces were available.

I guess I have two alternatives:

1. Buy a nicer, cross cutting shredder with larger blade.
2. Burn my documents.

Or shred AND burn them. That would be entertaining and most effective.

I was unfortunate to be covering the primary pager for the hospital this weekend, which is Academy weekend. Generally speaking, this is the worst weekend to have an eye problem, because your primary ophthalmologist is probably out of town in a meeting (or getting drunk). My pager rang early yesterday morning with a long distance callback number. Bad news. When the emergency room or floor resident pages me, I usually receive the hospital extension. A long distance number always means that you’re getting shit that you don’t want to (and should not have to) deal with.

The call turned out to be from one of my attending’s wife. She woke up with an itchy eye and foreign body sensation. Her husband was at the AAO meeting in San Francisco, and she did not wish to bother him with a call. Her son-in-law, daughter, nephews, and nieces were all ophthalmologists at the meeting as well. Her primary ophthalmologist was in town, but she did not wish to bother him either because it was Saturday (Jewish sabbath).

WTF?

I suppose that leaves me, the on-call resident. I offered advice to the best of my abilities over the phone and offered to see her in the emergency room (the one where patients wait 4 hours to be triaged). She politely declined.

Lesson to be learned: if everyone in your family is an ophthalmologist except you, you should go with them to the Academy meeting.

I remember when Instant Messaging flooded the workplace computers back in the tech-boom days. My colleagues working at IBM would get company-wide emails stating that IM decreased productivity and was prohibited. When company threats weren’t heeded, port 5190 was blocked on the company firewall.

Now that instant messaging has been superseded by text messaging and MMS, I see my colleagues “texting” away during conferences and lectures. It’s become a nuisance. If you’re simply notifying your spouse that you’ll be late for dinner, that’s one reason to be texting during fluorescein conference. However, checking the stock ticker? Chatting with your medical school classmate? What are you thinking? That is simply abusing technology. Perhaps I say this only because I don’t have a data plan on my phone, but there is a point in which your attention should be directed toward the lecturer and not your iPhone.

Our eye clinic is in the basement, where our cellphones unreachable by the outside world. You’d think that there wouldn’t be any contact with the outside. Wrong. Last week one of the technicians (who are supposed to be obtaining visual acuity for our patients) was logged onto her MySpace page. Another computer was logged onto Facebook.

I wonder how much social networking affects workplace productivity. A quick search online shows that this actually increases productivity. USAToday also states that we work better with social networking… The caveat? None of these companies are involved with healthcare.

Other cases are not as obvious. I had a young diabetic teenage patient who was admitted for drainage and antibiotic treatment of an infection neck abscess. He left AMA before bacterial cultures could be speciated. While he was unlikely to die from premature cessation of his antibiotics, he did not complete his treatment and risked developing a superinfection or worse, a superbug.

Interestingly enough, the one universal bond that I have noticed about AMA patients is that they were all cared for by a medical team. Not a surgical team. Not a gynecological team. You can argue that fewer surgical patients leave AMA simply because there are fewer surgical patients in the hospital, but I believe the explanation is simpler: surgery has more tangible results.

The argument that surgeons “do more” for their patients is not only stated by surgeons, but also perceived by patients. When I was a medical student, the surgical attendings considered themselves the “Physician +” because they are expected to manage their patients medically and surgically. Those students choosing to specialize in surgery crave the satisfaction of intervening in order to make the patient better. Patients admitted to the surgical service expect a tangible intervention, like removal of an organ or excision of a tumor. They are not likely to leave against the advice of the doctor. Even those surgical patients who are managed medically, such as the small bowel obstructions, almost never leave the hospital without a doctor’s blessing. They are in pain, they cannot eat, and they also know that there is still a possibility that they may be cut open.

Sadly, the same cannot be said about patients managed by internists. The diabetic in ketoacidosis will start feeling better when their anion gap is near closure, but we cannot send them home if their white count is sky high from an unidentified infection. The patient doesn’t see this. He feels better, and wants to go home. The HIV patient with cryptococcal meningitis feels great after I hit him with some narcotics and a dose of amphotericin. He thinks that all he needs are some painkillers. Think again. If he goes home after this, he will be as good as dead–the amphotericin will have just enough time to frag up some fungi in his system to trigger whatever is left of his immune system to go berserk and maybe put him into sepsis.

It is unfortunate that medicine is perceived in this manner, by doctors, patients, and even insurance companies. It is at times frustrating to practice medicine in the context of this disconnect; it feels as if doctors are broadcasting on a different frequency as everyone else. Policy needs to be revised. Policy is being revised. But in the meantime, we will have to wait it out.

10. Consulted on 12 surgical cases while covering a service of 58 patients while on call. (A new pager battery died in a matter of 10hrs)

9. Incised, drained, and packed thigh abscesses on the floor. (I read a blog on how to perform the procedure beforehand)

8. Closed up subcuticulars in several inguinal hernias and lumpectomies.

7. Ate 10 chocolate chip cookies and drank 3 20-oz Powerades for dinner.

6. Served as first-assist in a laparoscopic J-tube placement on a woman with peritoneal mets–the case started at 8pm and ran 3hrs. I read a website how-to guide on the general progression of the operation. My responsibilities were minimal–just holding the camera at awkward positions, keeping the field clear, and working the 2nd alligator and dolphins.

5. Diagnosed an acute appy in the ED (cool!), but had to assist in the case at 4am. (I watched a video from some website in India beforehand to figure out where to put the trocars)

4. Replaced a G-tube that had fallen out of a floor patient (with guidance from a nurse and the instruction manual).

3. Placed a G-tube via endoscopy (with supervision from attending)

2. Hand wrote 16 progress notes in one morning.

1. Performed 50% of a lumpectomy including sentinel node biopsy and tagging. (Attending thought I was a surgical resident and did not listen when I explained that I was a non-surgical intern; I did however prepare for the case extensively beforehand)

The experience, while harrowing at the time, was actually extremely gratifying afterwards. Now that it’s over, I suppose that I’ve added to my adventures of residency.

* Note: In no way should the aforementioned anecdotes be construed as a reflection of those parties involved. Ophthosurgery and its authors hold no responsibilities to any parties mentioned on this website. Ophthosurgery is not liable for the use or interpretation of any content found on this website. See disclaimer for more details.

The attendings also seem content with their work–several of them noted that the best part of their job is that they rarely exceed 50, even 40 hrs a week! That leaves adequate time outside of the hospital to stay sane. Not bad.

typical Anki screenshot

I finally managed to register for the USMLE Step 3 after going through all the hoops that the NY State Department dishes out for physicians. Now the only thing left is to learn the material for the test. The test itself is a two-day exam with clinical scenarios relating to general medicine. It’s run by the National Board of medical examiners, but is actually administered by the folks at Prometric. (I’ve taken MSCE’s and IBM AIX licensure exams by them in the past, as well as Step 1/2 exams).

I haven’t decided how to prepare for the exam. I haven’t purchased any books yet, nor have I the urge to. The exam itself was $690, and the NY State Dept charged me $735 to make sure I’m not a villian.  What a rip.

However, since I’m not necessarily in the mood to do any group studying, I might try to use some spaced-repetition software to help some of the material sink in my head.  Spaced repetition memory is neither a novel nor cryptic concept. It simply means that the more you see something, the more likely you are to remember it. It’s all about registration and recall. We do it when we learn languages–you probably used flash cards in the past. That’s all there is to it.

Supermemo was one of the first softwares that I had used for electronic flashcards. There was a Palm version [whose website appears defunct now], that you could load onto your PDA and study on the go.  The two new open source flashcard programs that I like are Anki and Mnemosyne. They both work well, and have an intuitive algorithm to show cards that are less familiar more frequently so that you can learn them. Both of them can be used on a flashdrive; Anki has an iPhone/iPod Touch port as well. There are plenty of premade decks available online to use; most of them are for languages. I think the authors originally wrote them to learn Japanese.

If I ever get a chance to write up my flashcards, they’ll be available for download on this website. The downside to all of this? Time and motivation. Ah yes, inertia at its best.