John Boehner is a Jackass

“I think my proudest accomplishment is walking out of there (congress) the same jackass I was 25 years before,” Mr. Boehner said, according to the Stanford newspaper.

Yep

They Shoot Horses Dont They

Lazy

   Doctors

       Should

            Be
 
                 Shot

                    (or at least made to be patients) 

Have a Nice Day

Toxic rank mud, wet straw, and canvas
Dark and stifling
Spotlight on the freak in the corner
The crowd - quiet, reverent, ignorant

Welcome to the freak show
Welcome to your world

Cruz and his god - his second rate magic show
Funny bearded man in his barcalounger in the sky

Fuck you and your religion too 

190 million murdered in his name at least since we bothered counting 

Magic man 

But wait who's sucking cock in the oval office?

Frump and dilary

ISIS, smicess
Flags and fags
What the fuck does it have to do with anything?

Front row seats to this freak show you fuckers
At least the freak knows who he is

You all don't know shit 

Fuck you

On Global Warming - A Little Effort Please

Arguments from global warming naysayers:

Global warming is just a natural cycle. The earth has seen countless of warming cycles in the past.  This global warming event is just another one of many, so we can just ignore it. Well, no - not if you care about your children and grandchildren. In fact if we allow it to continue unchecked it threatens our existence as a species. Doesn't matter if its 'natural' or not - if we can take action to slow or stop it - let's do that.

Carbon dioxide is found in our blood and our bodies, in our food, in our colas, so how could it be bad for us? Stupid environmentalists.

Umm, what?!!

Carbon dioxide is a poison. I know that because as an ICU doctor I have had to urgently help many people who are dying from it on a daily basis. The body spends a lot of energy purging it. Too much of it and you die. But what does that have to do with global warming? Nothing.

Carbon dioxide is a gas that once in the atmosphere traps heat - not allowing heat to escape into space. Whether or not it is found in our bodies has nothing to do with it. The earth can handle the CO2 in our breath. It cannot handle the massive increase in CO2 release into the atmosphere that we are currently witnessing. CO2 that was trapped by plants millions of years ago and put deep into the ground, never intended to be released again - is being released - by us - in extraordinary amounts, in a very short period of time  - as we burn coal, oil, natural gas. And yes that process is in fact accelerating and intensifying global warming.

Who cares?

Global warming just means we can grow tomatoes in Siberia and sunbathe in Greenland. So we turn up the air conditioners in Miami - who cares? Except the air conditioners in Miami will be under water from rising sea levels. Much more importantly global warming will abruptly and dramatically affect weather patterns - worldwide. This will lead to interruptions in the food supply and the death of billions in not so pretty ways. It will destabilize economies worldwide, threaten peace, threaten our very existence. But wait - it's natural so that's ok? Well, mass extinctions are natural too - so ok?

My god the ignorance surrounding this topic astounds me. Scientists are telling us we have an ongoing problem that may destroy our species. Please, don't just take them at their word - but for god's sake inform yourselves before you so casually discard their warnings.  Arguments of natural cycles, CO2 in our bodies, and tomatoes in Siberia are embarrassingly ignorant, revealing a lack of understanding, and a real laziness as regards self-informing before coming to conclusion. Remember if you're wrong and the thousands of scientists and Nobel laureates are right, you're children, or best case, their children - die. Don't you think you owe them a little more effort than this?

Nature Abhors a Vacuum

Nature abhors a vacuum, horror vacui, first postulated by Aristotle and later restated by Galileo and others, basically states that given the chance energy/mass will rush in to fill a void, and therefore there are no perfect voids in the universe. For Aristotle it was an argument that vacuums could not exist in our universe. Considering quantum effects the idea of the perfect vacuum - empty of everything, probably doesn't exist, and so he was right. In fact his line of his reasoning if followed to its logical conclusions could have led to the development of quantum field theory, prediction of vacuum-energy, vacuum state, vacuum permittivity, quantum fluctuation perhaps then even leading to Heisenberg's uncertainty principle. 

Smart guy.

And So It Goes....

Septic related lung injury (ARDS), as presently defined, is a clinical description, not a disease - based on a blood gas and a chest x-ray in the absence of heart failure. 

The metrics are crude and highly confounded and do not distinguish specific disease. Just look at our largest post mortem analysis of so called ' ARDS' pts by Hemptinne et al, Chest and realize our present definition of ARDS included 13 different diseases at autopsy as diverse as diffuse alveolar damage to pulmonary infarct, to usual interstitial pneumonia, to hemorrhage. How then can we hope to advance disease specific care if we insist on using tired old insensitive metrics that do not distinguish disease?

But do we have disease specific therapies? 

Not really. If we had a therapy that worked at the cellular level to effectively decrease endothelial permeability it would become imperative to measure permeability or at least its surrogate - extra vascular lung water (EVLWi)  - but we don't. And so the arguing goes on. 

To significantly advance care we simply must design ways to identify pathophysiology at the cellular level and tailor therapies to these changes. But the horse here is the development of disease specific therapy - the cart, metrics that identify these specific diseases. And, for the most part, we have no horse. 

But in the meantime can we at least distinguish septic related permeability injury from early interstitial lung disease by measuring EVLW/PVPI? Or if convinced it's diffuse alveolar inflammatory damage - that our attempts at diuresis are working? Or using EVLWI to try to avoid drowning the lung in our 'resuscitative' efforts in the first place?

 

Apparently not as per Berlin  

 

And so it goes.....

Fits and Starts

In science the mundane abhor a vacuum. They will rush in by the thousands and argue over minutia - endlessly, exhaustively, for years. Running in place furiously whilst getting nowhere, except promoted, entire careers made.

Genius eventually steps in every now and then, destroys the vacuum with stunningly beautiful truth, we advance - sometimes unbelievably so, and then the whole process starts over again. All of science owes its major advances to a few dozen men and women, the rest just so much noise.

Academics - Narcissistic, Insecure and Lethal

The article suggests that the answer to the ICU doctor shortage in this country is not to train more ICU physicians - but to transfer sicker patients to "centers of excellence" phasing ICU doctors out of the smaller less 'esteemed' hospitals, and sending patients to the 'good' doctors at these so called centers of excellence.

Since there is no formal evaluation or standard for defining what constitutes a "center of excellence" and since these centers are for the most part self-named, one can't but help wonder what the author is referring to.

Ah, but I know exactly what he meant - he meant academic centers. I know that because I had to endure his type for the 14 years I worked in large academic centers. According to this arrogant buffoon, the moment one leaves the 'mecca', or the moment one arrives, skill sets magically change. Or the moment one attains a certain rank, or wears the starched white coat and tie, or graduates from the 'best' medical school, one then becomes by definition, an excellent doctor. To that I say - blahhhhhh.

ICU medicine is about instincts, good hands, rapid response and knowing how to always see the entire forest while paying attention to all of the trees. Its not about starched white coats, how well one scores on multiple choice tests, or arrogance and ego. And skilled ICU doctors, with good hands and instincts, are very hard to find - especially in academics.

Many academics are academics in large part because they would last about three days in the 'real world' of life and death clinical ICU medicine. Academics, for the most part, attracts narcissists and the arrogant or more rarely the gifted researcher/teacher - not the clinically skilled. For years I have seen so many of their patients die or be harmed unnecessarily as they blundered on, blinded by cocoons of ego to what even the ward secretaries could see - their utter lack of clinical skill.

Clinical excellence counts for almost nothing in the academic world. My promotions had nothing to do with my clinical skills - everything to do NIH grants, publications, research and smooze. For all but rare disease or the need for bone marrow or solid organ transplants or certain rare complex surgeries - academic medicine is the LAST place you want to receive your acute care - especially if you are very ill. ICU care demands excellence in clinical medicine from its ICU doctors - not titles, egos, and useless pedigrees.

Just by proposing this, this man reveals his simplistic, two-dimensional, hierarchical, magical thinking - and the reason he saw to it that he himself became an academic. It's how he defines himself. Narcissistic, insecure and lethal.