Do NOT jump to conclusions.

Warning, scenario number 4 may not be appropriate for all viewers...

Happy Passover!

I'm reposting my all time favorite matzah video:

I couldn't have said it better myself.

Hat tip: Jamil

The Iron Dome Game

Update: over 50 missiles have been fired into Israel since Saturday morning according to the Jerusalem Post. There should be no mistake, this is causus belli. Now the Hamas political wing is distancing itself from the military wing. We're not fooled. They are murdering savages as they always have been.

The boys in the neighborhood have invented a new game called "Iron Dome" (The antimissle system that has successfully intercepted and destroyed several of the missiles. The system intercepts only those that endanger major population centers): One kid throws a ball into the air, and another tries to knock it down with a frisbee.

Children remain children, even during war.

A Terrible Miracle

I was planning to post more about the doctor's strike because the media is repeating Treasury's propaganda about money hungry doctors. The best laid plans of mice and men...

The Hamas terrorism by missles has escalated. This is actually not true. There are always missles and mortars and katyushas, but this time the results were tragic. But that's not true either. The ongoing terror of Southern Israel by the barbaric arabs of Gaza is ever present. Whether there are casualties or not is irrelevent. The disruption of life is enough. This the world doesn't want to understand in it's quest to champion the cause de jour. We left Gaza, it was painful and traumatic for us. Despite Arab probaganda there is no shortage there of food, fuel or any commodity. What more do they want? It's obvious, they want us dead. To justify their barbarism the Arabs continue to perpetuate the lies that we are oppressing them, when it's the exact opposite. They oppress and terrorize us, and have been doing so for a 100 years.

I was supervising anesthesiologist in the OR two days ago. The alert came: send an anesthesiologist to the trauma room. There was a missle attack on a school bus, one critically injured child is being evacuated by helicopter. "Only one?" I thought to myself. Either there was a terrible tragedy and only one survived or there was a terrible miracle and only one was injured. As it turned out, the bus was empty except for that one boy and the driver. Minutes before, 50 children had alighted the bus. A disaster was narrowly averted. Later, the Hamas took credit for the attack that was perpetrated with an anti-tank missle. This means that the clearly marked bus was deliberately targeted. The bastards.

The neurosurgeon brought the boy, a teenager to the OR. The expression on his face told me all I needed to know. Critical head injury requiring a craniectomty to relieve the elevated intracranial pressure. We did all medicine can do. Now it's up to God.

When we transferred the boy to the PICU (Peds ICU), the parents were in the waiting room. The father stoicly quiet, and the mother crying silently.

Heartbreaking.

Self Service

I've been doing this medicine gig for over 14 years, if you count medical school it's been about 20 years that I've been living, drinking and eating medicine. During these two decades, I've seen some pretty astounding things. And every time that something extraordinary presents itself, I say, "That's it, now I've seen everything. I will never be surprised again." There is a limit to how many surprises one can encounter.

Right?

Wrong. 

Every time something else pops up. And it leaves me scratching my head in wonder. So yesterday I was on call in the OR. The surgeons were bringing down a guy who had stumbled into the Emergency Dept.  a few days ago drunk as a duck after having been savagely beaten by, as he put it, "some very bad people".

The CT scan found some sort of cyst or hematoma in the area of the pancreas and an intimal flap (a small tear in the inner surface) of the aorta.  He was in the ICU and so I prepared the room for an anesthetized ventilated patient. These preparations are actually quite simple since they come from the ICU fully monitored. I call these patients, "plug and play". Just hook 'em up to the anesthesia machine and the monitors and let the games begin.

The intercom crackled that the patient from ICU had arrived, so I hastened to the entrance of the OR. Not surprising, the patient was intubated. Not surprising, the patient was not sedated. Most patients develop a tolerance for the breathing tube, after a couple of hours if there is no other indication, they need little or no sedation. 

The BIG surprise, the thing that made this patient unique, the thing that made my jaw drop and rub my eyes in disbelief, was that the patient was not connected to a ventilator. Well, that's no surprise, I often transfer patients to and from without a ventilator and I ventilate by hand with an ambu bag. However, in this case, the accompanying physician was not ventilating the patient. In fact, the patient was being ventilated by ...

The patient! 

There he was, sitting upright in the bed, an ambu bag connected the the endotracheal tube, and he was ventilating himself.

Now that's  Self Service!

Now I've seen everything...until next time.

The Doctor's Strike

Today ends the two day warning strike of Israel's physicians. It's not a complete strike since for ethical reasons we must work a weekend schedule. I didn't strike because as luck would have it, I was on call.

The deputy minister of health Ya'acov Litzman has come out against the strike and the union and has tried to paint us as money hungry and blood thirsty. In an interview to the media he stated that during the last strike 11 years ago, less patients died. Strictly speaking, the latter claim is true. Furthermore, it has been true in every physicians strike everywhere else in the world. The reason for the drop in mortality is obvious and clear: During a strike only emergency operations are performed. The vast majority of operations are elective. So when these operations are postponed the accompanying morbidity and mortality are as well, until after the strike. So Litzman, strictly speaking is correct. What makes Litzman's comment troubling is his implication that we harm our patients either intentionally or because of malpractice. So I will say it loud and clear, the deputy minister of health, Yaacov Litzman is a horse's ass.

I now address his first claim, that we are money hungry. True, none of us live under the poverty line, none of us have trouble feeding our families. But the monetary compensation is woefully inadequate for the years of training, the separation from our families, the brutal call schedule, the personal and professional responsibility, the personal price we pay in our own health for working under such overwhelming stress. My friends in other professions were at the peak of their careers ten years before me. Such a "late" start directly affects our pension in terms of accrued benefits. So yes, we demand higher pay that will reflect the investment in time and effort that it takes to become a physician.

But we have other demands, which are really the primary issues at stake in this strike. Because the treasury ministry is squeezing the health ministry dry. We demand that more beds be alloted to serve the growing and aging population. We demand that the formula for physicians per bed be recalculated to alleviate the shortage of manpower. But this formula must be recalculated for the nursing and non-medical staff as well, because there is a nursing shortage no less acute than the physician shortage. And finally, we demand that the hospitals and medical services in the periphery be given priority in manpower and funds so that we can provide the same level of healthcare as in the center of the country.

I have no doubt that the talks will break down, and that next week the strike will be resumed. I have no doubt, because of our experience from the previous strike, when we foolishly agreed to not strike for ten years in return for binding arbitration. The "binding" arbitration dragged on for 8 years and even then, treasury didn't pay up. It took another two years for the courts to force treasury to uphold their end. During this time the public health system has become more ill.

This time, hopefully, will be different. I believe our current head of the Medical Association is more savvy than his predecessor, and we won't make the same mistakes.

For some sense of proportion, many countries, including the United States are suffering physician shortages. I direct the reader to Life in Medicine: A Reality Check by my blogging colleague Anesthsioboist.

Never Stop - The Bad Plus

Saw The Bad Plus at the Red Sea Jazz Festival (Winter Version). They were awsome.