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Just wanted to announce some new photographs I selected for the Photo Gallery section of the site. Most of these are self-explanatory but if there are questions feel free to let loose in the comments. Enjoy!\
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Monthly Archives: September 2010
Night Rider
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As the days grow shorter (autumnal equinox today), the time available for riding on the bike diminishes. Unless, of course, one is willing to ride in the dark. Yesterday, after not being able to ride for several days due to travel, work schedules, and laziness, I was determined to get in a good circuit. Although I rushed to finish work early enough, I still couldn’t get started until about 5:45 pm. I had a particular route in mind which was really tough (subject of another post?) but midway though the ride the dark descended quickly. That’s when I busted out the night gear:
- 2 watt Blaze headlight
- blinking red taillight
- reflective left arm band
- reflective mesh vest
- shoes with reflective heel tab
Plus, by that time in the ride I was on roads with very wide shoulders. I felt as if
was actually more visible than I am during the daytime. I returned to my starting point without mishap. As I finished the last couple of miles, I was on Lower Station Camp Creek Road
View Larger Map
which runs along a wide brook. White men have been using this route for over 200 years in this community. There were few lights, the nearly full moon was peeking behind the clouds, and the only sounds were from the evening bugs and the nearly silent drivetrain of my bicycle. I felt as if I was skimming along the surface of the earth, a silent observer of the nighttime gifts, exerted but only with pleasure, a grateful recipient of the moment’s graces.
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Vacation from the Vacation
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Vacation is a mixed blessing. On the one hand, you’re away from the work routine. On the other, there are extra stressors: traveling to and from the destination, deciding about activities, spending money, odd food, irregular sleep patterns, and site-specific hazards. In the latter case, at the beach for example, one could include sunburn, biting flies, bedbugs, sand scrapes, and too much alcohol. Oh, and if you take children the list expands exponentially. For example, if the children are not off from school, you might try to take the assignments for the week with you to the beach along with all of their textbooks, workbooks, pencils, erasers, paper, protractors, and assorted supplies. Then try to get kids at the beach to actually do homework-Ha! Or you could just give up and resolve to finish at home, with the following result:
So my advice is: don’t take any vacations until there are no children along. . . but then that would only be about half as much fun, right? Right?
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Knowing when to stop
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Knowing when to stop
There’s a delicate balance in medicine when performing a procedure on the human body. Each patient is different; human biology is not stereotyped despite vast homogeneity of physiological principles. In attempting to reach a therapeutic objective one has to gauge how hard to try, when to push, when to let up, when to quit.
Coronary intervention is no different. Here’s a general guide to the technique. Study this description for a while and then come back.
OK, you studied, now you’re ready? Recently I had a patient with recurrent angina despite the best in medication therapy. We decided to perform a diagnostic coronary angiogram to examine his native coronary arteries as well as his bypass grafts ( he had undergone previous bypass surgery many years previous). Turns out there was a severe blockage in the native coronary artery supplying the bottom part of his heart. At the outset, it looked straightforward: about a 90-95% narrowing but in an accessible region of the artery with a reasonable diameter to the vessel. So I began. The first clue was that it was difficult to find a guiding catheter that stayed put. Although the guide wire went down easily, every time I tried to advance a balloon, the guide catheter disengaged from the artery back out into the aorta. I then tried multiple different combinations of guide catheter, wire, double wires, shorter balloons, smaller balloons mixed with small aliquots of cursing, praying, and hoping. It looked doable, and I didn’t want to give up. Fortunately the patient was stable and not symptomatic during the procedure. At one point, I actually managed to make the artery worse with the initial severely limited flow now being no flow at all-that is not a good thing. The staff in the room were getting restless, and I was wondering where the risk/benefit ratio now was. Every new combination of hardware meant more time, more fluoroscopy, more radiation, more contrast potentially toxic to the kidneys, and more frustration. Every re-engagement of the guide catheter increased the risk of dissection. Every new wire brought the hazard of perforation. But the patient had not been helped yet.
Finally, with a certain combination of catheter, two wires, smaller balloon, and perseverance, I managed to get the balloon across the lesion and inflated. Stenting followed with a good result. The patient was quiet and without complaints. Everyone in the room was relieved to be done.
Similar scenarios occur in any medical procedure. Sometimes you can’t get it done. Sometimes the result isn’t perfect. Sometimes you violate the principle of “primum non nocere” because taking no risk means getting no useful improvement. “The enemy of good is ‘better’”, a wag once uttered. But the enemy of bad is sometimes gritty effort with measured calculation-where’s the philosopher for that one?\
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