The advantage of age is that it gives you the time to make mistakes

One of my friends (yes, I have a couple) confessed to me that he disassembled a home network (not his) because he was getting a flakey connection. He ended up taking the whole thing down, with no internet connections for anyone.

Ouch.

After listening to him describe the problem I had some ideas how to fix it. I have installed any number of home networks and routers, and have screwed up enough times to figure out what probably had happened. And fortunately I had worked with all the equipment involved, so I had an idea how to fix it.

There’s really no reason to let all your embarrassing moments and awkward screw-ups go to waste. Wear ‘em like badges along with all the other scars – physical, mental, and spiritual – and let people know you’ve survived you. And that’s something to be proud of.

Clonidine, the wonder drug that does

Clonidine was originally used to control high blood pressure. An alpha-2 adrenergic agonist, it stimulates those receptor sites and reduces activation of the nervous system mediated by the brainstem vasomotor area. Upshot: it drops heart rate and blood pressure, gets rid of the hot/cold flashes and the sweating, and produces a mild sedating effect. It is also supposed to fix insomnia, which I will test tonight (it’s been two weeks since I have slept more than a couple of hours in a row at night.)

The sedation hit so fast it was kind of scary – within an hour I felt like I needed a nap, which given the early hour I took it was pretty inconvenient. There wasn’t much choice, either – I was going to lay down or fall down, and once I was down with my CPAP mask on I relaxed into the arms of Hypnos. Once the nap was over, though, I awoke without the grogginess I associated with sleeping pills and antihistamines. Pretty amazing.

I’ll be using the clonidine while I dry out from the opiates. So far it’s a much better ride with it, and I wish I would have gotten a scrip earlier.

Which brings me to my next point…

For those of you who still stop by here to check on me: if you have written anything in the last few months/years that you think I should take a look at, would you please let me know? I have punched up NetNewsWire and am working my way through the feeds, but it’s going to take some time and lots of stuff has slid passed that iconic satellite dish.

Back from the opium den

I want to talk about my opiate dependence.

I stopped writing – all writing, not just my blog – when I started using opiates to control my chronic back pain. That was a conscious decision at first; as a nurse I know that opiates can be disinhibiting and I had a new job that I did not have a good “feel” for how much I could discuss publicly.

But after awhile the urge to write faded. One of the things that chronic opiate usage does is to decrease testosterone levels, which diminishes drive for all sorts of activities. To tell the truth, for the first time in my life I was much more interested in being entertained rather than in entertaining myself by learning and doing. Bit by bit I forgot about the folks I read online, the news feeds I followed, and the forums in which I participated. Even MMORPGs slowly lost their ability to give me a dopamine “kick” as I slowly withdrew into my room with my library and my television.

Recently I began to have other, more advanced symptoms of testosterone deficiency which you may well guess, affecting both me and my wife. While I was perfectly content to allow the opiates to drag me down, the thought of forcing my wife to endure them was repugnant.

So I have stopped taking opiate pain medication. Years of using them has left me quite physically dependent (not addicted, thank Ghu; I am still enough po’ white trash to prefer stimulants to sedatives or euphorics) and the withdrawal symptoms have been everything they’ve been made out to be. There are medications which can help, of course, but I decided to try and tough it out on my own. I do not suggest this. A brain that has been increasing the amounts of norepinephrine it produces while losing it’s dopamine stores is acutely uncomfortable if you have spent your life seeking “the middle way” – particularly if your role you have developed in your life is the calm, centered, and empathic “eye of the storm” personality that I think most ICU nurses try to emulate.

The worst is over, and I have a prescription for clonidine to block those nerve receptor sites should  they continue to irritate me. I am well down the path now, and have no urge to stick on another patch. It’ll take awhile – hormone/neurotransmitter problems don’t return to homeostasis overnight, particularly when disordered this long – but I just wanted to let you know.

I’m back.

Thanks for listening.

Kickstarter: Banshee Horn Project

As this engineer notes, motorcycle horns are pretty ineffective in an emergency, something that always concerned me back in the days when I rode. The Banshee Horn Project is a Kickstarter project to fund a circuit with a better/louder horn that will sound along with flashing the high beams when the horn button is pressed down and held. Brilliant!

Happy New Year

My brother came over and picked up the nephew’s MacBook Pro, and he was fascinated by the writing tool Ommwriter. For those in need of a distraction-free writing space – or in need of a little ambient noise in the background for stimulus – Ommwriter is a fine solution. Both a free and a pay-for version are available (the paid version gives you more choices in backgrounds, ambient music, and key-click sounds), and both worthy of your time and attention.

On a side note, it is really hard to get used to not working holidays after doing so for a couple of decades. It still feels a little like slacking, though I know that the demands of an office and a hospital are totally different. You can take the nurse out of intensive care, but getting the intensive care out of the nurse doesn’t come as easily.

New Drive for a New Year

Not everybody in my family is a geek. My brother, for example, uses computers all day long in his work (he is a draftsman/designer for an engineering firm) but has little time to acquire knowledge beyond that he needs to do his job. His avocations are exercise and farming.

It wasn’t a big surprise when he came over Christmas day dragging along his son’s 2 year old MacBook Pro. Seems it had been stuttering along, reluctant to do much of anything. A quick survey with Diskwarrior got to the root of the problem: the drive was failing, unable to reliably read what it had just written to the disk. Modern hard drives are built to deal with thousands of bad read/writes per hour; it’s a known problem and things are corrected “on the fly.” But eventually things wear out and then that fragile house of cards known as the hard drive collapses.

After many frustrating attempts to retrieve the information off the disk, I finally gave up and went in search of a replacement drive. I had a number of older drives of the right size factor, but I had heard that Seagate had been building a new type of drive, mixing a high-rotation speed conventional hard drive with a small solid state drive (SSD).

Now, for those of you who don’t keep up on such things, an SSD is like one of those memory sticks you use to store files on, but can generally hold more information, are  much, much faster. There are no moving parts so mechanical failure is not a problem, , and thus should be more reliable and use less energy. The problem is that these things are spendy – you will pay at least US$1.00 per Gigabyte, and the prices go up steeply from there. I had installed a couple of these in my wife and college-bound daughter’s laptops as they did not wish to give up the trusty, reliable machines that had began to show their age. The speed improvement was phenomenal, and they appreciated not having to plug in their machines as often.

I couldn’t justify dropping that much money into a high school kid’s machine. The idea of using a small amount of SSD storage for frequently accessed information and leaving the rest of the information on a larger conventional drive intrigued me, so I ordered Seagate Momentus XT 500 GB from Tiger Direct (who had them on sale for US$139).

Installation into the MacBook Pro was simple – it looks like a conventional 2.5″ hard drive – and the formatting, partitioning, and software installation went off smoothly. The speed increase was fabulous – no more “spinning rainbows of death” (the Mac version of the Windows hourglass, indicating the system is swapping information between conventional RAM and the hard drive), much shorter boot times, and application launching became lightning fast. A relatively inexpensive upgrade that dramatically improved performance in a 2 year old machine.

Nice performance upgrade at a decent price. Recommended.

In which Al has a medication reaction

One of the problems with topically applied medications is that the dosing is based on average absorption through intact skin. Skin breaks such as small scrapes or rashes can change that absorption rate, and so the manufacturers caution you to use them on normal skin.

Some medications cause skin reactions as a normal part of their action – for example, can cause localized histamine release that can result in a rash. When this happens, you can get a much higher dose of medication than intended.

It’s one thing to be educationally aware of such, another to have an object lesson with yourself as the focus of the experiment. Lesson learned.

Inn at the Crossroads: A “Game of Thrones” cooking blog

Okay, this sparked my bad soul foodie self. I, too, have a great love of culinary anthropology, and tend to bore my wife, children, and their guests at the drop of a conversational crumb.

Yeah, I suck. This, though, looks cool.

 

Inn at the Crossroads: A “Game of Thrones” cooking blog: “

I’ve long been a big fan of modern attempts to cook medieval cuisine (see: Medievalcookery.com, University of Chicago Press’ The Medieval Kitchen, and all the various scanned, historic cookbooks available through Wikipedia). There’s something about the cultural anthropology of food that just really appeals to me. Plus, I love the way historic cookbooks assume you know how to do then-basic parts of household labor and will start a recipe with instructions like, “First, butcher and dress a pig.” Oh, okay. Sure.

The Inn at the Crossroads blog combines the geeky joy I get from medieval cooking with the geeky joy I get from George R. R. Martin’s A Song of Ice and Fire series. The results: A brilliant collection of recipes for dishes mentioned in all five of Martin’s novels, many developed using medieval cookbooks and techniques.

In a way, this blog is almost inevitable. I haven’t read a series of books this obsessed with the food its characters eat since Little House on the Prairie. Unlike Laura Ingalls Wilder, however, George R. R. Martin doesn’t provide much instruction in how to make that food. So bloggers Sariann and Chelsea should get serious props for reverse-engineering recipes for everything from medieval pork pie , to marinated goat with honey, to honey-spiced “locusts” (actually crickets). This is one of those food blogs that’s totally worth gawking over, even if you never plan on cooking the recipes.

Thank you, Laci Balfour!

 

“

 

(Via Boing Boing.)

Medrants: J’accuse

I’ll buy into this. Physicians who complete disability insurance forms often use ICD-9 codes instead of the actual diagnosis. This may be a subtle difference to most people, but not to me: ICD-9 codes are for the purpose of billing medical insurance companies.

Some physicians write the ICD-9 code that pays them the most, not that which they are using as a framework to treat the patient. Which is why I could care less about the billing code. I need the diagnoses *and* the examination findings that support them, not a reimbursement inspired shot from the (finger)tip.

And  don’t get me started about cut and paste EMR notes. Or prescriptive practices to maintain payments. Or…

Oy. Moving on.

J’accuse: “

 

J’accuse is a famous French term.  For the next several rants, I will point fingers at problems that decrease thinking in medicine.  Clinical judgment often requires thought.  Thinking uses energy.  Thinking is tiring.  We would rather start with intuitive (fast) thinking rather than resort to analytic (slow) thinking.  But often we need slow thinking.

Our fast thinking works well only when we have invested the time to develop accurate problem representations.  Part of our training (both during school and residency) will help that, but only if we have clinician teachers who can express the essence of the problem.  Our knowledge is not generalizable, but rather specific to each presenting problem.

So today I accuse CMS billing for harming clinical judgment.  Like most physicians my age I see clearly the flaws in our current note writing.  (Younger physicians know this also)  We no longer write notes about the patient’s problems, but rather make certain that we have checklists of review of systems and physical exam findings that have little relevance to our patient.

We develop checklists to meet billing requirements.  We see cut and paste history and physical exams on EMRs.  We can hardly read the notes because of the extraneous data included.

We need clear note writing that reflects our thought processes.  We need our trainees to display their thought processes so that we can help them think more clearly.

When I learned to write SOAP notes in the 1970s, I learned valuable lessons.  Writing my notes as an intern helped me develop my thought processes.

When we look at notes today, they resemble a Where is Waldo picture.  We suspect that they continue some useful information, but the extraneous billing words make the information very difficult to discern.

We must rid ourselves of this illogical requirement.  We must demonstrate that this requirement hampers clinical judgement.

J’accuse

“

 

(Via DB’s Medical Rants.)