Irony

“according to General Motors’ director of community health initiatives, Sam Shalaby, “If [GM] ran an auto plant like they run hospitals, we’d be out of business.”

from 11/2006 article in MD Net Guide about medical records that my dad sent me today

I also don’t remember GM being forced to give free cars to people just because they show up without money complaining that they need a ride.

Fuck the bailout. Let’em die.

Nano Reef Tank

The tank continues to progress slowly but steadily as I hope my skills are as well.

The cyanobacteria has all but disappeared completely and I’m not sure why. I was aggressively removing it manually but that shouldn’t have done it. The nitrate and phosphate levels had remained undetectable, so unless they were low because they were being eaten, that shouldn’t have been the problem. Light and flow are strong and haven’t changed. Water changes are with RO/DI water and there was only mild phosphate in the source water. Things that changed: reduced photoperiod from 12 hours with the 1st and last hour being actinic only to 8 hours both lights on at all time, changed water from grocery store bought to LFS bought, added Stomatella, added mediabasket without changing media and added some macro algae. The thing is, the cyanobacteria disappeared before most of those things should have had a chance to take effect. Maybe I just got lucky.

I got one of StevieT’s mediabaskets and am loving it. I took out one back to the Chemipure Elite to make everything fit and now only have one bag of it and one of Purigen it. I added the stock filter back it because I’m adding some macroalgae and I didn’t want it getting caught in the impeller. For mechanical filtration, I’m using PureFlo filter pad at the beginning of the column, which is probably overkill and would not be good if I had to leave for an extended period of time as I’m washing it out daily, but the water is pristine.

I tried to add some macroalgae, but am not finding a good place for it. I was stuffed some down the 1st chamber where I have the heater but haven’t put a dedicated light in there yet. I’m not sure if this is going to work out or not. At least I got a cool Stomatella out of it and the rest is in a modded AquaClear 50 for a pico I’m starting up.

Coralline algae is growing rapidly on my rocks and a bit on the walls. Along with pristine chemical test results, I’m taking that as a sign my water is of acceptable quality.

I’ve added a coral that was sold to me as a “Christmas Tree Coral.” It doesn’t look like pictures of the corals of the same name on the internet but I suppose it doesn’t matter. It seems to be happy and growing bigger. It hasn’t duplicated itself yet and it’s not very pretty, but I wanted something hardy to start with.

My blue-green ricordea is still alive and colorful but I can’t get it to settle down and stay put or grow any. I rearranged the rocks for the third time today in an attempt to create a place for it to latch on to a rock with good light and low flow. Anyone have any other ideas?



In the near future, I’d like to add more coral, but currently the LFS don’t have anything I like. I also have my eye on a pretty Money Cowrie Snail and purple short spine urchin, but am lacking even the smallest of funds for it. I’d also like to add another fish at some point, but don’t know which one.

Any ideas?

Nano Reef Tank

The tank continues to progress slowly but steadily as I hope my skills are as well.

The cyanobacteria has all but disappeared completely and I’m not sure why. I was aggressively removing it manually but that shouldn’t have done it. The nitrate and phosphate levels had remained undetectable, so unless they were low because they were being eaten, that shouldn’t have been the problem. Light and flow are strong and haven’t changed. Water changes are with RO/DI water and there was only mild phosphate in the source water. Things that changed: reduced photoperiod from 12 hours with the 1st and last hour being actinic only to 8 hours both lights on at all time, changed water from grocery store bought to LFS bought, added Stomatella, added mediabasket without changing media and added some macro algae. The thing is, the cyanobacteria disappeared before most of those things should have had a chance to take effect. Maybe I just got lucky.

I got one of StevieT’s mediabaskets and am loving it. I took out one back to the Chemipure Elite to make everything fit and now only have one bag of it and one of Purigen it. I added the stock filter back it because I’m adding some macroalgae and I didn’t want it getting caught in the impeller. For mechanical filtration, I’m using PureFlo filter pad at the beginning of the column, which is probably overkill and would not be good if I had to leave for an extended period of time as I’m washing it out daily, but the water is pristine.

I tried to add some macroalgae, but am not finding a good place for it. I was stuffed some down the 1st chamber where I have the heater but haven’t put a dedicated light in there yet. I’m not sure if this is going to work out or not. At least I got a cool Stomatella out of it and the rest is in a modded AquaClear 50 for a pico I’m starting up.

Coralline algae is growing rapidly on my rocks and a bit on the walls. Along with pristine chemical test results, I’m taking that as a sign my water is of acceptable quality.

I’ve added a coral that was sold to me as a “Christmas Tree Coral.” It doesn’t look like pictures of the corals of the same name on the internet but I suppose it doesn’t matter. It seems to be happy and growing bigger. It hasn’t duplicated itself yet and it’s not very pretty, but I wanted something hardy to start with.

My blue-green ricordea is still alive and colorful but I can’t get it to settle down and stay put or grow any. I rearranged the rocks for the third time today in an attempt to create a place for it to latch on to a rock with good light and low flow. Anyone have any other ideas?



In the near future, I’d like to add more coral, but currently the LFS don’t have anything I like. I also have my eye on a pretty Money Cowrie Snail and purple short spine urchin, but am lacking even the smallest of funds for it. I’d also like to add another fish at some point, but don’t know which one.

Any ideas?

Just another manic…

Monday.

Woke up a bit later than normal, but I’d stayed up too late last night watching 88 Minutes. Pacino always seems to be playing himself in each role, but I’m note sure I’d want it different. He rocks.

It’s a day off for me so that meant working harder than normal rather than resting. As busy as we are at the hospital and the insane hours we work leaves little time for regular life stuff like paper work, bills, car maintenance so that was what I’d scheduled myself to do today.

First, though, had to get the family to work. Since Halo has to been at daycare by 715 if he’s going to be assured of having breakfast I got him dressed and took him first. Ikuko was not ready by then, so I came back and picked her up and dropped her off at the U. She was working at the V that day, but I drove to the wrong hospital initially and she wanted coffee from there anyway so she was fine with the mistake.

I headed home and picked up the place. Today the cleaning service was coming, so I wanted my toys put away so they wouldn’t be in the way of the vacuuming and such. Then it was off to the Honda dealer where I expected to be raped over their service and was not disappointed. I came in for an oil change and they found 1800 dollars worth of work that needed done. Since I didn’t want to spend the whole day at the dealership I told them to do whatever they could get done by noon, i.e. the faster you work the more you’ll make, but otherwise you may not see me again. I walked around the dealership for awhile. Sometime in the next few years we’ll probably have to buy a car. I like the Fit but the cheapest model on the lot was 14K, about 4 more than I’m wanting to spend. When the time comes I’m going to have to play Scion, Toyota and Honda against each other to get down to a 10K small, 4 door vehicle for the family. May have to go used too.

I put the time waiting at the dealership to good use after that. Made some phone calls to set up appointments. Figured out where I have to go to get my fingerprints taken for the FBI background check for my Iowa medical license. Read a lot about adynamic bone disease and renal osteodystrophy since I know nothing, literally, about it but am supposed to give a lecture to the department on it in two days. I also found good number of articles on retinal vasculitis. One of the graduating rheumatology fellows has already notified me about one of her patients I’ll be inheriting in 3 months. He’s a retired physician being treated initially at the Mayo and then at the U for RV, something I know zilche about. Now I have some reading material to get myself educated with and yet another reason to love Papers. That’s the best program ever for a physician who wants to bother to keep up to date and organized in the literature.

After the car was finished, I spent a few hours perusing the local dealerships. It was like going on a first date over and over: “do you live here in town?” “what kind of work do you do?” “are you good in bed?” Well, maybe not that last one, but pretty close. It was actually relatively enjoyable. So far, the best way to find a good used car is at a different dealership than the one whose car you want to buy that has the car due to a trade in. They seem to mark their own used cars higher and their competitors. Still, I think it’s going to be a few more years till I need to buy one, but it’s better to be prepared well in advance.

I hit up the local jail to get my fingerprints taken for an FBI background check in order to get my medical license. Then I drove up to North Liberty to visit a fish store. Ended up buying my second coral while I was there. It was cheap as dirt and the live rock it came on was probably worth the price I paid for it and the three coral that were on it. I didn’t get the name of the coral but the owner said that they’re easy to take care of and grow like weeds so I’m optimistic it’ll cure my need to add things to my take for awhile by giving me something to watch. The first coral, ricordia, has been a bit of a disappointment by moving consistently to the very back and bottom of the tank.

I headed home after than, searched through some old paper work looking for our gym membership contract. After a year, I’ve gone less than 7 times and I’m not sure Ikuko has done much more, but she wants to go to another gym across the street from us that has yoga so she’s going to cancel the membership and sign up there.

Made dinner for the kids. Watched some TV and then put them to bed.

After that I stayed up way too late playing Left 4 Dead on the 360 with PB, his brother and friend online. The new survival pack was out and we played that till we bled.

The Next Generation

An email I received from a student today:

Hi, Mike:

This is K___ L__, M4. I know you see a lot of students, so I’m not sure if you’d remember me, but I spoke to you about going into Family Medicine while I was on IM, and you had recommended V__ C______ to me; now I just would like to share with you that I have matched with the program! Thank you for the advice.

Best wishes to you as you finish your residency!

Sincerely,
K__

***
I don’t know why, but it was touching.

Nano Reef Aquarium, Part 2

The clean up crew has been making short work of the prior algae problem. The hermits, astrea and ceriths are great fun to watch and I’m frankly amazed sometimes how mobile they are. The astrea actually manage to climb all over the Hydro Flo and clean it spotless of diatoms. I’m seeing lots of little ‘pods and other creatures I can’t identify roaming around. There is a lone feather duster than must have come along for a ride with the LR. There are also a whole bunch of redish, flower like gelatinous growths coming off from some of my better LR that I don’t know what they are.

<Several weeks later>

Things have progressed nicely for the most part. I’ve realized that I made quite a few mistakes in the beginning that I hope won’t end up causing any long term damage. For example, I didn’t let the tank cycle before adding Purigen and Chemi-Pure Elite. How I missed such a basic concept is embarrassing. I also can’t seem to get rid of some redish, slimy algae that seems to grow over the sand. It seems to grow when the lights are on and die out overnight. From what I read, this is most likely due to too much nutrients, tap water and/or low flow. I hadn’t added any nutrients at the time, was using store bought DI/RO and had pretty brisk flow, especially where it seemed to grow the most. I’m not sure what to do about it at this point. One idea is to start growing Chaeto as soon as I can get one of StevieT’s mediabaskets and see if that’ll reduce the nutrients more. If that doesn’t work, I may try to find some kind of CUC that’ll do the job, but nothing I have currently is touching it.

I figured out that those “redish, flower-like gelatinous growths” I mentioned above are actually apistasia and apparently are “undesirable.” I’m still not sure why they’re not ok, except that maybe they’ll hurt coral? After researching about the biological and chemical ways to get rid of them, I tried my own mechanical way by just grabbing them, but they’re pretty dang fast and slippery, so I ended up buying what I think is a peppermint shrimp. He’s a cool little guy. My wife seems to like him the most and the way he dances around at feeding time for the fish trying to grab their left overs. I’m not sure he’s actually a peppermint and not a camel because I haven’t noticed the apistasia decreasing in numbers. I’ll give it a few weeks, but then I may have to try killing them chemically.

I’ve added three other new members to the tank. I bought a Ricordia coral. He’s really small, about the size of a nickel, blue and green. At first I had a really hard time with him because he kept being carried off in the waves and didn’t seem happy. I rearranged the live rock and found him a nice little perch about midway up the tank in a small crevice with low flow and in just a day has seemed to blossom out. I’m going to let him go for awhile and if he does well, will try something else.

I also picked up two clown fish. Both Ocellaris. One black and one orange. They’re both beautiful and fun. The larger one seems to be bullying the smaller one quite a bit and I’m concerned what will happen if this continues. I’ve named the orange one J.D. and the black one Turk after the characters on Scrubs. I’m feeding them New Life Spectrum Marine Formula pellets on the advice of the NCLFS. I was feeding them twice a day but may cut back to once or every other day to hopefully stimulate the shrimp to go after the mantis. I also am giving a small amount of frozen cyclops a couple times a week.

Two of the blue-legged hermits died, which was unexpected. I had been more worried about them killing the Astrea for their shells. The original three ceriths and all 5 astrea seem to be going strong.

In other news, the coralline algae on the larger piece of LR started to turn green with a few spots of pink/purple mixed in. I’m supplementing daily with Purple Up and hope that the coralline will start expanding soon.

For now, I think I’ll just stay the course and try to keep from buying anything more for at least a month, which will be hard given that I have vacation time coming up.

Nano Reef Aquarium, Part 1

My newest hobby is saltwater aquarium-ing-uh…something.

Actually, due to my limited budget and space in my flat, I’m making a nano reef. It’s 14 gallons of saltwater, 20 pounds of sand, 14 pounds of rock, coral and fish…at least it will be someday. So far I’ve just bought the tank, set up the filtration, gotten the water right, cycled the rock and sand and acclimated some “clean up crew.”

I started off with the Oceanic Biocube 14 gallon. In my opinion, it was the most cost effective, aesthetic, and well-light all-in-one reef-ready tank for beginners. It also happened to be in stock at one of my local fish stores and to have plenty of testimonials in online forums with explanations of modification options.

Long before I bought anything directly related to the reef itself I spent hours and months reading through review sites and forums determining what exactly would be involved with cost and time to see what I was reasonably able to do. I also got Natural Reef Aquariums by John Tullock and The Nano-Reef Handbook by Chris Brightwell to help round out my self-education. I found nano-reefs.com to be a great resource of facts and opinions and at a perfect price.

I originally wanted a 47 gallon column tank with metal halide lighting and Marineland canister filter. I soon figured out that just the rock and water alone would cost a few hundred dollars and the initial start up costs would be a few grand. This was a bit too steep right off the bat so I went with something smaller, more manageable, cheaper and if everything crashed, less expensive to walk away from.

After setting up the stock stand and aquarium I filled it with distilled water and let it sit for a few days to make sure that it wouldn’t leak or the stand warp. I took out the bioballs because the consensus is that they are a poor biofilter substrate and I was planning on using LR/LS anyway as any good RT should be made with. I also removed the stock pump and replaced it with the MaxiJet 900 (247gph up from 106gph) as recommended by many in a way to increase the flow. I’m also planning on getting a longer tube so that I can remove the 90 elbow bend that greatly slows the flow. I installed a Hydro Flow for water agitation. A week into cycling I also ordered a Koralia Nano to install under the top intake for more flow and agitation on the other side of the tank that is blocked by the LR.

In the 1st chamber, I removed the stock mechanical/chemical filter as I’d read it was crap. I also removed the false bottom (permanent filter tray) because the heater didn’t fit well in there and I’d also read that it became a trap for sludge. In order to remove it, I had to use a flathead screwdriver to slide down the right and left side where two plastic pieces are glued that create grooves for the stock filter to slide into. The fast bottom is partially held in place by these pieces. The rest of it is glued down across the back, so I used a butter knife to rub that loose and then pry up the front of the false bottom to remove it.

The heater went into the 1st chamber. In the second, I placed some filter floss at the bottom, then some Purigen and Chemi-Pure Elite, then more filter floss. I removed the stock sponge and put another bag of Chemi-Pure Elite in there. Eventually, I’m going to have to chose between Chemi-Pure Elite and Purigen. I’m leaning toward the later. In the future, I’d like to get one of StevieT’s mediatrays at mediabaskets.com to place in Chamber 2 and run cheato, the chemical filter and filter floss or whatever other mechanical filter I end up using.

I also bought a 5 gallon bucket for mixing up new water. I used the old stock pump for mixing the new water. I bought two Coralife thermometers for the tank and the mixing bucket. For acclimatizing new creatures, I bought about 10 feet of silicone tubing and cut the top off of a milk jug. A few knots in the tubing let me drip 1 drop a second into the milk jug for slowly mixing the water. I got a 50 watt submersible heater for about 15 bucks at the NCLFS (national chain local fish store). You can’t set the temp (preset at 78+/-2) but it is small and completely submersible to can even work in very small amounts of water, i.e. as when acclimating new creatures and the water starts off with only a few cups. I also got a Coralife day/night power timer. It’s the most expensive one, but the guys who run their own home tanks at the NCLFS said the digital one didn’t work very well. It’s really nice to set up a morning, day, evening and night light scheme. Other odds and ends came along too, including the ubiquitous magfloat and plenty of chemical testers.

I started off the water with Instant Ocean salt using the Instant Ocean hydrometer to measure the SG. Once that was right, I bought some LR at the NCLFS. I got a nice big, round piece with plenty of white coralline algae growth and a couple of darker, younger looking LR for a total of 13 pounds. I also got some Agra-alive white LS. After placing these in the tank, I still felt like I had some room for more, so I hit up the LOLFS (locally owned local fish store) and bought two smaller pieces of older, purple coralline algae encrusted LR. The tank looked brilliant for about 4 days as I measured the water, watching the ammonia spike and then start to drop as the tank cycled. Then is all turned very brown. The purple color disappeared, the white seemed to be eaten away. This brown dust, and long brown hairs and even bubbling stuff was everywhere. At first I thought something was dying but then I read that this was an algae bloom, common in new tanks. I went that day to the NCLFS and bought 5 blue legged hermits and 5 Astrea snails for a “clean up crew” (eat waste and algea). They did a brilliant job getting rid of a lot of the algea overnight. The brilliant pink and white were back.

The day after that I decided to get some Cerith snails because I needed something to shift the sand as well as eat the algae. I got these at the LOLFS and I’m amazed. They’re much smaller but seem to be much faster and more useful. I also like the hermit crabs. They’re quite entertaining. I’m not as much a fan of the Astreae and may end up getting rid of them at some point. Now I plan of waiting for a month or so for the tank to get a little mature before seeking out some coral to plant. (Maybe I’ll add a few more Ceriths while I wait.)

So that’s my tank so far. Pictures and more to come.

Risotto with Mushrooms

Since I’m on vacation, I decided to try my hand in the kitchen. I came across a recipe on Jamie Oliver’s site for risotto and was planning to try that but thankfully Ikuko told me about using the Zojirushi instead of the traditional method, saving me hours of time and I’m sure disappointing results.

Above and below you’ll see the dried mushrooms I used.

I love the texture and smoky flavor that the mushrooms add to the dish. Hell, I love mushrooms in general all the time. Especially the “special” ones.

Soaking the mushrooms in water for an hour or microwaving for 5 minutes yields a mushroom infused broth for cooking the risotto.

I mixed the mushroom broth with enough chicken broth to equal three cups of liquid for the heaping cup of arborio rice.

Using the Zojirushi to cook the meal not only had the benefit of being cooked to perfection but also skips the initial sautéing of the rice by doing it in the rice cooker itself. A tablespoon of butter and another of olive oil is used to sauté the 1/2 cup of onion. Some dry wine and the rice is added and sautéed for a few minutes. Finally, the broth mixture and mushrooms are added and the Zojirushi placed on the porridge setting.

The recipe called for Parmesan cheese, so I splurged and got the Parmigiano-Reggiano. That’s some damn good stuff.

The result was a warm, creamy delight. I just wish Ikuko hadn’t acted so surprised that it was edible.

A mixed herb with toasted sesame asian dressing and some toasted ciabatta with tapioca for desert rounded off the meal.

Electronic Medical Records not a Panecea

The Joint Commision recently released a sentinel event report.

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.

This sentinel event was a warning about Health Information Technology.

Basically, I’ve been reading articles since I started my medical career that first tell about all these medical mistakes that occur and then point to computers, electronic prescribing, electronic medical records etc. as the cure-all. The problem with any new cure-all is that people neglect to think about the unforeseen problems that may occur from it. For example, while it is true that computers will decrease errors due to poor physician handwriting, they increase errors caused when an item in a long is is incorrectly selected because it was one item below the correct item. Since it comes out neatly printed, no one questions it. I worked at a hospital that had to discontinue CPOE (computer order entry) because 4x more errors were occurring than vs. the written orders.

I’m not a luddite and I am looking forward to technology making my job easier and better, but at the same time we should not except anything forced down our throats by politicians wanting to win popularity because they “did something” about a perceived problem or businesses out to make a fast buck off some error prone software.

We should put no less effort into investigating our EMR, ERx etc. than into the drugs we prescribe and surgeries we order.

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm ‘

6^Songs for a MedPsych Unit

Even if I say it’ll be alright still I hear you say you want to end your life.

Never too late – Three Days Grace

I’m hearing voices all around.  I’m hearing voices calling out.

Hearing Voices - OneRepublic

I can’t sleep now, no, not like I used to
I can’t breathe in and out like I need to

Goodbye Apathy – One Republic