wearing the clothes of the man that birthed me

Washing my hands today, I looked up into the mirror to see printed right-ways across the front of my scrub top: "Kaiser Hospital - Harbor City." Then it occurred to me: I was born in that hospital.

What are the chances that the doctor that pulled me into this world wore these very scrubs?! Extremely doubtful, for sure, but interesting to ponder. I work about a mile from where I took my first breath.

go ahead and draft us

First, W's "war czar" Lt. Gen. Douglas Lute (aka "Let this guy be the "decider" for a while, he he he") puts the option of a military draft on the table:

NPR's Michele Norris: But does it make sense militarily?


Lute: I think it makes sense to certainly consider it, and I can tell you,
this has always been an option on the table, but ultimately, this is a policy
matter between meeting the demands for the nation's security by one means or
another.


Full interview here.

Then, the Pentagon "sharpy rejects" that assertion:

"I can tell you emphatically that there is absolutely no consideration
being given to reinstituting the draft," said Pentagon spokesman Bryan Whitman.
"The all-volunteer force has surpassed all expectations of its founders."

ABC news digs little deeper into the socio-political implications:

Until recently the rare calls for a return of the draft have come from liberals, who see the existence of a professional military as one reason there was so little public opposition to the US invasion of Iraq. Some conservatives have worried that the absence of universal military service would lead to a generation of civilian leaders with no military experience. And there has
been a rumbling of complaints that the war's burden has not been broadly shared.

And presidential candidate John Edwards call for an end before it begins.

What do I think? I say, reinstate the draft, ask us all to go to war, to chance paying the ultimate price that our soldiers' and their families are paying, for a war that never should have begun, a war for oil, money, and power, a war fought for rich men, a war to which they've given everything of themselves.

A draft is a wake-up call to the rest of us: our troops need us to share the battle with them. When they try to draft us, we will take our battle to the streets and demand they bring our comrades home now. When parents, complacent and numb to the world beyond Mail Street shudder in the way mothers and wives send their sons and husbands off to war, when young men - students and artists and doctors and businessmen and laborers - get the letter in the mail calling them to fight BushCo.'s war themselves, watch how fast we get our boys and and girls back alive.

I'm with Lute. Bring back the draft...and bring back a dose of reality to the American people.

update on Yelley

Since I've started using the biodiesel, I've noticed the Benz stuttering a bit on starts, a bit bigger exhuast cloud, and poorer mileage. From what I've read, the Bio-D actually cleans the engine, removing decades of grime from petro-diesel use. All that gunk needs to go somewhere - into the fuel filter, clogging it and resulting (somehow) in the above symptoms.

I've bought the filters. Next step is to get them changed, and to have the mechanic show me how to do it myself!

You can follow my adventure on this calendar while I'll be listing all the momentous events of me and Yelley!

Representin’ at the AAFP conference, Kansas City (part 2)

Want to make Casey happy? Then ask me to travel to a great city with my friends (and colleagues) to talk on and on about a job and place I love. Just look at how much fun we had.
Join us next year!

Harbor Family Medicine heads to Kansas City!

Only one thing can beat that, and that's having the chance to meet dozens of enthusiastic, engaging medical students from all over the country ready to take on health care and transform family medicine.

Even while we physicians and residents grumble and lament over a crumbling health care system, inefficiencies, inequalities and stagnation in health and medicine, medical students can reignite our idealism and passions for change. Below is an account I wrote from last year's AAFP Resident and Student Conference that details just what I mean. I'm happy to finally have the chance to share it!

Every year medical schools around the world graduate young physicians eager to continue the beautiful struggle. It is a pleasure to watch them work and to work with them. We owe it to them to help keep their (and our) dreams alive.

~Casey

Title: The future of Family Medicine is bright, I gotta wear dark-rimmed glasses
Subtitle: Report from the AAFP Resident and Student National Conference, Kansas City, MO 8/2 - 8/5/06

I've been known shine about the joys of working with med students. After all, I was one for 4 years and worked exclusively with them for 5, now going on 6. What is it about working with med students? Why is it SO darn fun? Maybe it's their energy, their idealism, their readiness to take action and make change as we as docs struggle to keep from melting away.

Well, I went on and on and on about this all weekend at the AAFP Resident and Student Conference. How could I not? We'd been chatting it up with only the most stellar med students and soon-to-be family docs out there, and to Jose and Linda, my dear fellow resident recruiters, it became quickly apparent that I had had my share of acquaintances there at the conference, thanks to AMSA. I was being recognized somehow. Few times by face - maybe a talk I'd given at their school. A lecture I'd hosted. More often it was the email address that gave me away.

We had reached a lull on Friday afternoon in the exhibit hall and the Harbor crew was chatting it up about all potentials we'd met when from around the corner and at high speeds comes zipping Justin from Vermont. He's hard to miss: Stylish and slender even in his V-neck undershirt (the kind I could only get away with wearing, well, as an undershirt or when paired with black dress socks and Ray-Bans, a la Tom Cruise in Risky Business). His scruff and dark-rimmed glasses reminiscent of Elvis Costello though he really doesn't look a thing like Elvis Costello but name someone with dark-rimmed glasses who doesn't recall Elvis Costello. Physical attributes aside, what draws one to Justin is his energy: pure, creative, and infectious. With the speed at which he approximated our booth, I knew he was up to something - something big - and that I was in for trouble...

"Hey, Casey" he greeted me, grinning, and we exchanged a hearty soul grip and the guy's guy half-hug. "Dude, do you know anything about these resolutions?" Not knowing the AAFP political process a lick, I didn't. Yup, Justin was up to something...again. "Dude," I cautioned, "what are you up to?" I grinned back. Whatever Justin was up to, I knew I wanted to be a part. Of course, he had decided that for me already. "Dude, check it out." He handed me 2 sheets of paper. I noticed my name etched in xerox. I didn't recall putting my name on anything. "I wrote these two resolutions and introduced them this morning." I was in for it. "They need a resident sponsor to get into the resident congress. I didn't think you'd mind. You don't right?"

Of course I didn't mind. Actually, Justin had read my mind from the night earlier. On flipping through the conference schedule when we arrived, I noted the Resident and Student Congresses. I had missed the session on writing and introducing resolutions but I recalled it from last year when our own Harbor graduate Dr. Fred Kim made AAFP news in his testimony supporting a closer eye on and narrower practices of drug reps and residents in academic medical centers. I gave brief thought to standing on Fred's mighty shoulders and continuing the fight against Big Pharma...but I was tired. I was there to talk with prospectives, give my support to Harbor and to Family Medicine, not to stir up AAFP like I had in my AMSA days. This wasn't AMSA, after all. I as in unfamiliar territory. I was an unknown and the last thing I intended was to get caught up in it, tarnish the good Harbor name, and wear myself out on the back & forth of the Big Pharma debate.

Justin had cut straight through the B.S. that I had piled high up around me, and the spark of action had been set. I thanked my friend: "Justin, dude, you are the MAN!

(for some reason, perhaps his laid-back style, his Vermont-cum-Southern Cal vernacular, I'm compelled to say "Dude" around Justin more than usual. Go figure.)

I can't believe you pulled this off." He had been out checking the KC music scene late the night before and at some point he'd drafted and printed these two great resolutions, one encouraging alternatives to accepting drug company free samples as the solution to our patients' need for meds, and a second to restrict access of drug reps and their marketing practices at academic medical centers, including residencies and medical schools. 2 great approaches to limit the influence of biased marketing practices and advertising on patient care. 2 great stances, I agreed, the Academy could support to ensure excellence and integrity in medical education and practice. I chuckled and glanced at Justin again. "Dude, I'm so in." I didn't need to read the resolutions to know I supported them and that I'd speak out for them. Justin had done the tough part: he pushed himself, put pen to paper and started the machine. My standing up and speaking was the easy part. "Where, Justin? When?" The kid was on top of it. Me, I could hardly remember being booted from the exhibit hall later that day. "Dude, no sweat. I'll give you a call with all the info. But check it, I gotta run and get these out." From his bundle of papers peeked a stack of green half-sheets. "Dude, what are those?" "No, check it out. Surveys." Not to be outdone by his own butt-kicking activism, he had managed to produce a 5 question survey on what policies the 200+ residencies in attendance had on residents interacting with drug reps. The kid was en fuego. He handed me a survey, said "Dude, Ill call you in a few" and sped off down the carpeted aisle, distributing surveys, a dust cloud at his heels.

Well, Justin's hard work came through. We pulled it off and as a result the Resident and Student Congresses of the AAFP voiced strong policies against the relentless marketing influences of Big Pharma.

It might have been my name that made it onto the website, but it was a medical student's drive and focus that put me there.

kicking my oil addiction

my car smells like french fries -- badly burnt french fries

Exciting stuff, friends. My little baby "Yelley Elley", my sunny yellow new-old diesel 240D Mercedes Benz, has made the leap off the grid. Just last week I started filling up with biodiesel. Straight out the pump, can you believe it?

What is biodiesel, exactly? Well, in this case, it's B99.9 - 99.9% walnut and soy oil, 0.1% diesel fuel. So while I'm not 100% off the grid, I'll take 99.9% any day. I'm paying a bit more ($3.30/gallon) but that's $3.30 not going to Big Oil. Plus, my car smells like burnt french fries out the tailpipe (better than than smoky mess that spews from a semi-truck), helps the environment, and runs smo-o-o-oth.

There is at least one other of us at Harbor using biodiesel. Another uses compressed natural gas (and she wants just 5 mo' minutes of sleep - hint hint). Several - I count 5 - use hybrid gas/electric engines including Su's ever-recognizable Prius. So I KNOW at least a few of us are taking action on our wasteful use of the Earth's precious resources, and I'm CERTAIN that we all are at least somewhat concerned. So, below I've posted a upcoming conference in LA on biofuels.

And check back here on my blog for more updates on my life driving the fried flyer.

FIRST LOS ANGELES BIODIESEL COMMUNITY CONFERENCE TO BE HELD AUGUST 1ST

Press Contacts:Rob Reed: 310-399-3659 - rob@conservfuel.comGretchen
Gray: 310-880-3892 – gretchen.gray@sbcglobal.net

The first Biodiesel Community Conference will he held August 1, 2007 from 7pm to 10pm at Mt. Olive Church,1343 Ocean Park Blvd., Santa Monica, CA 90405. Los Angeles, CA – (July 16,2007) The Los Angeles Biodiesel Community Conference is open to the general public and will offer action-based discussions on Biodiesel Basics, Legislation, Local Distribution, School Bus and Other Fleet Usage, Biodiesel Education, and more.

The event is being sponsored by Southern California Disposal and Recycling, and will be hosted by The Los Angeles Biodiesel Working Group, the LA Biodiesel Co-op, Socalbug (the Southern California Biodiesel Users Group), and Josh Tickell, author of “From the Fryer to the Fuel Tank” and “Biodiesel America.”

The purpose of the conference is to empower and educate the public, local businesses and community leaders in their efforts to make biodiesel a viable fuel option for Southern California. Collectively we will establish a groundbreaking action plan that will provide the steps to expand biodiesel distribution in Southern California and establish new legislation that promotes sustainable fuel options.We, as a community, can make biodiesel an affordable and available fuel option. It is time for us to unite and take action today!

For more information, visit www.socalbug.org.Please contact Rob Reed or Gretchen Gray to schedule an interview with the following individuals to discuss the Biodiesel Community Conference agenda and action plan before or at the event: Josh Tickell – Author/Filmmaker; Kent Bullard - Chairman of Socalbug, a 501c3 non-profit organization, and Kris Moller – Owner/Operator of Conserv Fuel (www.conservfuel.com).

If you would like to attend the Biodiesel Community Conference please R.S.V.P. to: http://www.evite.com/pages/invite/viewInvite.jsp?event=RPOJJMHHFRVGPATDMHFR&unknownUser=true
-- Kent BullardCFO (Chief Founder & Operator)Southern California Biodiesel
Users Group, Inc.kent@socalbug.org
805-218-6945

from the desk of the Resident Clinic Director - improving patient care and diabetes

Hi all. No, not another anti-Pharm diatribe from me. This one is a clinical diabetes case from the Harbor-UCLA family medicine clinic:

You all know that a few of us family med residents have been involved in the diabetes chronic care collaborative with Drs. Snyder and Cheng. We've been trying to provide intensive and attentive care (including testing, treatment, education, and self-management) to our most out-of-control (OOC) diabetic patients. Heres an example from today's RCD experience that shows what were up to.

* Please talk to one of us if you're interested in participating in the collaborative!*

Mahdi alerted me to a nursing visit BS OOC - 269 fasting. (This is something you have to address in the few spare minutes you have while RCD between triage, med refills and the occassional fire that erupts in the waiting room. It's fun, actually.) This 66yo Latina lady with her daughter at her side explained that shes NEVER been in control of her diabetes in the 15 yrs shes had it. Her last A1c in 1/07 was 9.8. Her home BG is 200-400. She's been seen only a couple of times here, but already her meds are maxed out: metformin 1000/500/1000 (max), pioglitazone [Actos] 30, glipizide 20 bid (max). So, fair doctor, what do you do?!

Obviously her oral meds arent doing it. Your choices are: increase the actos to 45 (max dose)? Start a 4th agent - acarbose, Januvia? All of the above? Start insulin? Take a second - based on what you know about this lady's diabetic control, how can you best help her?

Well, a little bit more of the story helps. First, she and her daughter are asking for insulin. That doesn't happen too often (many patients fear that insulin causes blindness, amputation, etc - educate patients, people!), but when someone has a chronic, debilitating condition that isn't helped with maxed oral meds, she knows that only insulin can help her. Smart lady. Fortunately she's been given insulin in the past so knows the routine. I start her on NPH 10 units (she's thin, so 10 is a good start. If shes obese, I might start 16 units) before bed and counsel her on increasing the dose every 3 days by 2 units if her AM fasting BGs are >130. Both she and her daughter understand, but adjusting insulin like this is tough for newbies; she might need more counseling in the future.

What else do I do? She's already on 3 orals hypoglycemics. What else? carvedilol, lasix, losartan, simvastatin, warfarin - the ingredients of a cardiac patient. Turns out she has CHF and a prosthetic mitral valve. Question: Should she continue Actos? For one, it's not helping and increasing it to 45mg probably wont help either. Second, many speculate that the heart failure dangers of rosiglitazone [Avandia] may be a class effect, so right now we cant be sure that pioglitazone [Actos] wont lead to failure also. Especially in this patient who a) isn't helped with Actos and b) has a history of CHF, we may be doing MORE harm than good giving her Actos even IF she had had A1c improvement. So, I D/C it.

How about the glipizide? She is on a hefty dose of this sulfonylurea which, on its own and especially when given with insulin, can induce hypoglycemia. So I D/C that too.

I keep her on the metformin at the same dose to continue her peripheral insulin sensitization and inhibit gluconeogenesis, but not after checking her creatinine first to make sure it's <1.5 and she's not at risk for lactic acidosis.

Why this email and why this case? Many of our patients are languishing with OOC diabetes on the same stale regimen they've been on for months or even years. Don't be afraid to start ramping up therapy more rapidly. We are working on clinic infrastructure improvements to make doing this easier. Secondly, I, for one, will start discussing insulin therapy with all of my diabetics, even those on less-than-max oral therapy. Bringing up insulin early and in the context of physiology (insulin therapy is, after all, just hormone supplementation) may help patients understand their disease as well as dispell some of the myths and fears around insulin use. SubQ injections are, after all, a lot less scary than foot ulcers, amputations and blindness. Finally, don't forget to be a family doctor and see the patient as a whole. What is her understanding of her disease? What does she want from her visit? What other comorbidities does she have that would change therapy or clinical course? Protocols are tremendously helpful, but they aren't for everyone. Treat the person, not the disease.

Fortunately she has follow-up here at clinic with her primary doc on July 24, less than a week away, and I'm curious to see how well her sugars are controlled but moreso to see how well she and her family take to her new treatment regimen. I think they and I will be happy with the outcome.

~Casey

cross-posted at:
the Life of KirkHart
Harbor-UCLA Family Medicine blog
Cure This!

Wicked is Wild

April and I were finally able to appropriately celebrate our 5th! wedding anniversary last night. April had arranged for us to see Wicked at the Pantages in Hollywood.

What an incredible show. The music is unique and fun. The performances are out of this world, and if you are any bit a Wizard of Oz fan, then the official untold backstory to Wizard of Oz that is Wicked will get you going. Highly recommended.