Disenchantment is an Understatement

As I get older I find that I am completely apathetic about the state of the world today. I am not speaking just to my comfortable suburb with the vapid, ignorant, and wasted cohorts, but in each and every country, province and hamlet on the globe.

My one true passion, medicine, has become an object of hatred. I am disgusted with "Health Care" in the 21st century. There is a pill for everything. Piss too much? pill for that; piss too little? pill for that too; penis as flaccid as overcooked asparagus? they have that one covered entirely-much to the chagrin of every wife who thought that with her husbands impotency she had escaped the ritual of being used merely as a masturbation tool, and accepted 'pass me a beer will ya babe?' as foreplay. This does not come from bitterness. I take more pills than the average 90 year old, and my sex life is...well suffice to say I am smiling. In less than ten years in health care, I witnessed the black locust cloud of consumerism and profitability infiltrate what used to be a relatively noble profession. If I had wanted to attend budget meeting and fill out capital application forms, I certainly wouldn't have chosen health care. I would have acquired an MBA and slutted myself out to some Finance company with a decent benefit package and a lovely cubicle. Everyone is for sale. When was the last time anyone met someone that they would describe as 'honorable' or 'noble'? New physicians nowadays are patsy's for the "Big Pharma", nevermind that Mr. Smith lives on a pension, lets prescribe a pill that costs triple what he's on now and works half as well. I left health care shaking my head. Long gone is the naive twenty-something who believes that a hospital is a place of healing, care and compassion. Disenchanted doesn't begin to describe it.

This is the world now. Everyone needs money to survive, unless where you live happens to still use the bartering system; money is not my issue, it's the ravenous hunger for bigger and bigger profit margins, the desensitization of the masses to corruption; a politician lining his pockets or a department manager scoring a huge year end bonus when her staff all received pay cuts barely registers a cocked eyebrow these days. Enron has become a catchphrase. It's all about the money.

I don't really have a decent solution - just venting I suppose. Besides, in today's world if you really want to change things, you'd best find a sh*t load of cash.

Taking Chances

Have you ever thought of doing something, something fantastic or even mundane? Did you roll the thought through your head twisting it this way and that before dismissing it roundly from your mind? I am impetuous by nature, impulsive to a fault (on most things anyway), but I have done the same, we all have. Accepting an invite to a party for example, has thrown me into serious internal debate, do I? Don't I? I have work to do sooo... I won't go - well maybe for an hour...

Taking a chance, whether small or great, can bestow the best of life's gifts. The best thing that ever happened to me, happened at a gathering I wasn't planning to attend. Seems like an inconsequential chance to take but in taking that chance, my life was upended and has never been the same.

Because I took that chance (wait for it - it's a love story) I met the love of my life. For this man, this love, I have conquered both internal and external summits, have surprised myself with what I am able to do. I have also been surprised by the love I have received; it is the stuff of chick flicks - but better.

It has made me look at life very differently, how things happen to align in such a way that the path we had originally set upon becomes entirely different as we travel along. I never believed in fate, destiny, not to the extent as I have witnessed it. I had believed that destiny was a quaint scapegoat for the pitfalls of life and to act as a salve to explain away why someone else has the life you want. I don't recognize my life now, after the first chance meeting from a chance decision, I have taken bigger and bigger chances in life some so large that I have shocked myself.

The moral of this story, dear friends, is that if you have an inkling to pursue something (or someone), give pause to the fact that the inkling came from somewhere, somewhere that may have a better idea than your conscious mind does. Believe it or not even the smallest chance can be overlooked; you may be embarking on the biggest adventure of your life!

Too many things to think about this week...

Since a recent injury has rendered me all but totally useless, my daily consumption of books, magazines, hell, the ingredients list on a jar of cheese dip (its not really cheese in case you were wondering), has exponentially increased. A recent issue of Macleans provided enough fodder to boil my blood as too did the recent issues of Vanity Fair and Marie Clare (of all things).
So, to provide the top articles topics that boiled my blood - nay - incinerated it, are the following:

1) Honor Killings in the USA
2) G20 and G8 Summits
3) Saudi Arabian Vacation feat. Maureen Dowd (love her - Saudi not so much)
4) BP oil spill (I don't have the strength to go there tonight)

I will start with the honor killings. I'm sure unless you live in a yurt somewhere in northern Canada and are deaf, you heard about the killing of Mississauga, ON teen Aqsa Parvez in December 2007 by her father and brother for failing to wear a hijab, a head scarf commonly worn by Muslims to supposedly adhere to the edict from the Prophet (PBUH - so I don't get my head cut off...) to dress modestly (ahem). I'll start off by questioning the wisdom of travelling to one of the most liberal countries in the world and expect to adhere to the edicts from 'back home'. I know plenty of Muslim women who dress modestly without wandering around looking like they have a perpetual head injury - I'm sorry if this is inflammatory however to my mind in this country at least, it only serves to bring greater attention to these women. They stick out. My head swerves when I see a woman dressed in a floor length tweed coat and black hijab in the middle of July in 90 degree weather versus a scantily clad woman - which one would you like to sit closer to on a crowded bus? I agree with French president Nicolas Sarkozy - this is a country where we don't dress like this. If I were to travel to, say, Riyadh what are the chances I could move about in shorts and a tank top without being arrested or harassed? Slim or none? Hijabs are donned when an aircraft enters Saudi airspace, never mind waiting until getting to your hotel! So why is it then that people come here and are not expected to conform to our society? 'Religious freedom!' they all scream. Yes, very true. But if I were to gouge the eye out of the man who poked me in the eye whilst riding the bus and said to the judge 'but your honor, it says so in the Bible! An eye for an eye', I would surely be escorted to the nearest jail cell to carry out a short term for assault.
An honor killing (not just carried out by Iranian and Iraqi Muslims) is the elimination of a family member - 99.9% of the time a woman - who has in some way, to varying degrees "disgraced the family". This can range from a mild flirtation with an unrelated male, to sex before marriage or (gasp) a rumor that she has a boyfriend! These accusations, whether real or imagined, whip the family into a frenzy that can drive them to desperate measures, namely the murder of the female to "preserve the family honor". This translates to how the 'community' views the family's integrity. Well, I have some sad news for the over zealous and over proud families out there concerned about their 'honour' - listen closely now - here in North America WE-DON'T-GIVE-A-SHIT! We are all too busy trying to make money to feed our kids so that they have enough energy to play soccer then go to bed early so mum and dad can have some languid sex before passing out and doing it all over the next day. What you and your family does, doesn't concern me or mine in the least. To drive my point home, your daughter can shoot up on your driveway then hump her boyfriend for hours and I won't bat an eyelid; so long as its not on my lawn I don't care!
And a final word here on the blatant misogyny of this whole issue is this; these "Muslim" men who are so concerned with having their daughters and wives' adhere to the Koran and the Prophet are the same men that ogle white women on the street with their tight jeans and flowing hair, who gamble in the casinos (definitely clearly delineated as again Islam), have mortgages (again a no-no its called usury) and entertain themselves in the local whorehouse (conveniently the Koran is a bit vague on this one).
'Gentlemen' (for lack of a synonym - used extremely loosely), before you can fix someone else's shit, best make sure yours is still standing - just saying.

I don't have the energy to address my other grievances therefore, until next time...

How Pure the Little Girls Are

I have often wondered what I would say to a daughter, if I am ever blessed enough to have one, when she begins to grow into a young woman. Would I follow my parents example - which is a good model to follow or go a bit further, a bit more graphic. I have followed political policies on women for quite some time. There is a common thread whether it be regarding sex, pro-choice vs pro-life or access to contraceptives. The common thread is this; as women we can now become surgeons, pilots or scientists just to name a few opportunities that have opened up to us, but when it comes to our reproductive health we need man, particularly in the form of government policy to take our collective hands and show us the way - their way. If I were to subscribe to a personal view it would be pro-choice. I know better than anyone what is good for me and my life. If I need contraceptive because having 20 children is not my idea of fun (not all of us can write our properties off as `places of worship`) and I really, really enjoy sex with my partner, I am smart enough to decide this for myself. If I want a child but not the man that usually comes with that package, I reserve the right to become artificially inseminated. I also reserve the right to not give two shits about what any ones judgement may be on my decisions because at the end of the day, the have their bed to lie in and I have mine.
Policy makers start small. Pre Roe vs. Wade that `small` thing was calling abortion murder and making it illegal to seek or deliver such a therapy. We won that one. But that didn`t stop the policy makers, oh no they are a persistent bunch to say the least. One councillor in Virginia proposed the following:
Women who miscarry MUST report the fetal death within 12 hours or face a possible 12 months in prison. The details of this proposed (it got yanked off the table) bill can be found at this link. http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=132x1481676
This was proposed by a man, a man who had never delivered a 3 month old fetus into a toilet, who never felt a child growing inside get ripped from his body, and who never will. But in addition to this traumatic experience, he expected a woman to report it and undergo questioning that would rival a murder trial. Why. Who does this benefit. This is a prime example of men gone wild. When did men become the gate keepers to female sexuality. I am not referring to a decision whether or not to abort being decided between the parties involved - that should be between those who made that child - I am referring to the ability for a woman to decide her and her children`s course without interference from policy. Do some women abuse this freedom, definitely, that said we can`t throw the baby out with the bath water (pun intended). Most women do make sound choices that benefit all involved, and in the event they do not, who are we as society and policy makers to comment.
My point (yes there is one) is that I would teach my daughter how to critically think situations through. How to rotate a situation and view it from all angles. Cause and effect. Arm her with all the education to make those choices and, better yet, by providing this education prevent her from needing to make the really difficult ones. In the end she may decide to abort a child conceived unwanted, or she may have 10 children or none. These are the things I feel a well informed woman can handle just fine without policy and penalty being enacted. There are laws against theft. Do people steal - of course but most don`t.
Gentlemen of the senate, parliament etc., our women, your women, all women are not to be feared as juvenile half wits in need of guidance. We are mothers, wives, professionals, and moreover soulful people who are able to decide our own path. Allow us that basic human right, nay basic God given right (Deuteronomy 30:11 and Luke 6:46 to reference a few for all you bible thumpers out there) to exercise our free will and personal reflection without reprisals.
Ladies, we must not let policy be shackled to our wombs, do not allow government to control our bodies, our minds or our hearts. We have come so far, this is the home stretch.

The Big V

I have written about this before - virginity - although I'm quite at a loss to describe what it is. I am not alone. Many books and articles have been written about this subject and what confounds me is why society is still obsessed with it in the 21st century. When this subject is brought up I personally feel that we are debating the virtues of corsets and bustles. Antiquated. In the last 20 years there seems to be a resurgence of virginity crusades from Purity Balls, where a girl as young as 5 years old pledges her virginity to be protected by her father until she marries (a little creepy) to abstinence only programs (a petrie dish for a new generation of AIDS and other STI recipients). My question still is 'why?' How can this benefit our society? Why is a woman's purity even a subject after women's lib? Why is a man's purity never mentioned? So here it is, a girl gets married as a virgin while her new husband 'sowed his wild oats' a la Old Testament. Neither has received proper information on contraception or safe sex and BAM! He's given her a funk STI and she's knocked up before the honeymoon is over and neither one has a clue how to handle the situation. They got married at 19 because the blue balls was crippling the guy and she just couldn't hear anymore of his whining about it. I'm generalizing I know but this isn't unrealistic. My parents didn't do the whole 'wait until marriage' spiel. They advocated informed decisions, action-and-consequence, and sex as a sacred expression between loving partners (at least at the outset). Lo and behold, neither of their daughters were sexually active while in high school. Their teachings rang true and taught us to make a sound choice. There is a pervasive fear that one's daughter will become a trollop while still cutting her teeth in the world, taking many men to her bed until no one wants her and she's end up an old, lonely, slut. If that isn't the Bogey man of all tales to tell one's daughter I don't know what is. Also, in the case of this Purity Ball crap, the parents are essentially saying to their daughter 'you are only an acceptable woman if you get married', not to mention extremely sexually frustrated until you do. With youthful hormones raging, this can be a recipe for a disastrous marriage made not with a sound mind but driven by a libido in overdrive. Can I hold up for the jury Exhibit A - Jessica Simpson and Nick Lachey. She daddy's little virgin, he really effing horny; flash two years later and divorce. Now what? Do we have to wait until marriage again or because the horse has been let out of the gate no one is too worried about how many cars get parked in her garage. Well, now here's a problem. She has no idea what a condom is or how to properly use one, never mind the pill. These were completely unnecessary in the bridal bed.
Virginity is a concept that was originally used as assurance that a man's line would not be contaminated with another man's seed. You knew the little filly you just bought and bedded was carrying some other guy's bastard child which would make you the laughing stock and jeopardize the family fortune. Here in the 21st century this isn't a concern. Two of man's greatest items - birth control and DNA testing people! In a world where girls and women have more than enough body issues and self doubt on the precipice of their dawning adulthood, do we need to add this one? Virginity, vulvuloplasty, re-virginization? Why? WHY? We are surgeons, business women, CEO's, PR exec's, writers, academics, or just plain old Jane trying to get through another day but hell! This is not something to encourage in women, a self hatred of our sexual selves. And gentlemen, believe me when I say that you will have a far better time in the boudoir if your lady isn't a shrinking violet in virginal white. Who wants to be a teacher all the time huh?
Last I checked, Darfur was still a horrific mess, Haiti is effed right up and there are starving children all over the world - maybe stop obsessing about vaginas and expend the energy more constructively huh?

These are the options?

It's no secret what my stance on women's reproductive issues are. Again, I am flabbergasted by the BS that is shoveled out by the pro-life movement. Here is another rebuttal about one of their "alternatives" to abortion. Adoption. "Oh dear, you need to love your child so much you are willing to give it life then give it up for adoption into a loving home". Ah yes, a loving home, with a dog, a cat and rich, white parents with the matching white picket fence. However, to get there dear children you'll hang out in the system for a while. The adoption process takes YEARS and MONEY - and lots of it; think $30 000 of it. And, if you happen to be less than the adorable, wide eyed, cherub cheeked child, well, you'll be on the shelf a lot longer sweet one. The adoption agencies are impenetrable walls. I myself have looked into adoption. I meet the requirements. No problem right? Wrong. I DON'T have to $5000 up front cost to OPEN a file. Oh yes just to OPEN a file. Shit and I do that for free daily! Then we have visits, more cash, and a long waiting period. If the agency doesn't think a particular child I have chosen to be a "fit" they turn me down. The autistic child for example or the diabetic child; I'll need a degree in ECC and an RN certification to get one of them. This is just the domestic adoption agency. The foreign one is much more complicated. You will need to attend classes where they teach you how to make sure your child stays connected to their heritage and doesn't turn around and say that you were a shitty parent because you treated them like a Canadian child with no roots - God forbid!! Well if you can wade through that swamp and actually get assigned (literal - you don't choose) a child, you must then go to the country where they live and spend two weeks there with them; great idea, makes sense; but wait, you're not done cousin! If your child is deemed medically unfit to be let into Canada, you put the child down, walk away, board your plane and start again - FROM THE BEGINNING - which means, all together now, MORE MONEY! So the child whose mother so selflessly and lovingly gave her up to the system, may very well languish there amid other children whose fate is similar or bounce from foster home to foster home until they are either adopted or become of age. I think we need a better Plan B.

The Future of ICD's?

Returning from a weekend conference, I am feeling refreshed from professional discourse, idea sharing and not a little merriment. One of the most interesting presentations (for me at least), was an intriguing talk given by Dr. Riccardo Cappato on the initial patient experience with the still investigational subcutaneous ICD's. The positives of this novel approach to CRM device implantation were immediately apparent namely the following:

• Fluoroscopy is not required intraop


• risk of complications such as pneumothorax, hemothorax, myocardial perforation and lead dislodgement are completely removed


• No introduction into the vascular system - especially useful in pediatric patients and patients with difficult or not vascular patentcy


• No risk of SVC vein occlusion or need for possible laser lead extraction for subsequent lead revision


• lower risk of lead dislodgement

These risks are minimized or bypassed due to the fact that the lead system is implanted entirely subcutaneously. The defibrillation coil runs parallel to the left aspect of the sternum and the lead body is then tunneled along (approximately) the 6th intercostal space to the device which is implanted parasternally (approximately 5 inches inferior to traditional placement and slighly more lateral).

The initial experiences that were reported described a virtually equivalent tolerance to alternate device placement, and not perceived increased patient discomfort when compared with traditional placement. DFT's were also successful at 65 joules or less allowing for a safety margin of at least 15J, given the devices maximum output at ~80 joules. This method of course is contraindicated in those who DO have an underlying pacing indication. That being said, the investigators did note that success of the post-shock pacing at higher than traditional values.

I personally am cautiously optimistic about the early success of this approach to implantation. I would like to see how the lead behaves chronically while it is in perpetual contact with subcuticular tissue. How will the leads perform chronically? How (if at all) will lead maturation manifest? Can the defibrillation coil become indurated with scar tissue? Will weight changes or either a decrease or increase in fat affect DFT's? How will that impact the leads efficacy? Only time will tell.

Discuss...

Arrhythmia Device Follow-up 101

I have been encouraged to share the meager knowledge I have of arrhythmia devices for those who may be interested. A brief background of my involvement in these devices: I trained in Diagnostic Cardiovascular technology both on the electrophysiologic and imaging level. I began my arrhythmia device training (moving forward I will use the industry accepted acronym CRM - Cardiac Rhythm Management) at a university hospital in downtown Toronto back in early 2003. I currently run a pacemaker clinic at a different Toronto hospital. I wrote two exams, both the Canadian CRM specialty exam in 2006 and the IBHRE (International) exam in 2007. My posts will tend to run on the side of generality, but I hope even veterans in the industry may glean some benefit from this and future posts on the subject. I do not endeavor to insult any one's intelligence, nor is this an instructional post per say. I merely wish to share my experiences to either the benefit or amusement of my fellow cohorts. So, enough about me and on with the show so to speak.

It may sound a tad hokey but the greatest tool (usually) you have in your arsenal for following and troubleshooting CRM's is definitely your patient. Unless the patient is clearly a veterinary historian or otherwise inclined to vague and non-specific symptom relation, they are your best jumping off point. I can illustrate this with a very good example I recently encountered. A patient of mine, Mr. P, came to clinic for his annual check up. His original implant indication was sick sinus syndrome and for the past 5 years has had a total pacing percentage of no more than <0.1%.>30 bpm. He indeed after 5 years of almost no pacing, became fully pacemaker dependent. This is not an unusual occurrence as ~15-25% of SSS patients will develop varying degrees of AV block.
Mr. P was programmed to a rate responsive mode with a conservative rate response curve and performed a hall walk. In comparison with his marked shortness of breath walking 20 feet from the waiting room to the clinic versus the hallwalk totalling 60 feet, he was totally relieved of his symptoms with the new parameters.
I was quite lucky to have such a diligent and observant patient to aid me in programming his appropriately. More often than not, you will be met with stoicism or vague reporting of symptoms and parameters will by and large become trial and error.
The take home message here is listening to your patients can make your job easier.

Divorce Diary 1.2

I haven't wrote in a while so here is the update of things I have learned .
1) Have $300 cash when you go to your lawyer - they WILL wait until a cheque clears to get to work.
2) I can't stress this one enough - READ EVERY WORD OF EVERY CONTRACT. THOROUGHLY - dictionaries are useful in the event of legal jargon
3) You divorce spouses, not family. This is much easier in theory than in practice.
4) You will get angry, you will feel homicidal, suicidal and every other '-cidal' in the book. This will pass I promise. Have extra-strength Advil available at all times.
5) Negotiate.
6) Cost and worth are VERY different
7) Facebook is NOT your friend
8) Your next relationship can't possibly be as bad as the last one; if it is you'll recognize it sooner - sooner than the wedding is optimal.
9) Get the dog
10) Don't hate your ex - it'll cost you; both lawyers will see to that (I totally avoided that one)
11) There is an untold, smug joy that the divorcee gets from watching "Say yes to the dress" and other associated wedding shows that plague television. You can't help but think 'sucker'.
12) Ladies, you will eventually realize that you can hammer, screw and calk just fine - in and out of the bedroom ;)
That's it for now my little divorced dollies. Stay tuned.