• People Talk and My Ear Bleeds


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    Friday, September 05, 2014

    Apprenticeship in America

    Recently, Cathay Pacific instituted a program titled "I Can Fly," which hopes to give juniors and seniors in high school 8 weeks of direct experience to aviation. Not flying, but aviation - learning about everything from passenger sales to airports, cargo to catering. This is a Canadian program, partnering Toronto with Cathay Pacific.

    America lost it's apprenticeship culture years ago. Sure, we all read of our Founding Fathers learning watchmaking, or silver smithing, or printing at the hands of someone else. But by the end of World War II, America's government-subsidized public high school network was robust enough to provide basic education. People graduated, applied, and got jobs. Then they received on-the-job training.

    As the economy developed and higher education became more important, that model persisted. Now, some companies are going back to Europe to study their apprenticeship systems. The hope is that large companies, like Siemens in Germany, can help counterparts in the USA close a gap where 4 million jobs sit unfilled although 10 million people are unemployed.

    The problem is, this hasn't extended to one sector of the economy gravely hit by this labor shortage - health care. Physician training, specifically, is woefully inefficient - a byproduct of this stage-by-stage top-down, myopic, it's-always-been-done-this-way approach. Since the Flexner report in 1910 (see pdf), American medical education time has been seen as an empty cardboard box to be filled with whatever is possible until the timer dings. As medical knowledge advances, we try to shove more and more into the box faster and faster, without stepping back and reimagining the box itself, or the method of pouring.

    "Then I wised up and got out while I still could."

    It is time for a serious look at the ACGME, AAMC, and LCME - the accreditation bodies of American medical education. They are bloated dinosaurs that do not move fast enough to deal with the times. With expected shortages of up to 52K physicians by 2025, it's past time to look at other ways of educating future medical professionals.

    We need to shorten medical education by at least 2 years. We need to decrease debt incurred by physicians in training. We need to change the culture to make medicine more family friendly. We need to increase responsibility given trainees to help them progress to self-sufficiency faster.

    Perhaps we could learn something from Cathay Pacific. We should at least look.

    Tuesday, September 02, 2014

    2014 TBE Play For A Cause Winner: Baton Rouge Children's Advocacy Center!!

    I'm incredibly sorry for the long delayed post. Congratulations to all who played in the TBE March Madness pool this year. It was a great tournament that hinged on an Elite Eight game. If Arizona had beaten Wisconsin, many possibilities would have remained alive. However, Wisconsin won, and that sealed the deal for Dr. Z and the BRCAC. Congrats!!

    Below is the press release.

    ***Dated: May 9, 2014***

    Congratulations to Dr. Zeretzke and the Baton Rouge Children’s Adovocacy Center!

    The Bleeding Ear’s Play For a Cause March Madness charity pool (“TBE Play For a Cause”) was started in 2008 as a way to funnel a good time into good deeds. Two years earlier, while volunteering at an orphanage in Vietnam, I saw how much $100 – a relatively small amount in America – could do for needy children.

    That first year we raised $100 for Heifer International. Every year we’ve had an increase in players, money, fun, and watched some excellent tournaments. This year we have raised $260 for the Baton Rouge Children’s Advocacy Center. Congratulations to all involved.

    The Baton Rouge Children’s Advocacy Center (BRCAC) is a non-profit organization whose mission is to “lessen the trauma experienced by child victims when abuse allegations are investigated, and to provide support during any subsequent proceedings within the criminal justice system.”

    The BRCAC:

    •Protects children who have been sexually and/ or physically abused and helps prevent further abuse.
    •Provides therapeutic counseling during the time of disclosure and thereafter.
    •Maintains and reconstitutes a healthy family by healing the scars of abuse
    •Enhances community safety by preventing the perpetration of sexual/physical abuse.
    •Coordinates the prosecution of the criminal cases

    In 2013, BRCAC served 312 children who were sexually abused, physically abused, or had witnessed a severe crime.

    We cannot be more proud to help support the Baton Rouge Children’s Advocacy Center.

    The Bleeding Ear
    Largest donation in the history of TBE Play For A Cause

    Wednesday, May 15, 2013

    Winner! 2013 TBE Play For A Cause!

    Well, March Madness is far over, and the payments have finally come, so let's give credit where credit is due: congratulations to Julie and her charity, the Ovarian Cancer National Alliance!

    Unlike last year, the battle royale lasted until the championship game. Julie and James, long hovering in the middle of the pack, rose slowly and steadily as people's championship picks were eliminated. In the Final Four, James' wife was eliminated when Syracuse bit the bullet. The championship game featured Marc for Michigan and Julie/James for Louisville.
    The game was exciting, as Louisville mounted a fierce comeback at the end of the first half to make a game of it, and pulled away just enough in the second half to seal the deal. BUT, that only eliminated Marc. We had to go to the tiebreaker - absolute value of game score guessed vs actual game score - to find out if James or Julie would be the winner. With an absolute value of 12 vs 18, the Ovarian Cancer National Alliance won the day.

     The best part about everything is the $200 raised for ovarian cancer research and awareness. Together we all had fun and pooled resources to give a gift that can truly make a difference.

    Sunday, October 07, 2012

    DIY: Idle Air Control Valve

    Someone once said, "when you're poor, your save money and pay for it in time. When you're rich, you'll save time and pay for it in money."

    Well I'm poor.

    Lately my 1994 Honda Accord (4 door LX 4 cylinder) has been idling low - I mean really low - somewhere around 300-400 RPM. Besides the incredible shakes that make you think it will die at any minute, it has started dying as I back out of parking spaces. This problem happened when the engine is warm - starting in the morning with a cold engine got a decent response until the radiator fan came on.

    Unable to pay for someone to diagnose and fix this for me, I scoured the internet. I found this post on Honda-Tech.com. People smarter than I had ran into the same problem.

    **Now, sometimes all you need to do is turn the idle control screw on top of the throttle body and adjust the idle speed, but I figured my problem was deeper than that given my car's 260K + miles.

    This post described how to clean your Idle Air Control Valve (IACV) which adjusts the amount of air let into the engine (if I understand it correctly). A clean IACV gives you better idling RPM and more fuel efficiency.
    I'm not going to recreate the excellent "How-To" on Honda-Tech.com, but I will give you some thoughts.

    There it is waaayyy in the back
    A closer view
    On opening the hood, I spotted the IACV well in the back. This made it incredibly difficult to get to - especially from someone like myself who's passably good with tools but not even remotely experienced with cars.

    Yes, that's a battery

    First, I disconnected the battery because 1. electricity runs through the IACV and you need to reset it after cleaning it, and 2. I don't want to die.

    Darn black tube in my way
    Ah! Much better!
     Second, I had to take the top off the air filter and disconnect the intake manifold.  I tried for too long to disconnect the IACV without doing that, and I couldn't reach it. It's WAY too crowded and small back there. Taking that big black tube out of the way made it MUCH easier.

    Soiled shut

    Once I got it off, I easily saw how right I was about the etiology of my problem.

     I bought IACV cleaner from Autozone (although I've read that Carburetor cleaner would work fine .. don't know if there's even a difference) and this is what it looked like afterward (O-ring removed during cleaning so it wouldn't get damaged. Don't forget to put it back in!).

    After putting it back in, I almost didn't check the radiator fluid. The resevoir was almost dry, because of the lost fluid from the tubes that run through the IACV. Topped it off after another trip to Autozone, and it's idling at 750 RPM like a champ!

    The whole experience was awesome, because I realized I can fix a car without breaking it more, I saved tons of money, and it reminded me again how similar car repair is to surgery - without the malignant residency to go through...

    Saturday, September 15, 2012

    Congratulations ASPCA!

    This post is rather late in coming, but I would be remiss if I didn't acknowledge the results of our last "TBE Play For a Cause" March Madness pool.

    Congratulations, Andres, and the ASPCA. They sealed the deal after the Elite 8, when UNC went down. Once the Final Four was set, nobody could up end them.

    I asked Andres what made him play for the ASPCA this year. A love of pets? A soft spot for those less fortunate or unable to care for themselves?

    "No," he replied. "I saw an advertisement on the ESPN website as I went to register."

    Well, whatever your motivations, people and animals everywhere are thankful to all who played, and those who played are in awe with his great prognosticating skill. Until next year!

    They will bark your name for years to come, Andres!

    Saturday, July 21, 2012

    Vietnamese Communal Street Culture

    A typical small street in Saigon with mom-and-pop shops
    One of the amazing parts of Vietnamese culture is the "night scene." As in many societies - perhaps because of a lack of air conditioning and lighting - people typically take to the streets in the evenings and then retire early. In Vietnam this daily routine is codified as arising one or two hours before sunrise, starting to work about 6 - 7 am (sunrise), taking a siesta in the middle of the day, returning home about 5 - 6 pm, and hitting the streets. Because of the now "stable" electricity (rolling blackouts are the subject of another day), people often stay out past dark, but in general, the country goes to sleep about 9 or 10 pm.

    Saigon stays out a little later than the rest, maybe due to the expatriate influence, greater electric stability, westernization - who knows. Anecdotally, the majority of people in the city still go to sleep at 9 or 10 pm like the rest of the country, but their are enough people in the city that a vibrant culture from 10 to midnight still exists.

    A "hẻm" (small alley) during the day where most people live 
    This street scene is enhanced by the communal nature of Vietnamese family culture and the living proximity of people in the country. Vietnamese society, like most Asian societies, live in large family structures. Typically three or four generations in a household. This creates a large network of closely related people to interact with on a nightly basis. Also, it manifests itself in gastronomical ways: family dinners are usually social affairs where many dishes are placed in the center of the table for people to share as they talk and joke.

    Vietnam has a population density of 280 people per square kilometer, according to the World Health Organization. Ho Chi Minh City has an even higher population density - 9450 in 2006 - and according to Vietnamese research, the inner city (old Saigon) has approximately 30,000 people per square meter!*

    The same alley alive around dusk as everyone comes home 
    *In comparison, the United States of America's density of 34 people/sq. km, and the two most dense cities - Washington D.C. and Los Angeles - have densities of 3886 and 2750, respectively.

    What all this close living does is create not only a "night scene" as thought of in America - clubs, bars, restaurants, etc. - but a small community "night scene" with local alleys (hẻm) alive with children running and playing, women gossiping, families and friends eating, and old men drinking coffee or beer and playing chess. These "micro-communities" are the true social structure of Saigon, and any visitor would be remiss to not experience it.

    Vince and Linh

    Travel blogs are nothing new, but I do enjoy perusing ones dealing with Vietnam to see other people's perspectives on my second (third?) home. In this case, the travel blog happens to include a good friend of mine, fellow white-boy-speaks-Vietnamese, adopter of Viet culture, Vince and his girlfriend Linh. So, if you want a fresh, biased-only-by-America, virgin view of Vietnam, this is for you. I'm too old and jaded now...

    Check out http://vinceandlinhinvietnam.wordpress.com/ and tell them hi from me!

    Monday, July 09, 2012

    Lang Co Clinic

    Three days of working in a rural clinic went by like a whirlwind. This is incredibly different than my previous medical experiences in Hanoi and Ho Chi Minh City (HCMC), but, it really is about what I expected. The disparity in care (and life) is amazing here. Some stats from a Vietnam News article I read yesterday:

    1. HCMC accounts from 21% of the nation's GDP (this is an improvement, I think, because it used to be 75%. Now Hanoi and Da Nang have grown tremendously, siphoning this off) including 44% of tourism dollars.
    2. Average income is 2.4 times higher in HCMC than the rest of the country.
    3. The city has an average economic growth rate of 11% over the last 25 years - 1.5 times the national average.

    What does all this mean? It means if you live outside of HCMC (and definitely outside of it plus Hanoi and Da Nang) you are markedly poorer than the rest of the country. It logically follows that your health care will also suffer, since all the major hospitals are in HCMC or Hanoi, and you will have little if any ability to travel for medical services.

    Consequently, clinic saw both run-of-the-mill malnutrition and parasites (probably 80-90% of cases) mixed with really interesting cases that had little to know previous medical follow-up.

    In the three days I was in Lang Co, I saw an average of 40 patients per day. One young boy, about 2 years old, came in with his mother who complained about a large lump behind his left knee. On examination, I noticed he had a rather large (7cm by 5cm), non-tender, immovable, solid mass behind the right knee. Nothing noticeable on the left. Mother stated that the mass had been there since at least 3 months of age, and had gotten bigger as he had grown. A local physician had seen the child early in the course, performed no tests, and said it was totally normal.*

    *(aside: this is common in Vietnam, where medical tools are scarce and money to pay for them more so - to do almost no tests, except an ultrasound of the abdomen which is done for everyone regardless of chief complaint because ultrasounds are so prevalent - and not explain to the patient anything. Although, in America we explain everything and the patient never hears or understands what we say, so perhaps that is just universal...)

    So, I ordered some xrays of the bilateral knees and femurs and told the mother to return the next day. Early the next morning, in she walks with xrays in hand, showing growths on both femurs (left markedly greater than right). Luckily, one of the other physicians on the team, Mark, is an orthopedic surgeon, so I walked next door to get a specialist consult. He had the child walk, looked at the xrays, then declared it was most likely an osteochondroma - a benign tumor of the bone. It's monitored through periodic xrays and removed if it impacts function (walking in his case) or grows rapidly (small chance of becoming malignant).

    Mother went away happily knowing a diagnosis, and knowing what to look for, and I moved on to the next patient - more worms.

    In all, I saw probably three or four cyanotic heart lesions, a previously undiagnosed brain mass, juvenile idiopathic arthritis, hodgkins lymphoma not receiving treatment because of no money, cleft lip, and - jewel of the diagnosis crown - Russell-Silver Syndrome (stories for another day). Sleep was welcome each night. It's amazing how much good you can do with so little.