Farewell 2020, But F*ck You 2019.

While everyone is celebrating the farewell of 2020, and looks worriedly ahead to 2021, I just want to point out that 2019 was the year that fucked me over.

Last year's lockdown and COVID was a breeze in comparison.

Retirement investments in HK were fucked over by the extended and futile protests, the violence of which only exacerbated the problems there. There went a potential seven figure boost, my all in one egg-basket smashed by a HK police baton.

Then there was a very major health issue which fucked over any chances of reemployment and therefore residency in Singapore with my well-established (if diminishing with the usual expat curse of impermanancy) social circle of 16 years, and it has fucked over any future employment. At all. 2020, 2021... 20untilIdie, tearing through my savings until I qualify for a pension. 

Just saying. Looks like I'm stuck on my balcony, musing over a G&T and another sunset.

I found a Beefeater Gin bar-set in a local antique mega-store. Awesome. The highlight of 2019 

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I've been planning to write about all this in detail for a while now. NY resolution is to fix that ommission. 

Hopefully this year you'll hear a lot more frequently with shit-load of clever self-deprecating wit flying (with appropriate humility) in the face of overwhelming adversity from 

E@L

Who Is This E@L?

Who is this person staring back at E@L?

The person in the bathroom mirror with the zipper line of scabs peeling from a scar down the middle of his chest. The person with the healing wounds where drain tubes once sucked out blood accumulating in the spaces between his heart and his chest. Who is the person who would submit himself to such surgical ignominy? Certainly not E@L. E@L would never let people hack at his sternum and prise open his ribs, nor let let them stop his heart, nor let them place a clamp on his aorta - the source of oxygen to his entire E@Lness. He certainly would not let them dig arteries and veins from arm and leg. E@L does not know this front-to-back reversed E@L.

Who is he?

What sort of person is he?

What sort of person is this E@L, who decided such violent effrontery was the best idea at the time. This acquiescent E@L, this bowed into submission by logic and research E@L. This E@L who knew that he might die, and comfortably made the choice to take the risk. This E@L who put thing in order: will and testament, bank accounts, password list. 3% is not an insignificant statistic when they do 60 of these a month. This E@L who really thought he was going to be the one in 33 1/3 who died, the one every month and a half. This E@L who shelled out $50k for the promise of staying alive a bit longer. The E@L who wanted to live but knew, in his cramping heart, that he could die: and die easily, quietly, quickly, never waking up. Death. If not now then eventually, and he couldn’t decide which would the be best outcome. The slipping into oblivion, into annihilation and pre-birth emptiness. Peace. Who is he?

Where is the E@L without these battle wounds? The E@L who feared the pain and dependence that would last for months after, should he survive those first few days. The E@L who said “No fucking way.”

Who is this E@L who dismissed the anxiety. Who is this E@L who knew what could go wrong, but shrugged. Who is this E@L who, while on the operation table, agreed to being intubated while still awake, because of his severe apnoea. The E@L who was hit with a massive headache that burst up the large muscle (sterno-mastoid) in his neck next to his skull, that went up into his brain when the central venous line was inserted, and who mentally shrugged and thought (he could still think!), well that’s it, a massive stroke, but whose both hands still felt strong when he squeezed them as he kept testing them.

But the E@L who joked with the anaesthetist about upgrading his ultrasound machine when he came through this, now that sounds like the real

E@L.

Not Writing Enough

E@L has fallen out of the habit of writing; but haven't we all.

He is not sure what habit might have supplanted it (for him at least - whatever nefarious alternatives you might have found are matters for your own conscience and the ability of the neighbours to get a good night's sleep), but he is certain it is a bad one, not worthy of spending any time on, and not productive of anywhere near the enjoyment he used obtain by pressing "Publish" (followed by three hours of correcting typos and blind links) and thereby pushing his bullshit into this isolated and brackish backwater of the Web to be ignored by the billions of people who might conceivably benefit by the experience.

Wouldn't it be good if he could throw Famebook out the fucking window and let his communications open up in this antient forum, at least to the four* people in the world who might possibly still read his rambles, as opposed to those few of the 246 "friends" who have not Blocked or Ignored him (there's probably about eight as well) on Flakebook.

Wouldn't it be good if everyday he could achieve what Michel Faber managed to do in order to write his most recent novel (while his wife was dying); just write six sentences (at least) a day.

Every word of every sentence is a step in the right direction because... because what?; a sense fulfillment; the exclusion of boredom; a way to prevent eyelocking the abyss... because blogging used to be the way we'd get our opinions, feeling, frustration, thoughts and exploits out there and maybe even contemplate turning the output (or deflecting that energy and enthusiasm) into something more substsantial, and make money and find eternal fame and undying adulation, as some, and others seemed to have done, back in the day.

So here we go - let's see how long this latest promise to himself lasts.

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E@L is back on a bad-food restriction programme - no-one says "diet" anymore - with added calorific expenditure augmentation - no-one says "exercise" anymore - motivated by the fact that E@L has a Dr's appointment in a coupla weeks and that he had promised the good Medico that 5kgs of ugly/fair-to-middling fat would be converted into CO2 and H2O over the three months since his previous visit.

The authorities at E@LGHQ have, under the exigencies of reality, recently reset that goal to a barely feasible 4kgs in 2 weeks. Hmmm. E@L do be looking for a dose of some gastro-intestinal disaster to drop the reading dramatically. Any suggestions? KFC? Pizza? Newton Food Court?

It is now, what, just over 3 years since his dramatic IAI (Italian Angina Incident - no-one says "heart attack" anymore), and the Caring and Supportive Cardiologist (perceptive and perspicacious E@L can tell) is on the verge of dumping E@L because he have only put on weight, and dropped off to lower degee of exercise since they joined forces in this battle against arterial plaque. He said, mustering an impression of involvment, "Well, mmm, I guess we should do another test of some sort. It's been a while. Um. I think that maybe we should try another ECG stress test, see if anything has, you know, gotten worse." "But you said last time that nothing was wrong on the stress test! How can anything get worse when it is good!" "Um, yes, that's right, I think; I meant, um, you know, changed."

And as, persistent reader, you no doubt realize, an exercise test involves, um, you know, exercise, E@L is back on the treadmill in his gym in anticipation of that momentous treadmill test in the Good Doctor's office.

Walking uphill, a bit of jogging, getting the pulse up there... It all reminds E@L of the high level of cardio-vascular, umm, fitness he had achieved in the months leading up to the IAI...!

Having had a normal PET stress test two weeks before the IAI, plus his own experience of patients he has seen or people he has known, E@L realises that things happen, no matter what. Normal everything, healthy everything, but you can still just...

... just obssess about it.

E@L

* Quote from Colin Farrell's character in True Detective, on why he has so few friends" "I like to limit the number of people I disappoint.")

Health Care Rationality In America - Do More Ultrasound Scans!

Is it possible?

Try here at the NEJM for a calm chat.

Things are seriously wrong in American Health Care and something needs to be done.

The quality is killing people -

- Out of 19 industrialized countries, the U.S. ranked last on deaths amenable to health care, which are deaths that could have been prevented with timely and effective care.
- As many as 101,000 premature deaths a year would be averted if the U.S. was able to achieve the same mortality rate as other leading countries.

The cost is killing and hurting people -

- Economists have found that rising health care costs correlate with significant drops in health insurance coverage, and national surveys also show that the primary reason people are uninsured is due to the high and escalating cost of health insurance coverage.
- A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance.
- According to another published article, about 1.5 million families lose their homes to foreclosure every year due to unaffordable medical costs.

(Quotes are from The National Coalition on Health Care.)

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Personally, and being biased as a sonographer, I think US Health Care costs could be cut dramatically if instead of ordering a CT or an MRI as the first line diagnostic imaging test, Doctors ordered an ultrasound scan.

I don't have the breakdown on the financial stats but certainly the defensive use of imaging tools - doing a diagnostic study not because you believe there is anything wrong but just to cover your goddam ass in case of a malpractice suit! -and the widespread availability and advocacy of these expensive MRI and CT machines must means that diagnostic imaging is a much more significant part of health care costs than it is in other countries.

And certainly the number of articles published on diagnostic MRI and CT topics in both American and European journals that could sensibly be handled by competent ultrasound scans is stunning to an Australian. Sports medicine studies, peripheral nerve studies, a lot of vascular studies, the search for metastases in oncology patients, I believe in most of these cases and in many others, ultrasound should be the first line of diagnosis.

The main problem is the (often correct) perception of ultrasound as being unreliable primarily because it so operator dependant. The referring physician wonders if they can really trust the report. Ultrasound scans are considered so difficult to read by untrained eyes that the images themselves are pretty worthless to the referring physician. So here's a study in which he/she cannot confirm the finding for him/herself and which was performed by an anonymous somebody who could be the office cleaning lady for all the Doctor knows.

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I had a buddy in Australia who was about to proclaim at our annual sonographers' conference back in the early 90's that "70%" of ultrasound examinations in Australia were crap. He had made up that stat after completing an assessment during a training tour of some of the hospitals and clinics in Sydney. I pulled him up on using that exact number, but he certainly did have a point. Even in Australia, where we are proud of our advanced ultrasound standing, forced upon us by the strict control of MRI machines, the standards of many sonographers was indeed marginal at that time. In my own experience as an examiner for one of the Australian Societies, I had to fail some of these people for their sub-standard skills on several occasions.

Since that time, in Australia we have developed an Accreditation Board to oversee the development of courses available at the universities, and we maintain a Registry of suitably qualified sonographers (I was involved in the set-up of those boards) and I believe the relatively new imaging tool of ultrasound has advanced remarkably. Certainly many of those sub-standard wanna-be sonographers have now gained the experience to make them worthwhile scanners, even champions of ultrasound. Eventually, as a trainee you reach a point where the whole thing just clicks and from then on you really know what you are doing and what is expected of you. But that "click" takes time. That is why I favour longer periods of clinical training. It is not perfect in Australia yet, but it has come a long way.

In Australia, Sonography is a post-graduate degree (a Masters, for example), so we are already dealing with radiographers or Nuclear Medicine techs, or even nurses who generally already understand the anatomy, pathology and the science of imaging. We do have a more structured supervision for students and the universities all require tutor sonographers to supervise, and the students must present case-studies for assessment. At least one of the qualifications in Australia requires direct assessment by a third party during the clinical examination of real patients.

In comparison, the education and registration of American sonographers suffers in relation to Australia's in that it is an undergraduate degree, assessed by a standard exam for all applicants with no input from the students supervisor, no case studies, and no over-the-shoulder assessment.

It would be good if all American sonographers could also be educated in a similarly structured way to the Australian method (which is based on the British accreditation process). I personally would like to see something more like the Nursing registration schemes, where nurses are sort of mirco-accredited for specific skills. Each one of the ultrasound applications (abdominal, Sports MSK, Neuro-MSK, OB-Gyn, vascular) requires relatively huge amount of knowledge, skill and experience.

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However, what I have said doesn't mean that ALL American sonographers are bad and that is why MRI is winning, but I do believe that as they are coming from a lower level of education, American sonographers (as a whole, not specific songraphers, who may be exceptional if they have already had the "click") can only achieve what must be a lower level of INITIAL competency during their shorter training period. This might be one of the explanations for referrers sending their patients directly to MRI or to CT.

Another of the ways to gain the trust of American referrers is to standardize the examination to ensure a certain minimum standard is met. Improved technology is being placed in most high-end and even mid-range ultrasound scanners to help achieve this aim: such as recording short video loops instead of still frames, of taking 3D volumes and processing them like CT scans (not just for babies but for the upper abdominal and the pelvic organs), of programmed protocol guides that ensure the sonographer does a complete study and doesn't miss anything. These sorts of innovations might make the exam easier to read and review by a referring physician (so long as he has the software to read them).

There is an accreditation system for hospitals and medical clinics in the USA, but it doesn't really go far enough and compare the outcomes of the actual sonographers who do the scans, because that is the critical interface: where the patient meets the machine that goes "ping". Neither does the Australian system, but it is something that was being looked at.

So it comes down to education, the processing of accreditation and the continuing appraisal of a sonographer's continuing education.

So maybe this is another path on the road achieving lower costs of health-care in America. It would of course require the skills of experienced sonographers to give that advanced training and make these assessments. It would also require funding from the socieites to provide this service and pay the costs. Hopefully, the vast amount of money that could saved woudl more than cover the costs.

I wonder if there is anyone I know who could fit that bill?

Waddabout

E@L