Sexualization of Young Girls

I was at the Thursday night street market, where every week on Saipan you'll find food vendors and live entertainment.  Tonight, a dance schools performed.  I'll tell you, it was a sad scene.  There were kids, girls, six, seven, eight years old, dressed like teenagers, with short skirts, makeup, and shin-high boots, and dancing suggestively to lyrics like "Let's make love, ooh, baby, let's make love."

When did this happen?  When did parents start looking the other way, and give their assent to the sexualization of their young girls?  It's like they all went out for a walk, let some stranger called  a dance instructor come into their house, and in the name of "developing talent" twist their kids into these vacant performers.  It disgusts me.  What happened to protecting innocence?  What are these parents thinking?  Do they think this is okay?  To have their young daughters thrusting their pelvises while lip-synching these overtly sexual lyrics?  I don't get it.

Nagoya City University Hospital

A few years ago, I needed some surgery that wasn't available on Saipan, so I was faced with finding a surgeon to undertake my care.  Part of the issue for me was that I wanted to get the care close-by, and being self-insured, I needed it to be cost effective.

My main four choices came down to Australia, Hawaii, Manila and Japan.  I visited one of the top surgeons in Sydney during a trip there, and I wasn't impressed.  I scratched Manila off the list pretty quickly.  I've had a fair bit of experience with patients going to Manila for care, and although one of the surgeons I've worked with there is good, I've found that in general, the delivery was not up to the standards I expect when sending a patient to a major medical referral center.  Sorry guys, but that's the truth.  I wouldn't go to Manila unless it was a last resort.  I'm sure many have had good experiences there, but seeing many of my patients return, I haven't been too happy with the quality of care they received.

Hawaii was an obvious choice because, well, it's US quality medical care.  The problems with US care is that it's expensive.  If I'd had the procedure in Hawaii, it would have cost me $10K.  If I had had insurance, my 20% co-payment would have been $2K, for an outpatient procedure.  So, I just held this option in reserve.

I started to look seriously at Japan.  In the world of medicine, Japan is one of the areas, along with the US and parts of Europe, that lead medical research and publish in medical journals.  I know the quality of care there is top-notch, and that the cost is reasonable.  I ended up finding one of the best surgeons in the world for my condition, and headed there for my surgery.  I was very happy with the quality of the care I received, and the cost was only $2K.  That included the surgery, and five days in the hospital, getting fed and watered.  The system of care in Japan is a little antiquated, and many expatriates in Japan complain about it for this reason, but as someone in the medical field and as someone who has experienced the care first-hand, I think that the care is on par with anyplace in the US, and even better than the US, it's cost effective.

After I returned, I tried to convince the powers that be to start looking at Japan as a place to send our medical referral patients from the CNMI.  It close, it's cheap, and the quality of care is outstanding.  It's taken a while, but finally the CNMI has a relationship with the Nagoya City University Hospital (NCUH), and we have liaison people on the ground to help patients navigate a foreign country.

Nagoya City University Hospital is an 800 bed medical center (CHC has 72 beds).   The first patient from the CNMI that went there was an infant, a few days old, who was on the way to Hawaii for cardiac surgery, decompensated while on the tarmac in Nagoya, and was taken to the NCUH where the pediatric cardiac surgeons did an outstanding job on a very complex surgical procedure.  Since that time, the relationship has deepened, and in the next few weeks, I hope to send the first ophthalmology patients there.  This should provide closer and less expensive care than is available in Hawaii, and  as high a quality of care.   I'm looking forward to using NCUH as a referral center.

Grand Rounds from the South Pacific

Welcome to this island edition of Grand Rounds. Yes, I really live and practice on a tropical island in the South Pacific. And yes, you can too. I’ll let you know how, in next week's edition of Grand Rounds, which will be hosted by My Three Shrinks. But now, on to this week’s edition.

I’ve always wanted to be a newspaper editor, not because I want to edit, but because I want to write headlines. And not for a respectable paper like the New York Times. Maybe for a newspaper, like the Enquirer -- you know, where an editor can have some creative freedom with the facts. So, finally, I get my chance with this week's Grand Rounds. Sometimes the headlines I’ve written relate to the post, sometimes, they are just a whacked out free associations. Like all headlines, their purpose is to get you to read the posts. I hope I can entice you. There are some really great writers out there. Great job everyone.

Let me know if there are any problems with the links, and let me know if you want to exchange links. Grab your beach towel and snorkel, because here we go... Leave only footprints and comments.


Life is Not Just About Breasts

“What do you think about my breasts?”Random women never asked me that question until I started offering Botox. Now I get it all the time. Let me give you some advice. Don’t even begin to try to answer it. It’s a trick question destined to land you in hot water. Just have your press secretary issue a statement that “The doctor can neither confirm nor deny that your breasts a) are as pert as a pair of saluting Marines; or b) like the jowls of a hound-dog.

If you’ve ever wondered what a set of rejuvenated boobs looks like, drive on down to Arkansas and head to the grocery store with plastic surgeon, Ramona Bates. Her patients may lift their shirts, right there next to the kumquats, just to share with Dr. Bates their joy of a job well done. Read about it, and other awkward plastic surgery moments, at Suture for a Living, on the post, aptly named, Hi!


Indiana Jones and the Kingdom of Malaria

I love Dr. Paul Auerbach’s specialty:“Wilderness Medicine.” Is that cool, or what! Sometimes I refer to myself as a Tropical Ophthalmologist (okay, actually, this is the first time), but I think I’m going to switch to Wilderness Ophthalmologist.

Paul has a great post that gives a fantastic overview of malaria, and links to an article that describes an important drug regimen for the disease. Read about it at Artesunate for Falciparum Malaria


Humanity is Good

Once in a while, I read something on a blog that brings tears to my eyes. Dr. David Loeb, a pediatric oncologist at Doctor David’s Blog, is sure to touch your heart with this post on A Different Kind of Memorial Day. He tells of the annual Memorial Day service held at Johns Hopkins Children’s Center for the families that have lost children to cancer, and the lessons learned.


Humanity is Really Good

I like Susan Palawick. She is an improbably optimistic ED chaplain, who shares a beautifully written portrait of two patients whose encounters renewed her faith in God and in humanity.Renewed Faith


Just When You Thought Humanity Was Good

Can somebody get Bongi an agent? He is a great writer, but he’s too busy opening and closing bellies to put a book together. Someone just needs to go through his blog and put it all together. His post this week, South African Crime, is not pretty in terms of the picture it paints, but like the above two posts, it gives us a peek into the human soul.


Stethoscope Doubles as MP3 Player

Dr. Joshua Schwimmer’s old stethoscope broke, and he reluctantly purchased a new electronic one. He’s a convert and explains Your Next Stethoscope Should Be Electronic. Here's Why.


Bottomless Pits + No Wits = Champion Eaters

A world-class competitive speed eater can put away 60 hot dogs in 12 minutes or 100 hamburgers in 8 minutes. Where do they put it all? (And why?) A recent peer-reviewed radiologic study sheds some light on what it takes to be a champion chomper. The Samuri Radiologist from Not Totally Rad, explains it all on the post Radiology of Competitive Speed Eating


Waiting for India on My Lap

Ian Furst over at Wait Time helps health care providers to decrease wait times and delays. He submits India's Health Care System which looks at the private/public divide in India's Healthcare system and the lessons we might learn in North America.

While you’re on his site, scroll down to Things to do while waiting at the doctors office. Shocking! There is probably some business opportunity in there somewhere.


Is Your Name on This List?

InsureBlog's Bob Vineyard is naming names. He confirms the explosion in diagnoses of ADHD and Bipolar Disorders among children, and names some of the doctors that are fueling the fire, and their payments from drug companies. Drug Money.


Wave of Bad Information Kills Web Surfer

I was impressed with the fact that Dr. Val and the Voice of Reason really is a voice of reason. This week, she writes on How Is Healthcare Like A Garden Fungus?, and points out, “Medicine is incredibly complex, and that a knowledgeable healthcare provider is critical in helping patients successfully navigate the maze. With all the health information on the Internet, it's tempting to self-diagnose. But that's a dangerous proposition - one that might lead you to presume that (to use my analogy) a poisonous mushroom is edible, or that a life threatening symptom is innocuous.”


“Art, this is Death. Say Hello.”

Talk about creative, Christian Sinclair and team have launched a new blog, Pallimed: Arts & Humanities, where palliative care meets the humanities. The underlying concept is that both death and art have been around forever, closely linked to one another. Christian submits a post about a song that discusses dying in the ICU. Included is a video representation of various instruments representing a death in the ICU. (Cool!) Check out, "What Sarah Said" by Death Cab for Cutie: "This presence at the bedside of a dying person can be a demonstration of your love, but it can also tax and exhaust family. A variation on this line ("Love is watching someone die") is occasionally heard from palliative care professionals to allow family credit for the 'work' involved in being present at the deathbed.”


Cool Kid Reject ADHD in Favor of Bipolar Disorder

Did you know that 500,000 children and teenagers were given at least one prescription for an antipsychotic in 2007, including over 20,000 children under age six? What I want to know is, why didn’t anyone tell me? A half-million prescriptions, and not a single one of my four kids was offered the stuff! I feel gypped. Dr. Zhang who is the author of the book, Coackroach Catcher, writes about Bipolar Disorder in Children at Cockroach Catcher Blog. "ADHD was the old black. Bipolar became the new black."


Renegade Diabetics Take Charge of Own Disease

Amy Tenderich hosts the blog, Diabetes Mine, which is “a gold mine of straight talk and encouragement for people with diabetes.” She submits the post, Diabetes... RELOADED, which includes video footage of some of the activities of this group. I deal with diabetic eye disease all day long, and I was encouraged by the innovative vision captured in the post: “Our theme was "Diabetes Reloaded", which stands for redefining not only the role of technology in managing chronic diseases, but also for the newfound self-confidence and ambitions of 21^st century people living with health conditions. What’s special about this new web-enabled world of healthcare? It’s proactive, technology-based, empowered, revolutionary, against all odds, and – if needed – outside the establishment.” The blog is a 2006 Winner of LillyforLife Achievement Award for Diabetes Journalism. Congratulations, and keep up the good work.


Patient Prescribes Own Drug. Doctor Does Own Taxes.

And if the internet weren’t bad enough, people are now taking the next step:
picking up the phone, and telling doctors what to prescribe for them.
Read about this wacky patient’s expectations over at EverythingHealth


Got Munchausen’s? AMA Has Jobs Available

Did you realize that the next patient that walks into your office could be a fake, commissioned by the AMA to check the quality of care you provide? David Williams at Health Business Blog delves into the controversy, Do we really need mystery shoppers in health care?


Pharmacist Sleeps with Drug Researcher; Takes pill to blunt remorse

This doctor has one of the best named blogs ever: The Blog that Ate Manhattan. She takes on Big Pharma yet again, this time noting that Care/CVS seems to be in bed with Bayer. She parodies the "Dear Doctor" letter used to get new drugs to the medical community. A very interesting discussion in the comments section, in particular the input of a Pharma commenter who tells it like it really is in the business of making and selling drugs.CVS/Caremark – Detailing for Bayer?


Blame Informed Patient on Doc Gurley

When your next patient comes in and has a normal fasting blood sugar, then insists that you order a HbA1C, will you wonder why? It’s because they read Doc Gurley’s post, Blind Men and the Diabetes Elephant. She takes a look at this week's mammoth-sized news in diabetes research. Like the fable of six blindfolded men who tried to describe an elephant ("it's a snake!" "it's a tree!"), lots of news reports only got hold of one isolated piece of the action. Her post shows how three different news items, when viewed together, take on pachyderm-sized importance for all of us - diabetics or not.


Poor Ethicist Gets Spanked by Doctor Rich

The Right Way to Think About Medical Ethics, appears on The Covert Rationing Blog. In this post I take medical ethicists to task for promulgating a new utilitarian system of medical ethics that is a) absurd, and b) destructive; and, not wishing to leave the poor souls completely adrift (which would be unethical), Dr. Rich kindly offers for them a system of ethics that both honors the needs of society, and restores the classic doctor-patient relationship.


End Years of Debt-Free Living: Go to Medical School

Why do so many doctors struggle financially? Theresa Chan posts MEconomics, Part Two: The Long Reach of Med School on her blog Rural Doctoring. "Part Two of this series on physician compensation and my personal bottom-line addresses where all the difficulties begin: with medical school debt. Let's walk through the process of accumulating educational debt and estimate whether the published averages tell the whole story."


Cheech and Chong Appointed to Judiciary

Have I been away from America so long that I missed the legalization of medical marijuana? When do you prescribe marijuana? When not?. Theresa Chan at Rural Doctoring shares her opinion in 15 Minutes of Fame: Medical Marijuana in Rural, CA. "For the record, I support medical marijuana use for those patient populations for whom it was originally intended: for cancer and AIDS patients, in order to suppress nausea and promote appetite, and modulate pain symptoms. I have worked with these patients as a physician and a hospice volunteer, and I do believe marijuana is helpful for the nagging symptoms of people facing the end of life. However, I do not believe that marijuana should be recommended generally for chronic diseases such as…” Read the post to find out more.


Man’s Jokester Friends Name Womb Disease After Him

Dr. T posts on "Asherman's Syndrome" which is a condition related to scarring of the intrauterine cavity, usually as the result of a failed pregnancy and a D&C in the presence of infection; or another intrauterine surgical procedure, that causes hypomenorrhea or amenorrhea, infertility, and recurrent pregnancy loss as well as other pregnancy complications. It is more common than most women realize.


Ferret Diagnosed with ADHD; Parents overjoyed

This is actually a very important post. David Rabiner outlines Promising Cognitive Training Studies for ADHD. "Results from these two cognitive training studies highlight that cognitive training interventions may provide an important complement to traditional medication treatment and behavior therapy. Both studies included appropriate control groups, employed random assignment, and had outcome measures provided by individuals who were "blind" to which condition children were assigned to. They are thus well-designed studies from which scientifically sound conclusions can be drawn. They add to the growing research base that intensive practice and training focused of key cognitive skills can have positive effects that extend beyond the training situation itself."


One Should Always Have a Penguin When Needed

I didn’t even make that headline up! It’s the description of the blog, Prn Penguin. I will now start contemplating when a penguin might come in handy. In this outstanding and comprehensive post, the author gives a detailed overview of How to survive your practicum placement as a nursing student. It is also useful information for medical students, job applicants, and humans of all varieties.


That Dang Medical Records Department

Home of the Brave submits Where Are The Ellis Island Hospital Medical Records? Did you know that Ellis Island had a premier large scale hospital and contributed to major public health advances? Help solve one of its tantalizing mysteries by searching for its missing patient records and registration logs. Ten thousand patients, 3500 deaths and over 300 births, plus countless successful treatments and discharges to a new world and new lives are a testament to the hospital and its USPHS physicians and nurses.


Four out of Five Doctors Smoke Camels. (The other one smokes goats.)

I learned something by visiting Peter Zavislak’s blog, Medical PasticheI learned that a Pastiche is a pie made of many different ingredients. I did not know that. The purpose of his blog is to present medical economic analysis, personal experiences within the field of medicine, somewhat-interesting medical factoids, and slightly-humorous tongue-in-cheek medically-themed comic relief. You can find all of this in his post, "'What Cigarette Do You Smoke, Doctor?'", which looks at advertising in the 1950’s.


ER Nurse Strikes Patient

“She was telling me a story about one of her grandchildren when she stopped mid-sentence and said "oh" followed by seizure like activity. I was stunned into immobility for what seemed like an eon but really was only a second. The monitor showed v-fib, a lethal heart rhythm where the heart quivers like jello without pumping any blood. Basically the patient in v-fib is dead and will stay there unless something is immediately done.” Read more about what comes next at ERnursey, under the title, When the Precordial Thump Works


Controlling Your Urge to Control

Laura Edwards is “a 28-year-old writer and college writing instructor trying to balance multiple chronic illnesses (PCD, bronchiectasis, celiac disease, etc) with, you know, the rest of my life.” She submits In Control which explores the relationship between control and chronic illness.


Coke Shares Plummet; Rival bottles water

Nancy L. Brown, PhD writes about Sugar and Soda Free Summer. "The SF Bay Area is gearing up to have a "Soda Free Summer!" Six counties are being encouraged by the public health department and many community-based organizations to learn about the health risks associated with soda consumption and help families avoid soda."


Uninsured Mob Threatens National Security

“So now in addition to 47 million people without any health insurance at all, there are 25 million more who have health insurance but don't really have access to health care because they cannot afford to pay the high copays and deductibles on their policies. So all told that's 72 million Americans who are likely to skip routine health care and recommended non-emergency treatment because they don't know how they'll pay for it.” Read more about this outrage at Colorado Health Insurance Insider’s post, Number of Underinsureds Rising Rapidly


Canada and Australia are Different Countries?

I once made the mistake of telling an Aussie that I thought he was from Canada. He never called me "Mate” again.v(What a relief.) No such luck for Vitum Medicinus, a Canadian medical student, who tells readers of his experience shadowing a doctor in Australia, and how medicine down under differs from what he's seen in Canada. Read about it at Vitum experiences medicine down under!


From Pulp to Electrons

Are you thinking of converting to Electronic Medical Records?DrPenna discuss about advantages and disadvantages of Electronic Medical Records and his experience using them in his hospital.


Serious Feelings

“Few things in medicine are harder than trying to explain to a patient that you don’t understand what is going on.” Thus begins The Mormon MD's post, My Entire Life, where he writes, ” The art of medicine is learning solutions that don’t always involve causes. Beyond that, patient’s are not as passionless and rational as textbooks. This can be a hard thing for a scientist. After all rationality is the only virtue that matters in science. Emotions will only get in the way. On the other hand, The doctor patient relationship is deeply complex, much more that say, mechanic and automobile, or scientist and experiment.”


More Serious Feelings

In Sickness & In Health is a place for couples going though an illness experience - to find resources and advice, hear stories, and discover support. Whether the illness is chronic or acute, the result of disease or accident, couples can learn strategies for coping with the changes illness brings into our relationships and our worlds. The information provided in this blog is for educational and support purposes only. It should not be used as a substitute for seeking professional care. This weeks submission, How to Have the Hard Conversations discussed how to stay connected to your sweetie when he/she wants to go to the movies and all you want to do is lay down in a dark room with a heating pain?"


Vermox Stockpile Available

Frankly, I’m relieved to learn that Global Warming is occurring. All this time, I thought it was Global “Worming,” and was preparing for that. Fortunately, medical student Thomas Robey has a better handle on things. At Hope for Pandora, he has been considering how the lowest rung on the medical hierarchy can reduce medical procedures' carbon footprint. His latest target is the operating room. He gives tips for Reducing and Reusing, if not Recycling in the OR. For example, "If you salvage the batteries from each suction irrigator used for ectopic pregnancy or cholecystectomy cases you assist with, you'll amass 10 hours of digital camera usage per irrigator, or put another way, a lifetime powering of remote controls per surgery clerkship."


Radical Canadian Editors Blog

The editors of The National Review of Medicine have their own blog. That sort of thing is apparently allowed up there in Canada. This week they discuss, Should we screen women over 70 for breast cancer? (Just don't mention "rationing")


Neurofibromatosis Headlines Are Tough to Write

alter Jessen at Highlight HEALTH briefly reports on the 2008 Children's Tumor Foundation Neurofibromatosis (NF) Conference, the preeminent annual meeting of NF researchers worldwide, and describes the three distinct types of neurofibromatosis. Neurofibromatosis: From Genes to Complications to Treatments


Neighborhood Masochist Buys New Suit

Apparently, someone has developed a suit that mimics the pain of osteoarthritis.Read about it at Simulation Suit To Feel the Pain of Osteoarthritis . Visit the blog, The Fitness Fixer “to see how to move in healthful positioning so that your exercise is healthy rather than injurious. You don't need to get treatments, or adjustments, or surgery, or shots, or medicines. It is a win-win situation where you do not have to give up favorite activities, and can become healthier than before. Just use healthy movement as part of normal daily life and get free exercise, better physical abilities, and stop the processes that cause injury, all at the same time.”


D is for Depression

Vitamine D for Depression in the Elderly? Dr. Shock points out that a large population-based study found an association of depression status and severity with decreased Vitamin D (serum 25(OH)D) levels and increased serum parathyroid hormone (PTH) levels in older individuals. Causes of vitamin D deficiency in the elderly are: less sun exposure as a result of decreased outdoor activity, different housing or clothing habits, and decreased vitamin intake. The question remains whether the vitamin D deficiency is secondary to depression, or is depression the consequence of poor vitamin D status.


Cut from the Same Clot

The folks at Clinical Cases and Images - Blog submit Video Interview with Tim Russert's Doctor -- Cause of Death Was a Fresh Clot in LAD. The site also has useful information on studying for cardiology boards, the Mediterranean diet, and how to use Google Blogger’s schedule feature.


How to Get a Hot Body Without Resorting to Kidnapping

Crank up your metabolism, baby! Tara Gidus, who is the team dietitian for the Orlando Magic, gives 10 tips on increasing your metabolism (which is going to help you lose weight) at Turn Up The Heat


Stiff

Dean Moyer of The Back Pain Blog shares a response to one reader's question about Mysterious Morning Neck Pain. In this post he attempts to reassure his readers that most neck pain is not serious and gives them some guidelines for what they should do about it. For example, "… the most common cause of neck pain is muscle or ligament strain ... In most cases the pain will subside within two to ten days without medical attention. However, if it lasts longer than that, you should see your doctor."

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Thanks again, everyone for your outstanding submissions. Join the gang next week for Grand Rounds, hosted by My Three Shrinks. The theme will be the upcoming iPhone 3G.

Saipan Sunday

We gathered at the beach yesterday evening to welcome Angelo's mother, Donna, back to Saipan for a visit, accompanied by Jim and Katie and Kevin. It was a typical Saipan event, in that two dozen people represented half-a-dozen nationalities and ethnicities. I love this place.

Arman spent the afternoon with his new buddy, Norman, learning the intricacies of Chamorro grilling. There's the half-eaten hotdog to prove it.

Walking on the sandbar with Kian.

A slightly below average Saipan sunset.

Friends watching the sunset.

Angelo and his mom. (This is actually Brad and Kat, who are more interested in my camera than the sunset. I didn't take a single picture of Angelo or his mom, so this one will have to do.)

The bonfire to end the day.

Back home, bikeless

I'm back from a few days in Guam. Most of my friends in America don't have to get on a plane to see an orthodontist, but that's the way it is on Saipan. I took Arman over for some orthodontic work, and Nava tagged along. We had a nice time staying with our friends, the Johnson's, and had a chance to get together with many old friends, as well as eat some fantastic Persian food.

We bought bikes for the two older kids, and I found out that if you want to put a bike on a plane, you have to have a box for it (or buy one from the airlines for $30); you have to be able to put the bike in the box which requires having the tools to take off the pedals and the front wheel; and you have to pay another $30 to get it on the plane. Given this combination of impediments (we rode the bikes up to the checkout counter), the bikes are still in Guam.

Saipan's Flirts with Third World Status

In his book, and The End of Poverty: Economic Possibilities for Our Time, economist Jeffrey Sachs points out,

When the preconditions of basic infrastructure (roads, power, and ports) and human capital (health and education) are in place, markets are powerful engines of development. Without those preconditions, markets can cruelly bypass large parts of the world, leaving them impoverished and suffering without respite.

Let’s take a closer look at this dense statement, that gives a very simple formula for economic success of a people. Development requires the combination of human capital (which consists of two parts – health and education) and basic infrastructure (which consists of three parts – roads, ports and power). Here on Saipan we lack reliable power, and therefore, we simply lack one of the key elements required for development. The lack of power is not just an inconvenience. It changes our status as a developed jurisdiction

Yesterday, at our home we had over five hours of unannounced power outages spread throughout the day. One came during mealtime, another just as we were getting children to bed. We were unable to cook, and our children cried as they tried to fall asleep in the sweltering heat. This is not a scene that you expect in a developed place, especially when it happens daily, as it is now. Power is part of basic infrastructure, and without it, there is limited opportunity for our markets to develop. I hate to say it, but our protracted power problems now bring us into the company of most third world countries. Our power situation puts us in a particular category of underdeveloped nations, and market opportunities cruelly bypass us.

Marine Monument Dies

I'm going to predict that the proposed Marianas Trench Marine Monument in CNMI has effectively been killed. After reading the story in today's Saipan Tribune, I don't think President Bush will give much attention to the Marianas. A variety of local government officials here have voiced their opposition to the idea, while no one at the same level is voicing support. Meanwhile, other jurisdictions are clamoring to have a monument designated in their area. If I were the President (or one of his advisers), I'd recommend taking the path of least resistance. Why fight with the CNMI?

As far as I can tell, the resistance to the monument ultimately comes down to a certain psychological stance that is explained in Bornstein's How to Change the World (who is quoting from O'Toole's Leading Change).

Resistance occurs when a group perceives that a change in quesiton will challenge its "power, prestige, position, and satisfaction with who they are, what they believe, and what they cherish....The major factor in our resistance to change is the desire not to have the will of others forces on us."

Green Power in Saipan

It's been a year or two since the "Green Power" law was passed. Basically, it allows for a concept called "net metering." There are two basic ways people use alternative (solar/wind) power. First, you can buy the power generating stuff -- solar panels, windmills -- and buy batteries that store the power generated, and use it when you need it. There are a couple of difficulties with this. First, the batteries are really expensive, so cost goes up. Second, you have to generate enough power to meet your demands. This is the method people use to live "off the grid." You generate and store their own power.

The other method is "net metering." You buy the solar panels or windmills, but your house is still connected to the utility. The power you generate is gets fed into the city power grid. If you don't generate enough to meet your needs, you get the extra you need from the utility. If you produce more than you need, you feed it into the grid for others to use, and the utility pays you for the power. The excess feeds through your meter and runs your meter backwards, thus the term "net metering". With this method, you use the grid as your "storage" so you save the cost of batteries. Of course, without storing the power yourself, when the CUC power goes out, yours does too.

The fact that we have this net metering law opens some huge possibilities for the consumer to bring down the power rates and also to contribute to power generation for other customers. The glitch for us has been that although the law has been passed, the regulations that define the practicalities of implementing the law have yet to be written.

I fired off an email to an undisclosed source close to the issue to find out about the status of the regulations. Here is a summary of the reply I received. It looks like we're getting close.

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The net metering regs are being drafted right now. They are a blend of regs from a US green power NGO and 3 or 4 states. The adminstration is committed to making net metering happening, so that the private sector can help CUC meet its customers' needs cost-effectively and reliably. Oil will soon become unaffordable to small markets like the CNMI. We will need the sun, the wind, the ocean and geothermal resources to power our lives.

The consumers issues will be, of course, cost/revenue and reliability (both of your system and CUC). The regs should lock you into revenue of 1/2 the price of power at the time you install the solar. Solar is relatively expensive, but, when installed correctly and maintained (so the panels are clean and connections are protected from the salt air) should last for 10-20 years.

1. The kwh. As you may know, solar panels don't start working at 100% capacity the day you install them. The solar capacity increases to manufacturer's specs over a couple years, then slowly, slowly degrades over time. So, if you are figuring revenue, you will multiply an average output percentage times manufacturer's spec times "availability", or the number of hours per year expected of the "insolation".

2. The rate. You will want as much guarantee as possible that the rate you sign up for is the one you get. One argument from the statute is that your rate will vary as the CUC's rates vary. That means that if oil gets outrageously expensive (it's at $127/bbl now and on its way to $200/bbl by year end), our rates will increase past the 26 cents/kwh we now pay just for the oil, and you will like the variance. (Overheads, operations and maintenance and debt service typically cost about another 8-10 cents/kwh.) If we discover geothermal sources on Saipan, however, the bulk of our power will cost less than 10 cents/kwh total. You won't like that, because you will have paid for expensive solar and CUC won't be paying you very much back.

3. Rate stability. One way to make this all stable is through the regs. Another way is through a contract. The law will protect you better from the Legislature's rate orders for rate decreases if you have a contract. Ordinarily regs are a strong way to protect a customer, but a new statute trumps regs. Also, someone might argue that the CUC's interpretation of PL 15-87 to allow long term stability will stretch the statute's terms.

4. Another consideration for you is batteries. With solar, of course, you are unlikely to generate enough power during bad weather to run your house. And CUC may not be reliable during a supertyphoon. But batteries can easily double your investment. Many people use their utiltiy company as the "battery", relying on their own power when the sun shines.

If cost is not a big issue with you, you will want to buy a system that makes you energy independent -- oversize it, so you never peak in excess of your capacity, and use batteries. Of course you will also purchase very efficient mechanicals and appliances and superinsulate your home, and design a home that orients properly to the sun and the wind. These strategies provide you with much more value than buying the solar panels.

ONLY if there is an active group of potential green power producers examining the draft regs and contracts will you wind up with something satisfactory.

Retinal Physican Blurb: Our Man in Saipan

I'm not sure why I seem to be bursting upon the national scene at the moment. There was the recent interview by Ophthalmology Times, and now this piece that appears in Retinal Physician. There is also an upcoming story in Ophthalmology Management.

I'm trying to raise some money for a scholarship fund at Brilliant Star School, to allow low income children on Saipan to attend the school, so I'm hoping that the stories will lead to some benefactors. In any event, it seems to be my fifteen minutes of pseudo-fame. I can't say "fame," because, after all, these may be international magazines, but really, they're ophthalmology publications. In the Retinal Physician magazine, I'm wedged between stories titled "Antecortave Acetate Has New Target" and "OPKO Gets Key Patent for siRNA Drugs." The subtitle of the second piece is -- and I'm not making this up -- "But Controversy Erupts Over siRNA Concept." That context very nicely sums up the level of my fame.

I recently found out that the title of the story is a play on words from a 1970's sitcom called "Our Man in Rataan" about a journalist assigned to a god-forsaken post at the ends of the earth.

The best part of the story is where they refer to Marianas Eye Institute as "one of the best-equipped eyecare practices in the Asia-Pacific region." That's something Saipan can be proud of.

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Our Man in Saipan
Dr. Khorram Finds His Tropical Island

David Khorram, MD, who received his retina training during residency at Northwestern University under Lee Jampol, MD, is the only ophthalmologist on the Pacific island of Saipan. Dr. Khorram passed up a retina fellowship because he wanted to practice in a part of the world that had a great need for an ophthalmologist. After doing some research, he chose the Pacific islands, and after a year practicing in American Samoa, he made his way to Saipan.

Over the course of the past 15 years, Dr. Khorram has built the Marianas Eye Institute into one of the best-equipped eyecare practices in the Asia-Pacific region, providing a wide range of both retina and general ophthalmology procedures.

He is also active in civic activities on the island, writing a weekly newspaper column and organizing a national soccer team [I think this is a reference to being a founding board member of NMIFA]. He recently published a collection of his columns in a book titled, "World Peace, a Blind Wife, and Gecko Tails" (available through Amazon.com). Dr. Khorram and his wife, Mara, have four children ages 3, 5, 7 and 9.

Dr. Khorram reports that he sees "a ton" of diabetes-related eyecare problems but almost no cases of macular degeneration, which he attributes to the island's relatively young population as well as genetic factors.

Saipan, which is located about 120 miles north of Guam, is the capital of the United States Commonwealth of the Northern Mariana Islands and has a population of approximately 60,000, many of whom are contract workers and not permanent residents.

The island was the site of fierce fighting in World War II as the United States established a base on Saipan for B-29 bombers that could reach the home islands of Japan.

Marine Monument Activities

Folks are in town to educate the community on the proposed Marine Monument. Here is the list of upcoming activities.

Tuesday, May 20^th, 11:45am – Hyatt Giovanni’s Restaurant

William Aila will speak to the Rotary Club of Saipan

Tuesday, May 20^th, 5pm-6:30pm – Hawaii Bar & Grill, Garapan

Meet & greet for Jay and William to meet project supporters

Tuesday, May 20^th, 7:15pm – American Memorial Park Auditorium

Presentation to Saipan Fisherman’s Association by Jay Nelson with special guest William Aila

Wednesday, May 21^st, 7:00pm – John Gonzales Show, KSPN Channel 2

General introductions and project information the first half-hour followed by a call-in Q&A in the second half hour

Thursday, May 22^nd, 7:00am – KZMI Radio Talk Show with Harry Blalock

General introductions and project information with Jay Nelson and special guest William Aila

Thursday, May 22^nd, 6:00pm - American Memorial Park Auditorium

Presentation to general public by Jay Nelson with special guest William Aila

Jay Nelson

Director - Global Ocean Legacy for Pew Environment Group. Ocean Legacy originated as an outgrowth of work done by Pew in 2005–2006 to support the creation of a fully protected marine reserve in the northwestern Hawaiian Islands. Partners supporting Ocean Legacy include Pew, the Sandler Family Supporting Foundation, the Oak Foundation, and the Robertson Foundation. Inspired by this success, the Pew-managed Ocean Legacy project is dedicated to establishing, globally, over the next decade, at least three to five large, world-class, no-take marine reserves. Ocean Legacy marine reserves will provide ocean-scale ecosystem benefits and help conserve our global marine heritage.

William Aila

William is a long time harbormaster on the Waianae coast of Oahu and commercial fisherman. He is well-known as an advocate for indigenous Hawaiian rights works closely with the group Na Imi Pono. In 2006 he ran for Governor of Hawai'i in the Democratic primary. William was intimately involved in advocating for the protection of the NW Hawaiian Islands for Native Hawaiian cultural and religious reasons from the late 1990's through today. He remains active in decisions about the management of the NW Hawaiian Islands today. William is very familiar with fisheries management in the Pacific through his more than ten year’s service on various Wespac advisory panels.

Netfilx works for Saipan

After the movie theater closed, and we started having more trouble getting movies at the video rental shops, we joined Netflix and have been getting our DVD rentals mailed to us.

I'm a big proponent supporting our local businesses, but when the service fails me, I go elsewhere. At our "one week rental" place, the videos are always out because someone else has them for the week. I'm not sure I understand the business model. And our mom and pop video store recently went nutty. The last time we returned a DVD, the clerk insisted that we had returned it in a different case. We returned it in the same case we got it in, complete with all the labels and bar codes, but for some reason she insisted we peeled these labels off of the original case and affixed them to the case we were now returning them in. "Why in the world would we do that?" "I don't know, but I know you did." "Listen, why don't I just pay you for a new case. It's like two bucks, right?" "I don't the money, I just want the truth." And the next couple of times we went in, she gave us the "tsk tsk" for having pulled some sort of a case switcheroo. Life is weird enough without gettin silently scolded every time you go to rent a DVD, so we looked to Netflix.

Netflix works great. You pay a monthly fee, they mail DVD's to you, and you mail them back whenever you're done watching them -- no due date. There are no shipping charges, and they include a mailer to send it back to them. You just open an account with them, create a list (or queue) of movies you want to receive, and as soon as they receive one back from you, they mail the next one out. They mail out of Honolulu, so the total turn-around time to Saipan is about 4-5 days.

The monthly fee varies depending on how many DVD's you want out at a particular time. If you get one at a time, it's around $5.99 per month.

I love it. We are watching some classics that the kids are really enjoying and that you just can't find here, like The Princess Bride, and Big. Any time I hear of a good movie, or see a preview that I like, I just add it to my queue. It's because of Netflix that I know I'll be watching Gandhi next week. You can browse by genre -- Drama, Comedy, Foreign, Documentary, etc. They also have nice collection of TV shows on DVD.

It's another option for cheap entertainment here on the rock.

Lower Back Pain on Mother's Day

I've been flat on my back for about five days now. I'm not sure what I did, but my lower back has been killing me. I tried to ignore it for a while, but it's been pretty loud. For the past two days, I've been getting up minimally, like just to eat. The ice is helping, and I'm taking ibuprofen around the clock. I had a similar episode about two years ago, and managed to get long-term relief with some core strengthening exercises (Pilates). But, man, when a body gets to be 40 or so years old, it takes active work to maintain it.

I did get up yesterday and headed to the Hyatt for Mother's Day brunch. It's still the best Sunday brunch on the island, combining great food, beautiful atmosphere, and good company. But over the years, the price has gotten really high, and our family has gotten really big. So, we hadn't been for five years, or so. It was an opulent experience, and I even ate flesh from some formerly-living animals. (I don't want to say "dead" because that would be too graphic.) It was good. Savage, but good.

The end of an era, the beginning of a new one...

President Bush signed the "Federalization" law. The Commonwealth of the Northern Mariana Islands will no longer control it's own immigration, and we will come fully under the US immigration system.

The repercussions are not yet fully known, but lots will change, for sure.

Various statements from members of Congress regarding the signing of the law can be found here.

Movies, Power, Federalization and Pew

(My Saipan Tribune column for this week.)

Well, it’s been a newsworthy couple of weeks. The closing of Hollywood Theaters has definitely put a damper on spirits, even for those who never went to the movies. Its presence made us feel like a part of the “civilized” world. I was in Guam earlier this week, and when people asked me “How are things on Saipan,” the best way to sum it up was to say, “Our only movie theater just closed.” People immediately understood, and shook their heads in disbelief. Yes, things are bad, and “consumer confidence” is dwindling.

People would ask me what I think needed to be done to improve things, and really, I don’t think there is an easy solution. Certainly, we need a reliable utility. But we don’t control the price of oil, and it’s predicted to climb from its current level around $100 a barrel, up to $200 a barrel within the next year or two. Repairing the power plant can give us reliability, but it might not prevent the cost of power doubling. How can we cope with that? Alternative energy sources such as solar and wind power are simply not cost effective, however, they may become so as the price of oil rises.

Certainly another area that still needs improvement is government waste. We’d have more money available for various public services if waste wasn’t present. And honestly, much of that waste is related to power. Anytime I visit a government office, I take a jacket with me, because I know I’m going to be cold. It’s still beyond me why we don’t just adjust the thermostats around here.

A couple of years ago at the energy symposium that was sponsored by the Chamber of Commerce, one of the presenters told the story of a utility in California that was meeting increasing demand for power and was faced with building a new power plant. They analyzed the situation and realized that it would be more cost effective for them to hand out free energy saving light bulbs so that every home and business would convert to the compact fluorescent technology. It cost the utility money to give away the bulbs, but it saved them the expense of building a new plant. Just an idea that might help address a piece of our current problem. But honestly, there is no silver bullet.

Tourism is generally holding steady, but it’s clear that with rising travel costs, we cannot expect to see a significant rise in the coming months. There are no new industries, and we’re scratching our heads wondering how we can stimulate the economy, attract investors, create jobs. But we’re not alone. I take some consolation that at least the entire globe is flirting with recession.

And of course there is federalization. Whether you were for it or against it, it’s now a done deal, and though it’s certain that it’s going to happen, we don’t know what it’s impact will be. There will be things that some of us like about it, and things that we dislike. It will require the passage of time to sort it all out.

A ray of hope that was on the horizon was the proposed “Sanctuary at Sea”. Forget about all the arguments about more jobs, more tourists, and more federal money. Certainly those are beneficial outcomes. But for every good thing, someone else can give evidence of some possible bad outcome. Arguments at that level of “what can we get out of it” can go on forever. I felt that the monument was simply the opportunity, perhaps never to come our way again, for us to have the privilege of giving a gift to the world. The practicalities will work themselves out, if the desire is there. Let’s set our gaze outward, and into the future, and think of this as a gift worth giving to humanity. “Why should I? Maybe there are diamonds there for me! Maybe there are fish there for me!” Maybe. Yet, maybe, we can rise above these “me” centered concerns and think of leaving a legacy. Maybe centuries from now, we will be remembered in human history for our foresight and generosity in preserving a piece of the planet that increasing population pressures will threaten. The “Monument at Sea” is an opportunity for us to leave a positive mark, to create a positive image. And for people that care about being respected, that’s worth more than diamonds. It’s an opportunity for us to live up to our heritage as people of the land, people of the sea, people of the planet for whom we’ll serve as trustees. The monument is a small ray of hope that doesn’t solve all the problems we face, but it is something that lifts the spirit. And I have a feeling that with the myriad challenges sure to mount, it will be our spirits that guide the way.

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David Khorram, MD is a board certified ophthalmologist and director of Marianas Eye Institute and the author of the book, World Peace, a Blind Wife, and Gecko Tails. Comments and questions are welcome. Call 235-9090 or email him through www.MarianasEye.com, or leave comments at www.MarianasEye.blogspot.com. Copyright © 2008 David Khorram

Ophthalmology Times Interview

A few weeks ago I was contacted by a writer from Ophthalmology Times, a biweekly nationwide publication that goes to every ophthalmologist in the United States. They wanted to do a story about me -- you know, guy in the middle of nowhere. The story is up on their website. Click here to read the article. I didn't realize how much of the story would be about blogging.

(Edit: Actually, I'm posting the article here in case it disappears from their website.)

Practicing ophthalmology in Saipan

Apr 15, 2008 By:Noelle Creamer Ophthalmology Times

David Khorram, MD, meets many ophthalmologists who wish they could work internationally and make a difference in a society that needs their expertise. Some travel for a week or two every year and find opportunities to help around the world. But Dr. Khorram is living the dream.

He is an ophthalmologist in private practice on the island of Saipan in the South Pacific.

Finding his island

Dr. Khorram grew up in Kentucky and attended Northwestern University, Chicago, then the University of Kentucky for medical school, and then returned to Northwestern for his ophthalmology training.

"This was a very exciting time, and although I had the opportunity to pursue a career in academic medicine, my heart was set on serving a community that needed an ophthalmologist," said Dr. Khorram. "I had always wanted to serve internationally, so I sent letters all over the world, and ended up in the Pacific."

He spent a year as the director of ophthalmology at the Lyndon Baines Johnston Tropical Medical Center in Pago Pago, American Samoa, before going to the Commonwealth of Northern Mariana Islands (CNMI). For his first 5 years in Saipan, he worked at the Commonwealth Health Center before co-founding Marianas Eye Institute in 1998.

Different needs

Running an eye institute on this tropical island is different from doing so in the United States for several reasons, explained Dr. Khorram. "There are no subspecialists nearby for me to refer patients to," said Dr. Khorram. "I'm the only ophthalmologist serving the island. So when something needs to be done, I'm the one to do it.

"I handle a much broader range of cases than I would in the States," he added. "Many people here delay eye care, so I see a lot of end-stage disease. A good chunk of the cataract surgery that I perform is on white lenses. Diabetes is rampant, and a lot of people walk in the door for the first time with a vitreous hemorrhage."

The demographics of the island distinguish the practice, too. Dr. Khorram explained, "There is an indigenous population of about 20,000. People die young, often in their 50s. The rest of the population is made up of young, healthy contract workers from Asia who don't access health-care. I'm doing about 80 or 100 cataracts per year. That's just all there is on the island. Minimum wage is $3.55 per hour, and the average annual income on the island is around $11,000. So there isn't any significant disposable income for people to spend on the elective facets of eye care, which, from what I understand, is driving American ophthalmology—refractive surgery, presbyopic correcting IOLs, and cosmetic procedures. We provide a lot of free care and a lot of indigent care.

"Yet, I love my work because the people I serve are extremely appreciative," said Dr. Khorram. "Economics are obviously not the driving force behind working here."

A wired practice

Technology plays a huge role in Dr. Khorram's practice—in part because he values it and in part because his remote location demands it.

"I think our level of technology is probably not typical for even U.S. mainland practices," he said. "When ophthalmologists from Japan, Australia, and the US have passed through and visited our office, they have commented that the combination of technologies in our office far surpasses typical comprehensive ophthalmology practices in their countries.

"For example, because the people here are more visual learners than verbal learners, we have digital cameras attached to our slit lamps, which project images onto computer screens in the exam rooms. The families can watch the exam, and we can freeze the images and explain to our patients what is going on with their eyes. The pictures make sense to them, and the education helps them understand their condition.

"I'm also an early adopter of new technologies. Even though I'm in the middle of nowhere and not very busy, I still want to practice first-world medicine. Because of the technology, we probably look more like the sort of practice you'd see in an academic center, rather than in this tiny practice on a far-away island. We need the best in diagnostic equipment, because if we don't have it, it isn't available down the street.

"I also rely on telemedicine quite a bit. When I have a challenging case, I send the [images]—OCTs, retinal photos, anterior segment photos, visual fields, fluorescein angiograms, you name it—via the Internet to friends around the country. The digital imaging technology makes this possible. And my friends are a great help."

More than an ophthalmologist

But this cutting-edge practice is only part of the story, part of what sets Dr. Khorram apart. The rest of the story centers on the fact that Dr. Khorram has come to realize that who he is as a person is much richer as a result of his interests beyond his profession.

In addition to being an ophthalmologist, Dr. Khorram is a husband, a father of four, writer, blogger, stand-up comedian, coach, and more.

"Because the population of the island is relatively small, I'm not very busy. It leaves me a lot of time to pursue other things," he said.

In his blog Marianas Eye, he writes widely about daily life on Saipan, his practice, his travels, family life, politics, religion, history, geography, even the "wacko of the week." He shares beautiful photos of friends and scenery and—also a popular feature—the "gory eye" pictures.

He writes a weekly column for the local newspaper, and his first published book, "World Peace, a Blind Wife, and Gecko Tails: Intriguing thoughts from an island on making life happier and healthier, and laughing along the way," is now available from Amazon and other retailers.

He is also working on a few other books. "One of them is a collection of stories by a few friends about day-to-day life on Saipan, and I think that will be the first one that's completed," he said.

"I'm a writer, so blogging is a way to capture random thoughts and experiences and let others read about them," Dr. Khorram explained. "With blogging, readers can give feedback. Sometimes the pieces that appear on my blog develop into parts of other writing projects. So, in some way, the blog is like a laboratory for my writing.

"My audience is made up of people on Saipan who just want to check in and see what's going on with me and what's on my mind. I also seem to have a following that's scattered around the globe, but mostly in the United States. There aren't too many physicians who are blogging, and certainly not many in the South Pacific, so it all makes for an entertaining story, I suppose. Quite a few people come to my blog via search engines, looking for some specific piece of information that happens to be on my blog."

Dr. Khorram said he is trying his hand at stand-up comedy, too, organizing and participating in a comedy workshop. "I'm enjoying it. It's an opportunity to focus on the funny things in life and to make people laugh. You can't ask for much more than that."

Another way to teach

Another interest of his is education. He and his wife, Mara, founded Brilliant Star School on Saipan in 2000.

"When our first daughter turned 1 year old, she seemed a bit bored at home," Dr. Khorram recounted. "We looked around the island for an enrichment program of some sort, but none existed. So, Mara and I started doing some research and came across the work of Maria Montessori. We had a friend who was a teacher at a public school and was ready for a career change, so we banded together to open Brilliant Star School as a not-for-profit toddler enrichment program.

"The program started with 12 kids. The families liked the curriculum and the philosophy behind it, and so each year, we added more grades. Our goal became to give kids on the island the opportunity for a world-class education. Eventually, the government granted us a public land lease and six buildings, which we renovated."

Now, the school is on a beautiful hillside campus with 7,500 square feet of classrooms. About 100 children represent some 15 ethnicities, from toddler age through sixth grade. Dr. Khorram and Mara continue to serve on the board of trustees but are no longer involved with the day-to-day management of the school.

"Our biggest challenge is that education, particularly high-quality education, is very expensive for the sort of incomes we have on the island," said Dr. Khorram. "We need to recruit dynamic teachers from the States and offer them competitive salaries, which is a challenge.

"Right now, I'm in the process of trying to find 100 benefactors from around the world who are willing to donate $1,000 per year, for 10 years or so, to help continue providing outstanding education to the people of this island, who otherwise might not have the opportunity. A thousand dollars a year is the sort of contribution that isn't much for a U.S. ophthalmologist, but in terms of the education it provides, it can change generations to come."

Homesick?

Dr. Khorram said he considers Saipan home now but does miss things from living in the United States.

"This may sound mundane, but I really miss the variety of fresh fruits and vegetables that are abundant in the United States. I miss things like fresh berries, varieties of lettuce, mushrooms, asparagus, things like that. When I walk into the produce section in a grocery store in the States, and see the abundance, I get choked up. We just don't have that here."

He added, "It's also hard being so far from my sister and her family. If we're lucky, we see each other once a year."

And, occasionally, he misses things such as live blues, trendy restaurants, the super store, comedy clubs, and fall weather.

But, he's happy that he doesn't own a suit.

"Seriously," said Dr. Khorram. "Most of what makes me different is that I took 'the road less traveled.' The differences are focused around having left the United States to practice international medicine—living out here in the South Pacific, exploring, and pursuing a variety of interests."

SurgeXperiences 19 - Surgery Carnival

I'd like to thank Jeffrey Leow, the Monash Medical Student down in Australia, who found my blog and invited me to host the 19 edition of SurgeXperiences, the worldwide Surgery Carnival. As anyone reading my blog can see, the practice of medicine is just one of the activities I pursue, and so I have never really wandered the blogosphere looking for medical blogs. But now, through hosting this Carnival, I've found that there are some really fascinating ones out there. It's also inspired me to write a bit more about my own medical and surgical experiences.

I designated the theme of this Carnival,"Funny Operating Room Moments," and there are quite a few of them here, but many are just entertaining posts about various facets of surgery and medicine, and, well, the human condition. I'm posting them in the order they were received. Here we go.

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One of the most fascinating surgery blogs I came across is from Israel, and belongs to The Sandman, an anesthesiologist in Tel Aviv. (The Sandman -- get it? Puts people to sleep.) I found two of his recent posts quite compelling. The first is a story of having an elderly couple in his office. Because he took the time to get to know them better, they shared with him their story of arriving in Israel after the holocaust on the ship that was at the center of the story of the historical novel, Exodus. His second post that I enjoyed shares his thoughts on the calm face that seems to often be present on people who die violent deaths. It's a graphic post, but gives a peek into the task of pronouncing a person dead. ("I now pronounce you dead.")

You can also browse through his blog and get a different perspective on the violence in that country -- as seen from the inside of an operating room. The Sandman did send a post for this Carnival, "It ain't over til' the fat lady sings" which points out the importance of making sure your patient is asleep when you think they're asleep.

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Jeffrey Leow forwarded a few links to save me time finding them, including A Lesson (Not Just a Joke) From an Orthopedic Surgeon posted at The Differential: Medscape Med Students Blogs. It’s a story by medical student Ben Bryer that describes the unexpected use of a hand drill (instead of a power drill) to fix a patient’s leg. It’s just like here in Saipan, where improvising is a way of life. In fact, there is a sign hanging on our OR wall (by the former chief of orthopedic surgery) that reads, “If you have to have everything you need to do the case, you probably shouldn’t be here.”

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All of us have experiences of non-nonchalantly almost killing someone. I almost did it when I was an intern and admitted a patient who was experiencing weakness. I tucked him in for the night, thinking we'd deal with the problem in the morning. The resident stopped by to see him an hour later and diagnoses Guillane-Barre syndrome, a rare disorder that causes paralysis and therefore stops breathing. If the resident hadn't stopped by, the patient would have been dead by midnight. It was a learning experience I never forgot. In How We Learn posted at The Differential: Medscape Med Students Blogs, Anna Burkhead describes witnessing a surgical resident's similar learning experience.

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Jeffrey also brought my attention to the post, Surgery and the Blowfish, again by Ben Bryner, who gives proof that we surgeons are way smarter than blowfish chefs. Find out why.

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Pimping. Do other professions use the word the way we do? In medicine, it refers to the endless series of questions that will come the way of a "junior" medical type, by a "senior" medical type. Most commonly, it is a hapless medical student getting pimped into oblivion by the attending physician (the "professor"). It's usually conducted on rounds or in the operating room, and it's rare that there isn't a gaggle of spectators present -- the whole medical team -- silent witnesses with downcast eyes, folder arms and beaded sweat. Pimping ends when either the pimper runs out of questions, or the pimped doesn't know the answer. And the pimper never runs out of questions. So, the session will conclude when you're wrong, which is why pimping never feels like it has a happy ending. If you have a sense of humor, you can get away with a lot, especially if you know the answer. Once during rounds when I was being pimped, the attending, while studying an EKG asked me "What is one of the clearest indications of an elevated blood potassium level?" I answered, "The word 'HIGH' next the the letter 'K' [the symbol for potassium] on the lab sheet." Jeffrey Leow directs us to How to Survive Pimping in the OR posted by Anna Burkhead, where she gives some useful tips.

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Sid Schwab, who like myself is the author of a book, has written about a tube at an unexpected orifice. For some reason, whatever the conversation may be, orifices seem to be fertile ground for a giggle. Sid's post is Snakes on a Pan, over at SurgeonsBlog.

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When people move to Saipan (the island on which I live) and work for the government, they typically rant incessantly about the problems with the system, as if problems and inefficiencies are unique to this island. I usually respond, "Dude, you haven't ever worked at a VA, have you?" Dr. Rob Oliver paints some accurate (and funny) pictures of life at a VA at his post VA Voodoo Economics - Krugman wrong on John McCain posted at Plastic Surgery 101.

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Dr. Oliver also presents Dumb laws and smart laws re. plastic surgery. It regards legislation in California that will require medical clearance for all plastic surgery patients. Believe it or not, I get medical clearance for all my cataract patients, mostly because here on the island, you can rarely get a straight story about someone's medical problems. I send them all to see their internist, and we find some interesting things (like blood sugars in the 400's, just walkin' around). It's best in my opinion to leave medical decisions up to doctors, not legislators. We get medical clearance when we think it's necessary. And we're generally a careful group of folks, particularly in America where a lawyer with a briefcase is only a stopped heart (or an inconvenient rash) away. Thank-you, Dr. Oliver.

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All stereotypes are based on some element of reality. In medicine, we all know the stereotype of the orthopedic surgeon ("As strong as an ox, and twice as smart.") Dr. Val Jones shares some excerpts from a talk by an orthopedic surgeon, which I honestly found refreshing. I like these guys. They're the surfer dudes of medicine. Check out her post at Revolution Health.

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"I was filming a nipple reconstruction..." Thus begins a "Tale of Two... " um, no, I'm not going to say it... thus begins a tale by Norwegian surgical videographer, The Sterile Eye, who presents Yo mammae! That sentence is sure to become a classic in medical blogging literature. I give Sterile Eye the "Call me Ishmael" Award (which I just created) for week's best opening sentence of a Carnival post.

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Dr. R Bates, a plastic surgeon and quilter in Arkansas (who, by the way, is married to a wonderful man) is author of Suture for a Living. She explains the surgeon's "druthers" card, in her post appropriately named, Druthers. Her post, She's a Beautiful Girl! , which comes complete with it's own music video (is that Dr. Bates on the drums?) tells the touching story of a young girl who gains new self-image as a result of Dr. Bates skill. It's a reminder to all of us to pause and recognize how some of the little, "insignificant" things we do can so greatly affect the lives of others. Thank-you, Dr. Bates.

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South Africa's Bongi has some great posts at his site, Other Things Amanzi. If you're one of my regular readers who gets cheerfully grossed out by my "gory eye pictures," you're gonna love Bongi's writing. Here is a "taste" from his post, Fettuchini:

the patient came in after being involved in a car accident. he had an acute abdomen, but was otherwise stable. x-rays confirmed free air in the abdomen. easy call. the patient went to theater. we opened the abdomen. it was full of intestinal content. not too surprising. and then...lying in this soup, free in the abdomen we found a meter long tape worm! i'm not embarrassed to say i gagged. i threw it in a kidney dish where it entertained us with its peristaltic movements.

Bongi's hilarious post on operating in various states of undress deserves reading: Fashion Statements.

And what's worse than poop? Well, according to Bongi, it's poop that has gone rancid. Yep, rancid poop happens, and if you want to read about how it happens, and how to remain a macho surgeon in the midst of its indescribable fragrance, read this entertaining post, Tough Surgeon.

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Surgery has lots of "laws" -- dicta (that's apparently the plural of dictum) that give pithy bits of knowledge and wisdom. Many of them are specific to a particular institution. At the University of Kentucky where I went to medical school, there were "Five Laws of Surgery." I remember two of them: A bump in a breast belongs in a bottle; and Surgery, like sex, should be slow and gentle, and requires good exposure. (You're welcome to share your own opinion on whether or not good exposure is really required.) Bongi writes about this law of surgery: Eat when you can, sleep when you can, and don't f@*% with the pancreas. If you ever need advice on getting some sleep when little time is available, you can read this chilling post: Other Things Amanzi: Wakeup Call. Thanks, Bongi, I enjoyed your posts and I'm bestowing upon you a coveted Marianas Eye Funniest Medical Blogger of the Week Award.

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Doc Ness, an anesthesiologist not far from me, writes about the experience of being in the operating room, not as a doctor, but as a patient. Most of us will have to face the other side of the table sooner or later. You can read about Doc Ness' experience at random ness.

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And that's all folks. Thanks for stopping by. And buy my book, World Peace, a Blind Wife, and Gecko Tails. It's available on Amazon. (Yes, I know it's shameless self-promotions, but hey, I have four kids to put through college and Oprah hasn't called yet.) I hope you enjoy reading this Carnival as much as I enjoyed putting it together. I look forward to your comments and to regularly visiting your blogs.

The next edition of SurgeXperiences will be hosted by Dr. Sidney Schwab and will presented on April 27.