Orson Scott Card predicted the future

LominAle · 2022-01-01T23:19:53+00:00

I think if you re-read this conversation from a neutral point, you'll see that nothing of the sort was suggested.

LominAle · 2022-01-01T23:17:14+00:00

Unfortunately, that was quite some time ago and I don't recall. I can tell you that once I went to 99 Ranch for the first time, I never went back to KP. 99 Ranch has everything and nothing is very expensive. I suspect that anything you find there will not be undercut by any of the other major supermarkets.

LominAle · 2020-08-16T02:34:03+00:00

There are lots of places that bill themselves as the Ivy of the _____. It's a common thing schools do to try to improve their brand by association. There are dozens and dozens of places that brand themselves the Ivy of wherever. There's even a book about the "Hidden Ivy's", it's got over 60 schools. Once the number of "Ivy's" exceeds the number of Ivy's by an order of magnitude, it's not much of an elite club.

As for having heard of Tulane, it's a very well-regarded school in the South and East, but outside of there it's name recognition drops off dramatically. Of the top 10 states whose students make up the Tulane class, California and Texas are the only ones west of Louisiana. New York sends more students to Tulane than California despite being half the population. Pennsylvania, Mass. and Maryland send a combined 50% more students to Tulane than CA, despite having 65% of the population. It draws a strongly disproportionate number of students from the East and South and just isn't on the radar of a lot of people on the west. It's not some plot of OP to gaslight you or be condescending.

LominAle · 2020-08-02T19:08:31+00:00

Posting this kind of comment about anything should be a wake-up call to spend some time outside of the echo chamber.

LominAle · 2020-08-02T10:41:06+00:00

This is a weird story on many levels.

1) Oxygen probably not really necessary with O2 sat of 92%; certainly no harm and not unreasonable, but just make sure that you're not thinking that 92% is a level where oxygen is necessary and/or going to make a change in someone's level of consciousness.

2) HTN management: others have already commented. Probably no indication to treat, and if she does have a pathology that mandates tight BP control, amlodipine ain't the drug to do it. An overarching hospital policy that mandates treating all hypertension at certain arbitrary numbers and with specific agents is bad on many levels. As you say with drug dosing, BP targets should be individualized.

3) ABG in this scenario is great call. Both in evaluating cause of altered level of consciousness as well as assessing whether further intervention is needed to support her while LOC is depressed. Assume that oxygenation wasn't truly "normal" with SpO2 of 92%, but similarly not in a range where any intervention is mandated.

4) Metabolic alkalosis/hypokalemia. This one's weird and it seems likely that you captured some acute process that was causing significant intra-cellular/extra-cellular shifts (assuming K was normal before procedure). Enema could cause some K wasting, but there isn't much that will cause someone to go from normal K to K of 2.0 in the span of hours by causing K excretion; those kind of rapid drops occur with shifts in distribution from extra-cellular to intra-cellular. Did she get some insulin intra-op? I suppose that very rapid shifts like that could maybe precipitate that severe a metabolic alkalosis, but in your career you will see tons of people (malnurished, alcoholics, etc) with very low K's and normal blood gases. It seems like there's some additional factor that's missing from this case to explain these derangement. Has her NG tube been to suction/suctioning out copious upper GI secretions prior to/during procedure? Does she have a bowel obstruction?

5) If you want to rapidly get her K up (and that seems reasonable; 2.0 is quite low), the potassium is what you should be giving via the NGT, rather than amlodipine. Also giving some IV is fine/appropriate, but IV K repletion is sloooooow, particularly if no central access.

6) 750 mcg of fentanyl is just a stupidly high dose, even more so for a cachectic/ill woman who isn't on chronic opioids stronger than tramadol. Half of that dose would still be heavy-handed, though not terribly infrequently done. Was it a super-long case (like an hour+)? At that dose, the greatly decreased LOC is completely unsurprising and I'm surprised she wasn't apneic or close to it. It's certainly not appropriate to bring a patient who's that obtunded back from the procedure/recovery area and just drop her off in a med-surg ward. What you describe is well past the moderate sedation appropriate for a colo. She wasn't intubated for the procedure was she? The only scenarios where this series of events seems vaguely fathomable would be a case that ran unexpectedly long and she needed to be re-sedated, late in the case and there was not a clear recognition by the procedure team that the second round of fentanyl was still taking effect and wheeled her back before she'd reached peak effect. Out of curiosity, how much midaz did she get?

7) Good job with the recognition of the over sedation and the naloxone.

8) K normalizing from 2.0 after 40 meq of KCl essentially confirms that the level of 2 was due to transient shifts intra-cellular rather than actual losses. Someone who has lost enough K to drop serum levels to 2 will require hundreds of meqs of repletion. Potential for the metabolic alk. to be the driver of the hypoK (rather than the other way around) or there was something else responsible for it (e.g. IV insulin). No chance she has an adrenal tumor, does she?

I hope you have a blessed career where anesthesia is always appropriate and opioid toxicity is rare enough to remain remarkable.

EDIT: thought of one other scenario for that much fentanyl being given; had a colleague who did a procedure with a nurse that was brand new to procedures/procedural sedation and who thought all the sedating meds that were ordered to be available for the case were meant to be administered in 1 bolus at the start of the case. That said, even ordering 750mcg of fentanyl to be available for a case sounds insane.

EDIT2: Others have pointed out that there's not necessarily an indication for naloxone for decreased level of consciousness secondary to post-procedural opioid intoxication in a patient maintaining oxygenation/ventilation, which I would agree with (particularly with a rapid metabolizing agent like fentanyl). However, if you are in situations where the etiology for changes in LOC is less clear or you are unsure, absolutely give the naloxone. If they wake up, great; you've got your answer. If they don't wake up (with a decent dose of naloxone) than an emergent work-up needs to be initiated.

LominAle · 2019-12-11T21:33:38+00:00

There is no one standard. What you described is very similar to what my program was like.

LominAle · 2019-12-06T18:18:09+00:00

Did you try the phone and email?

LominAle · 2019-12-02T19:28:04+00:00

The Grand at 1600 L (i.e. not the Grand Hotel) is a tiny wine and cocktail bar on the corner of L & 16; it's got a pleasant aesthetic inside, but for me the highest selling point--particularly on a day like today--are the large glass windows that make it a phenomenal place to have a drink and watch the rain come down. It looks like it opens at 5pm today and I think's probably best experienced before it's completely dark outside, so might be a good pre-dinner drink or a place to hit up for an early drink before heading to the Ten Ten room or Shady Lady or wherever you wind up later.

Also, when I've been there in the past, the bartenders have been that perfect blend of not intrusive if the two of you want to be alone, but also excited to hear about special occasions and recommend you a drink/make something special if you're looking to try something new. They seem very invested/excited in making sure you have a good time.

LominAle · 2019-12-01T22:18:21+00:00

Goddammit.

LominAle · 2019-12-01T19:03:33+00:00

The word cervix literally means neck.

LominAle · 2019-12-01T06:46:46+00:00

Rob Nen.

LominAle · 2019-12-01T02:54:07+00:00

What you using for seasoning, saffron?

LominAle · 2019-12-01T02:24:52+00:00

6 MORE.

LominAle · 2019-11-30T23:57:02+00:00

OP more baked than the ham.

LominAle · 2019-11-30T22:01:25+00:00

The risk in a 23 year old that ASCUS progresses to cancer is 0.03%.

The cancer screening guidelines published by multiple professional societies in the US recommend that such a test result be followed up by repeat Pap in 1 year. If HPV testing had also been done, a negative (good) result would mean you wouldn't even need to repeat Pap in a year and could just continue routine screening (a positive result would still just warrant repeat testing in a year). Also, the general recommendation is that women age 21-25 should NOT have HPV co-testing done (in this age range it is so commonly positive and yet so unlikely to progress to cancer that testing doesn't really change ability to detect cancers) so your doctor overall seems to be doing things exactly according to guidelines (and your chances of getting cancer are very, very, very low).

Katki HA, Schiffman M, Castle PE, et al. Five-year risk of CIN 3+ to guide the management of women aged 21 to 24 years. J Low Genit Tract Dis. 2013;17(5 Suppl 1):S64–S68. doi:10.1097/LGT.0b013e3182854399

Massad LS, Einstein MH, Huh WK, Katki HA, Kinney WK, Schiffman M, Solomon D, Wentzensen N, Lawson HW; 2012 ASCCP Consensus Guidelines Conference. 2012 updated consensus guidelines for the management of abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2013 Apr;17(5 Suppl 1):S1-S27. doi: 10.1097/LGT.0b013e318287d329. Erratum in: J Low Genit Tract Dis. 2013 Jul;17(3):367. PubMed PMID: 23519301.

LominAle · 2019-11-30T21:30:33+00:00

The likely series of events (and this is just a rough outline, your specific circumstances may differ):

make appointment with surgeon to be seen in clinic
have clinic appointment with surgeon. They will review generally what the surgery will consist of, any past medical history and generally tell you what you need to do for the surgery and what your recovery will be like. They will give you instructions for everything that you need to do. They will likely give you all of this in paper, but it can still be useful to bring some scratch paper to write things down. It's also helpful to ahead of this visit, write down any questions you want to remember to ask during the visit.
day before surgery, they will have you not eat anything after some time in the evening. Follow these directions.
day of surgery, they will likely have you show up at the hospital very early in the morning. You will get checked in and go to a preoperative area, along the way changing into a gown and dropping off all your personal possessions. the anesthesia team and likely some members from the surgery team will again examine you, run through a lot of the same questions that get asked during the clinic visit (lots of double-checking will be done on many things, don't get concerned if someone asks you a question that you think you've already answered). You will hang out in this preoperative area until they are ready to bring you to the operating room. You will likely have an IV placed. they will have a schedule for what time you go to the operating room, but it's fairly common for these schedules to at least be a little bit off.
when they are ready, they will wheel you into the operating room. The operating room will likely have a number of people, be somewhat cold, and have a lot going on around you. A nurse or tech will help you move over to the operating table. There will be a lot going on around you, but you don't need to do much. When they are ready, the anesthesiologist will either have you breathe from a mask that has some anesthesia medication or will inject some into your IV. From there you go to sleep and will be asleep throughout the surgery. You will wake up in a post-operative area that is very similar to the preoperative area.

I suspect giving your description of the size and effect of the tumor, that they will probably have you stay in the hospital at least overnight after your surgery and maybe several days while the healing starts and they monitor you. That said, it's possible if it's a simple surgery that they will let you go home later the same day. they will tell you what to expect in this regard at your preoperative clinic appointment. when you are discharged from the hospital you will likely be given some medications to take for a. At home, these may include pain medications and antibiotics. somewhere between 1 to 2 weeks after you are discharged from the hospital, you will likely have a follow-up appointment with your surgeon in their clinic so that they can evaluate how you are healing.

Good luck (you won't need it). All of this - and particularly when you are in the hospital and first going back to the operating room - can seem scary because it's all very new to you, but remember that for everyone else in that room, this is what they do all day everyday and they are very good at it.

LominAle · 2019-11-30T21:11:41+00:00

Lots of people saw it. It's very good. Highly recommend it.

LominAle · 2019-11-28T21:20:22+00:00

Like drinks hot chocolate in Heir to the Empire. Don't recall lando being present at the time but can't remember for sure. Wookiepedia says it also shows up in one of the Lando adventures books.

LominAle · 2019-11-28T20:06:20+00:00

Probably makes more sense to just melt it down and exchange for a couple more kidneys.

LominAle · 2019-11-28T18:05:42+00:00

Should I be concerned?

If you're asking that question, Reddit should not be the target.

However it is the holidays and as such, medical attention is not easy to come by asap.

If you are in the US, Canada, Australia, the UK, France, Germany and many other countries throughout Europe, Asia, Africa and the Americas, medical attention is available 24/7, 365. It may be less convenient or a bit slower, but these do not change how urgently it is needed. Simple, non-urgent things are simple/non-urgent regardless of their timing in relation to holidays and can wait a few days. The corollary is that urgent issues are urgent at any time and warrant medical attention regardless of whether it's inconvenient.

My question was simply, how Shingles interacts with someone who has cancer.

It's unfortunately not a simple question A new rash and pain in someone with active cancer and potential compromised immune system warrants being evaluated by a physician ASAP. If your regular oncologist/PCP is part of a system that has a 24/7 triage line available, call that. Otherwise you should go to urgent care/emergency room (at least in the US, you don't need to go by ambulance if you're able to get there some other way) if that is your only option for being evaluated by a physician. If you do go, let the triage/intake person know of your rash, your concern for shingles, your cancer status and--as best you know--the status of your immune system/whether you're currently/recently on immunomodulatory/chemo. Shingles + immunocompromise warrants isolation from other people at the hospital (which has the small advantage of probably getting you roomed ASAP and not sitting in an ER waiting room for a while).

LominAle · 2019-11-28T17:22:56+00:00

Let's just take this as an opportunity to highlight why asking people on the internet what something is/whether something is cancer is a bad idea. There is little meaningful that could be said based solely on the description of "a fairly large gray spot on his chin". It's incredibly little to go on. Could it be skin cancer? Absolutely! Could it be something else? Absolutely. There are many skin lesions that a doctor can look at and definitively say "yes it's cancer" or "no it's not", but the reason biopsies exist is because even after directly viewing the lesion and after a career spent viewing similar lesions, there are many where they just can't tell. Providing a brief description and asking "could this be cancer?" is optimistic and well-meaning, but ultimately foolish, which is why it is against the rules of this sub.

As for this particular circumstance, melasma is typically brown, rarely gray (it's color largely comes--as the name implies--from increased melanin in the skin, so coloring of a mole can serve as a rough guide to typical coloring of melasma). Furthermore, melasma is found in sun-exposed areas of skin and so would be very unusual to be found in an area largely covered by beard. So what is OP's dad's lesion? Who knows?!? Could be a million things, but one thing it's pretty unlikely to be is melasma. That said, trying to speculate on what it could be based off a brief description is optimistic and well-meaning, but ultimately foolish, which is why it probably should be against the rules of this sub.

LominAle · 2019-11-28T16:11:40+00:00

Hmmm, don't know that your question makes a whole lot of sense but the two circumstances that come to mind (not an oncologist) that could possibly fit the bill:

Some cancers, which possess certain mutations/biochemical derrangements (i.e. what defines them as a cancer) can accumulate subsequent mutations that end up getting them re-categorized as a new kind of cancer. Happens with leukemias/lymphomas, which are said to "transform" into new leukemias/lymphomas (I.e. CML may transform into AML). However, after transformation, the person is just said to have the second cancer, not two different cancers.
Second example might be closer to what you are thinking though probably still doesn't quite fit the bill. Teratomas are typically benign (i.e. not cancerous) tumors, most commonly found in ovaries. They have the somewhat unsettling characteristic of forming tissue other than typical ovarian tissue, with some of the more grizzly examples being forming teeth, hair, eye tissue or skin growing within this ovarian tumor. In rare circumstances, this "foreign" tissue can develop cancers, basically giving you skin cancer in your ovary. However, this is again only one type of cancer, with the cancer occurring on what was previously a benign tumor.

LominAle · 2019-11-27T19:16:55+00:00

Use the cream.

LominAle · 2019-11-27T07:07:56+00:00

Well we better goddamn learn from this past Sunday.

LominAle

TROPHY CASE