Agreed. With respect to penetrating STAB wounds to the chest, pts. can die immediately, or be talking to you in the ED with no signs of shock. Stab wounds are very unique, and there really is no way to know when this man died (short of being cut entirley in two). Interestingly, The highest survival rate from resusitative ED thoracotomies is with pts suffering from low energy penetrating trauma to the thorax (i.e. stab wounds).

I’ve gotta psych myself up for a) buying a console, and b) buying a TV to plug it into. So I’m at least a couple of days away from actually playing anything…

First I think Gawande was blowing alot of hot air into the lungs of these new grads. I mean what system really runs seamlessly? Surely not medicine, and surely not in the near future. I think alot of this speech was lip service, which is my impression of Gawande from reading some of his writings. I don’t think he really intends everything in the practice of medicine to run as smooth as the gas flow in the fuel injection of a lexus or the power seats in a BMW (do BMWs have power seats?). I really think he is trying to portray a vision of the implementation, regulation and monitoring of quality in medicine across all providers, hospitals, technology and pharmacy.
His reference to the “Individual craftsmen brewing plans for whatever patient comes through the door,” I believe is referring to physician accountability. For example recall that less than 5% of what we do in medicine is truly evidence based-this allows providers a wide scope to practice medicine, some of which is borderline malpractice. Thus to implement and regulate a range of the standard of care within the realm of known evidence is reasonable (for example practice guidelines with the review of the current literature). However by no means would this be a perfect system, and likely would be fraught with many holes that even the best seamstress or surgeon would not be able to mend.
One problem I have with his essay, and what I personally feel is the root of our medical systems’ flaw is its intrinsic conflict between profit and patient care. Gawande states technology and science have changed medicine-sure. However, it was money and profit earned from the sick that fueled the technology and science in the early 20th century, and still does to date. These two opposing endpoints (profit and the welfare of the patient), cannot and will not be in harmony, and thus we will always struggle with efficiency and accountability despite our best efforts to improve quality by normalizing/intergrating our goal-directed therapies

Red Dead Redemption (RDR) does look like a pretty bad ass game. I must say Rockstar (creators of Red Dead Redmeption), did an excellent job with Grand Theft Auto IV–one of my favorite xbox games (yes I have some vices and this game is one of them). Im not much of a gamer but like GTA IV, RDR looks too good to pass up.

Peace

And yes, the way I see it is, if you need a dog that can fit in your lap, you’re better off getting a cat.

I agree that a high-energy herding dog like a collie would need to get outside a lot. Unless you could put him in a day care during the day that would let him play outside, that poor doggie would be in a world of hurt. And good day care for doggies costs a ton of money, too.

But hey, I’ve been surprised how well we’ve done with our dog. Living in Chicago and Seattle, we’ve managed to keep him healthy and active. You just manage to find ways to do it, once you’ve committed to a dog.