purplekow

Most of the long term and short term care facilities in my area have many CoVid patients. They have set up a separate area and supply the staff with PPE to see those patients. There are also areas for PUI (patients under investigation) areas where patients are placed while waiting the result. As for people who test positive working, most facilities are allowing people who have been exposed to work using social isolation and a mask. Some facilities are requiring 14 day isolation if there is a know exposure. In general, f you are positive, unless you are working from home, you are not working,

If you have a choice, why go for 18 to 25 year old twinks. Unless you do not enjoy men.

That is correct. The medical schools could educate more physicians here in the US, they choose not to do so. When I first started in medical education, there were about 15000 American graduates a year, that is about 40 years ago. As you can tell the number has not increased substantially. At that time, there were medical schools in the Caribbean, Europe and the Middle East training US students. In addition to that, you had the same influx of FMG physicians (Foreign Medical Graduates) plus all those US citizens who were training abroad. There was a program that probably still exists, in which after two years training abroad, US students could, if they passed proficiency examinations, transfer for clinical training here in the US. Schools would take up to about 5 of these transfers and there were about 114 schools at that time. Some did not take any. So basically US school were taking back the highest testing US born graduates, usually around 150 in total. Regulations tightened as a result of Venture capitalists taking an opportunity to provide education in small countries in the Caribbean mostly, and charge little for their citizens' tuition, gratifying the government and charging US students tidy sums. Those who have sharp memories of the invasion of Grenada during the Reagan era, know that one of the reasons used to send US troops into Grenada to topple that government, was the imminent risk of US medical students training there. These relatively fly by night schools would get part time faculty from the US and organize a mostly large lecture series with most of the education coming from reading assignments. Some schools, such as those in Europe and Mexico were well established at training their own country's physicians, but these of shore schools had few clinical experiences and if students did not transfer out back to the US, the school would find clinical opportunities, usually at non university associated hospitals around the globe. The hospitals got manpower, the schools got training and of course, the lucrative tuition, This was the 70s and 80s and US schools could have simply opened 20 or more positions per year each and that would have cut the need for these schools. A few more schools in underserved parts of the US would have done the trick too. They did not do that, but they made regulations for US graduates to return to the US from those off shore medical schools much more difficult and stopped the influx of US students who had circumvented the US system. Replacing those US grads were an even a larger number international graduates from foreign countries. That is where we are today except the world changed and those doctors may not get here,

I agree that immigration regulations have been made more difficult by the pandemic and the closure of government offices in other countries as well as the immigration difficulty here. However, foreign born foreign graduates have been a mainstay of medical care in the US for decades. Medical education has done little to change this. Immigration rules have only become more stringent. As an example, in 2014 there were 17000 or so United States Medical School graduates in first year positions in training in the US. At the same time there were about 6600 International medical graduates in the same role. The vast majority of those international graduates were foreign born and trained and a small number were Americans who attended school internationally. Now in 2019 there are about 18000 US graduates for just about the same number of positions meaning that there has been little movement away from international graduates in the last five years. Going back further, the numbers would probably be about the same. So it is clear than the US has been importing physicians and in relatively large numbers. I have worked in medical education for 40 years and ever has it been thus. These FMGS are usually well qualified and hardworking individuals. They need to pass qualifiying tests to get a chance to practice here. These are physicians who support the medical care system in the US in a way that is generally underappreciated. Now, with that supply chain slowed, it will be difficult for some areas to keep up with adequate medical care and training.

Yes but now we cannot even import them.

Well after four months of doing direct patient care in a position that is supposed to be mostly educational, I was scheduled for two weeks of administration for preparatory work for the upcoming academic year. Major problem is that we usually have more than a dozen incoming residents and most of them have J1 visas. Less than half of the residents are here in the US already and the rest may not make it on time. The government red tape here and in the countries of origin is keeping the certainty of a full staff at a level of "extremely doubtful." That means there may not be residents to care for the patients and though the teaching physicians such as myself have been doing much of the direct patient care, the residents have been the ones staffing the hospital at night. There is no way the hospital can be staffed appropriately with physicians should there be more than a few missing residents. So right now I am working on filling in a schedule that should have more than forty people with only 28. In addition, at the onset of the pandemic here, several of the part time physicians decided that it was a good time to retire. So we are down about three physicians who were supervising residents in clinic and doing educational rounds. This is a teaching program and although the residents, as part of their training, perform services for the hospital, those services must be educational and must not exceed the purely academic portion of their training. Those regulations from the supervising certification programs are not going to change. So the squeeze is on. We can now add physicians to the list of things the US cannot supply for itself which already includes personal protective equipment, Covid testing kits, ingredients for vaccines and medications. On a happier note, though I have not been caring for him through this week, I have dropped by to see the 37 year old who has been in the hospital for more than 5 weeks and who spent about 4 of those weeks on a ventilator. He is doing so much better. His memory is clearer. Today he was eating a regular diet. His breathing is doing well with minimal oxygen. His heart rate still jumps to unacceptable levels at times, but he is getting medicated for that. He started physical therapy and he has been able to walk around the room. Yesterday I asked him if there was anything he wanted from the outside world and he said no. Pizza? No. Hamburgers? No. Chocolate? No. Nylon stockings? He looked at me very confused. I explained that in WWII that nylon stockings were a frequently asked for item. He still looked confused and I told it was a bad joke and let it go at that. Donuts?.....Dunkin Donuts? he asked with widened eyes. Sure. Dunkin Donuts. Yes...yes, I would like that. What kind? Orange. Hmmm, I though, orange donuts. I was thinking that perhaps they had donuts with orange sprinkles or some pumpkin colored donuts. I told him I would try but I was not sure if they had orange donuts. Sure there is never a cop around when you need one, so I went to a secondary source of all things donuts, the nursing desk. Sure enough, the consensus was that orange donuts were in fact, glazed donuts that have an orangish glow off the multiple layers of sugar. So this morning, on the way in, I stopped at the donut shop formerly known as Dunkin Donuts and which is now just Dunkin and got a dozen donuts for the nursing staff and another two glazed donuts in a separate box for the 37 year old. When I got to the hospital, I went right up to the floor and gave the nurses the box and then gowned up, masked up and went in with the donuts. He was surprised to see me as it was much earlier than I usually arrived. I gave with the D and D box. He opened it and smiled. He then took out one of the two donuts and he offered it to me. Off course, with gloves and mask and face shield, I was not in a position to accept it but I thanked him for the offer. The exchange made me wistful in that a simple act of sharing a bit of food with someone had been coopted by this disease. In any case, he took a bite. He slowly chewed and then swallowed and he put the donut back in the box. "Thanks for the donuts. I will have more in just a bit". I waved to him as I walked out. After I had shed my PPE, I looked back through the glass of the door and saw him savoring another bite. I wondered what he was thinking, sitting there, eating a donut as if his whole life had not been ripped apart and only partially put back together. My guess is he was thinking: "I could sure use a cup of coffee right now."

. A year is a long time. Last year at this time I was wondering if the Mets would have a winning season. This year, I am wondering if the Mets will have a season. It will not be the same but it will be a lot more the same than it is now.

It is in the Journal I suggested but when I look it up I cannot find it there but there article itself has that stamp. I will get you the link and post it here.

As it stands now, only one viral has ever been known to have been eradicatedt and that is smallpox. Even that is not totally extinct as both Russian and US laboratories have stores of it. One need to be able to consider eradication of a virus is that it have no animal vector as a reservoir. Coronavirus 19 seems to also be present in bats and has been found in other animals as well. Viral elimination or limitation of disease has been largely successful,, when it has been successful, by mean of vaccination and isolation. Diseases, such as polio, measles, mumps and several others have been limited due to that means. However, even those are around and break out once and again. People are tested and isolated and contacts checked, That is what has been successful in controlling those diseases and it is what has been successful with Coronavirus in places that put that brand of control into place. Test, diagnose, isolate, and limit the spread. Here is the US we are so far from that right now and headed in the opposite direction. It would not be surprising for the rest of the world to put limitations of travel to the US the way travel limitations were placed for Ebola, no one in or out. Just recently in Korea, a place where control of the disease has been good, there was a Covid positive patient who went to a crowded nightclub and now they are searching for thousands of people who may have come into contact. That kind of ability is just not within the current US system. Besides the more than 70000 deaths in the US the cost can also be measured in hospital days resulting from the disease. The average length of stay of hospitalized Covid Survivors is 14 days or so. Most hospitals have an average stay between 4 and 6 days. The cost for caring for Covid patients is also very high given the need for protective equipment for personnel and for the rooms. So the cost of Covid is in lives, in jobs, in health care costs and since it is likely that there is a vector in bats, it is not going away.

Either I am hallucinating or there was another post on here in which someone said that it was hopeless. That was the resignation to which I was referring. We should not resign ourselves the the loud and uninformed.

This is too important a situation to have voices of reason drowned out by non-believers or silenced by exhaustion. If those opposed to science shout to quiet the facts,, the fact givers need to yell louder. It is exhausting. It will take determination and education. What it does not need is resignation. So I beg those who are tired of yelling, to take a deep breath, put on a brave face and be as loud and as truthful as you can be. Stop wasting energy in causes that are lost, such as relying on a change of heart from the present government,

I just read an article from the Journal of Virology from October 2011 concerning the development of a Coronavirus vaccine,. Yes 2011. In that article, it predicts the need for a vaccine and speaks to the difficulties in producing a vaccine. Much of the article is above my pay grade and might be beyond yours too. The main aspect of producing a coronavirus vaccine of which I was unaware, is antibody dependent enhancement (ADE). While some antibodies prevent the movement into the cells of the coVid virus through the main gateway, there are some coronaviruses that actually attach to the antibodies produced as a result of the vaccine and the antibody=virus complex finds a side door into the cells that the virus by itself cannot use. So that giving the vaccine actually allows the antibodies formed to facilitate further destruction by the virus. This is not true of all coronaviruses but it presents another hurdle to the manufacturing of a vaccine. Testing will need to be done not only to prove that a vaccine is beneficial,, but that it has to test that is not detrimental. The fact that there has been work on a vaccine since 2011 is a double edged sword. Among the negatives are that they have not found one yet so 10 years of research has not done what we are being told will be accomplished in the next few months to a year and one half. The good news is that there has been a lot of ground work done and pitfalls have been recognized. The take home message from this: a vaccine is not a new idea, it has not been developed over a decade of work, it might make things worse in some cases, but at least we are not starting from ground zero.

You elect a business man president, you get someone who puts business, his own mostly but business in general as well, first. Business interests and medical interests do not have to be opposite poles but that is the narrative that is now out there. I for one, am not hopeful, but I cannot predict the future and I can hope that I am wrong.

I agree with most of what he wrote and I think you will find a lot of similarities in our experiences. The one difference however is his belief that herd immunity may win the day. He has suggested he feels comfortable with allowing young people to get what is probably a mild disease for them but just keep them away from others. That shows great faith in a group of people some of whom have shown disregard for the situations others face. They flocked to the beaches of Florida during spring break and brought the disease back to places like Wisconsin and Indiana. They crowded to buy Air Jordans in Georgia. So perhaps he is more of an optimist than I am or has more faith In the ability of young people to take this seriously. I hope he is right because it seems the country is going in his direction. I expect a surge again if not immediately, certainly in the fall. I can hope that the American people do well and make us proud, because we are in need. However, if it is a half hearted attempt, it will turn out to be pride before the fall.

Guess this a fairly old song but I ran across it down a rabbit hole.

Something about this is poignant and haunting and more moving than any vocal version I have heard

https://video.search.yahoo.com/yhs/search?fr=yhs-dcola-015&hsimp=yhs-015&hspart=dcola&p=halledluha+hauser+youtube#id=1&vid=1cab65edc2bf7f363eaef8fda809fbdf&action=click There is a summer one on Instagram but I cannot post it.

That is my local bank

After 4 straight months of the general medical service for the uninsured and underinsured, I am on administrative duty for two weeks. I admitted patients every other day and night and I estimate that of the more than 200 people I admitted and of whom I took primary care, about 60 were CoVid patients and about 12 of them went to the ICU. Two came back, which is about average for this disease. Up until this week, two had come back, 5 had passed and 5 more remained in the ICU. Those numbers do not tell anything of the lives of those people. The numbers about coronavirus in the media tell even less about them because as the deaths pile up, the faces get lost, the stories get lost, the humanity gets lost. Todays media star, the sad 8 year old who lost both her parents, fades into the emotional support dog no longer with a target for its emotional support, turns into the police officer who contracted Covid while delivering a baby in the back of a squad car. The stories are told heartlessly heartfelt with wholehearted dispassion hitting a discordant note on the heartstrings. None of those stories tell the look of fear in the eye of the breathless, the tear in the eye of the pained, the tremble in the voice as the realization of the reality is spoken. So, I was not looking forward to this administrative respite, but I really am now. The last week has seen nothing but heartache and death for my patients and there does not seem to be an end in sight. The last of the five patients I had in the ICU took an unexpected turn for the worse just as I was posting last night that he was doing somewhat better. Euphemistically called the man in the black bikini, he had an unexpected turn at midnight and he did not survive the night. I did not know these five people who died. In most of the cases I met them on the night they were admitted to the hospital and within a day or two, they were off to the ICU. Still, in each case, I felt a part of me was lost in their passing. Maybe that is always true and I am just more aware of it in these intense times. In some cases, I was the last touch they felt, the last voice they heard, the witness to the last moments of their life. And at that time, that seminal moment, it was a stranger trying desperately to get them back from the edge. So I ask you to take a moment, perhaps quietly contemplate how the lives of the Mexican mother whose last words were "Te amor mi amor", the man in the black bikini, the senior man with Parkinson's, the stocky wide shouldered landscaper gardener, were abruptly taken. Give thanks for the 37 year old man who continues to move forward and whose laugh brought hope to me and, as it would happen, also brought hope to the intensive care doctor with whom I was discussing his care and who told me: I told him a Joke and when he laughed, I felt like maybe we would all be okay". This without knowing of my similar encounter. Life, I guess you need to be in on the joke.

This is a critical decision in people's lives but it a difficult one to face and as a result people put off even considering what it is that they want. In NJ at least, there is a POLST form, Physician Orders for Life Saving Treatment, that delineates what the person wants and who should be making the decisions. This form only comes into play at the time the death has occurred or is imminent and plans for invasive life extending treatments are being made. This is a brief, codified form of a living will. Living wills may include things which are not covered by this document. For example, if someone has opted not to have life extending treatment and they are being attended to in a way to allow comfort to be the goal, a living will might include such things as the kind of music the person would like to be playing in the room, or the specific visitors one would want to see. The POLST only deals with medical issues. The main questions ask things such as do you want to have mechanical ventilation, do you want a feeding tube placed, do you want CPR to be done, who is the person you want to be making your medical decisions should you become incapacitated, The form we use is one side of one page. I have seen living wills which have 15 to 20 pages of instructions.

Thanks to all of you for your support and kind comments. On a day such as today, it is particularly difficult to keep a positive outlook Believe it or not, I think that despite all this tragedy and illness, I have kept a positive outlook. I am not sure that comes through in the accounts, but when I consider how we were doing at the beginning of this and how we are doing now, my spirits are lifted and I do have hope; Though today was probably one of the more difficult days to work and to have hope and then one small thing changed that. Starting at the beginning of the week, I had transferred five patients to the ICU who were still being treated in that unit. Today, a little more than three days later, there is one left. Three have succumbed to their illness. I have related the story of the healthy middle aged gardener and his struggle for 30 days on a ventilator and who slowly slipped away. Another patient was a man in his 60s with Parkinson's disease who had been in the ICU for less than a week and who seemed to be doing well, until he was not. The end came quickly for him, quickly enough that his passing was surprising even to the ICU nurses who are heroically attending to each of their patient's every need. The third one to pass was and elderly man who had spent nearly a month in the ICU. His passing, while tragic for his family and friends, was expected. He had Covid and was 94 years old. Religious beliefs prevented anything less than a full out onslaught of medical treatment and invasive procedures. In the end, 94 years was his allotted time and his death was treated with care for the patient's family but otherwise perfunctorily by the staff who have seen many 94 year olds pass from a variety of illnesses in their experience. This may sound callous, but the efforts with this man were extraordinary and the outcome was as expected, except in the length of time the combined medical caregivers gave to what was seen as a largely futile effort, The patient who remains in the ICU is the man in the black bikini underwear. Well who was in the black bikini underwear, I am not sure where they are now. He is hold on and there is hope for his improvement. Still, setbacks are a sad reality and in this setting almost an eventuality. So he will be attended to carefully. I hope he joins my team back on the regular CoVid unit. The fifth patient was the 37 year old man who was transferred out of the intensive care after a month on the respirator. The one who had been cleaned and shaved and propped up for his photo meeting with his wife and who was able to tell her that he was okay. Today I spoke with him. He was more alert and awake than he has been and he was started on liquids by mouth once again. His voice is still a whisper, probably related to trauma from the endotracheal tube being in his throat for almost 30 days. I reminded him who I am, and asked if he remembered me from when he first came into the hospital. He said he did not. In fact, when asked if he remembered anything from the time in the hospital, he said no. The medically induced coma had been kind to this man. Sometimes patients in that state still dream or have nightmares or are awake enough to be aware that they are there but they are unable to move or do anything at al except think and lie there. It is reminiscent of a book I read in high school "Johnny Got His Gun." about a soldier who finds himself in that space between life and death. I told the patient not too worry about the missing time and why he had no memory of it. I told him I had been monitoring his progress all during his hospital stay. I asked about pain. He had none. I asked about other symptoms of shortness of breath and nausea. He denied those as well but the numbers told a slightly different story. I always try to believe the patient rather than the numbers. Numbers do not account for personal strength, desire to improve, ambition and willingness to succeed no matter the odds. How could you accept the numbers when this man had all of those things in abundance, So after examining him, I prepared to leave, knowing I would have to watch the numbers, but that there was an indefinable quality to this man which had gotten him to this point. On the way out, I said: "Adios, y portanse bien." It is a phrase I usually use with Spanish speaking patients and roughly translates as: Go with God and Behave yourself. I sometimes forget that this is not something everyone would understand and I will say it to patients who do not speak Spanish. The patient then said, straining his voice to be heard: Now I remember you. I smiled and said: "who could forget a doctor this good looking". And then much to my delight,, he shook his head and laughed. I do not know if it is the first time he has laughed but it was the first time I had heard it and it feed my soul. I firmly believe that this man is here, not because of every single medication we gave him, or every second of care or the technology that kept his lungs moving even when they should have stopped. All of those things are never enough. I believe he survived when others had not was in his ability to laugh at a bad joke and in doing so, lift the sagging spirits of a fatiguing physician. I look forward to seeing him tomorrow. I have lots of bad jokes and for right now, he is a captive audience.

I am ready for a break from patient care. Since mid January I have been doing clinical round. I see patients every day. I admit patients every other day. I am on call every other evening. And over the four months I have had one 6 day break. When I finish this week, I have two weeks where I will be doing some of the other aspects of my job. Mine is an academic position and in July we start with a new group of interns with the other years moving up to more repsonsible positions. With the CoVid drain on the hospital, most of the educational component has been restructured or abandoned. Lectures have been moved to on line conferences. Small group mento sessions have centered on CoVid and keeping the residents up to date on the ever changing policies and plans. July first will bring a new group in, maybe. Many of our incoming interns are foreign nationals. Many of them have a J1 visa, which is basically a work visa. CoVid spurred changes in immigration as well as government work changes has made getting these visas much more problematic. So far, only 3 of the 13 interns have managed to get their papers in order. The residents who are staying on also need to update their paperwork and several of them have been caught up in red tape. It is conceivable that we will be down as many as 10 or 36 doctors in the program. Add to that the inexperience and CoVid may be even more problematic to handle come the summer. My responsibilities will change from clinical to educational and administrative. Usually I find this aspect of the job tedious at best and torturous at its worse. Now, I am looking forward to the work because it gives me a physical and emotional break from the patient care. It also allows me to try to structure a program that will insure that those patient get an excellent standard of care, even with manpower shortages and inexperienced doctors. It seems this part of the job may be more important than ever. Meanwhile, I am still working with patients and I have managed to send a few people home, CoVid and regular patients both. Last week I had five patients on ventilators in the ICU under the care of the intensivists. Now there are three, The 37 year old was officially transferred today and while physically he is doing about as well as can be expected, he has suffered some setbacks. Attempts to feed him failed. Usually failure of this type is related to difficulty swallowing water an endotracheal tube has been in place for a long time, injuring the structures that allow for swallowing. The patient underwent a swallow test (get your mind out of the gutter) and he passed. However, once he was fed, his gut did not handle the food. He has been receiving nutrition by vein and now, his system is not up to handling the intake. He will have to be slowly readjusted to eating. He has been up to the hair but he remains weak and unable to stand. His mental functioning which seemed to be at the level expected when the tub was first removed, has not improved that much. There are several possible reasons for that and right now it is unclear if or when he will start to be more of the person he was before all this. So, after a hard fought victory, the battle to return this man to himself goes on. Unfortunately, the battle for another one of my patients does not go on. The landscaper who came in looking like the picture of health with a mild flu and quickly went downhill has died. After 28 days of intensive care, there were no more tricks in our armamentarium. His blood pressure stopped responding to strong medications given to allow his limited oxygen to get to the organs. His lungs transferred less and less oxygen. His kidneys failed. Ultimately, there was no more to be done except the phone call to his anxious family. His. wife, 3000 miles away screamed out when I told her. I am still not sure if I heard the scream through the phone or across the continent. It was a deeply pained scream that oscillated and reverberated and ultimately faded off into the universe to haunt other planets and other solar systems. Most times when I have told families of the passing of a loved one, there is a gasp and then a muffled cry and then a turn away to sob as privately as possible. Usually they have stopped hearing anything said after the opening "I am sorry to tell you..." So while it may seem dispassionate or cold to basically say "I am sorry your relative has died. My condolences on your loss" and then nothing more. Experience has told me that any explanations will go unremembered. Any information will not be retained. The pain overtakes every aspect of the brain and the kind thing to do is to allow the survivors time to regroup. Usually I tell them I will be back and then go off. Frequently when I return they are surprised to see me as they did not recall that I had told them I was coming back. Then there are the cases where the pain is so intense or the shock is so severe that a scream is emitted that seems to take every molecule in the persons body and transfigure it into sound and then reach a pitch so intense that it causes anyone in the area to have a skipping of their heart beat and a temporary sensation of their own lives in empathy. The scream that the gardener's wife let out was a difficult to hear and absorb as it must have been for her to hear the news of his passing. Tomorrow, I will be seeing the patients who were admitted during the evening and night and I will hope that I never have to hear that scream from one of their loved ones.

Well he did not actually lay anyone just gave a few blow jobs.

Today was an interesting day. Spent an hour on the golf course this morning. Wait, a doctor on a golf course, its unheard of, well on a Tuesday anyway. Wednesday is usually doctor gold day. I was on my way to work and I have been taking slightly different routes than I usually would because the traffic is light, some routes are more scenic and due to the decrease in cars, the trip is not any longer. Well this morning, I took a new route and about half way there there were workers doing tree trimming and the road was closed with a detour marked. Now they do seem to be doing a lot of road work here, which is probably a good idea. It keeps people working and it is not as inconvenient as when the traffic is usual. Well I took the detour and it went through a golf course. This was only about 8 minutes from my house and I never knew there was a golf course there. It was a nice day, I had the oldies station on and was singing along and just relaxing and trying to have a bit o peace on the way to work. The phone rang and I briefly looked to press the dashboard to answer the phone call and in that moment, I now know, I missed the sign that indicated that a turn was needed to continue the detour. So oblivious, I continued to drive. It seemed like an unusually remote detour and I realized that I was probably off course. There were people walking, but when I pulled up to ask how to get out, the response was basically a shrug and a sorry. I continued driving. I made a turn that I thought was about to take me back but it just didn't. 45 minutes later, I happened upon the detour sign and followed it and eventually wound up just where I had started. So my usually 20 minute ride to work took more than one hour and 15 minutes. It was a welcome break. Usually I would have been cursing or at least anxiety ridden about being late, but this seemed like a well deserved respite. I suppose I could have used Google maps, but that would presume I know how to use Google maps, which I only kind of do. My resident team did not seem disturbed by my absence, Today was a changeover day and so I had a new group and they took the time to catch up on the 10 or so patients we had. We had a lull in CoVid cases so all of our patients were either CoVid negative or Covid suspect with a low level of suspicious. One still needed to dress up in medical battle gear but the sense of foreboding is a bit less when the suspect is low risk. I do try to be fastidious about the technique of approaching these patients. Gown. Mask. Overmask. Face Shield. Gloves. Double Gloves. I t is routine but there is usually some glitch. My glasses fall of or the mask string breaks or I pull too hard and the neck of the gown opens up. It is usually more annoying than it is serious but one cannot be cavalier when gearing for battle. Today was kind of a coast day. The patient's got slowly better with little assistance from us. The notes got written and the needed conversations were held. I got a nice thank you from an older woman who is slowly improving from her breast cancer and the pneumonia the cancerous spread to the lungs had caused. She is still very sick for the long run but in the short run she is much more comfortable and she should go home in a day or two. So a mundane day. These are rare these days and though I have only golfed rarely, I enjoyed telling my patients that I was late getting to see them because I was out on the golf course. Most of them were actually happy for me, though I did correct the misdirection I gave them. Those course corrections went a lot more smoothly than my ride to work corrections did. Hope all of you had a nice day on the course, whatever course you are taking these days

I always liked his movies, especially Roamn Holiday with Andy Hepburn.