My brain is trying to kill me

In the last two weeks my brain has been giving me ample evidence that it is trying to kill me. Here are two little examples.
I am an ex smoker. I smoked since I was fourteen until a few years ago. I quit intermittently, for years at a time just to start smoking again. Stupid, right. The last time I quit it was really hard but eventually I did it. I used nicotine patches, stopped drinking soda (because diet coke and cigarretts go hand in hand), no alcohol and I avoided all the places where I used to smoke (like my car parked outside of my house).  
It was hard but I did it. I missed it for several weeks and maybe even maybe months but it passed. Whenever I walk by someone smoking on the sidewalk the smell triggers cravings. That I can understand. Here is what I don’t. Two weeks ago I was in Titusville where my new job is and I was walking along the fishing pier taking photos. No one was smoking . All of a sudden someone hooked a fish and the fish started running making the clicker of the reel click. Like a hammer hitting my brain, I had the worst cigarette craving I have ever had. I used to go fishing frequently on a party boat in Miami Beach and I would easily smoke a pack of cigarettes in the 6 hour trip. One sound is all it took for the cravings to come rushing back full strength. Apparently I am not ready to go fishing again just yet.
The second example happened yesterday. I was working in a small hospital in a little town in Virginia with very limited culinary options. You had Wendys, McDonalds, Greasy Pizza or Subway. I am fat, have a bad lipid profile and I am very aware that I am pretty close to a diabetes diagnosis. I know I should eat healthy, avoid carbs and excercise, so I was complaining to the nurses about the lack of healthy options. After Infinished my rant, I got my fat rear end on my high horse and told them that I was going to drive 40 minutes to the next town (a college town with many more restaurants available) in search of some healthy choices. I am still trying to figure out how that intention turned into a really big plate of chicken pad tai (mostly pasta) and a delicious strawberry milkshake. My freaking pleasure centers are really trying to do me in.  

I can’t help my son.

My son has Asperger’s syndrome. I have watched him struggle since he was very young.  My wife has spent countless upon countless hours in therapy and doing homework with him.  Teaching him to talk,  read,  write, and do math.  She has a lot more patience than I do.


Now that he is approaching adulthood, he is struggling a lot with communication. He wants to fit in, to be part of a group, to be loved. That is pretty normal. It is also pretty hard for normal kids.  Adolescence is bitch.  For my son it is particularly hard.  He has difficulty processing speech.  It is like he lives in a foreign country with a language similar to his own but not quite his language.  If you speak Spanish and you have ever heard a conversation in Portuguese or Italian, I think that is how it must feel.  You kind of get what they may be talking about. You miss all the nuances, if they speak fast you are lost and there is a fairly good chance that you understood something completely different than what they are actually talking about.  That is how I see my son right now.


I don’t know how to help him. I spend my days fixing people. If your blood pressure is high, I make it lower, your blood pressure is low I make it normal.  You can’t breath, I put a tube in your throat and help you breath.  I don’t know how to help my son.  That is very frustrating. On the other hand, imagine how frustrating it must be for my son.

If you are religious, please pray for all the children that have special needs and for their parents.  If you are not, then just send us your good vibes.

Three doctors in three days

In the hospital I worked this week, the hospitalists have instituted “geographic rounding” which means I was assigned to a specific nursing unit and I would care for patients in that unit exclusively. It also meant that if you got admitted after 5 pm another doctor would see you first. (we took admissions until 5 pm), the next day I would care for you but if you got better enough that you did not need to be in the telemetry unit and you got downgraded to a regular floor you would be seen by a third doctor the next day. Three doctors in three days, I think are not great for patient care.  

And I thought it was just a stupid waste of time

I have always thought that Facetime was a solution in search of a problem.  I feel kind of goofy when I use it to talk with someone else, I don’t think that it adds much to the conversation.  I also think that Facebook live, Snapchat and all the other livestreaming apps are a virtual hand grenade without a pin.  As soon as you are not paying attention, you are going to do something stupid with it, it is going to blow up in your face and change the rest of your life,  probably not in a good way.

My opinion about livestreaming apps just changed.  I was eating an ice cream in a little shop in Staunton when I say this gentleman doing sign language with someone on the other side of a livestreaming app.  I guess what for someone is just a waste of time is life changing for someone else.



I like old stuff

I don’t know why I gravitate to old things when I am taking pictures.  Old cars, old technologies like typewriters, old people.  It may be that it is a symptom of some sort of a midlife crisis.

In my life I have seen more than a few technologies go the way of the dodo bird.  Rotary disc telephones, analog telephones, public phones. Telex machines (yes I saw one used in my father’s office), fax machines.  35mm film cameras, polaroid cameras. Betamax videos, VHS videos, Blue Ray videos. Cassette tapes, open reel tapes, 78 rpm records, 33 rpm records.


I think that it is my head telling me I am getting old.  Expiration day is approaching.

Either that or old stuff just looks cool.   Or both.


Old pick up truck. Hot springs Va. Nikon D7100. 35mm f/1.8


Some days I hate my job.


Today I had to explain to one of our hospital administrators how cumbersome and annoying our EMR was.  Among the things that surprised her was the use of the ICD10 coding system to input data into the EMR. For those of you that are not in the healthcare field, the ICD (international classification of diseases) is a classification system that was originally used in 1900 by the American Public Health Association to classify causes of death and was revised every 10 years from then on. Later it was used by insurance companies and healthcare researchers too.  ICD-9 had 17,000 codes and the current one,  ICD 10 now has 155,000.

Every time I have to put into the EMR someone’s past medical history or document a diagnosis, I have to choose from a drop down box (sometimes several drop down boxes) a code from those 155,000.  As you can imagine this is quite time consuming to do correctly.  Just to give you a little taste of this, if I type “pneumonia” into the problem search box in my hospital’s EMR, I am presented with 67 options to choose from.

Just your delight, here are some of the better ICD10 codes:

V91.07XA: Burn due to water-skis on fire, initial encounter.

V97.33XS: Sucked into jet engine, sequelae

W61.42XA: Struck by turkey, initial encounter

Y92.146: Swimming pool of prison as place of occurrence of the external cause

So the next time you see your doctor’s eyes look like they are about to come flying out of their sockets while he/she is using the computer, don’t be too harsh on them.  They did not go to medical school to become glorified data entry technicians, but that is just what we have become.

Working in a small town.

This week will be my last week working at Bath Community Hospital.  I have worked here for two and a half years.  I started working here almost by accident.  I was hired as a locum tenens physician in a hurry by the hospital and then accepted a contract to work on a permanent basis as a hospitalist.

Working 7 days at a time in this little town and then going back home to Miami for another 7 days has given me the opportunity to compare and contrast two completely different ways of living in the United States.  I have to say that people here in Bath County are good hearted people.  I am used to living with certain degree of anonymity but in a town this seize it is not possible. Everyone knows who everyone is, who they are related to, who is having problems and who is not.  The community sticks together and they help each other.  They are a good example to follow.

I am thankful for the time I have spent here, I wish all my friends in Bath County the best of luck and I will miss you.

Joaquin Barbara MD


Eating some of my words for lunch.

July 19, 2017

As some of you know I underwent bilateral knee replacements last December.  It has been a really interesting experience and in the future you will hear more about it but today I want to write a little about my experience with generic drugs.  In medical school we have been taught that generic drugs, with some exceptions (thyroid hormone replacement, warfarin, phenytoin) are pretty much just as good as brand name drugs.  I believed them.  I have said so many times to my patients.  I was wrong.

After surgery I was prescribed tramadol for pain control.  It is a good drug. It does its job and its side effect profile is ok.  I was prescribed 100 mg of tramadol 4 times a day.  I was getting my prescriptions from my local CVS(in Miami ) and everything was going well. The generic version of tramadol that I was given was working as intended.  Three months after surgery I went back to work and I had my tramadol prescription filled at the local pharmacy in the town where I am currently working in rural Virginia.  That pharmacy gave me a different manufacturer’s version of tramadol.  I took my first dose of 100 mg and I felt HORRIBLE, sedated and having a difficult time functioning.  Nothing like I was feeling with the original pill.  I had to cut my dose in half.

So it turns out that the FDA in order to let a manufacturer create a generic version of a drug, the drug has to be ” identical or bioequivalent, to a brand-name drug in dosage, form, safety, strength, route of administration, quality, performance characteristics , and intended use” and the FDA requires that the 90% confidence interval of these properties fall within 80% to 125% range of the brand name medication.

In English, because I was taking two different versions of generic tramadol, they could vary in potency the equivalent of 80 mg of Ultram to 125 mg of Ultram (Ultram is the brand name of tramadol).  IT SUCKED.

So having eaten my words, I promised to myself to be WAY more understanding when my patients complain that the generic pill does not work as well as the brand name.


Joaquin Barbara MD


If you are a nurse, thank you.

I was looking though some old magazines today (like 1945 old) and just clipping out interesting pictures that I am going to scan and use later (still don’t know for what) when I ran into this illustration of a nurse.

I love the old nurse’s uniform with the white dress and cap.  When I have spoken with nurses that work with me they either love it or hate it.  For most, the last time they used it was at their nursing school graduation and some have never had to wear it.  Cap and uniform issue aside, I think that we need to give our nurses way more respect than they get today.  They take care of our patients 24 hours a day while most of us physicians will visit with our patients for a very brief period of time and then walk away.  They have to put up with a lot of stuff.

In the last 20 years (which is how long I have been practicing medicine) I have seen their job not just get harder but turn into an actual nightmare.  They still have to take care of the patients just like before but now they also have to take care of the stupid computers.  Every pill has to be scanned, every interaction with the patient documented.  They spend more time charting useless information in the computer than interacting with people and I am sure they did not decide to go into nursing school to click drop down lists and fill in text boxes.  I feel really bad for them.  (I also feel really bad for us doctors because we have suffered exactly the same problem but that rant is reserved for a different day).

I guess this picture just reminded me of a different time in the practice of medicine.  To all my nurse friends, thank you for taking care of our patients and for putting up with me for the last 20 years.


Shame on me.

So as promised I will try to write a blog entry every day.  This is the first day and I was already making excuses not to do it but here I am.  I would like to share something I ran into by accident recently.  While watching Youtube I ran into an interview that Chase Jarvis did to Dr. Brene’ Brown.  Chase Jarvis is a commercial photographer with a large amount of content in Youtube but he is very engaging when he interviews someone and Dr. Brown, whom I had never heard of is a “shame researcher”.  I think that she is really on to something.

Below are two links, one is to a 20 minute TedTalk that she gave on shame and the other one is to the longer interview she did with Chase Jarvis.  I think that both are very interesting.  Please let me know what you think.


Ted Talk

Chase Jarvis Interview