Solutions to the Problems in Emergency Medicine and part of my current Survival Plan Some education here is for you about investing. Please note this is just education if you would like to consider self investing in the stock market. The stock market has risen a lot in the past 1.5 years after it leap from a DOW in the mid 17,000 to now over 24,000. Do you wonder why? Are you afraid to invest? Please note, I am not a licensed financial advisor so any of this is just information purposes for education and you must always seek the advice of a licensed professional in finance; I can’t give you financial advice and I am not. I am sharing myobservations. Interestingly when I asked a “pro” at my investment firm and they did not know anything about any of this in 2015 when I asked. I took an inexpensive $47.00 a year newsletter from Paul Mampilly’s (Banyan publishing) and he has been very accurate in his advice and assessments of stocks…i follow it as a paper investment because I don’t know him personally. You might want to look into this newsletter because he has mutiple stocks that are up over 100% one (ticker symbol STM) is up usually around 300% since 2016 but as of Dec 2017 it went down a little. He expects this stock to grow 80x its original value based on the 50 billion devices expected to be upgraded to the “internet of things” by 2020…I watched this stock go from $5.15 to almost $25.00 a share in just a little over a year. Now it is dropping a little down to 21.00 a share. He has written some very interesting concepts about the market and one of the main lessons is his explanation for why we have bull markets. He takes an approach that examines the stock market based on every bull market in history. He made a very logical presentation which you may be able to watch on what drives up the markets: the short answer he stated has always been a confluence of two things: new life changing technology plus a large increase in the population. The 2nd part is very important because self investing really took hold when it became convenient a few decades ago with the baby boomers. Because they could and did represent a huge new increase in the population and they had access to investing which increased in the short time that computers and websites became available to use for investing all of this is important for why the stock market boomed with the “baby boomers.” Now we have many, many millions of more investors who are located not just in the US but they are worldwide and each likely has with few exceptions like most of North Korea, access to open a self-directed investment: these are the milllenials and they have grown up with computers and related devices that access the internet. I mentioned the Stock STM because it is also being driven up by Congressional Law! STMs stock is being driven up by a Congressional Law which passed on March 1, 2016 known as the Digit Act. The Digit Act was written to ensure 50 billion devices (initially mostly automobiles) would be connected to each other by a type of chip called MEMs. MEMs: microelectromechanical chips are tiny, use a very small amount of energy and do amazing things. The issue with this move by Congress is it is mandating that 50 billion devices be connected by MEMs by 2020..so from the time it was in place only 4 years will pass and 50 billion devices will be connected: this is the start of the “Internet of things.” The initial internet connected people, now we are connecting machines to machines as well as to people. There are many, many kinds of MEMs chips. STM is a huge company with a large number of patents and their R/D is highly valued and augmented by the Co’s devotion to making machines act in new ways. Much of the function of MEMs if to add efficiency which increases profits for companies, cities, businesses and people. They can help people in many, many ways. The current estimate is that 50 billion connected devices equates to 19 trillion dollars of money flowing. That money is more than 7 times all the money ever spent on all the computers, tablets, cell phones, and “pod” type devices sold in the past 40 years. Now all of these items were not present for forty years but computers go back that far. So imagine how this huge amount of money spent over 40 years is now going to be spent over just 4 years. Estimates are that STM could go up as much as 80x the price it was in the Spring of 2016 which is the same way of saying an increase of 8000%. Another stock FMI is also way up over 100% and still considered a buy by this expert (Mampilly) as of Dec 2017 as are several more. FMI went up over 17% on Dec 1, 2017. Mampilly is prompt and courteous about his programs and he has three (in reporting when to buy and sell). I think based on his published history, that he left Wallstreet to help the “little guy”…is a good sign. He lives with his wife and daughters in North Carolina and is happy to be away from what he faced for decades in Wall Street…in his newletter he is very careful to use simple language and logic. So he is one of the “experts” who explains: the stock market boom we are in is going to go much much higher and will last for at least 10-15 more years…why? if you look at history every stock market boom is based on the convergence of two elements I mentioned…and this time we have more than just these two elements. People are much more informed and able to use the internet for business. We need to remember than in the 1990s all of the internet was so new that giant companies did not have websites and were not sure if the internet was just a fad that would disappear. Then programmers showed them that people were using the internet in ever-increains numbers and every company opened a website. The ones that were successful are still successful and now we have several companies that are on the verge of having one trillion dollars…several are approaching this number. So these companies like Facebook and Apple and the list is very long, evaluate and store data collected by copmuters. MEMs creates more date, huge amounts of it. So now we are well past the terrabyte and companies will use data created by the sensors that are MEMs to make computer driven decisons based on a society that now uses data for efficiency, comfort, healthcare, even war. So nothing you can think of that is really bad like war will stop the use of these and other chips. There is another whole new chip that works for machine learning. It can be reprogrammed by a computer itself. Huge data farms are growing worldwide because as the both types of chips are used computers will use that data in many ways…it will just be a cycle that feeds on itself to grow and just keeps growing. MEMs chips will make all vehicles self driving. A new type of technology will also make it possible to do what GPS does without satellites. So with all this new technology comes new opportunities. Computers, robots, the mining of the digital currencies like BTC (Bitcoin, Etherium, Litecoin) is occurring 24/7 365 days a year. If you look at just the oldest and most well traded of the cryptocurrenices it is important to note that over 100,000 people are currently signing up with Coinbase alone EVERY DAY NOW (and there are other companies to hold your digital money). The huge demand, the limited supply by design of how cryptocurrencies serve to solve a problem, like no middleman, privacy, multiple computers around the world that make it all work (a decentralized system) prevents many problems of paper money, now also called fiat money. Fiat money is paper money not backed by anything. It is based on trust. The main point and I will have a whole ongoing page just for cryptocurrencies is it too is a whole new way of having a transaction without middlemen (this is huge because every time you wire money especially if you did it overseas, at least 6 organizations get fees and the risk of human error is great. All of this is eliminated by the cryptocurrenies. It has been present for a few years and the investment in all of the current available cryptocurrency is roughly 200 billion dollars. The amount of money the world uses is a massive hundreds of trillions so as more and more people use this form of transaction and because it is designed so that there can never be excess secret printing of new cryptocurrency (the programmers can see all the code worldwide so they know this wont happen by designing the system that way), the value of a Bitcoin is still skyrocketing and likely will for years to come. Estimates are that one Bitcoin in many years could be worth as much as $500,000 to $1 million US dollars so it is, of course, creating a “feeding frenzy” to mine and buy Bitcoin and other cryptocurrencies. There are now double digits of millionaires (20 million worldwide), just their desire to invest plus that banks and funds are starting to develop plans to have ETFs based on crytpocurrency means there will be more oversight of it but it will just keep being used more and more. Quantitative easing is not allowed in the world of crytptocurrency so high demand will keep pushing even what some of you thought is an “old too late to the party investment” keep going up…I mean Bitcoin. So it is still early as far as adoption by the world. Let’s leave that for now with a final note that even governments will and have announced they want to have use of cryptocurrency. They want to be able to use it for their “private transactions” Ok back to the stock market: The basics are: population growth (the oldest millenials are now over 34 years of age and they are many millions more in the US than baby boomers). Their age is important because now we have a new much larger group of investors who understand computers (they grew up with them) and each of them has, on average, an income of $40,000.00 a year. The number may be higher than you would expect but I have seen this in much of the reading I have done. So with this group also being a worlwide (not just in US) group of investors, this huge population worldwide is also investing in the US markets. MEMs are chips are the technology that is stated to be so revolutionary it will change the world as much as if not more than anything ever invented by man (and I said $19 trillion dollars worth of these chips are slated to be installed by 2020 (mostly in cars but virtually any machine) and much of Entire countries not just cities are adopting this technology. That is massive. So population (people) plus investing in life-changing tech is what has driven the major booms every time. War does not stop it….and can promote it as this tech is now used in our “war machines”. It is just more people plus technology…it is that simple. It does not even require AI (artificial intelligence). But newer chips that can be put into computers are already in production by these companies or the companies they hire (if they are fabless: meaning they don’t produce but rather they design chips). The newer chips for AI are able to be reprogrammed by the computer itself as it is self-learning (also called machine learning). These are chips made by Xilenex and many other companies. The chips are so important the president prevented China this year from buying one of these US companies: Lattice (ticker: LSCC) and others include: MSCC, TSEM, AMD, CAVIUM, and QUIK (Quicklogic). All of them make chips that can be made then they are retrained (reprogramed) as machines (computers) learn on their own…this is AI. Several experts are concerned about the progress of AI but keep in mind all of it is still programmed by humans and it took IBM years and lots of money to get a computer to beat smart folks on “Jeopardy”, the game show. Hopefully mankind will harness this to do good. We have data that suggest that AI will help with better treatments for cancer and that is already happening with companies like FMI (Foundation Medicine) a company that works with MD Anderson and huge data banks of successful cases (it is so much data it is measured in petabytes or more). It is genomic treatment so medicine will be designed based on the genome of your cancer and your personal genome. This is happening today. Targeted genome therapy which greatly increases cures for not just cancer but virtually every disease that has a gene for it. So part of my plan is to educate myself and stay on top of what is happening and I hope giving this information to you will give you hope and help. :)

IMG_0459This is an audio CD of a common household medicine Acetaminophen.  I produced over 35 such educational CDs.  The closest “partner CD” is one I entitled “Salicylate poisoning” i.e., aspirin poisoning.  Believe it or not so many errors are made in the care of patients because patients may misreport which of the two they took.  We have tests to determine this rapdily.  Both CDs are 1 hour in length.  I chose these two topics because patients and their families often confuse the two and without the bottles your medical history may be incorrect.  APAP (acetaminophen) has 4 stages of toxicity and they are easy to remember because they occur over 4 days. The difficulty for many new physicians is the first stage which lasts only 24 hours is a presentation of vomiting not unlike just a viral gastroenteritis…like a common “stomach flu” presentation and not to test is a potentially serious error.  Just to treat with medicines to stop vomiting can cost a patient their liver or their life.  This is why hospitals restrict acetaminophen to no more than 4 grams per day in a hospital.  The dose that in one dose can destroy you liver is 7.5 gm and this can be lower in people who are of small or low body weight and how they also individually metabolize acetaminophen.  Ingesting alcohol can be in general make the situation worse.  I have seen physicians prescribe tylenol with codeine and attempt to discharge a patients with toothaches but on showing them the patient’s bottle and that the patient reported to me they took over 35 grams of Tylenol and yes they are vomiting and being sent home..no I stopped it from happening…so this is common.  I am only one person…I could only save this one 28 year-old because I saw it and I had enough of a relationship with this doctor so he ordered the test that confirmed this patient had inadvertently taken a massive overdose and she was admitted and treated and did well.  The point is a simple toothache can kill you if you don’t follow the directions on the bottle…it is just 15 extra strength APAP tablets, each 500 mg which equal 7.5 grams (the serious hepatotoxic dose that requires treatment with the antidote mucomyst AKA NAC-N-acetylecysteine).      The cover of the CD depicts an image of pills and a girls face but don’t read anything into that except my kids were very involved with my products.  Now one has started a business in crafts;  so just like seeing my mother in business and learning from her, my kids are doing the same.  The CD presents all of the pathophysiology of acetaminophen and the treatment which currently is IV Mucomyst.  Some cases of any poisoning may be treated with activated charcoal when they arrive early.  There is now essentially no indication for the use of ipecac to induce vomiting in but a few agents.  One is benzene ingestion if the patient arrives early.  Gastric emptying and  absorption of benzene is a very high risk for future liver cancer.  I have an interest in toxicology because I studied and still study chemistry, biochemistry and especially clinical toxicology.  It is an unlikely ingestion but the type of item you might fight on a board question.  The American Board of Emergency Medicine has a Life Long Self Assessment Examination which is devoted exclusively to toxicology readings and questions.  I took that examination too.

ABEM TOXICOLOGY CME 2015 LLSA EXAM Certificate.pdf

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Blue sky © 2016 Dwight Collman MD painted with the Ipencil on the IPAD Pro…yes realism is very possible on this device. I use the Program: Procreate to make all of my computer generated art.

This will be moved to its own page:  Based on the statements I made about APPs (advanced practice providers) you might assume I don’t like them.  Nothing is further from the truth.  The problem is the system designed to educate and select them.  Just as in medicine, physicians need rigorous prolonged education that begins with the selection process that is much to late to solve our current problems in medicine.  Students are interviewed after they complete their Medical College Admissions exams and all of the requisite education.  This is backwards in my mind.  We should seek out young people even as young as children and begin to ask the nonspecific question, what do you want to be when you grow up?  Why do you think you would like that job.  It is amazing how children can state their future.  In those with an obvious interest in medicine you will also be able to find by talking to their parents and family that they are reading medical books or articles on topics, just like I did.  Capture those and you have captured the essence of what you want, the people who will make the finest physicians because they were essentially expressing their need to help others from childhood.  So many people never get their dreams because some people are not creative in their thinking.  We should not have a system with “partially educated providers”.  That is what happens to all of the people who did not get into medical school.  If you talk to medical students all of them will tell you it is competitive.  You would find so many more of the best in aptitude and desire to help the sick and informed by simply looking for it in childhood, educating them year by year in a program of life long study.  That is what produced me.  I was reading endocrinology as a child, human physiology as a child…on my own.  I am not unique or special.  There are many, many bright people.

The medicine category (and even in every category) is full of people who would make great health care providers in our service industry of patient care.  They are expressing it when they take the time and energy to compete locally at their schools, then at the local colleges and universities and finally at the international level.

Medicine has so many bad providers because they are not selected correctly and/or they are inadequately educated.  I knew a lot of medicine by the time I was 17 because my desires were advanced by the people around me.  For, example I needed to know how to perform and did perform what for me now is an uncalculated, but large number of blood gas studies which I documented just as any researcher to design what became the first membrane oxygenator (ECMO).  I conceived that idea by the age of 15 and had a working machine with real blood flowing through it and I had used gas chromatography initially with saline and then blood and blood gases to show the idea worked.  Because of this project I gained the knowledge of an ABG lab technician as a teen.  I was using real blood.  Years before that in the 9th grade I was allowed to self-educate with a mentor and complete a college class in human physiology.  I understood homeostasis and Starlings law and it is easy for me to still recite it here for you and since it is about flowing fluid across a membrane I put a painting at the top of of this page.  I enjoy painting flowing water and crashing waves.  Here is Starlings Law for the flow of fluid across a semipermeable membrane like the interface of the of capillary nextwork that surround pulmonary alveoli, pick up oxygen and release carbon dioxide.  Well fluid can also traverse the membrane interface from forces normally kept in check by an intact membrane.  Damage to the membrane as in the adult respiratory distress syndrome (ARDS) can cause fluid to accumulate in the alveoli and this is the equivalent of making the membrane too thick so gases cannot properly diffuse…so hypoxemia (lack of oxygen in the blood) and ultimately hypoxia (lack of oxygen in the tissues) occurs.

STARLINGS EQUATION

Q = Kf(Pc-Pi) – σ(πc -πi)

This formula is permanently in my head like many others I know and use for teaching and clinical practice.

Q is the net flow of fluid across a membrane, like the pulmonary-capillary alveolar membrane.

This formula determines when hydrostatic forces (the first half of the formula before the minus symbol)  and oncotic forces (the second half of the formula which is subtracted from the first half) will result in net movement across the membrane and produce pulmonary edema (one use for it).

Here are all of the key definitions.  

It is not that complicated.  You are subtracting an opposite force (oncotic pressure which normally tends to keep fluid in the vascular compartment and out of the alveoli) from the hydrostatic pressure inside the vessels that surround the alveoli and would push fluid into the alveoli except normally, a healthy membrane prevents this).

Q is the net flow of fluid across a membrane

Pc is the capillary hydrostatic pressure

Pi is the interstitial hydrostatic pressure

πc is the capillary oncotic pressure

πi is the interstitial oncotic pressure

σ is the reflection coefficient….hence

when there is damage to the membrane as in adult respiratory distress syndrome which has many causes [burns, sepsis from bacteria but viral infections can cause it too), blunt injury to the lungs, etc], the number [absolute value] for the reflection coefficient is 0 (zero) and that part of the formula is thus removed.

σ is the reflection coefficient and in ARDS it is zero so the entire second half of the formula, the part being subtracted, is zero (0)

Remember,  when you multiply any value by zero it becomes zero.

so this:  Q = Kf(Pc-Pi) – σ(πc -πi)

Becomes:

Q = Kf(Pc-Pi)

 SIMPLE!

Thus, what determines net movement in ARDS is purely the net difference between the hydrostatic pressure inside the capillary (the space where the red cells and plasma normally exists) versus the hydrostatic pressure in the interstium Pi.  Now you should not forget there is an interstitium: the space where the lymphatics are and it is present between all cells of our organs.

Pulmonary edema occurs when the former (the intravascular hydrostatic pressure is greater than the latter (the interstitium) when the pulmonary interstitial alveolar membrane is injured.  Each part of that complex long sentence is important.  The actual membrane that separates gas in the alveoli from the blood in the capillary that surrounds each alveolus is multilayered and can thicken in disease.  It is “functionally” thicker whenever there is pulmonary edema.    So pulmonary edema occurs in ARDS just because we have a “leaky” membrane that now is susceptible to fluid flowing from the capillary space into the alveoli and it is only flowing into the alveoli because of hydrostatic force that is higher inside the capillary than in the interstitium.  None of the fluid flow in ARDS into the alveoli has anything to do with oncotic pressure that normally keeps fluid in the vessels because that part of the equation is zero).

If you don’t recall what defines oncotic pressure is a system of two compartments separated by a semipermeable membrane.  When it is healthy, the pulmonary membrane has blood with particles like albumin in the vessels that allow water to flow from the alveoli, to the interstium (then to the lymphatics or back into the capillary).  So anything that depletes albumin, like malnutrition, could lower The oncotic pressure in the capillary and the tendency of capillary water to remain in the vessels would be diminished.  So oncotic pressure is an interesting phenomenon because water will flow from the side of the membrane with no particles (just water) to the side that has water and particles.  The albumin particles thus have the ability to keep water on the intravascular side of the pulmonary interstial alveolar membrane when the membrane is healthy and not leaky.  When it is leaky again it would not really help to use albumin (it has been tried in many studies) when the membrane is damaged the albumin particles, although big, can pass with water across the membrane…so that is not good.  Once across that water will stay in the alveoli with the albumin.  That is why most of the time we just resuscitate with 0.9% saline or Ringers Lactate.

So what is the point:  CLINICALLY, WE CORRECT INTRAVASCULAR VOLUME DEFICITS then limit hydrostatic (intra-capillary) pressure by limiting the amount of intravenous fluids such patients receive.  This helps to alleviate fluid flowing into the alveoli which would drown the patient if they have a leaky membrane.  IT IS VERY IMPORTANT AND CANNOT BE OVERSTATED THAT PHYSICIANS OFTEN UNDER-RESUSCITATE PATIENTS AND LEAVE THEM IN A STATE OF RELATIVE DEHYDRATION AND THIS IS NOT GOOD.

IT IS ALSO IMPORTANT TO REALIZE THAT WE HAVE EASY WAYS TO DETERMINE THIS ISSUE BESIDES THE CLINICAL ASSESSMENT WHICH MANY EXPERTS TRY TO SAY IS SO INACCURATE.  IN LARGE PART THEY ARE WRONG.  IF YOU HAVE A DRY DIAPER AND A BABY WHO CRIES AND MAKES NO TEARS WITH DELAYED CAPILLARY REFILL, THAT KID IS DEHYDRATED.  CHILDREN ARE MUCH MORE SUSCEPTIBLE BECAUSE THEY ARE MOSTLY WATER.  AT BIRTH AS MUCH AS 85% WATER.  Adults my age (61 at the time of this writing) are only about half water.

Why do we correct intravascular compartment volume deficits first and always?  AGAIN, the answer is because you need to make sure there is adequate perfusion to the brain and kidneys (core organs) for the patient to survive.  You know this answer clinically by knowing the patient is awake and alert: this tells you the brain is getting enough blood flow; likewise you know this by confirming there is adequate (normal) amounts of urine being produced.  The normal value is from 0.5 to 2.0 mL per kg of body weight per hour.  In children since they have more body water per kg of body weight, they produce urine at 1.0-2.0 mL/kg/hour and adults are in the range of 0.5-1.0 mL/kg/hour.  So a 10 kg one-year-old should make 10 kg x 1.0-2.0 mL/kg/hour = 10-20 mL per hour while an adult makes 70 kg x 0.5 mL/kg/hour = 35 mL per hour.  So even though you think a small baby is so small they are making ⅓ or more the amount of urine per hour yet are only 1/7 the weight of an adult.

In the acute settings with sick patients like the ED, a Foley catheter is important so you know the kidneys are getting enough core perfusion.  It is the hydrostatic pressure that is supplied to each glomerulus (just like the alveoli in the lungs), that will determine if the fluid will flow across a membrane and into the urinary tubules to make urine.  You have to ensure both the brain and kidneys are being perfused before you limit fluids.

You must correct hypotension (hypovolemic shock).  Then fluids from that point are determined by knowing the filling pressure (which is again hydrostatic pressure) in the heart chambers (typically pulmonary capillary wedge pressure was measured and that reflects or represents the hydrostatic pressure inside left ventricle at the end of diastole AKA “filling pressure of the heart).

 Today that measurement can be done non-invasively with an ultrasound machine.  The wedge pressue which we used to measure with a centrally placed catheter (Swan-Gantz catheter) is now a museum piece, because it is invasive and can cause a host of problems and infection is number one on that list.  Number two is thrombosis of the vessel lumen (like the subclavian vein or the internal jugular vein).

A bedside ultrasound can provide the same data.  So we don’t want to ever give a patient with ARDS an infection; they will surely die.  I recall years ago in a pulmonary ICU, a 3 bed unit, that almost all of the patients died despite all of our monitoring and careful management of their fluids.  Each of them had a chart with many many numbers we were monitoring from their body weight to the urine output as well as their filling pressure.  All had a SG catheter.  We measured every possible parameter we could but many died because that catheter carries risk.  The nature of the illness such as ARDS is just often fatal too.  That does not mean we don’t treat and try to do all we can…and we do.  Today monitoring is done non-invasively.  Virtually every area of medicine is trying to do less to harm any patient.  Those are the scientists who do studies.

NOW AS USUAL WITH ME THE DISCUSSION IS GOING TO DIVERT HERE INTO A REALITY ABOUT MEDICINE.  IF YOU DISAGREE WITH WHAT I WRITE PLEASE WRITE ME.  THIS IS WHAT I HAVE SEEN AND THIS IS NOW NOT THE SCIENTIFIC MEDICINE I WAS TALKING ABOUT ABOVE, I AM GOING TO DIVERT ALSO BECAUSE THIS IS ON MY MIND 101% PERCENT OF THE TIME:

In real world medicine, after one is trained and on their own in life maybe practicing in a community hospital of any size:  I would have to say that statement is not true because so many people do not practice high quality medicine.  There is no one type of doctor who fails to do right by the patient.  There are many causes.

Some chose the wrong profession, some are “burnt out”, whatever that is.  I say that because despite 37 years of work I still love clinical medicine.  I don’t equate with such negative terms and I don’t live my life looking at a clock.  The skills one needs to be happy and well should be clearly present before one entertains a life of medicine.  Being a doctor is such a huge responsibility.  It IS peoples lives.

I am going to tell you, I understood much of human physiology including most of the homeostatic mechanisms as a child because I learned it as a child on my own, through my own reading.  I did not write that to brag; what I know is I am not as unique as people have said to me.  It is a choice I made and I am sure there are so many kids who did the same thing and also compete to go to medical school.

Some tell me after they became a doctor, they did not make this choice to study medicine.  Many have told me they were pressured to be a doctor because mom or dad was a doctor or they chose it because they believed it would be financially, a good life.  This is the worst kind of reason to go into medicine.  I have heard this hundreds of times in interviews of physicians behind a closed door when I am testing them preparing them for their oral board exam: “I only became a doctor because my parents made me do this.”  Such an absurd statement.  By the time you are an adult you should know that you are the only person who makes you do anything.  It is just like the idea of “your words hurt me.”  Well in part this is true but in large part, it is the person (who has to interpret what is being said to them) and if they interpret something as harmful then well to them it is.  Our perception of our reality shapes our reality.  Not everything said is awful or evil nor is the opposite concept totally true.  The same words mean something different to many people.  But people often choose to use a negative connotation because they were raised that way.  You can hurt a person by shaping them negatively in their childhood.  At that level that is abuse and it can alter them for life…it can keep them from succeeding.

Some physicians are at a disadvantage because they were not guided to their gifts.  I once told one of my kids he should be a musician to see what he would say and it was clear to him I was not serious and I was also pretty sure of what his answer would be…yet I was curious to really hear his response…he was and remains a great musician and plays many instruments.  He told me as a child, “Dad I need a real job, I will need to be able to buy a home and feed my family.”  He went on to state further that homes would be more expensive when he would be an adult…so he understood inflation as a child.  He became an attorney.  At graduation he told me, “I went to law school to learn how to think.” I remember we were walking to our car after his graduation when he said that.   I just listened.  One piece of advice is just listen and do not give advice; if you just do that, you have done a lot to improve the world.  Now if you are asked start with a response that allows the individual to reason…don’t give your opinion so they will understand that is real life.  You have to come to solutions mostly in life on your own.  You can listen to advice but you ultimately must make critical decisions all through life.  The decisions in medicine are often over-stated as complex.  It is a form of avoidance to just simply cut corners and not do their job.  My son will make a great physician. He made the decision to practice law then go into medicine so there was no doubt he would be of the highest caliber.  He is.  He is in his 30s studying for medicine.  If he decided to reverse that decision I would also be totally fine with that.  I doubt I could talk him out of anything and I think that is the way it should be.

So at graduation from law school he said, “Later I will go to medical school to become a doctor.”  He had told me as a child he wanted to be a doctor.  I never discussed it with him before that and not after either.  That was my son’s statement of his desire.  I definitely exposed him to medicine.  He came to the hospital; he saw patients in the ED.  He understood much about real medicine.  So he knew what he wanted and his experiences with me their likely reinforced his decision.  This was his plan not mine and I certainly did not try to influence him away from his plan.  It was clear to me he knew what was best for him, just like my other little ones at that time.  I did tell him also you will be a great attorney because when you argue you do it so well and that is the truth.  Sure in that I was definitely saying you have another gift besides music…the gift to argue your point effectively.

Our nation does not guide our youth with their gifts and the proof is that we do have to import our intelligent people or we would not be a fraction of what we are today.  We definitely import intelligent people and they get a visa because of that.

I am unique in that I had so many people in my life recognized my abilities and kept me encouraged and helped me. We need others doing the same with children well before the time of entry into medical school. As a school teacher my daughter made a decision to go down one grade, she told me I need to have time with children when they are younger, because these parents in the grade she was teaching, she felt were damaging the kids so much that she decided if she met them earlier in life it would help them more.  She was quite serious.  She was tutoring kids when she was in the sixth grade.  I had no doubt about her future profession and I never said be a teacher…I could not stop that if I tried…it was her passion.  If you identify a child’s passion it is a good thing to get them involved in a way they enjoy it but it should not be anything that is burdensome.  There is plenty to learn as a child and it is not always important to add extra stuff on top of what kids add to their own lives.

It is just like punishment…people are really often so heavy handed.  All you can do is have time out one minute a year up to age six…that is six minutes…followed by a brief discussion and then let them go back to their happy life and that “brief discussion” should be private…so you don’t embarrass your child.

People often enter medical school and they actually don’t want it, don’t like it and it is not for a person who is not ok with the sight of blood and other “complex”, “boring”, or “not so fun issues”, like performing a rectal examination.

I cannot overstate how many physicians today who fail to do this examination and miss serious pathology.  It is their sworn duty to due the examination if a patient has symptoms, but wearing gloves is  apparently not enough mental protection and they simply find it a mental way to justify not doing it…so they don’t do it.  It is not that they really believe they should not do the examination they don’t do it because they don’t want to do it.  You will see the words “rectal deferred” over and over or just no documentation by some physicians.  How can this be justified?  It can’t.  The problem in medicine is simple; if you are not  up for this stuff that is not fun, don’t become a doctor or nurse or anything to do with healthcare.  The most intelligent mind with the most positive attitude toward patient care with a dose of confidence is all important good quality “doctor-making stuff”.  That is the right stuff.

YOU MAY NOT KNOW THIS: CONFIDENCE IS TESTED ON ORAL EXAMINATIONS AND IS GIVEN AS MUCH WEIGHT TO THE TEST RESULT AS THE DIAGNOSIS…EVEN MORE.

Patients have to know their physician is confident or they won’t trust them nor follow their advice.

I have also seen literally dozens of nurses refuse to help a patient with disimpaction.  It is both a nursing procedure and a physician procedure both…and now I should include APPs (nurse practitioners and physician’s assistants) since “they practice medicine”.  So, if you don’t like to deal with urine and feces, you should not be in the medical profession.   Do not think i have some weird thing about this.  I teach doctors the best ones have rectalmania.  Yeah it’s a joke but I use a lot of my own neologisms (words I make up that are to make a point). NEO: means new; a neologism is just a “new word.”

A sign of cancer, bowel problems is a serious health problem and the healthcare providers do send patients home often with an impaction (especially) in the elderly that can go on so long until it actually reverses as the bowel is “screaming mad” and now making excess fluid and the patient then presents with a distended abdomen and diarrhea.  They are then obstructed not only impacted.  How many people know this in the medical profession? My guess is they read it in medical school, what they do in real life is another question.  There are great doctors.  I don’t want to sound so pervasively negative but I emphasize it because I would not have met so many troubled physicians if there was no trouble.

In total, about 700 of the first 12,000 I have spent time with have sent me cases I could not defend.  Yes they sent me a case they were being sued for and I read the material they sent me.  I write nothing so no one can ask me for any written records ever and I have told about 700 hundred doctors I feel they should settle their case because they did not do what they should have done.  I have no idea if they took my advice.  It was free.  That is a huge number of doctors who were sued.

I cannot make any correlation between that number and the number who fail boards and most of the public, the recruiters, the people who credential have no idea that boards are super difficult and that many people fail multiple times before they are board-certified.  I have heard many say they had no idea that as long as you do what the board asks to remain board eligible you can fail and fail.  They are happy to take the doctors money each year to take their test.  It is, in part, a business. It is really big business.

I asked every client physician if they are coming because of a test failure; the majority answered yes and a huge majority had multiple test failures over many years.  That does not mean they are not good doctors.  Some become so removed from study and tests despite required CME that they do have test issues.  Mostly it is life issues and a perception they are inadequate.  This is especially true of those who are taking an oral examination.  The fear of public speaking then is real; yet at work they have no problem speaking.

In a university based hospital where there are clinical educators and people who are training medical students it is less likely to happen that people avoid proper steps of care because they are keeping the standards they know are correct in that setting.  Yet I see many abuses in those settings too.  All of it affects patient care.

If we better selected people for their abilities to do what is necessary because they desire to practice quality medicine, much of the problems would fall away.  The children who self-select to be a doctor are much more likely to be the right people to do the job well.

In education we have a huge problem.  I have not yet met the physician who could quote Starlings equation or verbally describe how to determine a fascicular block on a 12-lead EKG in 12,000 attempts-meaning none of my client physicians could easily do that.  Surprised?  I am kind and polite when I ask for someone to explain a concept like these.  You have to be able to think in 3 dimensions to understand fascicular blocks.  The heart is a 3-D cone shaped structure tilted on multiple axes. The left heart is all of this: to the left of the right heart, below and posterior to the right heart.  In books it is only a right left thing on a page; in real life it is in 3-dimensions in the body.

These are people who have had 12 years of schooling, then college for four years, then medical school for four years, and then finally an internship and residency for 3 to 7 more years.  None were fascile and all were unsure and incomplete in their descriptions if I put just those two items as questions on a page and asked each audience.  I have done this hundreds of times and  I don’t blame them; I help them.  When I go through the explanation it is not uncommon for someone to blurt out I never heard this explanation and I could never figure it out.  Now it makes sense.  That person is being honest.  Testing has changed for entrace into medical school; knowing the basic sciences is so important to build upon that knowledge base it cannot be overstated.  A computer simulation of anatomy today does not simulate anatomy.  You can smell a dead patient who has been preserved for a year of you to dissect them and you can recall that smell for life.  It does affect what you recall and by eliminating that input you fail to educate.  You leave the anatomy lab and know you need a shower.  The odor is in your clothing.  It is a different experience than a sterile computer.    This is why it is so important for young physicians to be taught to respect the people who donated their bodies for their benefit.  That is a serious place, a sacred place.  Now sure it is not uncommon for people in medicine to make lots of jokes that are not politically correct; this is how they handle their “stress” because they were not trained how to manage it nor that it is something to manage.  That is part of parenting.  The first rule of stress is that it is only stress if you make it stress.  If you got this far on this page you might feel out of breath but you never spoke.  It is a lot to read.  It is a lot for me to type.  But essential.

I never present information with any “attitude” that somehow I am better…that defeats why I am there.  I am so careful that I even dress down so no one will feel intimidated when I teach.  I come to the classroom in a sweat shirt and sweat pants, with walking shoes.  I often take off my shoes and walk around to let people feel everything is to be relaxed so they can learn.  Knowing how to make people relax is very important to being a great educator.  It is a skillset.

These are failures of the system and it all falls on the educators to fix; unfortunately many are not motivated to do this.  It is absolutely wrong to think that even the minds of physicians can easily understand such issues because we teach so poorly from the beginning and professors are not motivated educators because of a simple issue.  Money.  They don’t get paid the money of what an entrepreneur educator gets.  I learned that very quickly and I realized I would not have such a job if people did not need me.  So they don’t have the financial incentive either.  Why should an educator not be rewarded if they can educate well?

Teachers are so valuable yet so many leave as soon as they are not happy or possibly happy and pregnant.  If they leave permanently, that is a wasted education and now they become a mother which is the most important job on the planet.  My daughter has been teaching for 11 years.  She will not retire from teaching and she didn’t  waste time at her university dating.  By 19 she was at an elementary school teaching and done with her university education just like her siblings.  I saw this gift in her and I made sure she entered that profession because she, like my other two adult children are able to perform this function because they enjoy it.  Then it is not work.  It is passion.   I can tell you she spent a lot of time with frenetic girls who had problems with their boyfriends. She was like their mother telling them how to manage their lives.  I said I made sure she would enter that profession.  I exposed her to teaching and she decided she liked it even more.  All of my kids have taught doctors as children.  They were well compensated too.  I never saw so many doctors laughing to hear a child teach them the pediatric fluid lecture I have on this site.  It proved a point that the physicians tried to get me to believe.  That they are no able to do fluids w/o a calculator.   I remember telling them I will bring in a specialist, actually a few pediatric specialists…that was the short but important teaching by my children.  It benefitted them and it benefitted the doctors…and i got to sit back and relax. And laugh.

Young people today waste so much time on the internet, on cell phones (which damage the mind by causing you to use a device and never to memorize) and now we have an entire 3 generations (possibly four) of humans in our country that are losing memory for this reason.  The issues about relationships, sex, drug use are so bad that we destroy we don’t build.  To see multiple young people with dentures because of meth is so awful to see but is not rare.

The people who need medication don’t always get it and so many who need no medication are self-medicating or physician-aided medicated.  Alcoholism is rampant.  If we don’t stop these behaviors we will end up like Rome…in ruins.  Think it can’t happen?  It is.

The problem starts with poor parenting and this includes how we address divorce and other similar issues.  Parents need to focus on helping their children find their gifts and let them be.  When you force anything on a child they will rebel.  Then they lose their dream.  Our culture spends more money on taking children to R rated movies than children’s books.  We are so unhealthy it is obvious.  We have to find ways to stimulate ourselves more because we forget how to acutally smell a rose.  In Eastern Europe it is common to see both men and women walk into a rose garden and do just that.  I could keep going but I think you get the picture.

If you home is not happy and in order your children end up losing their dreams because they lose themselves and then their lives.  Don’t let it happen.  Work to identify gifts and promote them.  If you are in medicine and you plan to remain then dedicate time each day to study.  It takes minutes after you complete your higher education to keep abreast of most of what you need to know.  Do simple things like record yourself reciting differential lists or formulas and practice everything you learned in your life again and again and again. If you feel the urge to ask why I am going to refer you to the next paragraph…my deceased father…

My father was a true genius.  He was a rocket scientist and much more.  He told me as a child if he could just remember everything he ever learned he would know so much more then.  He realized he was forgetting even in his thirties.  It is natural if you don’t keep reminding yourself until you form the permanent neuronal connections.  This is real and I teach how to do this.  You have to reactivate and reactivate in repetition your emotional brain which causes new protein synthesis in the brain and these are connections hard-wired to reinforce your long term-memory stored on both sides of the brain in the hippocampus (it is a complex structure by the way).  You have duplication throughout the brain for a reason.  Think of it as not having just one computer chip but two chips with the same functions.  Our brains are perfect computers and they don’t have a limit on what they can store.

I know more now than I ever did.  That is why I can speak nonstop even over a decade ago for 73.5 hours at a CME program and the doctors were asking me are you wearing an ear piece and someone is speaking to you and you are just repeating maybe what they are reading?  Nope.  They could not believe it and so they had these thoughts that I had help some how.  Nope.  It is just me and I am not special.  I just practiced and rehearsed and wrote my programs over and over.  I do not believe I have a photographic memory, but as an artist I do think in layers and in 3 D and I have been doing this all of my life.  You can see it in my art if you “look”.   I put that in quotes because my mentor taught me how to see…and I mean to see shadows within shadows and light sources and all sorts of 3D types of stuff but mostly he focussed on how to represent that with knowing how to mix and apply and blend colors.  WE used about 10 colors plus white to define all the things that we could ever paint; black  is available as paint but it is never used from the tube that way.  Even in total darkness if you allow your eyes to accomodate with time you can see light.  It is bouncing off of everything.  Do I think it made me a better doc to be an artist…that is an “absolutely.”  There is no area of medicine that it does not affect my judgement and decisions from looking at a patients color (like pallor) to defining a specific rash based on its key characteristics…and there is no area of medicine that I don’t see with an artists eye.  Perhaps that is my own perception of reality and it is not alway important but my experience tells me it is important enough that if a doctor cannot understand well enough to sketch what they are looking at (and it does not have to be pretty…it is just a concept), then it is likely  the concept did not sink in.

I have rewritten each manual for each program every year since 1989.  It took 8 months the first time. Now it takes days because I am just changing and adding information as medicine evolves.  Probably I am understating just how much time I spend at what I do.  Next is an interesting statement that set of the “I disagree” in me:

Emergency medicine has increased so much (the amount of what we must read) in what we need to know that the president of ABEM, years ago, stated that emergency physicians can no longer learn all they need to know due to the information explosion.  This is a failure.  She is wrong in my opinion.  She is jus not wanting to teach and use her supercomputer brain.  It is the methodology.  It begins like it began with me…learning how to allocate your time and then pushing your mind.

Your mind is what keeps you alive.  If you don’t use it you rapidly become ill and die.  This is not some new amazing discovery we have known this for eons.  When the mind goes, so does the body.

Now back to my childhood:

My high school principal and biology teacher made sure I was dual enrolled in college as a teen, that I had everything I needed to design and build my ecmo machine, which to my knowledge is the first ever working design of such a device (a silicone membrane oxygenator).  I used my money from my painting to pay for everything.  I used them for advice.  Often somewhere in the world someone is creating a similar ideas and similar devices simultaneously and medicine needs to look for them and help them just with simple advice.

That is why the science fair is not a joke when you think about practicing physicians and our health care system; it produced me.  I am a bone fide world expert and those who know me even ask me to autograph my books.  I don’t say this to brag either.  It is embarrassing for me, it seems silly.  They are showing me true respect for a life devoted to study and clinical practice…and for helping them get what they did not get in their university “education.”  It is in quotes yes…you may think it is sarcasm but it is my opinion that in so much our universities fail.  They are more concerned with having student cohabitant (male and female) than they are with education.  It is a mess.  FIX IT or you will go the way of Rome…we will be in ruins.  Now let me tell you more about how to fix it…

Children like me who make it to the international level are all brilliant, motivated minds and there were countless teens all competing for that first place prize every year.  I won first place in the medicine category in 1974 but all the rest are chldren who most likely ideal to be chosen as physicians, nurses, and APPs.  We need to look to these earlier methods and begin to see that earlier involvement in education in medicine is the answer to the question, “What is wrong with the providers of medicine?”  As I said, many tell me in private they were forced to go to medical school to become a physician because of their parents.  I wonder how many who wanted to be a physician and would have been a great one missed out.

I took down and hid all of my awards from my children.  I did not display them like a peacock because that is a lot of pressure for a child.  That is what these physicians are revealing.  Yet as an adult they do need to take the responsibility for what they choose.  I have read that most people have 10 careers once.  I can’t imagine having such a life like that.  For me that is no stability and total confusion.

Here is a classic example: I hire a 20 year-old to help me in the office and at the hotel in my city where I teach.  His mother is a board certified psychologist.  She was calling him every 20 seconds for about 20 phone calls.  He is a mess because she is a mess.  A lot of people go into the exact profession to try and solve what is wrong with them.  I am sure his mother was one of these people.

Many psychologists and psychiatrists choose that specialty to try and fix themselves.  They don’t seek help; It does not generally work.  It is my understanding that it is a requirement that all psychiatrist are analyzed by another in their training.  That is having the damaged help the damaged, but at least they go through an important process of discovery.  It can have benefits but it will never compete with the healthy psychiatrist or psychologist treating that individual who presents for such issues.  Do we really want a person who is trying to solve their issues in our ideal perfect theoretical medical system–practicing?  Maybe that is the joke my dad used to always refer to or he would say, “remember you get to bury you mistakes.”  He never said this in a harsh way.  He was trying to say it is a very important job.

I know mostly I don’t control anything, but I also know that mostly the choices I make are important and I view them that way and I know I can be the determining factor that creates the events to cause a patient to recover.  That was a fancy way of saying doing things like starting an intravenous line.

If I had my way, I would be teaching every doctor, APP, nurse who practice in the US and I would do it until they burn my body.  Because I can have a much more profound effect on healthcare by teaching what I teach, the basics of the science of medicine.  I notice that people don’t do that by some intuition that tells them they can’t or by just omission.  Some people are aware that teaching is not their thing.  Others think they can teach but can’t and the dumbest thing I ever heard is those who can’t do just teach…no I know plenty who can do both very well.  A doctor is supposed to also be a great teacher…it is inherent in the definition of what a doctor is.  Read this clinical event-it was recent:

Just last year in 2016, a board certified emergency physician ordered a lumbar spine series on a 76-year-old woman with facial trauma as the presentation.  During the handoff I learn she is in x-ray with “massive facial trauma”.  She has no airway, none of the process of ATLS has been done and no head CT-just a lumbar spine.  He had been with her for over an hour at that point.  She comes back from x-ray because I went over and immediately took her.  She was comatose with dilated pupils.  Her face was one big giant hematoma and the left pupil larger than the right.  Of course she has a huge subdural hematoma and he missed every step in ATLS.  Why?  He was looking at his watch.  “I have to get my wife to the airport.”  Have you heard of UBER?  Have you heard of a Taxi?

He is NOT caring for a seriously injured woman who face planted onto concrete while running down a sidewalk.  He is not concerned about his actions either.  He almost killed her in the ED in a Florida hospital and he was never admonished.  The director did nothing.  They hide it and I just keep thinking about the necromongers in “the Chronicles of Riddick”…”You keep what you kill Riddick” (or what my dad told me about burying my mistakes)…Well that doctor, he will be keeping his dead patients in a room that will fill if he keeps practicing to the “clock of his wife”.  HIS MISTAKE:  HE DID NOT LEAVE HIS PERSONAL ISSUES AT HOME WHEN HE ENTERS THE HOSPITAL.  At it’s core this statement is what also defines a true professional.  I will continue this discussion in great length so I can tell you how all of you are keeping what you kill…you may have good intentions but until you let your spouse call Uber you are dangerous.  When we have self-driving cars, perhaps this couple will solve their dilemma.  That is coming in months.  Uber has them in Pittsburgh already.  It is proven technology.  OH Technology…that leads me to another subject…

OR MAYBE WHAT FOLLOWS WILL GET ITS OWN PAGE LATER:

THE FOLLOWING IS SOME EDUCATION ABOUT THE INTERNET OF THINGS AND INVESTING IN THE STOCK MARKET; THIS MAY HELP SOME OF YOU GET INCOME, POSSIBLY WEATH BEYOND YOUR IMAGINATION IN JUST THE NEXT THREE YEARS…IT IS MANDATED BY CONGRESSIONAL LAW…TO ME IT IS A NO BRAINER.  ONE OF THE STOCKS I MONITOR (TICKER: STM) has gone from $5.15 May 2016 now to over $15.00 and is expected to continue to perform like this because they are making many of the 50 billion MEMs chips to make self-driving cars a reality.  Google, Intel, Microsoft, Tesla, Apple, Samsung, and many others are making devices that require MEMs (THAT IS A PARTIAL LIST).  You might conclude you should be buying the stocks of the companies that make the parts, the MEMs chips and I would agree.  Why?  It took 40 years to make all the computers, another near decade for all the billions of cell phones, and two years for the iPad like devices…all of this income is going to enter this chop manufacturers  in just three years time!  50 billion chips is 7x more than all the computers, smartphones, pad devices ever made and it will happen in just three years.  Read and learn about the Internet of things (IoT)…for me, it may save my life because I am unemployed.  Not by choice.  I will keep saying it and I will never take these words down because I should have employment…i have nothing in my past that says I should not practice.  Never even missed a scheduled shift ever in 34 years.  Never took a sick day.  Last time I had a vacation was in 2012.  I don’t own a car I ride a bike for everything so I keep my physical form.  My life is always very simple OR AS SIMPLE AS I CAN LIVE IT.

I took myself off the internet because THE INTERNET gave me stalkers who tried to murder me…but it is not safe now anywhere so I am back again in part because I don’t want to lose all I worked for and I want to go on helping others learn medicine and keep saving lives.  That is what I do best.  My art…I do it pretty well.  I am best at saving lives.

CT HEAD MOTION ARTIFACT ON LEFTINVESTNIG WHEN YOU DONT HAVE EMPLOYMENT-YES IT IS POSSIBLE

THIS IS NOT MY BRAIN BUT I AM USING MY BRAIN TO SURVIVE NOW

(There are multiple findings on this subtle CT which prove to be shaken baby syndrome.  fuzzy tack fall (sarachnoid hemorrhage adjacent to the posterior fall, a laceration of the rights cerebral substance (dark irregular horizontal line which could be confused with the space at the juncture of the temporal-parietal lobe region.  You have difficulty seeing the such and gyri because there is global brain edema. On physical exam all you may find altered behavior or mentation, abnormal cardiac rhythms, but the sine qua non are retinal hemorrhage and bruising of the upper arms aka grip-mark bruises from violent shaking which is always intentional and always means abuse).  In medicine when something is an it can be only one diagnosis…and it is an emergency, you need to know it!  This is always a board test item and a much more obvious image appears on the cover of my oral board program cover.  No one emergency physician could ever told me the diagnosis of that image…just more proof that we have a problem with education at the highest level of functioning.  These are emergency physicians in practice.  This is bread and butter stuff for them…the need to know it.

HELP ME KEEP MAKING THIS POSSIBLE…yeah the job I need :)))

OFF TO MY SURVIVAL MODE I HAVE BEEN IN FOR A YEAR BECAUSE NO MATTER HOW MANY DOZENS OF TIMES I SEND OUT MY CV SOMEONE ELSE GETS THE POSITION I SEEK-EMERGENCY PHYSICIAN

I am not a professional investor and I am telling you about this so you will find out on your own…dont wait…I didn’t.  Don’t take this information without subscribing to Paul Mampilly’s Profits Unlimited.  I did it last year when I saw i was being kept from working.  It is not what I want…I want to practice medicine.  Medicine is not going to lose me to the stock market…but this is keeping me motivated because some days I can make even more than I make in the ED.  Somedays not.  But I have to try.  I need to try because I am supposed to be getting married.  I am supposed to be helping my daughter with her wedding.  Hers will come first.  My discussions will continue to come back to the issue that I need to work.  My personal physician considers it tragic because I am your gift…and you have put me in a trash can for now.

Here are the stocks that you should buy if you want to earn money…these are the companies making self-driving cars possible:  MBLY, STM (has gone from $5.15 to over 15.50 in 8 months-wow), NVDA, ADSK, GE, IBM.  GE and IBM are both now huge software companies.  Predix software from GE and Watson from IBM will be crunching all the numbers in the future.  STM makes the chips that make self-driving machines of any kind.  Mobly makes the micro-sized cameras and devices that interface with other software.  Othe’s include PTC, PHG (Phillips corporation in healthcare now using MEMs: micro electromechanical machines)…they are doing it in health care and STM Microelectronics in Europe is doing if for all sorts of machines.  Our Congress passed the DIGIT law to ensure this tech is in widespread use by 2020-2021 so much so it will infuse 19 trillion dollars into this tech in just the car industry in three years.  That is 50 billion chips installed in the next three years.  It will continue.  The DOW went from 17,000 to over 20,000 in just 6 months and you still are afraid of the stock market. Look people like the world class mentor and winner of the Templeton Award, Paul Mampilly for your investing advice.  He made a greater than 70% profit in 2008-2009 by a simple method…investing in a system of stocks guaranteed to go up…why?  they are new industries and tech and if you look at history each time this happens in convergence with a rapid growth in spending and investing (happens when people turn 34 years of age and is happening now with the oldest millenials).  Mr Mampilly calls this a mega trend and he is right.   His portfolio which I have given to you much of it (also ROK, TER, S, QRVO) and a few others are providing what will be the second generation of the internet known as the internet of things.  It will drive the Dow to 50,000 by 2020-2021 and then in the subsequent years to as high as 200,000.  Think I am crazy?  Look at each time there was a boom in life and science and you see the stock market boom…Yes it will have little bust along the way but it is now in a parabolic upward curve on each of these stock and if not (like GE, PHG that keep getting stalled it is just insider manipulation-banks and huge investors making mini crashes of these stocks so they can acquire all the shares-don’t have what he calls “weak hands” keep your shares and get it now.  IT IS NOT TOO LATE.  Some have just exceeded their buy up to prices but you can still buy them cheaper by selling to open an option which will get you 100 shares if they are put to you when the price drops below your sticke price or just buy the stock…because all of these stocks are headed in one direction…up.  Now there is always risk in the market but while i sit and stare at the walls and paint and write and invest while I wait for my job I am surviving  on this income.  I don’t like playing stay alive by living in the stock market.  I have not seen a patient in a few weeks now since I declined a crazy job in Indiana with another crazy cursing angry illogical director… so please someone help me because I am powerless.  REMEMBER: THE MILLENIALS ARE A HUGE GROUP OF PEOPLE MILLIONS MORE THAN THE BABY BOOMERS, THEY COMBINED WITH THE IoT, and FLIGHT CAPITAL FROM EUROPE AND JAPAN (3RD LARGEST ECONOMY IN THE WORLD)..FLIGHT CAPITAL IN THE BILLIONS FROM EUROPE AND JAPAN COMES TO US NOW BECAUSE OF NEGATIVE INTEREST RATES IN MANY COUNTRIES:  THAT MEANS BANKS CHARGE INTEREST FOR SOMEONE TO HAVE A SAVINGS ACCT…BACKWARDS RIGHT?  YUP…SO THEY ARE SENDING BILLIONS TO US AND THIS IS A MASSIVE CONVERGENCE OF WEALTH YOU WILL NEVER SEE HAPPEN EVER AGAIN…COMBINING THESE FORCES WILL THE INTERNET OF THINGS AND THE STOCK MARKET WILL REACH AS HIGH AS 200,000 POSSIBLY IN JUST A DECADE.  THEN THOSE NUMBERS WILL DECLINE.  NOT ALL STOCKS WILL BE WINNERS.  I HAVE JUST GIVEN YOU THE KEYS TO THE KINGDOM OF RICHES YOU NEED.  CMG  is a megatrend stock  now well over $400.00 per share but set to soar much higher…if you can buy only one share buy it.  They have opened hundreds of new stores (Chipoltes’ folks…this is a favorite of the millenials).  They solved their E Coli problem and their stock is on the rise and in just a year they have opened over 100 new sites and this is ongoing.  Millenials and the IoT…keep saying it to yourself at bedtime.  Now check all of these stocks an see what you missed in just a few months…don’t wait…I will keep reminding you…DDC

Medi

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