November 2017

“All you need is the plan, the road map, and the courage to press on to your destination.” -Earl Nightingale

TASK AT HAND: This week I’m thinking about DADA. This abbreviation is borrowed from the covert playbook of spies and intelligence agents. The idea is to have a blueprint to evaluate, plan and execute in an instant. I commonly refer to DADA as “strategy on the run” because of the ease and rapidity of its use. Whether you are under duress or require a quick plan, here is how you can use DADA – Data, Analysis, Decision and Action – to quickly formulate a strategy.

DATA What information is available to you? Quickly gather all the information possible to best assess the situation. This can be something as simple as taking note of where the exists in a room are to more detailed accounts such as viewpoints of the people you are negotiating with.

ANALYSIS Analyze the information. The benefits of DADA are brevity so you want to make this analysis quickly. If you are under physical danger, you need to determine the likelihood of harm. Another example; if you are negotiating, you need to determine what the highest/lowest price you will go or the best alternative in case you fail to achieve a compromise.

DECISION Make a decision. You have gathered the requisite pertinent information and analyzed the possible outcomes. Decision involves reasoning an outcome you will be content with. With DADA, you are usually looking at short term plans and outcomes so this decision needs to be effective immediately.

ACTION Now, you must act! As I mentioned above, DADA is “strategy on the run”: it’s an excellent framework to quickly develop and execute plans of action around objectives. What is your objective? In situations where you may be in danger, safety is your primary objective; consequently, the decision is either to flee or stay and possibly have an altercation. You need to have made your analysis for the likelihood of each.

Next time you need a quick framework, consider DADA – Data, Analysis, Decision and Action – to formulate a plan. You don’t need to be Jason Bourne to make use of this technique’s effectiveness for situational awareness!

 

MEDICINE & MACULA: One of my favorite surgeries is retinal detachment repair. Each retinal detachment has subtle differences that make no two exactly alike. I like the fact that you can fix them multiple ways: vitrectomy, scleral buckle, vitrectomy with scleral buckle, air versus gas versus oil tamponade, approach to subretinal fluid drainage, membrane peeling in detached versus attached retina, etc.

Recently, I performed retinal re-attachment surgery on a monocular patient with severe colobomas in both eyes. A coloboma is a structural defect and can involve the iris, retina, optic nerve or choroid. It’s a congenital defect that occurs when the choroid fissure fails to close up completely before a child is born. In the patient’s good eye, they suffered a retinal detachment with vitreous hemorrhage. Here you see me performing vitrectomy.

Note the extensive coloboma present with a sole band of retinal tissue extending through the macula that provides photoreceptors and vision to this patient.

The patient did very well with full return to the vision they had before the retinal detachment!

 

GRATIS: “A really great talent finds its happiness in execution.” -Johann Wolfgang von Goethe

 

My best to you,

David Almeida

david@davidalmeidamd.com

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“God cannot alter the past, though historians can.” -Samuel Butler

TASK AT HAND: This week I’m thinking about revisionist history. This is a more complex topic than it seems. On the one hand, you cannot go back and revise history to fit your viewpoint. You can have an opinion on historical accounting but factual history must remain honest. Contrasting, our personal history displays more variance and offers us vast opportunity for accountability and ownership.

Let me illustrate the above point with an example. Go back and, sometime in the last five years, identify something you quit. Now, uncover the reasons why you quit that activity, pursuit or hobby.

Would the reasons why you would quit today be the same as they were when it happened?

What has changed?

When you start this self-reflection exercise you see that views change. The reasons for choices in the past evolve over time; sometimes into species that barely resemble their original proforma. Not surprisingly, we change. Consequently, our views evolve.

The goal of this exercise is to become a scientist with our history. Nikola Tesla stated, “The history of science shows that theories are perishable. With every new truth that is revealed we get a better understanding of Nature and our conceptions and views are modified.” We need to develop the skill to revisit strategies from the past and evaluate them under the light of who we are today. To forge new considerations so that we avoid previous pitfalls and can succeed when opportunities present themselves.

How can we apply this for improved decision making and strategy?

Use this exercise of reflecting on previous choices as a means to review your history. This can be of significant utility when you are faced with similar conflicts. Don’t simply apply the same strategy as in the past. Look to the past strategy, revise it with who you are today, and see if it still applies. Usually it does not. Revise your strategy and apply an improved framework.

 

MEDICINE & MACULA: This is a case of idiopathic intermediate uveitis, also known as pars planitis, showing peripheral inflammatory snowbanking.

Intermediate uveitis involves inflammation of the posterior part of the ciliary body and peripheral retina (pars planitis). It consists of mostly vitreous inflammation (“snowballs”) and may associated with inflammatory cells on the pars plana (“snowbanks”). In pure intermediate uveitis, there is usually no retinal findings, although patients may have a mild iritis.

In total, approximately 80-90% of intermediate uveitis cases are idiopathic pars planitis. Other causes include sarcoid, syphilis, inflammatory bowel disease, multiple sclerosis, lyme, tuberculosis, Behcet disease, Whipple disease and lymphoma.

 

GRATIS: “History repeats itself, first as tragedy, second as farce.” -Karl Marx

 

My best to you,

David Almeida

david@davidalmeidamd.com

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“I draw from the absurd three consequences, which are my revolt, my freedom, and my passion.” –Albert Camus

 

TASK AT HAND: This week I’m thinking about consequences; specifically, our personal consequences. The way you live has consequences. For Camus, he emphasized revolt, freedom and passion. For many years I have esteemed this quote as a reminder that struggling with the consequences of our actions is a worthwhile and rewarding duty. The concepts that Camus brings forth – revolt, freedom, and passion – are requisites for review here on today’s Sunday Surgical Scrub.

REVOLT How do you effectively express revolt? In my opinion, there is no better approach than the constant unyielding pursuit of independent thought. The struggle to hold back the convenience of conformity is a revolt we must pursue each day. Don’t let an hour go by where you don’t question dogma and doctrine. We have discussed this multiple of times here on the Sunday Surgical Scrub because this is something YOU NEED TO DO! Whether it’s fake news, peer pressure or groupthink, you need to revolt with independent thought.

FREEDOM From the bastion of independent though comes the freedom for independent action; the latter is not possible without the former. Necessity for autonomy, and the liberty to act independent without discrimination is, unfortunately, another consequence that cannot be forgotten for any lapse of time. Look at the daily news and you will see numerous examples of this consequence.

PASSION Finally, with passion, we surge the courage to pursue our desires. From the inception of independent thought, to the freedom of independent action, the final culmination is the courage to pursue these desires in our daily lives. The courage to pursue our desires – driven by passion – is perhaps the greatest of effects on the consequences we are capable of.

So, the call to action with today’s Sunday Surgical Scrub is to look carefully at our thoughts, actions and desires and ensure they are part of the pursuit of worthwhile consequences.

 

MEDICINE & MACULA: Here is a case of severe recurrent acanthamoeba infection presenting initially as keratitis, followed by sclerokeratitis and histolopathology-confirmed endophthalmitis.

For the first time, we document acanthamoeba involvement in all ocular layers. This severe case demonstrates that despite persistent medical and surgical intervention, eradication of organisms may not be possible.

This is the first case reported with confirmed choroidal involvement (histology shown above) and we have previously published this in a work entitled, Acanthamoeba Endophthalmitis After Recurrent Keratitis And Nodular Scleritis (Zaid Mammo, David RP Almeida, Matthew A Cunningham, Eric K Chin & Vinit B Mahajan), in the journal Retinal Cases and Brief Reports.

You can find the complete study here.

 

GRATIS: “Nobody ever did, or ever will, escape the consequences of his choices.” -Alfred A. Montapert

 

My best to you,

David Almeida

david@davidalmeidamd.com

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“In this world, nothing can be said to be certain, except death and taxes.” -Benjamin Franklin

 

TASK AT HAND: This week I’m thinking about death and taxes. Let me digress for a few sentences. This past week, on Thursday November 2nd, Republican lawmakers unveiled a sweeping revision of the tax code. Don’t worry, we are in no way going to get into the tax bill here on the Sunday Surgical Scrub. However, as I reviewed the proposal, it reminded me about the famous Benjamin Franklin quote above and the search for absolutes.

Today’s Sunday Surgical Scrub is about absolutes and our longing to grasp onto these as a means to reduce the anxiety of life and its transitions. We look for absolutes to reduce the inherent entropy of life. There is an overwhelming desire to find order and sense in the events that shape our days. But – and this should be apparent to anyone one of us who have attempted to exert control over extraneous circumstances that we cannot dictate – this is an anxious futile state. Instead, as we discussed on last week’s Sunday Surgical Scrub (you can find it here)you are not in control! As you master your ability to let go of this need for control, you find the peace it brings.

What does this have to do with death and taxes?

You can use death and taxes as reminders of absolutes. Everyone will die. Everyone has to pay taxes. If you are looking to grab onto absolutes, here are two that should make you relaxed that everything else is transient and you need not worry about it. In fact, you can argue that the paying of taxes is a somewhat negotiable and varied, albeit with consequences. I like this rationalization because it means that there is only one absolute.

Death is guaranteed.

This is not simply for macabre effect. This is actually a wonderful liberation that we should use our talents and energy to effect genuine meaning in our lives and those we come in contact with. The anxiety and worry surrounding most items is not necessary and often hinders our duty in the latter regard.

 

MEDICINE & MACULA: Here is a color fundus photograph of a patient with intraocular inflammation secondary to sarcoidosis. Sarcoidosis is a chronic systemic granulomatous disease from an exaggerated cellular immune response to a variety of self antigens or non-self antigens.

Characteristic funduscopic findings in posterior segment involvement include periphlebitis, sheathing of vessels, perivenous exudates and multiple small round chorioretinal lesions.

 

GRATIS: “The only difference between death and taxes is that death doesn’t get worse every time Congress meets.” -Will Rogers

 

My best to you,

David Almeida

david@davidalmeidamd.com

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