Pendejos at Pemex

I just saw what is perhaps the stupidest thing I’ve read in a long time. Apparently, many people from SoCal are driving to Tijuana to fill up their vehicles because of the cheaper, Mexican-government-subsidized Pemex (Petróleos Mexicanos) gasoline. Since the government controls the gasoline, Mexicans do not feel the week-to-week spikes driven by speculators and doomsayers (that also conveniently coincide with things like Memorial Day weekend) and enjoy a more stable price that’s based on longer-term, “reality-based” data.

The problem is that although it’s cheaper, Pemex gas sucks. It’s dirty and is, in my experience, at least a third less efficient than American gasoline (measured by mileage on what a fillup gets me on either side). It deposits more gunk in the engine, requiring more oil changes (which comes from, you know, OIL) and filter swaps (plastic = OIL) to make things run comparably. Additives like STP gas treatment to help boost fuel efficiency by raising the volatility of the gasoline in the combustion chamber (organic liquid = OIL) are often added by locals at fill-up at additional cost, negating savings. Since it’s less refined, the combustion of Pemex gas is also horrible for the environment, as any traveler who’s experienced the pollution in Mexico’s large cities can attest.

Away from the pump, you’re going to spend upwards of $2-3 each way crossing the border in tolls, and then you’ll have the random-ass inspection coming in on the Mexican side, combined with the all-too-familiar US Customs agent with a hard-on for being the one to catch an al-Qaeda operative coming in as a roofer (who, by the way, is in my trunk as we speak). I guess these people’s time isn’t worth anything.

I think the only way this could POSSIBLY make a difference is if one was filling up a very large tank or several portable tanks to make the crossing/time factor worthwhile, even with the 33% lowering in efficiency if one is saving at least 33% on the cost of the gas. Perhaps for some, like those that drive around town all day looking for that one filling station that has the gas at $3.87 instead of everyone else’s $3.89, it’s all about the satisfaction of proving …. something.

As pump attendants [in Mexico, you don't pump your own gas by law] struggled to keep up with dozens of vehicles lining up for fuel, U.S. and Mexican drivers traded insults. A few even brawled as they waited for hours in searing heat this week in the rough border city of Tijuana.

“I am not budging until I get to the pump. I don’t care what anyone says, I’ve been waiting for two hours,” said Jaime Rosales from Southern California, at a gas station where buses, trucks and cars all vied to get to the pumps.

Talk about asking for an ass-kicking. The article talks about border town violence like it’s everywhere–it’s not. But don’t think for one second you just might be pissing off the wrong person. In Mexico, the American is the foreigner, and too many cross over and think just because the USA is a few miles away that “someone has their back.” Um, no. I hope the gas was worth it for them, because the time it took for the average vehicle owner to go, wait, brawl, wait, fill up, wait and come back, I actually got something done without wasting any gas.

Dosing OTC Pediatric Meds

It’s been about a month or so that various OTC infant cold-allergy manufacturers [semi-]voluntarily recalled their products in light of dosing mismanagment. Our little one has never had any OTC medication from these recalled “infant” products, so I don’t have any experience with them. In addition, I can’t get my hands on any of the products now that they’ve been recalled to see what could have caused such problems. I mean, how hard can it be?

Obviously, as a med student with a research science background, I am not the “typical” parent one would use as a case study for following directions, but having used various brands of Tylenol (acetaminophen or paracetamol, if you prefer) for our daughter, significant directions and delivery variations DO exist. In the US, every brand of infant Tyelenol was in a concentration of 80 mg/0.8 ml. Look at that fraction. Some leftover from 5th grade fractions should be ringing about now regarding “same numbers on top and bottom.” (We’ll come back to this in a minute) The same 5th grade education should be telling you that mixing decimals and fractions, while not incorrect, is a no-no–much like leaving a fraction unreduced. Points off, no gold star. Mistake #1: When you’re dealing with…oh, I don’t know…the “lowest common denominator (LCD)” (har har) of society that’s going to read your directions, you might want to clean things up a bit.

“But Rico, nobody but math and science geeks are going to read the concentration.” Well, you got me there, but it’s still odd. Upon opening the box, you’ll find, depending on the brand, either a bottle with a dropper already built into the cap, or a separate lidded bottle (why?) and a separate dropper that you then put together, throwing the perfectly good original lid in the trash. Mistake #2: There are plenty of people who might just keep the two separate, and if they’re do that, they probably aren’t keeping the dropper sealed, away from dust, etc.

If you look at the dropper, you’ll find two markings: 0.4 and 0.8, or just one: 0.8. The dose for 24lbs or 2 years is given on the directions as 1.6 ml. Mistake #3: You’ve assumed that the LCD of the general public can add fractions, much less without a calculator while a feverish, screaming infant is in the background. In my opinion, worse still are the “Only use this dropper with [product]” so that the directions are foolproof, like “Fill dropper to the white line.” Yeah, but what if I have a Robitussin product, a Benadryl product, and a Dimetapp product that all use “special” droppers and all have no other concentration/volume information for dosing purposes on the bottle, not the long-thrown-away box? True, few people outside those in the “import/export” business have graduated cylinders or pipettes at home, but SOME information should be given plainly should that “special” dropper be lost.

We usually have things decently stocked from the US side for basic things since we travel back and forth often (especially my wife). However, we ran out of infant acetaminophen a while ago, and since Claudia was doing the shopping, she didn’t want to have to decide among all the various brands here in Mexico and bought name-brand Tylenol. At first I was shaking my head because she didn’t get a super-easy-to-find generic product, but then I saw the exquisite delivery mechanism.

Behold, friends: pediatric liquid oral dosing perfection:

The plunger is marked on both sides, one being volume and the other weight, for which the volume on the other side corresponds. Also notice the ultra-precise measurement graduations. It certainly doesn’t mean the plastic plunger is that accurate, but it’s nice to look at. Looking at the info, one finds the following concentration: 100 mg/1 ml. Look at the fraction on the US bottle: they’re the same! Except now that we’ve reduced the fraction like good 5th graders, we can make sense of this from any angle without having to multiply and divide decimal fractions. And as a bonus, since this long quasi-syringe and the bottle clearly don’t physically go together, there is a plastic housing for the setup to keep it clean in between uses. Even if I had several products from different brands, if they all had this, it would be trivial to know which ml/kg measured syringe belonged to which because there’s a clearly visible “Tylenol” on the plunger! Score 1 for Mexico. (God knows the way things have been here lately, Mexico could use some bonus points…)

Seriously people, this foolproof delivery system is where it’s at. In the US, pounds would be the unit for the general public, obviously, since asking people to do MORE math–and to use the eeevil metric system–would surely not be good for little livers everywhere. If all the pediatric OTC medicines in the US were to have had something as universal and consistent as this, one wonders if there would have ever been a recall.

The Week from HELL

Oh. My. God. I am so blissfully happy it’s Friday. I don’t care how those little boxes line up on the calendar, I’m marking today–THIS DAY–as the end of my week from Hell. Dante doesn’t know shit. To type it all out would take forever, but I’ll just hit the highlights.

One of the most frustrating things living in Mexico is how slowly everything moves. For many, life is like a permanent vacation, with few consequences for tardiness, because practically everyone else is the same way. It’s not trying to get away with as little as possible or being lazy, it’s simply at an ingrained cultural level, there’s no hurry unless there really needs to be one. Regarding a pending problem with school administration, I spent two days shuttling from office to office talking with people, each of them telling me their very reasonable side of the story, but always ended with, “But because of [problem with next-door office's issues], I can’t help you.” Repeat 5x, try to talk to person in charge but get met with secretary who specifically says they remember explicitly a phone conversation that was had for 90 seconds two months ago and how I’m incorrect. Oh, and I can’t see “person in charge,” because nobody knows when she’ll be back. Not her secretary, certainly not, who can’t (or won’t) even confirm if she’s in town.

But compared to what I had to deal with financially, the above was a cakewalk. I was trying to get things set up to rent a house and do the signing, etc. on Wednesday. Tuesday, the day before, the realtor tells me that the owner wants everything paid in US dollars in cash. I don’t have a bank account here in Mexico; the US account we’ve always used does just fine here for ATM purposes, and there’s always the credit card route. However when you’re talking in the thousands of dollars, pulling it out of an ATM (in equivalent currency that’s worth 10x less, mind you) is just not possible. For a crippling 2.5 days, I was figuring out how to get money, ready to go in my account, here in my hand. I couldn’t do a standard wire transfer, since you initiate that in person. Online, there were rules about either being with the same bank in a different location or if a different brand of bank, I had to own the account. Both strikeouts. Adding insult to injury (but good to know), my bank has ALWAYS had a service to send money to Mexico for free. LOVELY! Thanks for letting me know, now that I am in Mexico and can’t go into a US branch to paper-sign the agreement form. The whole reason I agreed to pay the landlord in dollars was so I could write a check; in turn, he got paid in a much more stable currency. Only 36 hours prior did he discover that his bank’s terms for foreign checks were unacceptable (they were), and that set off the mad scramble. Since we’d already given notice here and they’re waiting for us to move out next week, the prospect of potentially scrambling for a place to live vs. not being able to change bank/international trade rules became a rock vs. hard place squeeze.

In the end, many phone calls with lots of small but incorrect details that cost me serious time, and energy. Just as I was going to explode, the last person I spoke to at the bank said, “Why don’t we just up your daily ATM limit? I can approve an increase to $2,500 per day temporarily for 14 days.” Um, last time I checked, I wasn’t moving kilos of Columbian snow, but THANK YOU for pointing out what had always been the easiest option that everyone else missed. Unfortunately, I still had to pay in cash dollars, which means pulling dollars out of my account via ATM into cash pesos, then buying dollars (at an obviously less-than-favorable rate), twice taking transaction/exchange-rate hits. But this is the last time this will ever happen, because when I go home for the holidays, I’m adding some services to my account–including the one I mentioned above that will allow me to wire rent money down here monthly so I don’t need to walk around with a briefcase full of multicolored Mexican money.

This is primarily being shared so all you would-be foreign medical students out there in the US–make sure you understand: you are NOT going to be in the US–whether it’s Mexico, Israel, Poland, or the Carribean–and how you’re used to dealing with things will change dramatically. No matter how much you think you can get acclimated, or you speak the language there, the reality is that there will always be serious, unforeseen events that can potentially make you reconsider if it’s all worth it.

On top of all that, work takes a turn for the worse when I find out that the application I was developing for one academic entity is really for an executive member of the Univeristy, because he wants to make sure it passes muster first before showing it to them. I find this out 36h before it’s expected. I’m a part time employee with some vague instructions on this and no feel/inference that this is a politically sensitive project, or I’d never have accepted it. (Large state universities are typical of malignant bureaucracy just like above; things have to filter down and percolate up in “the proper chain of command.”) Last night, I pulled an all-nighter and I got it done (and billed appropriately), but I still haven’t slept. I feel like hibernating, but I have to pack this weekend/week, Grand Rounds is Tuesday (compilation is on Monday, though), and movers come on Friday. HELP!

Feeling like a metal tube was rammed in my gullet

You’d think I was speaking figuratively, but actually, that’s precisely what happened. I had an EGD (endoscopy) the other day. It represented my first actual “procedure” here in Mexico which actually carried some risk/doubt about it. I had no qualms about my doctor per se, but previous (minor) experience as a patient and what I’ve seen as a trainee had already cemented the fear regarding crappy pain/analgesic management here. The reasons why are very complex and include cultural factors and a bit of severe government retardation in the way of what/how “controlled” substances are controlled. I don’t want to say something incorrect, about it so I won’t, but trust me–acceptable pain management standards are not a given everywhere and is highly stratified by economics as well. So when my Dr. finally arrived at the hospital, I asked about the sedation (something I took for granted when we had the office visit), and he said two words that made me just sink back in my pillow and know I was in good hands: midazolam and fentanyl. “Do what thou wilst, Dr. RotoRooter; I am thy faithful servant.”

The endoscopy room was big enough for two patients to fit, but since I was wheeled (already in the bed) after they started an EGD before me, they just parked me out in the hall for a bit. I got to listen to the banter (there was an actual anesthesiologist working the sedation) about the weekend, etc., and it wasn’t long before I heard that they were done. I made the mistake of peeking behind my shoulder into the room just in time for the doctor to be holding the ’scope handle practically above his head. A long black, striped metal (or some hard polymer) fiberoptic snake ominously dangled almost to the floor. It reminded me of those Sentinel tentacles from The Matrix movies. Seeing this thing in person isn’t the same thing as seeing it on pictures, TV, etc. The article above says it’s about “the width of a finger” — sure, if you’re Mike Ditka, maybe.

In the end (and since this wasn’t a colonoscopy, that wasn’t a pun), it was a totally painless, non-traumatic experience. The crap they sprayed in the back of my throat to numb the gag reflex was the most foul thing about the whole process. I’ve experienced the ugly banana-tasting Hurricane(tm) spray, but this was like an un-natrual product of an organic chemistry lab experiment. It might very well have simply been lidocaine in ether for all I know, but it worked. Into the lateral decubitus position I went (I’d have worried if it was the jackknife position), and in went the Happy Juice.

Some minutes of prep later, (and time enough for the appropriate receptors to kick back and chillax on their little Barcaloungers) in went the scope. I remember being told to swallow, and a brief “WTF!” moment, but I guess once well past the upper 1/3 of the esophagus, it was a done deal. I remember bits and pieces of the video screen images, but not a complete whole (hardly “Ah, I see we’ve arrived at the lower esophageal sphincter” — not even close. More like, “Ooh, mucosa.” *drool*). Embarrassingly, the most numerous individual memories I have are of me burping. You see, they insufflate you with gas, sort of like laparoscopy so the camera has some visualization room, but it’s done as needed. Knowing this beforehand and burping uncontrollably, half-awake with a metal tube down your throat are two different worlds of experience, trust me.

After the deed was done, I just lay there and sort of semi-watched them type stuff on the computer screen and flip through images, selecting the ones they wanted to print. Still dazed, I remember talking to the nurse and had enough consciousness to realize 1) I was talking and what I was talking about, and 2) I was just talking random shit like a drunk who’s about to pass out, which is appropriate because that’s about what I was except, thankfully, I was coming to, not going out. At least I wasn’t trying to hit on her (so I recall). After more time passed, and some quick checks, questions, and so forth, I was led (on my feet–no wheelchair) carefully and directly to…THE BILLING ROOM.

Yes, my friends, this is where the account is settled before you leave. I had left a deposit before the procedure, but now it was time to pay the piper. It’s just totally different here, that’s all I’ll say. I knew all the costs beforehand, so there was no real surprise, but it was kinda “rude” to be still drugged-but-functioning, but settle your account first before leaving. I’m not OK to drive (and they verified I had transportation taken care of), but I’m OK to hand over cash and/or a credit card and sign financial forms. Riiiight….

Anyway, that’s my story. I found out that there was nothing wrong with me except for generically useless observations, such as probable chronic inflammation (pending histopathology of a couple of biopsy specimens), mild gastritis, and generalized esophageal mucosal edema. No Barrett’s, no ulcers, no nothin’. “Pale mucosa noted throughout.” Duh. My Hgb is actually up at 10.2, but my MCV is still in the mid-60s. My serum iron is low-normal, and TIBC is not elevated. Totally atypical presentation of iron-deficiency anemia. No, it’s not like I need transfusions or anything, nor am I unable to get out and about, but the fatigue does catch up with me, as does the reactive compensatory tachycardia, etc. which has severely hampered my trying to exercise more. We’ll see. I won’t go into more details of my personal bloodwork, but it’s a head-scratcher. I just wanted to share my EGD experience here in Mexico. Total cost for everything, including hospital, anesthesiologist and GI doc was just under $500 cash. As a point of reference for those who may be traveling here, mine was a nice private hospital so this procedure can certainly be found for cheaper, but for those used to US-based care, I wouldn’t recommend it. Oh, and the icing on the cake: I got a DVD of the whole thing! (and no, my esophagus will not be going on YouTube )

Good GI (and hematologic) health to all!