Archive for January, 2010

ANNULAR ECLIPSE IN KENYA, 15 JANUARY 2010

January 15, 2010

I must be crazy to fly 10K miles to risk getting clouded out.  But eclipse chasers are a bit nuts.  And while it was another nail biter (thick clouds still over the Sun with 30 minutes to annularity, but then they started to burn off), it was a successful trip.   The three photos across show second contact (Moon just inside the Sun), mid-annularity and third contact (Moon just inside the Sun–leaving it).   Then there are two slide shows of wildlife and a final slide show of the eclipse site, the people, the cloud bank that sooooo worried us and other eclipse shots.  The final shot is mid-annularity.  Click on it and the stretching will disappear.  The video is on YouTube of both the eclipse and the safaris.  I shot the stills with a Canon 12x optical, hand held, through a Mylar filter.  The video was shot through a Panasonic S26 camcorder and Mylar filter (you can see that on some of the eclipse stills.)  The sandwich video has wildlife-eclipse-wildlife with stills pasted into the video.  The first three pictures below were taken from the video, put on full screen, photographed and sent to iPhoto.  Tried to do all of this at Nakuru but the wifi was slow and occasionally the power went out.  I’m the guy wearing the True Value hardware cover (good to store filters and other stuff quickly during an eclipse).  We had a polyglot group (well, not me, other than my very limited KiSwahili), with Russian and Japanese being the other languages.  People just appeared, and next to seeing an eclipse, showing it to people and explaining the phenomenon is as enjoyabl as well.  This was my fifth annular, and  I’ve seen 11 totals.  Total eclipses are much more beautiful, but annular ones are pretty neat.  It’s just that I usually need a very good excuse to go to one.  Kenya provided that excuse.

Next total 11 July 2010–I’m heading for El Calafate, Argentina and will fly it, hoping to see it over the southern Chilean Fjords.


WEARING RED

January 7, 2010

“For them is sweat and toil, hunger and thirst, and the fierce satisfaction that comes only with hardship.” Sigurd F. Olson (1938)

Forty-five years ago, after three summers at Camp Pathfinder, a canoe tripping camp in Ontario’s Algonquin Park, I became staff, “third man”  on canoe trips.  Being staff was different.  I no longer knelt in the bow, looking for rocks and setting the pace; I was in the stern, responsible for steering, orders and keeping up with the other canoes.  When we reached the portage,  I flipped the 90 pound canoe over my head, carrying it anywhere from a few yards to four miles.

I no longer had to wash dishes, only chop wood and help cook.  But I had difficulty with my new role.  I abused my new power by excessively bossing campers.  So, on my second trip I was third man under a second man who had never been a camper with my experience.  That hurt.  On my third trip, 14 difficult days, I struggled so much that I didn’t ask what my rating was.  Instead, I snuck in the cabin one night where the ratings were kept, and saw mine:  “He needs a LOT more tripping experience.”  I never forgot the pain of seeing those words by flashlight.  They were true.

The next year, I was 17, stronger, and vowed to do better.  I was sent out as second man, paddling and carrying well, kinder to campers.  I realized that my job was to ensure they had a good time on the trip, even as they worked hard, for hard work is what makes a canoe trip so satisfying.  On the first day of one trip, the head man and third man were hung over from a previous day off, and I had to keep telling my two canoe mates to slow down so we wouldn’t lead the trip.  When we reached the dreaded 1 1/2 mile Iris-Alder portage (named for the lakes it connected), I was allowed to go first.  I blasted over the wooded, rocky, swampy, hilly trail in 20 minutes, canoe on my head, well ahead of everybody.  I was second man for 3 more trips that summer.

There was a hierarchy of neckerchiefs worn by the staff.  It was an unwritten rule that nobody but a head man wore red, second men blue.  Pathfinder was and is known for its challenging trips and its red canoes, which today are part of their e-mail address.  That summer in 1966, I wore blue.  To entertain the campers, I thought up games like tree golf (I won’t describe it) and told scary ghost stories around the campfire.  When a camper’s asthma flared up on one trip, the head man and third man took him to help, several hours away.  I was left in charge, nervous, but thrilled to have the responsibility.

My ratings were good, and my last summer, I was promoted to head man on short trips.  I bought my red neckerchief, proudly put it on, and at 18, took 8 other lives under my care into South Tea Lake.  I navigated, carried canoe and a pack together, chose the campsite and cooked the meals.  The trip was only three days, and I was familiar with the area so that navigation wasn’t a problem, but I was in charge of two other staff and six pre-teen boys—no adults anywhere.   Even today, I am amazed that I was given such responsibility at my age.

Command changes one’s perspective.  When the campers swam, I counted heads, over and over again.  If I didn’t see one, I got everybody to stop playing until I was certain.  As head tripper, I had to decide the menu, time the meal right, and make special goodies, like fudge, which was how everybody rated a head man.  And every night in the tent, I listened to every sound, anybody crying out, responsibility weighing heavily on me.

Back in camp, I wore the red proudly, the way an airliner captain wears four stripes, or the commander of a naval vessel wears the five pointed star in a circle on their right chest pocket signifying current command at sea (left pocket for former command).  I took a second trip as head man, the responsibility still weighing heavily on me.  Two days after that trip, I went out as second man on a better trip, just like a pilot of a 737 becoming a co-pilot on a 747.  I put my blue neckerchief back on, helped outfit, did my job well, and made sure the campers had a good time.  I never wore blue again.  In late summer, my fourth trip as guide, I took six men six days on a super trip to Pine River farm and Big Trout Lake.  I didn’t remember all of these trips, but Pathfinder’s Web site lists them going back to my era.  My fondest memory of my final trip was a day a camper couldn’t carry his pack, so I carried it and my canoe—at least 140 pounds—a half mile with no trouble along the slippery shoreline of the Tim River.  To this day, I have worn the red neckerchief on nearly all the 60 additional canoe trips I’ve taken. Occasionally, I put on the blue as a reminder of the days I wasn’t in charge and what I had to do to earn red.  I have no other colors in my collection of neckerchiefs.

I practiced medicine for 20 years, a hierarchy if ever there was one, but I never once thought about the red neckerchief.  I wish I had.  For the past eight years, I have been a volunteer math tutor at two high schools, never being as busy or as in demand as I had hoped.  So this year, I set up a program to be an on-call volunteer substitute math teacher, teaching when the substitute was unable to do so.  I have taught twice, and that is a huge step up from tutoring, like being staff.  But I still felt I was wearing blue, not red.  I wanted to be in charge, to take full responsibility for running a class, even if only for an occasional day.  I got my substitute certificate and waited.  One day my call came from a statistical colleague, wanting me to teach AP statistics, sports statistics and his algebra 1 class.  I looked at his lesson plans, made modifications that I felt might help, and went to school to teach–by myself, no certified substitute in the room.  I put my red neckerchief on the desk beside me.  No student noticed it, but I looked at it frequently.  As expected, I made some mistakes that first day, but one of the students left the class saying, “You’re the best sub we’ve had all year.” I won’t take the neckerchief every time I’m called, but I will take it often, to remind me of what being in charge means—the responsibility, the worry, the challenge, the chance to do well.  Most importantly, I will remember where I have worn red:  on the lakes and rivers of the Canadian Shield, from Algonquin to ANWR, and many places in between.  I will remember the rain and sun, bugs, moose, fish and loons.  I will remember those days at Pathfinder, the eyes of my fellow travelers reflecting the light of campfires from Little Island Lake to Big Trout, my being in charge of the whole trip.  I earned the red once, and I have earned it again, doing different work, once again in charge.

AFTER ALL, THESE THINGS HAPPEN

January 3, 2010

A 52 year-old woman lies in extremis in ICU following a gastric perforation discovered after contrast is put through an NG tube. So what?  These things happen.  Yep, they sure do.  Here’s how this particular one happened.

The woman had an Upper GI four months earlier showing a paraesophageal hernia, where the esophagus went through.  The report mentioned the hernia, it didn’t mention its prediposition to gastric volvulus.  While one can’t mention every possibility in a report, it might have been useful to mention this particular fact.

Four months later, the woman presented with abdominal pain.  Her initial CT of the abdomen and pelvis mentioned the hernia and an ovarian cyst, but no comment was made about gastric distention or the type of hiatal hernia.  Unfortunately, the prior study wasn’t re-evaluated during the reading.  That was unfortunate, but many studies today contain a thousand images; indeed, a radiologist may encounter 100,000 images a day.  An NG tube was passed, and a second scan, with contrast, showed the perforation – really well.  Fatigue, the volume of images, hospital and referring physician demand for quick reads, compensation for number of studies (not images) viewed, make errors more possible.  Reviewing past studies is not compensated, so there is less of a  tendency to do so.  What do clinicians do if they receive a huge chart when a new patient arrives, inconveniently booked into a follow up slot?  Compensation is based on a numbers game; what game is played dictates what gets done well, what gets done, and what doesn’t.  Having been on both sides of the medical fence, I can easily spot a distracted, harried and hurried physician.  All three of these are a setup for cognitive errors, the single biggest type of mistake a physician can make.

The patient developed peritonitis.  Perhaps if fewer CT scans were ordered, it would be easier to routinely evaluate prior studies as part of the reading process.  Once having practiced neurology, I believe, and the literature supports, a person with intact cortical function, no neck pain, no tenderness to palpation and no neurological deficit doesn’t need a cervical spine CT after an injury.  Whole body scans are often done when clinical judgment would suffice.  Besides being a radiation issue, it is a time issue affecting emergency department throughput (we patients call it waiting), a money issue, because these studies are expensive, and a quality of care issue.  After my bicycle accident, I had several studies, but nobody took off my shirt to look at the road rash on my back.  Nobody palpated my entire body, since severe pain in one place may mask a significant injury elsewhere.  Those additions take perhaps thirty seconds.

Worse, if little clinical history is provided, it affects the type of study and the radiologist’s approach.  Differentiating PE from dissection makes a big difference in timing of the scan after contrast.  “Chest Pain” is not helpful to the radiologist.  Yes, you are in a hurry.  I was too.  But I always put clinical information on my neuroimaging requests.  The radiologists appreciated it.  I got better reports.  It helped my patients.

This woman survived.  The medical community ought to learn from this, rather than copping out and saying “these things happen,” “nobody’s perfect,” or “who made you the quality expert?”  “Nobody’s perfect” doesn’t cut it if a person dies from something preventable, either in or out of medicine.  You don’t hear the civilian or military aviation community say that.  They learn from the mistakes, and they publicize them.  Read a few sometime, and you would be surprised how much we could take away from their field, rather than the mantra, “We’re doctors.  We’re different.”

Rheumatic fever, polio and gas gangrene used to happen; 30 years ago auto accidents killed twice as many people per capita, anesthesia deaths were once far more common.  Sean Elliott and Alonzo Mourning would have died from uremia the way actress Jean Harlow did.

Excessive workload increases the likelihood of a radiologist’s not reviewing past studies and not dictating, “Paraesophageal hernias can lead to gastric volvulus.”  What does workload do to you in your field?  There ought to be a way that physicians can do a decent job, make decent money, learn from their mistakes and those of others, have a life and not fear lawsuits.  Here are a few thoughts:

It’s time we had community standards for common, high risk procedures that lend themselves to standardization: hyperalimentation, ventilator management, pre-op antibiotic delivery and central lines.  We can standardize and still respect individual differences.  It’s time disciplines who function together, like emergency medicine and radiology, work together.  It’s time to have legislation mandating a free from discovery error reporting system which I proposed in 2001 and which failed the legislature in 2004 and 2005; the hospital association worked to  kill it.  It’s time to have liability reform so physicians aren’t treated like criminals when they err.  Maybe if we did the first two and supported the third, we could get the fourth.  Along the way, we might additionally work towards complete medical coverage for childhood up to at least age 18 – with real-time data on outcomes and costs.  We might start having a better system.  Maybe we could expand age 18 to all.

And perhaps see fewer cases of preventable peritonitis.