Archive for December, 2012

PURISTS

December 29, 2012

In 1992, Arizona had a proposition banning leg hold traps, a particularly cruel way to hunt animals.  Unfortunately, a few decided to add some hunting restrictions to the proposition, and it was defeated.  Two years later, the same proposition, sans hunting restrictions, passed easily.  The purists caused two additional years of leg hold traps in Arizona.  They as well as the trappers were to blame for the pain of the animals.

In 2000, purists thought that Al Gore and George Bush were both bad choices.  They backed Ralph Nader, who had about as much chance of winning as a foot of snow has of occurring  in Tucson in mid-June.  We know how that turned out.  Florida may or may not have been stolen.  Without Nader, Gore would have won the state without any question.  The purists stayed pure, and they, as well as the Republican supporters, are responsible for George W. Bush. I don’t know whether the 9/11 attacks would have occurred; Condoleeza Rice, Secretary of State, ignored the warnings, yet few commented on that when Susan Rice, another black woman, was blamed for the 4 deaths in Libya.  In any case, I doubt we ever would have gone to war with Iraq, and as a result, more innocent people would be alive today, we’d have less debt, and Iran would not be so strong as it is.

In 1996, I did a quality improvement project in my hospital as part of my course work for Intermountain Health Care’s Advanced Training Program for Quality Improvement.  With a small team, we decreased time from ordering antibiotics to giving them to patients in the emergency room 80%, in statistical control.  This can save lives and reduce time in hospital.  It cost no money to implement.  I presented my project, the only one completely completed, and there were 30 taking the course.

“Did they give the right antibiotic?”  was asked by many.  I replied that the right antibiotic  was not the pertinent question, only the timeliness.  “Well, the type of antibiotic matters,” I heard,  this time becoming annoyed, replying that if I tried to ensure the right antibiotic and the timeliness, the study would have failed.  It was difficult enough to improve timeliness.  My critics were purists, and they can be dangerous people, for they prevent incremental improvement.

I can deal somewhat with the right wing, because I know immediately that they disagree with me.   Purists, however, are more insidious.  While they agree with my basic premise, they cannot tolerate an imperfect world, so they are able to block progress, and I often forget to watch for the danger.

In 2010, I decided to help clear buffelgrass from southern Arizona.  Buffelgrass was brought to Mexico as cattle forage from Africa.  Unfortunately, it spreads by burning, and it burns hot, too hot for native desert plants to survive.  I “adopted” an 8 acre wash (arroyo, dry stream bed), and in the next eight months, removed 20,000 plants, by digging them up, putting them in a large bag, and throwing the bag about 4 meters up a cement berm.  Each plant could be a meter tall with a base of about 30-50 cm. in diameter.  It was difficult work; I had to battle the occasional rattlesnake, heat, and fatigue.  I got a parking ticket for my labors. Part of a grass stem went in my nose, leading to a nasty infection that required antibiotics.  I filled more than 1500 bags.

Because I was throwing the bags, which was the only possible way to move them out of the wash, one of the dispatchers said seeds were falling out.  That annoyed me.  Seeds were going to fall simply by manipulating the plant, and if they did not like my work, they were free to come and help.  They didn’t, nor did a group that had “adopted the wash,” help.  That group was “fluff,” another annoyance.  Fluff is doing “feel good” things that don’t fix problems.  It is important to do things to feel better after a tragedy, but it is far more important to prevent future tragedies.  A memorial by the side of a road where a person died in a motor vehicle accident may make the living feel better, but where is the outcry for legislation for mandatory seat belt laws, requiring teenagers to be alone or with an adult if there is more than one teen in the car, and publishing monthly counts of deaths, so as to keep the issue in the public eye?  Fluff is cutsy commercials telling people that exercise is fun, rather than publishing numbers showing that the median Body Mass Index in 1100 local 6th graders was at the 89th percentile, 7% were over the 99th percentile, and we should screen every 6th grader in the county to determine the scope of the problem, which we never did, despite its being possible with virtually no cost.  I did all that in 2010.  Without knowing the baseline, you cannot determine whether there was any improvement.

In any case, four months after I cleared the wash, the buffelgrass had grown back, because I had failed to monitor the area.  I made a comment to the Sierra Club  chapter, to which I belong, that we needed to spray poison on the plants, only to hear that spraying was bad, and we mustn’t do it.  The next–and last–time I cleared buffelgrass was in the same area where I had first cleaned it a year earlier, with a group of 7.  Unless Tucson has several thousand people clearing buffelgrass, it will be impossible to eradicate without poison.  We will be pure, we won’t spray, but we will lose the battle.

NASA’s James Hansen is one of the leading scientists dealing with climate change, for decades speaking out on the issue.  Virtually all of his predictions have come true.  Without going into great detail about the science, Hansen’s key point is that we need to stop burning coal, period, and use breeder nuclear reactors, to buy time.  Is he concerned about their safety?  Certainly.  But he sees no other viable alternative to keeping the [CO2] from rising to 450 ppm, and indeed, he now believes that 350 ppm is required.  By climatic evidence, I mean that [CO2] has correlated strongly with sea level, and that a level of 450 ppm (we are at about 391 now), correlates with a rise that would flood many major coastal cities, including the US, which might get our attention.  I am ignoring acidity, coal dust causing earlier snow melts, and stronger storms from a warming ocean, since cyclonic storms (anticyclonic south of the equator) exist to shift warm air to colder regions, trying to keep the Earth’s heat balance.  Such storms must exist.

The Sierra Club is so pure on this issue, that even as a Life Member, I don’t bring it up.  But the reality is that we are not going to get out of our difficulty by conservation, Copenhagen conferences, Kyoto accords, or with renewables.  It’s nice to think, but conferences are fluff, and the rest is magical thinking.  Perhaps we can develop a solar powered way to remove CO2 from the atmosphere and a solar powered way to pressurize it into tanks and put the tanks somewhere safe, but I am not counting on that occurring.  Reactors have a lot of problems; we know that. but they are potential, not certain; whereas continuing to burn coal is a 100% problem.

I think that incremental health care reform might have worked, rather than what happened in 1993 and again in 2010.  We could have tried to expand Medicare to pregnant women and children under 5 or 10.  It might not have passed, but those not voting for it would have been on record as voting against the health of some of the most vulnerable people in our society.  Fixing health care reform means going against the ideologues on the right, many of whom are military retirees whose health care is ironically taken care of by the government, and the purists on the left, who want a national system.

Would I like a national system?  Yes.  Is there a chance we will have one any time soon?  No.

The perfect truly is the enemy of the good, until the purists learn that small, incremental steps in the right direction are better than no progress at all.

RATIONAL AND IRRATIONAL THOUGHTS

December 19, 2012

I’m a local substitute math teacher considering making an irrational decision not to teach any more.  A substitute teacher was one of those killed at Sandy Hook, and 14 of his students with him.  This was in a school that was locked at 9:30, had good security, intercom warnings, and somebody running down the hall warning teachers.

I teach in a school with only an intercom warning system.  The campus is spread out, and it is unlocked.  There are numerous entrances to the campus and to most buildings.  In the morning, there is a congregation of well over 100 students I jostle through, getting to where I teach.  I imagine what one shooter with an assault rifle–or two (rifles or shooters or perhaps each shooter with two assault rifles)–would do to this crowd.  It would be as Nate Silver calls it, an 8th or 9th magnitude earthquake in the analogy of school shootings, with over a thousand rounds fired.  What if there were 3 shooters?  We haven’t had that yet, but it does not mean it couldn’t happen.  After all, people wouldn’t fly a plane into a building–until they did.  It would be an order of magnitude worse than anything we’ve seen, and we’ve seen horrific scenes.

Yet statistically, I am far more likely to die in a car accident than in a school shooting.  But all of us use cars daily; far fewer use firearms daily, so my decision isn’t perhaps quite as irrational.

School shootings are American terrorism, and if Islamic fundamentalists did this, we would probably ban all Muslims from school, a very irrational–but would be popular–approach.  Terrorism deeply affects us.  Other drivers aren’t trying to kill me. But I worry about being the substitute who happens to be behind the door a shooter opens. Excessive worrying about unlikely events happens when we are terrorized.  After 9/11, we hid the mayor, and somebody who found powder in a men’s room called 911.  It was baby powder, not anthrax.  We were scared and a little irrational.

What if there are 20 shooters?  Twenty, you ask?  Yes, because now there are calls to arm teachers.  Some even want to arm students.  Here are 3 thoughts I have, first as a mathematician, then as a person in a school yard, and finally as a substitute in a room.

I carry a gun, which I don’t like, and which introduces an element of danger already.  Every teacher has one, and accidents can happen.  Oh sure, you say, they are unlikely, so let’s assume 1 in 10,000 has a gun go off accidentally on a given day, and let’s say one in a 100 of those produces injury and one in 100 of those produces a fatality.  That’s pretty conservative, don’t you think?  A teacher leaves a gun in a drawer, and a student takes it.  Of course, it could happen.  A teacher shows a curious student the gun, and drops it.  Or, and this is really scary, a teacher walks by a student’s desk, and a student takes the gun quickly from the holster.  All of these are possibilities, plus a few others I have not thought of.  Teachers are not well-trained in gun safety, and I doubt we will find the money to teach them, many of whom would be like me–scared–to handle a gun.  We have about 6 million teachers and 180 days of school a year.  That is 1.08 X 10^9 teacher-days a year.  With the above probabilities, because we can assume independence, we would have a 1 in 10 million probability of a fatality every day (wow, that is really low), but multiplied by the number of teacher-days, that would be 100 deaths per year.   That is the mathematical approach.  Low probability events, when occurring many, many times, produce winners.  The probability of winning the lottery is 1 in 110 million.  But if there are 330 million people buying tickets, the expected value of number of winners is 3.  That’s lottery winners, not dead people.

Here’s the second scenario, in the schoolyard:  Can you imagine an totally chaotic scene with students falling, others running into the line of fire, screaming, panicking, and crying?  Do you think you are going to know whom to shoot at in this situation?  Worse, if you start shooting, how will anybody know that you are one of the good guys?  This is a romantic, bad idea that would kill a lot of people.  When the police arrive, how will they know who is the perpetrator?  I am not being irrational when it comes to imagining a shootout at a school. Have we gone back to the OK Corral?

Here’s the third scenario- my biggest fear.  I am substituting, when a gunman walks in (or shoots his way in) the door.  My first–and last–thought is “This can’t be happening.”  Now my gun is available for the shooter.  I am not going to likely carry my gun on my hip, and even if I do, taking it out to shoot will take far too long to deter any assailant.

Guns for students, for whom a breakup or bad grade can easily hijack their brain, are a recipe for disaster, for it takes only a brief flexion of a finger of an emotionally distraught person to destroy a life. That is the fundamental danger with guns and unstable people–an impulsive response, a brief movement, are all that is required.

If we don’t change our laws, I am completely certain we will have another mass shooting with more than 10 deaths.  There is no credible evidence to suggest otherwise.  There is a high probability it will occur in the next 5 years, and a lower, but still a very significant probability a much worse future incident–10 times the numbers of deaths–a true 9/11 in our world of gun violence.

We must not kowtow to the perfectionists; attempts to ensure complete safety are impossible, may backfire, produce a backlash, and get no changes at all. This happened with leghold traps in 1992.  The purists wanted hunting regulations, too, and that killed the proposition.  We had to wait two more years to introduce a bill banning leghold traps only, which did pass.  We must ban true weapons of mass destruction in America, fund mental health care adequately, and stop sales at gun shows.  Finally, no male under 20 should have unsupervised access to a firearm, because we currently cannot separate the “strange” from the “strange and dangerous.”  These are all rational approaches that, while far from perfect, will greatly decrease the probability of mass shootings.

I’ll probably teach, but I will lock the door.

“OH CHRIST, SMITTY, YOU CONTAMINATED THE TUBE. DAMN YOU!”

December 18, 2012

The words might not be completely accurate, as this happened in the operating room of Presbyterian Hospital, when I was an intern, 37 years ago.  I spent the worst 24 days of my internship helping two cardiovascular surgeons during my surgical rotation.  I scrubbed on 12 cases, and was thanked on only 5.  That 41.6% rate is entirely accurate.  I am formal when it comes to thanking people, I count things, and I would bet any amount of money on those statistics’ being accurate.

I despise being called “Smitty.”  The older of the pair was in his 50s, and I got some perverse pleasure out of the fact that he had made a pass at the most beautiful ward clerk in the hospital and had been politely stuffed.  I knew that, because she told me.  She also told me one night, “It’s a shame you’re married, Mike, or I’d take you home with me.”  She was gorgeous, but I had been married 3 years to the same person I am married to today. Besides, I was chronically tired.  If I had been “taken home,” I would have certainly have slept …..and done nothing else.

The partner was in his late 30s, equally irascible, and ultimately had a nervous breakdown.  It was foreseeable, and it was to my credit that when I heard the news, I felt sorry for him.  The two surgeons beat up on me, as did their scrub nurse who, as we said in the Navy, “wore their stripes.”  They drove me to tears one day, and a visiting doctor from New Zealand, who wanted to become a cardiac surgeon, not only left the OR in the middle of the case, but I heard later he said he would never be a heart surgeon.

The only thing I could do well in the OR was answer their questions about anatomy.  The two would point out vessels and ask what they were, or where they came from, and I would spit out the answer like it was the easiest thing I had ever heard.  There was nothing they asked about anatomy I didn’t know.

I was a “Little Person.”  Oh, I had potential to earn money, power and influence, but as an intern making $10,000 a year, on call every third night (worse in the Denver General Emergency Room, I was a little person.  These guys had power over me, and they intimidated the hell out of me.

And that’s why I contaminated the tube.  They were going to put a chest tube in a patient in an unusual manner, and I was shown how the tube was to be held.  I didn’t understand completely, but I was too scared to admit my ignorance.  So, the tube was handed to me, and WHAP!  The sterile tube hit me in the nose, a most definitely non-sterile area.

This is why in 1978 a plane crashed in Portland, out of fuel, killing 10.  There was a problem with the landing gear, and while the pilot addressed it, the co-pilot noted the fuel situation.  Rather than forcibly confront the pilot, who was known for being….unsavory….the co-pilot chose to stay silent, and the plane crashed.  Aviation has addressed this problem in 1980 with Crew Resource Management and it has saved lives.  Medicine would do well to do it, too.

The Little People are the ones who can’t defend themselves, and I learned early in life from my mother that I was never to beat up on those who couldn’t defend themselves.  We were well off enough that once a week a black cleaning lady came to the house.   This was in the 1950s and early 1960s, when being a black woman was a whole lot different from how it is now.  If they knew that in my lifetime Michelle Obama would be in the White House, they would have dropped dead from shock.

Florence and Tillie were to be called that, and I was to treat them well at all times.  I was to say “Please,” “May I?” and “Thank you.”  They were “Little People.”  I could have told my mother lies about them, and they would have lost their job.  It never crossed my mind; my mother had power over me.

As a Navy doctor, I had to keep space between me and my enlisted corpsmen and chief, because I was an officer.  Still, I did well enough that the few times I went to the Chief’s Club in Subic Bay, in the Philippines, I never had to buy a beer.  I usually had 2 or 3 put in front of me.  I outranked them, and we all knew it, but I respected them for who and what they were, and they appreciated it.  We helped each other.  And we had a good time doing it.

During my residency, I “lost it” one stressful night in the Emergency Department.  The next day, I apologized to the nurse.  She appreciated it.  Like most, I don’t like to apologize, but deep down (or not so deep down) I knew I was wrong.  It only hurts for a little while.  I learned that apologizing defuses a lot of tough issues.

In my practice, I wasn’t always the greatest guy, since I was chronically tired and too busy.  But I thanked people.  I said “Please,” and I asked nurses often what they thought of the patient. I treated them as …. people.

I cleaned up after myself after spinal taps, and if one reads  Code Team, one will understand that I wasn’t afraid to clean up after patients, either. That astounded nurses.   I realized that social workers, dietitians, PT, and OT could help my patients.  I talked to all, and asked them what they thought.  I learned a lot, including the notion that people like to be asked what they think about something.  It is flattering, respectful, and makes one feel wanted.

Because the nurses weren’t afraid of me, they told me things I might not have been aware of. They learned about neurology; I learned about nursing.  I learned that abnormal cardiac rhythm strips were destroyed, because the nurses were afraid of telling the doctor on call, for fear they would be shouted at.  How does that make you feel about cardiac care?  Bad heart rhythm, throw away the evidence!

In 1992, I took a leave of absence.  I had an outpouring of good wishes from the hospital staff, which frankly surprised me.  I received several cards, which I still have today.  But there is one that I treasure most of all.  It came from a Dietitian, a young woman who was going to leave the hospital too, to go to pharmacy school in Washington State.  She wrote a simple note:  “You were always good to the ‘Little People.’ “

COME ON, MAN!

December 4, 2012

We now have one million people who have signed petitions for their state to secede from the Union.  We fought a war over secession 150 years ago; my side won.  The South has never really forgotten.

A half century ago, LBJ got the Civil Rights Act through the Congress.  I can still remember my mother telling me that there was “cloture” (end of debate), while I wondered what cloture meant.  It changed the US, and the South has been Republican since. That has cost us dearly: 6 years of Nixon (28,000 American deaths in Vietnam under his “secret plan to end the war, Watergate), 8 under Reagan (terror attack in Lebanon, Lockerbie, Iran-Contra, first known President with Alzheimer’s), and George W. Bush (9/11, 2 unpaid for wars, polarized country, Guantanamo, Patriot Act….)

When Nixon-Agnew were running the country, until each of them had to resign separately, there were a lot of bumper stickers that said, “America, Love it or Leave.”  I can’t remember when I last saw one of those.

Without doubt, had McCain-Palin won in 2008, my wife and I would have emigrated to Canada. We wouldn’t have talked about secession, because it is treasonous.  We had a choice, and Canada would have been viable.  It is a very different place from America, but I like Canada, have traveled it extensively, having spent 2 years of my life there.

I’m not sure why people are so upset, except that we have a black president that was elected to change things, and he has tried to do that.  Change is admittedly difficult.  Health care reform was incredibly polarizing, although many who complained about it were getting government benefits through Medicare or were military retirees.

Fact is, we have over 300 million people in this country, and at least 50 million don’t have insurance. The other day, my wife had some blood work drawn, and the man in front of her needed 16 tests.  Cost:  $2000.  Insurance?  None.  As the ESPN commentators say, “Come on, Man!”  How often is this scene repeated daily?  How often do people come into the ED and don’t have money, yet rack up five figure costs?  This remains the biggest cause of bankruptcy in the US.  Nice that you have yours, but what about the others?  Should they just die, untreated?  Is this America?  Is this how we solve medical costs in this country?  Let people die?  Come on, Man!

Back to the secessionists.  Eleven states have reached the 25,000 signature level for a White House response.  Eight of the 11 have had major hurricane damage in the past decade, the rest get major tornado damage every year.  Some get both.  We saw what Hurricane Sandy did to New Jersey, not a poor state.  Chris Christie, the Republican governor, who two weeks earlier had lambasted the President, praised him.  Governor Christie knew that New Jersey could not rebuild without the federal government’s help.  So to the secessionists:  If a Cat 5 hits Houston, another Katrina floods New Orleans, or an EF5 takes out Nashville or Montgomery, exactly what are you going to do, pass the hat?  Come on, Man!  Do you have any concept of how much a billion dollars’ damage is?   Let’s assume $20 billion, and divide it by say 5 million people in the state.  That is $4000 for every person in the state.  So, if you have a family with three kids, you owe $25,000.  If you aren’t employed, that is too bad.  You owe $25,000.  But the single mother with no income and 3 kids, because the man left her owes $20,000, and she isn’t going to pay.  What are you going to do?  Come on, Man!

Median health care costs are about $15,000 per year per family.  You will no longer have insurance.  Of course, if you have a bad accident, get the wrong virus, rupture an important vessel, your costs have just skyrocketed.  If you are younger, they may not; if you are over 65, they are likely to be more.  Your new state-country will need first responders, have to educate people, protect against crime, and maintain infrastructure.  Do you think that will be free?

Let’s look at how taxes were divvied up from 1990-2009.

                  Federal aid minus taxes paid

The 11 states                                            + $400 billion

New York, NJ, Illinois (alone)         – $2,400 billion

Number of blue states in top 10 for receiving less                9 

Number of blue states in bottom 10 for receiving more       4

In other words, the states with the most secessionists are getting MORE from the federal government than they are paying.  Two of them are Florida and Ohio, which are barely Democratic.  All the others were members of the once Confederacy.

I’ve known that for decades.  Growing up in New York State, which alone is $1 trillion in the hole to the feds in the past two decades, I heard often how the national parks and forests were paid for in large part by people on the east coast, many of whom would never see these places.  Then again, we believed in the Union and a strong country.

When my side lost elections, I whined, too, and I said that the country was wrong.  But I never said we should secede.  I would have simply moved to Canada.  I would have taken the advice to “Leave,” but I would have only affected myself.  The secessionists want to affect the others in their state who might not want to leave.  These people have rights, too.  Many of them get Medicare, SSI, and FEMA help, the last under Mr. Obama  again worth something.  The secessionists would hurt more people, poor people, who would no longer get the benefits that the federal government provides.

If you want to leave, then go.  You have that right.  But don’t insist others have to go with you.  Grow up, too; try to make the country you currently live in better.  It’s easier than making a brand new country. Quebec learned that.  Oh, Quebec is in Eastern Canada.