Archive for February, 2015

CHEWING AN APPLE

February 23, 2015

Yesterday, while looking for a pair of walking shoes, I was helped by a saleswoman who chewed an apple the whole time I was there.  I know people often need to eat while working.  I did it for years.  But eating in front of a customer one is helping seems rude.  I wondered about her education.  It was a good day to wonder, for the Sunday paper had reported that Lane Community College received a “scathing report” during their accreditation.  They are accredited, but there is a lot of work that must be done in the near future; a repeat visit is planned.

There are issues that clearly relate to Lane, regarding course structure, how students are evaluated, and a need to establish clearer goals.  There are other issues, however, not mentioned in the article, which I think need to be discussed.  I wrote a letter to the paper, but after finishing realized I had already used my allotted one letter per calendar month.

I am not an educator, only the son of two.  I have, however, taught at a community college and at a for-profit university, leaving the latter, because I thought it intellectually dishonest to pass students in statistics when they had neither the necessary math skills nor adequate time to learn it.  Not understanding the slope of a line makes linear regression impossible to learn. 6 E-5 on a calculator is not 6 but 0.00006.

I volunteer at Lane twice weekly tutoring math.  Yes, I eat lunch while there, but I put food away if a student needs help. In Arizona, I volunteered in 3 high schools for 9 years, eventually becoming a substitute teacher, because I wasn’t utilized enough as a volunteer.  I ate on the job there, too, and I barely had time to use the bathroom.  We need volunteers in the schools, but they must be kept busy.  Establishing such a system should be a national priority.

At Pima CC in Tucson, 80% of the incoming students flunked the math placement exam.  In a high school in an affluent district, I spent two years helping students do “accelerated math.”  The euphemism was an attempt to help 10th graders, with elementary school math knowledge, reach standards allowing them to graduate from high school, standards that have since been removed, after first being watered down.  We want math fluency; we just don’t want to hold students back from graduating if they don’t have it.  One may argue the test wasn’t good, but at least there was a way to evaluate students.  Now there is none.

The students I taught needed multiplication tables beside them, which I think should be known by everybody reaching junior high school, let alone 10th grade. I think students should know 8 x 6 or how to divide 3 into 12 without using a calculator.  I’m not exaggerating.  Each had been passed up the line despite their not knowing basic arithmetic.  They got “participation points,” “trying hard” was important, and some of their parents demanded they be allowed to finish high school with their peers who did know these basics.  Watch Suze Orman sometime, and it becomes clear what happens when people don’t understand finance.

Community colleges have become de facto high school finishing institutions.  I don’t know whether community colleges pass students to the next level—the workplace or a 4 year college—with the skills they need, like making basic change at a cash register.

Or not chewing on an apple when one is helping a customer.

I have three fundamental questions:  1.  What are we trying to do?  2.  How will we know we did it?  3.  What changes can we make that will solve the problem?

Funding tied to number of degrees awarded increases pressure to award degrees.  How do we know if the degree is worthwhile?  One can pass students up the line, but eventually I want a doctor, a mechanic, a pilot, or a computer specialist who is competent.  The piper must be paid.  Competence must be definable and proven.

It includes not chewing apples in front of customers.

I don’t believe a four or even a two year stint in higher education is necessary for all.  Many important jobs in our service economy don’t require college.  Education’s primary role might begin by teaching early and often that complex 21st century problems are not addressed by catchy phrases.  We need to grant meaningful degrees, not just count them, teach the myriad skills required today, pay for them, and keep education affordable.  Climate change, ocean acidification, immigration, religious fundamentalism, North Korea, Cuba, Iran, competition, environmental degradation, defense, can’t be addressed by “America first,” “boots on the ground,” “I’m not a scientist,” “deport all of them,” “de-regulate,”  “let the market do it,” or “allow parents to decide.”  None of these and other issues have clear answers.

We need to determine what courses are needed for today’s workforce and for those jobs we believe we will have in the future.  In 2045, people will be doing work that today not only doesn’t exist, we can’t even imagine what it will be.  Streaming video online, wi-fi and smart phones weren’t things I thought about in 1985.  Indeed, the words “streaming” “wi-fi,” and “online” didn’t exist, smart belonged with people, and video was defined in millimeters and called “film”.

How we certify students needs to be changed.  We need a required, sensibly structured way to state that an individual is prepared for the next step. These changes will be painful to higher education.  We have to pay for this as students and as taxpayers.  The debt load is burdensome; people need to learn what is necessary for a skill, which may not require 4 years, or even 2.  Stampers don’t need to know Chaucer, not if it is part of their $50,000 student debt at graduation, but they need to know enough math to do finance, enough English to communicate, and enough science, history and geography to be able to vote intelligently.  Professional golf management as a major once sounded like a joke, but given the popularity of golf, I’ve reconsidered my position.  By the way, learning to reconsider one’s position on a matter should be taught, too.

What are we trying to do?  Have an educated populace in the 21st century.  What is an educated populace?  I don’t know.  I offer my thoughts, and if our country were a place where we could discuss complexity with civility, not with talking points and shouting, we might be able to answer this question better.

How will we know we have done it?  We need better measurements than we have, ones that will tell us the bitter truth, which we all know exists.  We have millions of poorly educated citizens.  Let’s neither allow gaming of the system nor get hung up upon punishing schools.  The solution will be expensive, requiring money, volunteers, good ideas, but most importantly evaluating students honestly. It will be painful.  The truth usually is. We need multiple career pathways to accommodate variability in learning and intelligence.

How do we move forward?  Ask the right questions. Then answer them.  Honestly.

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THE “GIANTS”

February 17, 2015

A woman my age recently died at a hospital because she was given an intravenous paralyzing agent rather than the ordered anti-convulsant.  Ironically, she came to the hospital to discuss her anti-convulsants and anti-anxiety medications.  She had a brain tumor removed a month earlier.

We thought we are going to give one medicine, and we gave another medicine.”

You see, a drug got mislabelled in the hospital pharmacy and a paralyzing agent was put in the IV bag instead.  She was being monitored, but unfortunately, a fire alarm went off, so the nurses were distracted closing sliding doors.  Concatenation of problems.  The patient stopped breathing, nobody noticed until she had a cardiac arrest, and she was then taken off life support three days later.

Concatenation of problems, 1985.  Delta 191 coming in to land at DFW.  Thunderstorm in vicinity.  New Doppler Radar not ready.  No weatherman on duty.  Lightning strike ahead and rapid intensification of the storm.  Plane hits updraft and accelerates.  On the other side plane encounters a downdraft, driving it downward, altitude too low to recover, 137 died.

The hospital had now implemented several steps “to ensure that an error of this kind will not happen again in our facilities.”

If I hear “to ensure that an error of this kind will not happen again,” one more time, I will scream.

Or maybe die, if it happens to me.   What about other facilities?  Any other facility going to learn from this?  We learned from Delta’s disaster.

They include the creation of a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions and the implementation of a new checking system for paralytic drugs.  Airline pilots have long had “sterile cockpits,” where nothing but the aircraft is discussed below 10,000 feet.  A decade ago, I proposed the same for radiologists, who are interrupted frequently.  I think clinicians should do the same.  Very few phone calls are so important that they are worth disrupting a clinician’s concentration when seeing a patient.

Three enemies of good medical care: hurry, fatigue, interruptions or distractions.  In my training, I heard the “giants” could work 36 hours, when I couldn’t.  I dreaded days on call, knowing I might be awake for 36 hours.  The “giants” could work without eating, too.  I couldn’t. The “giants” could take phone calls while seeing patients.  I would be called out of the office, pick up the phone, and hear, “hold for the doctor” (who had initiated the call).  Some of those doctors were my partners.  The call disrupted my consultation.  I said this lifestyle was unhealthy and bad and told to suck it up.  I wouldn’t and left.  I was proven right.  Being awake for 24 hours is equivalent to being drunk.

Medication errors are common; twenty years ago my hospital, where I was medical director, were dealing with them.  How does a paralytic drug, rarely used, get into an IV bag? That’s a system that needs to be fixed quickly.  Move these drugs far away from all others in the pharmacy.

People are fallible.  We all screw up.  We are hurried, fatigued and interrupted.  We multitask; far too much is expected from too few personnel in many hospitals.  I interrupted radiologists.  Nurses are frequently interrupted, often by false alarms and incessant beeping, which is distracting. We live in a noisy, fast-paced world, dealing with huge volumes of information simultaneously.  But our brains have not equipped to deal with such.  I am a slow processor; I shut down when encountering questions from two or three people simultaneously.  When everything is urgent, nothing is.

But the “giants” dealt with that.  I couldn’t.

Very old people may hit the accelerator mistakenly, not the brake.  But you can’t shift a car into reverse without having your foot on the brake. Is that perfect?  No, but it is a good safety mechanism.  Compare that with the history of Vincristine, used to treat leukemia.

“We must be certain that there never is a 14th patient who receives vincristine intrathecally (into the spinal fluid) by mistake.”  I am not quite exact with the quotation, and I can’t find the article in the literature, but such injection, completely preventable, is almost always fatal, often in children whose leukemia was curable.  “It is unspeakable that this should happen in this day and age…”  That was said in 2001, long after the first quotation.  Google the issue now, and there is a recent case report of three children, two of whom were thought to have Guillain-Barre syndrome. The problem hasn’t been fixed, and it should never occur. Why?  In one article, twenty different system fixes were suggested.  What is wrong with medicine?

Stuff happens, yes, but this stuff needed to stop happening decades ago.  We’ve known about fixing bad systems for a long time.  Are we making progress?

Answer:  I don’t know.  We might review all hospital deaths using an ordinal scale to determine the role of medical errors.  Sample hospitals, and we have an estimate with a decent margin of error.  Do it over time, and we know trends, as well as numbers and types.

Those of us who study these issues believe in “root cause analysis.”  We also believe patient safety requires senior management’s seeing the data and acting upon it.  This does not happen in too many instances.  Reports need to be compelling and readable:  significant errors should be written up, the results of the investigation disseminated.  Delta’s crash made dealing with wind shear a major priority.  The American Airlines crash in Little Rock highlighted “get there-itis,” despite a thunderstorm’s intensification in the area, with failure to deploy spoilers, a combination of hurry, weather and fatigue.  Back then, two-thirds of pilots polled said they would land during a thunderstorm.  They no longer do so.

Medicine will never be perfect.  As technology changes, as medicines change; as illness management changes, there will be new challenges.  We need to face those challenges head on, anticipate them, have a safe way to report close calls as well as errors, and make these known to everybody in the field.  There should be no embarrassment, no hiding, but there must be an analysis as to what went wrong, as is done in aviation, what must change, and how to prove efficacy.  Top management must be involved and buy into these systems.  While we shouldn’t tolerate violation of safety principles, inherent system design must make it easier to do what is right, more difficult to make errors.

My ideas have been in the public domain for well over a decade.  Perhaps they aren’t good enough.  That’s fine.  I’m not perfect.  Offer better ideas.  Then prove it.

Just don’t tell me about the  “giants.”  They created the problem.

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SCHÖNER TOD AND DEATH WITH DIGNITY

February 11, 2015

A friend of mine in another state told us his mother died about a month ago.  I met his mother once, and found her a lovely, friendly person.  But we all get old, and her old age was complicated by strokes and gradual deterioration.  For those who say age is just a number, it can be a crappy number.  She was a widow, too.  A great majority women over 85 are unmarried; half of men.  Just a number?  No, real numbers.  Sad facts.

When she went to hospice, after another stroke, she developed disordered breathing, hyperventilation, which could have been due to the stroke or early pneumonia.  To me, it really didn’t matter, because once a person is in hospice, they are to be kept comfortable until they die.  That may require morphine.  Yes, morphine, addicting morphine that slows down breathing, suppresses coughing, and might actually hasten death.

Can’t have that, say some.

Admittedly, the feds have a schizophrenic approach to pain management, because the medical profession failed to manage pain adequately at both ends of the spectrum.  We gave too much pain medicine to the wrong people for whom it was not helpful and addicting, and we under-treated others, who needed more analgesia than they received.  It is entirely possible one day to be in a hospital, where smileys for amount of pain are measured, and 1 smiley is good.  A day later, one may be out of the hospital and pain medication strictly controlled so he doesn’t become a medication abuser. I may exaggerate, but not much.

Pain or agitation control, when a person is dying, should be easy.  You give whatever it takes to control it.  This lady, mother, grandmother, wife, was dying.  Her life was ending.  She, like my late mother-in-law, lived far too long.  Yes, that happens to many people.  Hey, it’s just a number, right?  Life is sooooo precious, until when one is ready to die and won’t.  Sort of like Dustin Hoffman in “Little Big Man.”  But this is real.

Or won’t be allowed to, naturally.  We say that not treating a pneumonia is “playing God,” but we resuscitate people who don’t want to be resuscitated.  I’m not a believer, but if I were, I would say that is much closer to “playing God.”  The Bible and the Qu’ran don’t say 300 joules to shock the heart, when a person with dementia suddenly has a heart arrhythmia.  My friend’s mother would have liked to have lived a long, healthy life, but the second adjective was not to be.  She was ready to die.  She had nothing left to live for.

I hope I am that brave, should I reach that situation.

I hope I don’t end up in a hospice where morphine is “metered out,” in small amounts, because someone fears they might be accused of killing somebody, by making them comfortable in their final hours, even if the final hours were shortened.  If that is wrong, then the world is wrong. Fear of the patient’s dying as a result is NOT a contraindication to give morphine.  Addicted?  The person is going to die, not seek drugs.  They are going to cease to exist.  It is the way of the world.  The verb is “to die”; the noun is “death.”  Use them, not euphemisms.

A sick person in hospice should never, and I repeat never, be denied medication to keep them comfortable.  If hospice workers do not agree, they should work elsewhere. Sadly, this is too often the case in America today.  Ask Barbara Mancini, who was prosecuted for having handed her father morphine, when it wasn’t even clear he was suicidal.  Because that particular hospice was a place where “death is an option in America” occurred, her father suffered hospitalization for four more days before he died.  He didn’t even need to go to the hospital.  Naloxone reverses morphine.  Indeed, I used it in the Navy in the Gulf of Thailand once, and it was the only clear life I ever saved. Ms. Mancini was arrested in the hospice and put through hell for a year and $100,000 by a prosecutor who may be in Congress, now.  The judge who threw the case out of court wrote a scathing 42 page report, if I remember correctly.

Fortunately, the medical profession is beginning to come around more and more to the idea that sometimes we need to allow patients to die.  We need to do whatever necessary to keep people comfortable, even if it means shortening their life.  And in five states, the patient who fulfills certain conditions can choose to shorten his or her final hours, because the end result is the same.

Let’s be clear about semantics, here.  This is not assisted suicide, Dr. Gawande.  Your book was well-written, except for the short shrift and the wrong term you gave to Death With Dignity.  This is an individual who is dying, soon, and does not wish to prolong the process.  This is a individual who is aware what is happening and chooses not to continue.  It is not assisted suicide. The disease is killing the person; they want to live.  But they want to shorten the agony of their final hours.

We can argue as to whether palliative care or hospice can deal with these conditions rather than a Death With Dignity Act.  Maybe they can, but in far too many places in this country, they are not.  That is a fact.  It may be religion, misguided, or financial.  I personally don’t think palliative care can deal with the conscious person with pancreatic cancer, sees the end in sight, and doesn’t want to live it out. I hope I don’t have to find out personally.  In my home state of Oregon and four other states, I don’t have to.

Any hospice that fails to give an elderly woman morphine, because her family members are upset by her breathing, should be closed down.  The lady is beyond knowing, but her family is left with a bitterness that will never heal.  I am both angry and astonished that addiction or “mustn’t give too much morphine to a patient” still exists in the 21st century, when somebody is dying.

It’s nice that Dr. Gawande and others are finally aware at the state of dying in America today.  Welcome aboard the train.  I boarded it 40 years ago in on the third floor of Presbyterian Hospital in Denver. I’ve been riding it ever since.  I’ve known when to quit, and I know how to do it.  I count things, and I think it’s high time we counted the number of people who die at home, the per cent who have living wills, the number whose living wills are violated, the per cent who used hospice, and how long before death they used it, and the number of “Schöner Tod” (beautiful death, a German term).  Everybody dies; on the death certificate there should to be a place for “Living will used,” “hospice,” “hospice at the appropriate time,” and since we are so in love with smiley faces for pain scales, whether the pain scale the last week of life was 1.  Dichotomous question.  Easy.

I wrote about it a decade before you, Dr. Gawande.  Did it in fewer words.  Here’s the link.  It’s in a reputable medical journal.  Welcome aboard.

I’ve been waiting.

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BELIEVING IS SEEING

February 9, 2015

My wife read a CT Scan of the heart, done to look for coronary artery calcification, and told the referring physician the patient had breast cancer.

Whoa!  What does that have to do with heart disease?  The answer is nothing, and that is my point: we need radiologists to read films formally, not clinicians, and I say that as a former neurologist who read CT head scans well.  A medical group may own an X-Ray facility and clinicians may read the images.  But every image must have a formal reading by a radiologist, an unbiased individual trained to look at everything on the image, every corner, every part.  There is no law in nature that says a person will have only one disease process.  It is entirely possible for a neurologist to look at an MRI of the spine and miss a large abdominal aortic aneurysm.  We see what we expect to see.  Seeing isn’t believing.  Believing is seeing.  We believe something, and we tend to look for it.  We also are pattern recognizers, often useful, but leads us astray when some see Jesus on a pizza or the “The Face on Mars.”

A CT scan of the Chest has a side view.  This isn’t a mammogram, but it certainly is capable of showing a breast cancer.  In addition to the breast cancer, there was a “ground glass” area in the lung suggesting there might be an early lung cancer, too.  Wow.  A CT scan of the heart is done for coronary disease, and two primary cancers are discovered.  Maybe the cardiologist would have found those, but I doubt it.  I doubt when I read CT scans of the head that I would have found a throat cancer, even though the throat was scanned and on the film.

In my defense, I was once asked by a cardiologist to see a man who had presented with a brief spell of unconsciousness, or syncope. Neurologists are frequently consulted for syncope, and it is usually due to a non-neurological problem.  The man had recently driven 1500 miles (2500 km) from Minnesota to Arizona. I examined him, noting his breathing was faster than normal. His neurological examination was unremarkable. I obtained an arterial blood gas, since we didn’t have pulse oximetry back then, and found pronounced hypoxia.  Thinking a cardiac arrhythmia might cause unconsciousness (strokes seldom do), thinking a pulmonary embolus could cause both an arrhythmia and hypoxia, I obtained a lung scan, since that was once the “gold standard” test. The man indeed had pulmonary emboli, likely because of venous clots in the legs occurring during prolonged sitting on his long drive.

It seems trite to talk about the “good old days,” when they were not always so good.  We didn’t have the technology we have today.  On the other hand, I think our physical diagnosis—history and physical exam—was a lot better than today.  We didn’t have scribes writing down findings and ordering a plethora of tests, many of which require a lot of radiation.  More than once, my wife has told me of head CT scans or MRIs with a specific lesion.  When I asked her what the history was, she usually answered:  “It was part of a complete body work up.”

That approach makes modern medicine foreign to me.  I ordered tests I thought I needed, and if I weren’t clear in what order I should order them, I called the radiologist.  I always wrote much information about the patient on the requesting slip, back when we used paper and still knew how to write, because a radiologist could give me a better reading when they knew the area of the brain or spine in which I was interested.  When I could, and I usually made sure I could, I would look at the films with the radiologist, when we still had films, so I could see for myself and learn more about reading images.  It made the radiologist better and feel more useful; I believe it made me a better neurologist.

So, when the MRI of my neck, done because of a concern about a pinched nerve, was unchanged from 9 years earlier, that was good news. I was chagrined, however, when the radiologist told me that I had a two thyroid nodules that were missed by even the radiologist back then.  It never occurred to me look for thyroid disease on my neck MRI.  It is sort of like people’s being surprised when I tell them the Moon is visible in broad daylight.  “It is?” they say.

“It’s there, isn’t it?”  I reply.  The thyroid nodules were definitely there.  Once I looked, there they were, quite obvious, like the first quarter Moon in the southeastern sky in the afternoon.  Try finding the Moon in daylight, if you haven’t ever noticed it.  The Moon is above the horizon half the time, and other than 2 days on either side of new, it is visible, day or night. You will discover a whole new world—literally, and wonder why you never noticed it before.  That’s the problem.  We notice only what we are willing to notice.  If we learn to notice many things, it opens a door to a new world.

Sometimes, we notice a thyroid nodule.  Sometimes, we don’t.  I was lucky; the nodule was benign.  Had it not been, my thyroid cancer’s discovery would have been much later than it should have been.

Sometimes, life itself lasts longer when people notice things.

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“MARKET FORCES”

February 5, 2015

I felt some queasiness as the plane descended to land in Tahiti, after a 4 hour flight from Auckland, New Zealand.  I’ve never been airsick, but I rationalized it that way.  After landing, we remained on the plane.  I felt worse, and then…..

When I awoke, having vomited all over my clothes, the seat, and myself, my wife asked me, “Are you all right?”

Obviously, I wasn’t.  My wife told me that I suddenly pulled “an exorcist,” threw up, had a seizure and became decerebrate.  That’s bad, and I won’t discuss the neurology, other than I briefly lost total function above my brain stem.  I didn’t feel too badly, although I threw away my shirt, the crew changed out the seat cushion, and I barfed two more times before we were airborne for LAX.  Those white bags are useful.

I got staphylococcal food poisoning from a cream pie I ate at the Auckland Airport.  A passenger in the row in front of me studied infectious disease and was thrilled to have a clinical example behind her.

That’s why food safety matters.  I probably should have been kicked off the flight.  But I lived. Food poisoning caused me to vomit, my heart rate and blood pressure fell, provoking a faint.  Children die here from bad food.  It makes the news.  Fifty-three people died in Germany in 2011; that epidemic cost $2.8 billion, so food safety regulations can save money, as well as lives, and are not government meddling.  Ayn Rand notwithstanding,  businesses don’t self-regulate.

Business has a friend in new Senator Mr. Tillis, (R-NC): ”I don’t have any problem with Starbucks if they choose to opt out of this policy (requiring hand washing after using the bathroom) as long as they post a sign that says ‘we don’t require our employees to wash their hands after they use the restroom.’  The market will take care of that.”

Mr. Tillis won a close election when a lot of people didn’t vote. Elections matter.  Now we have to deal with him for 6 years.  We have a standard requiring people in the food service industry to clean their hands after using the toilet.  They may not wash their hands, just like business can cut corners, but we require it and inspectors, too, to ensure cleanliness.  The Republicans would like to get rid of inspectors, too, because “the market will take care of that.”

Jesse Kelly, who almost unseated Gabrielle Giffords in 2010, shortly before she was shot, stated, “I would not require food safety inspections.” Voters liked his looks, his wanting to dismantle the ACA, which has insured 11 million people, apparently caring neither about food safety nor about insuring the poor.

It is difficult to know how many people are sickened by restaurant food, but we estimate 76 million cases annually with 300,000 hospitalizations and 5000 deaths.  That’s worse than 9/11.  We finally have a standard that doesn’t allow any E.coli in beef, but no such standard exists for chicken.  High rates of Campylobacter are in store chicken; E. coli are still in both products.  Left to “market forces,” does anybody think companies would worry about bacteria in beef if the government didn’t make them?  The NRA prevents the CDC from doing research on firearm violence; is Mr. Tillis going to introduce a bill banning research into food-borne illness?  Perhaps “the market” will sort it out.  Or the graveyards.

I volunteer in a school where peanut butter sandwiches, which I love, are not allowed, because of peanut allergies, a relatively new phenomenon. I can adjust my behavior, but I wonder why there aren’t signs that say “Unvaccinated Children in this Room.”

Ever had measles?  I have.  It’s the sickest I’ve ever been; 90% of my generation had it.  Measles is one of the most infectious viruses in existence, more than Ebola, with a 1 in 1000 chance of causing encephalitis, brain inflammation.  That is scary.

Pertussis?  My mother had that. Kids die from pertussis, or whooping cough.  Adults can get it, too, here and now.

How about Rubella, my generation’s favorite disease?  We got to stay home, and we felt fine.  Oh, one problem: if an unvaccinated kid gets rubella and the teacher, also unvaccinated, happens to be pregnant, the baby may be born with congenital rubella syndrome: mental retardation, deafness and cataracts. Rare?  My wife’s relative takes care of her middle-aged son, who has it.

Mumps?  There is a 40% chance of orchitis, testicular inflammation.  That is painful and might lead to sterility.  My brother had mumps meningitis.

Polio?  That killed 4000 Americans a year; some, paralyzed and in iron lungs, actually wished they were among the dead.  We stayed at home in summer, away from crowded beaches.  Jonas Salk’s injectable vaccine was so dramatically effective that the trial was stopped early.  Another brother had polio.

Herd immunity?  It exists, but what right do parents have to opt out?   Is it not child abuse to put children at risk for these and other diseases?  Ever see tetanus?  I have.  Should we let parents opt out of child care seats?  Should we let children play with guns? If that isn’t convincing, what happens when their child goes to a Third World country where these diseases are endemic? Have they thought of that?  Yes, polio is usually asymptomatic, and measles may not produce encephalitis, but why risk them when there is a vaccine?

To my generation, vaccines, including the one that decreased H. flu meningitis by 99.9%, were huge medical advances.  They occurred when science education was an American priority, when we believed in science and public education, not faith healing or for profit charters, made children get vaccinated and did it in the schools.

Ironically, my generation is getting vaccinated for pneumococcal pneumonia and shingles.  No, these aren’t perfect, but I’ve seen the misery of post-herpetic neuralgia, which has caused some to commit suicide.

Physician Ron Paul once spoke to an anti-pasteurization group.  I assume he knew something about brucellosis, otherwise called undulant fever.  Pasteurization made brucellosis rare. We now want to go backward and risk Typhoid, Listeria and Tuberculosis, too?

Perhaps we should consider that the chemicals we have dumped into our environment and our fetish with total cleanliness could be factors causing many childhood afflictions, instead of focusing on vaccines.  Perhaps instead of worrying about Ebola, which was limited, even in Africa, we ought to worry about measles, polio, E. coli, salmonella, and other scourges, all potentially treatable, which are microbial terrorists, with potential to do far more harm than two legged ones.

We haven’t become healthier by prayer.  We got healthier because of science, research, double-blind studies, good statistics, and legislating cleanliness, safety, vaccinations, and anything else that improved the public good, because we knew companies wouldn’t do it on their own.  The companies screamed it would put them out of business.

And the Dow keeps hitting new highs.  Market forces.

 

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THERMODYNAMICS

February 2, 2015

The first month I was an intern in medicine, we had a person with congestive heart failure who was on fluid restriction.  Despite this and diuretic therapy, the patient did not lose weight.  Maybe, he was getting fluid from heaven.  Or was he?

I decided to ask the man some questions.  What did he do in the hospital?  He took walks with his wife.  OK, good.  “Did you stop by a drinking fountain at any point?”

“Oh yes, I often did.”

“What did you do.”

His wife answered, “He took a big drink.”

When we restricted him to his room, his weight dropped and his condition improved.

At the weekly Stammtisch the other night, I got more than a German education.  One lady was talking about fire walkers, and a guy was talking about a man in India who allegedly had lived for 70 years without eating or drinking. I was polite, simply saying extraordinary claims (the second) require extraordinary evidence.  Fire walking exists, and there are reasons why people can do it.  We understand the science behind fire walking.  Don’t run, make sure the wood is dry before burning, and don’t try it on metal.

Getting one’s nutrients from the air, or from heaven, is another matter, unless one is moss growing from a Sitka Spruce on the Oregon Coast.  I hadn’t heard of people’s doing that, but these days there are so many new stories that it is difficult to keep up with them.  I decided to check online.

Indeed, such a man has claimed this.  He was checked with CCTV for 15 days and indeed did not eat or drink.  Interestingly, he was dressed while being observed.  Supposedly, he had no urine in his bladder and had no bowel movements.  I say supposedly, because maybe somebody filming him had an agenda and lied.  People do.  In addition, I did not see results of daily weights, electrolytes, BUN and Creatinine, UUN (urine urea nitrogen), urine specific gravity, if there were any, all of which would have been necessary.  If he were indeed getting nutrients from heaven, which plants do, his weight should have stayed the same. This story is an extraordinary claim; it requires extraordinary evidence, which was not forthcoming.  CCTV for 15 days is not enough.  I want to see the above.  Why?

There was no explanation of the few times the individual was NOT on CCTV, having gone to meet with his supporters.   I wonder if there were water fountains. He was dressed and could have hid a lot of food under his clothes.  I didn’t argue with the individual who told me the story.  He was equating some of this to “My Spiritual Beliefs” with a few references to Jesus.  Those arguments are un-winnable.  I was a bit disturbed that somebody would take such a claim at face value, but people do that these days.  I’ve seen pictures showing a huge eclipsed Moon from the North Pole.  It doesn’t work that way, and I can prove it, but many still believe this sort of stuff.  The local paper didn’t know that the Harvest Moon occurred annually, simple to research, a weatherman in Tucson thought local noon was at 12 p.m., which it is not,* and a different weatherman once commented that the Sun was “already” setting later on Christmas, “only four days after the equinox.”⁺ These are easily observable with the eye.  Technology is a wonderful thing, but photoshopping is too often believed; film was harder to fake.  I suspected nothing I said would convince the man otherwise.  I did mention “thermodynamics” twice, and he looked at me with a quizzical expression.

Obtaining food from heaven is reserved for plants, whose pyrrole rings have magnesium and not iron.  We can’t do this; indeed, people who have tried have lost an extreme amount of weight, had incipient renal failure, and some even died.  In short, there is compelling evidence suggesting that not eating or drinking leads to severe physiologic compromise and even death.  At the end of life, VSED  (Voluntary Stoppage of Eating and Drinking) causes death.  Why are there not survivors in this transition stage, especially given that impending death is an extremely spiritual time?

I try to be a reasonable skeptic, but here, reasonable has requirements.  “Spiritual,” and “God” don’t cut it with me as proof.  People used to call a child’s death from acute lymphoblastic leukemia (ALL) “God’s will.”  Today, 90% survive 10 years and are considered cured; half a century ago, ALL was a death sentence.  Sounds more like science to me.

I want the individual naked on a bare bed in a bare room with no evidence of food or water present.  I want the trial to be at least a month, subject’s health willing, so that possible over hydration issues or medications that were given (antidiuretic hormone, for example) can “wash out” and not be a factor.  People fake things all the time; I did a grand rounds on this for many years as a neurologist, to show how people could fake dilated pupils, paralysis and a host of other neurological conditions.

How did I know?  People who have paralysis from a stroke or a tumor do not lose sensation sharply to the midline, they do not lose smell on one side of the nose, and they don’t lose vision in the eye on that side.  Our brain does not work that way.  Those who present with a dilated pupil and coma, where fakery is a real consideration, require two things:  Pilocarpine should constrict a pupil caused by oculomotor nerve paralysis.  Drugs placed into the eye to dilate the pupil will resist pilocarpine.  As for “coma,” ice water squirted into the ear is not only exceedingly uncomfortable, but the eyes move in a way that cannot be faked. Some people want to be ill, as strange as that sounds.  I carried pilocarpine in my medical bag.

I feel the same way about UFOs.  There are many things for which we do not have an explanation.  I try to look for natural causes, rather than to postulate UFOs, Poltergeists, alien abductions, and government conspiracies (amazing secrets kept by a group of people who are often labelled incompetent bureaucrats).  During World War II, Venus was fired upon by the US from Maine when its bright light appeared over the ocean.  Our memories are fallible, they change with recall, and perceived sincerity, looks, or voice of an individual do not constitute proof. People have strange ideas how the body works.  They hear tales from their friends, see newspapers at the check out line, and assume these must be truthful.  I’m guilty of magical thinking, too. The difference is I know I am hoping for things to happen that I have no control over.

I found it interesting that the man who was so willing to believe a person could survive for 70 years without oral intake of food and water was so unwilling to believe that fire walking could exist.

Thermodynamics.

 

 

 

*Local noon is when the Sun is highest in the sky.  Not counting Daylight Savings Time, this occurs at noon only at longitudes evenly divided by 15 degrees.  For example, Tucson’s longitude of about 111 degrees is 6 degrees west of 105.  Local noon varies around the mean of 12:24.  Every 4 minutes is one degree of longitude:  1440 minutes/day/ 360 degrees of longitude/day.

⁺The equation of time is the difference in Sun time from clock time. The Sun runs faster than clock time in December, but every day it is slowing down much more than its southerly movement is occurring.  The first delays the sunset, the second speeds it up.  This makes the earliest Sunset about 6 December and the latest sunrise in early January.  By Christmas, the Sun has been setting later for nearly 3 weeks and is quite noticeable…if one looks.

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