Archive for November, 2015

ONLINE, ON COURSE

November 29, 2015

I received the following letters the past few weeks.  They made my day.

Thank you so much, I was struggling and your answer made it simple and understandable. UR GR8.

You are Amazing!

You have helped me in the past and always have accurate answers, I am so grateful you took your time out to help me today, thank you, I appreciate it so much!

Thank you, from the bottom of my heart, you have written this in a way that I totally understand. I will differently (sic) praise you to all my friends and family. God Bless you,

What did I do to deserve these?

Reason for the first:

The area of a triangle is 30 sq in. The base of the triangle measures 2 in more than twice the height of the triangle. Find the measures of the base and height. 

The area of a triangle is (1/2)*base*height.  Remember that?  Therefore, the base*height must equal 60 for the area to be 30.  Let the height= x inches, then the base is 2x+2, two more than twice the height.  Then, 

x*(2x+2)=60, 2x^2+2x=60, and dividing by 2, x^2+x=30.  We can write that as x^2+x-30=0 and factor it as (x+6)(x-5)=0.  That is 0 if x=-6 (not possible for a length) or if x=5.  So, the base is 5 inches and the height is 2(5)+2, or 12 inches.

For the last comment,  I answered the following, taking about a minute in my head, writing it down as I thought.

Write the slope-intercept equation for the line that passes through (-12, 10) and is perpendicular to 4x + 6y = 3. 

One gets the slope first by rewriting the equation as 6y=-4x+3 and dividing by 6 to get y=-(2/3)x+1/2.  The slope is -2/3. The perpendicular line has a negative reciprocal slope.  Turn the fraction over (-3/2) and change the sign (3/2).  That is the slope of the perpendicular line.   Using the point slope formula where we know the slope and a point, x=-12, y=10, y-y1= (3/2) (x-x1).  That is y-10=(3/2)(x+12).  This becomes y-10=(3/2)x+18, and finally y=(3/2)x+28.  Also, y=mx+b, so 10=(3/2)((-12)+b.  That is 10=-18+b, so b=28.  Both methods work; the more ways one knows, the more ways to explain it to students.  One of the ways is likely to stick.

For the one who called me amazing?

Find the accumulated value on an investment of $15,000.00 for 9 years at an interest rate of 11% if the money is compounded 

a) Semi- annually b) Quarterly c) Monthly d) Continuously 

 Here, one uses the formula 

Principal=Starting Principal{1+ rate/compounding per year} raised to (the number of years*compounding per year). P=Po{1+r/t}^nt.  Semi-annual is P=Po{1+(0.11/2)}^18, because it compounds twice a year and there are nine years.  This is $39,322.  For continuously compounding, it is easier, P=Po*e^rt.  e^rt= e^(0.99), because 9*11%=0.99.  Po*e^0.99=$40,368.52.  Continuously compounding gives you more money, although the difference between it and monthly is only $200 less than continuously.  The last formula allows one to prove that the doubling time of money in years is 70 (or 72, which is easier to work with) divided by the interest rate in per cent.  I grew up in the age before calculators, and we had to do this by logs.  On a calculator, it takes about 15 seconds. Dividing 72 by 11 gives a doubling time of about 6 1/2 years, so $15,000 should double once and be well on its way to doing it again.  The answer makes sense.

This is an online math help site.  More than 2000 tutors take part, some of whom have solved one problem, one nearly 70,000.  I’ve solved 2000.  About one in four thanks me.  That’s nice.

Several tutors offer their services for pay, $1 per answer, $2-$5 to show the work.  I do it to relax.  Yes, relax.  This stuff is fun for me, and I have learned the easier the problem for me, the more grateful people tend to be.  I don’t need to hear anything, unless my answer is wrong or not understandable.  I’m there to help.  I don’t know names; I do know I have helped parents help their children.

I’ve learned much.  It has been a great review of my statistics, I now deal with ellipses better, and I understand geometric series better than I ever have before.

I usually want a challenge, so I choose what I want to solve.  I have a big advantage:  I grew up in the era of no Internet, Chemical Rubber Company tables of integrals, no calculators, only log tables to do complex calculations.  In other words, I learned math from first principles, from the ground up.  Yes, it helps to have a genetic ability to do this stuff.  I can’t play the violin, but I can find the vertex of a parabola mentally and write it in three different forms.  Kids need someone to help them understand how to do it, not in their head, but to allow them to understand these and similar problems.

The current list has perhaps 50 problems, and I often work down it until I find a problem I feel like doing.  If interested, I go to the list of unsolved problems.  Last I checked, statistics had about 40,000.  A lot of those are tough, and if I don’t have pen or paper around, I don’t do them.

When I tutor at the community college, I answer algebra questions online while waiting for non-virtual students to ask for help.  I guess I am volunteering, but I am having a lot of fun.  It’s nice to lay out quickly an answer in simple form for a person who is struggling.

The other day at the CC, I was asked to go into the higher level math room to help out.  That was a compliment, because I was felt to be good enough to help out there. I’m the go-to guy for statistics.  The other tutors are really smart, yet all of us at one time or another have trouble with something.  I may struggle at the high levels, but I often find myself pulling stuff out of the air from the past and making sense out of it.  Or better yet, I ask a student where he got a specific term in an equation.  The student looks puzzled then suddenly says, “Oh, wow, I didn’t see that before.  OK, I understand.  Thanks a lot.”  And he leaves.

I hadn’t a clue how to solve the problem, but I think I helped him.

Math is mentally taxing.  After doing about a dozen problems, I take a break.  It helps me later solve troublesome problems.  In the math lab, I have concentrated so deeply that one day when I walked out of the room, I forgot whether it was Tuesday or Friday.

I think the absent-minded professor was probably working overtime on a difficult problem.

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WELL, I’M NOT REALLY SURE….

November 24, 2015

The young man came back to the large math lab help room where I had been working the past three hours.  Some time earlier, I had helped him.

“I took a practice test,” he said, showing me a paper, “and I think I probably would have failed.”

I looked at the questions and his answers, and well, I’m not really sure he would have failed, but I don’t grade at Lane, I just am a volunteer there to help students.

The young man was learning decimals and percentages.  He had almost mastered cross-multiplication, except he needed to slow down, so he wouldn’t make simple mistakes, which he immediately understood when I pointed them out. Percentages were different matter.  Part of the difficulty he had was that to him one hundred per cent was a ceiling.  He had difficulty conceiving of “138% of 87,”  a typical problem.  Mathematically, there is no upper or lower bound on what a per cent can take, but he was absolutely correct when he didn’t understand the statement “he gives 110% effort,” which I can’t either, because such is impossible unless there is some form of comparison, like to a previous year.  Trying your hardest is 100%.  Period.  I am really sure about that.

Indeed, he told me he had never understood percentages in high school and had spent the past five years not understanding the difference between 3% and 33%, so natural to me that I don’t even think about it.  Had he not come to the community college, he could have spent his whole life not knowing the difference.  It’s difficult to plan retirement when one doesn’t know rate of return.  Indeed, it’s difficult to live without knowing how to work with percentages.

I’m not really sure many know when or how to use percentages. People confuse a 25% increase in the possibility of getting an uncommon disease as a 25% probability of getting the disease itself, whereas the truth is far less.  We read about the percentage of growth’s declining and think the actual amount is declining, when it is not. I’d personally like an end to the term “three hundred per cent decline in xxxx,” because per cent decline is decrease over the original amount, and one cannot decrease sales, to give one example, three times the original amount, without a major giveaway.

Yes, the high school my student  attended should have taught him percentages better. But I was dealing with reality:  he was no longer in high school, and the community college—and I— was doing the teaching.  If the young man sticks it out long enough he will learn how to work with percentages.  That is assuming the community college sticks around long enough to be able to help people like him. A lot of CCs are under fire to cut programs because there isn’t money to fund them.  Mind you, we continue to fight in both Afghanistan and Iraq, because …. well, I am not really sure….  We eventually disengaged from Vietnam, a horrid mess, but we had to do it at some point.  I’m really not sure after somewhere between $2 and $6 trillion spent what we are getting for our money in southwest Asia.  Yes, trillion.  I wonder how many people can put in the correct number of zeroes.  Or can relate it to something physical, like the number of days the Earth has existed or the number of seconds in 31,700 years.

You see, when a person understands math and numbers, he can make more sense out of the world.  Note the he:  it is too often boys and men who have trouble, and that disturbs me greatly. I’m not disparaging other subjects, but math is so fundamental that a person without a good math background is forever handicapped in this society.  I could continue with my complaints about high schools, but it may be summarized by saying we as a country are slowly dismantling public education, one of our great gifts to the world.  We are leaving a lot of students uneducated, because … well, I am not really sure….  The pendulum swung towards standardized tests, because we were graduating students who couldn’t do basic math, write a coherent sentence, or know history.  Now, the pendulum is swinging in the other direction, because there were unpopular consequences—students didn’t graduate if they didn’t pass tests—so now we are backtracking from testing without well, I’m not really sure what….At some point, we have to determine competence.  I could come up with a 25 question test in a variety of subjects that I think every student ought to know in order to graduate.  I know educators could do better.

Back to money: for a lot less, say fifty million dollars, many community colleges in a region could have their budgets balanced with enough teachers and technology to teach things like percentages … or calculus, to their students.  It’s really cool to see a young person at a community college know calculus cold.  For one of those trillion dollars I discussed, we could remove all student loan debt nationally, which is holding young adults back from funding their retirement, which is critical, should Mr. Rubio become President Rubio and dismantles Social Security and Medicare for those under 45.  Will Rubio become president?  Well, I’m not really sure….

Until high schools are able to graduate those who should graduate and hold back those who clearly shouldn’t, the community colleges will have to pick up the slack.  It shouldn’t be the job of the CC, but somebody has to do it, and we need a lot of free help or money from those who can afford to give either—or both.  The tutoring I do at the CC helps the school helps keep open a pair of rooms to help students in lower or upper math courses.  I’ve worked in both, and it’s busy.  Tonight, I stayed an hour later in the upper level room.  My presence allowed the students to get help with less waiting time.  I was doing heavy duty calculus and pre-cal non-stop,  digging long forgotten math out of ….well, I’m not really sure where.  I found the derivative of arc cosine, and while I may have learned it once, it was a half century ago.  I was graphing fourth power functions, re-learning inflection points, and learning when L’Hopital’s Rule didn’t work.  It’s good for me, I think. But I’m really not sure….

Enough about me.  We need to pay teachers more and lower costs to attend community colleges.  I can’t think of too many better investments.  These students are training, not to become math professors, but as skilled workers in a very different economy from the one I grew up in.  I want them to have a solid educational background in order to live a fulfilling life.

Maybe they will get what they need, but I’m not really sure….

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WE THE GOVERNMENT

November 15, 2015

There is a mouse problem at the barn where my wife spends a week or two every month with her horses.  Much as she loves animals, she does not want mice eating the feed, and there are too few cats there for too many mice.

When she went to the local feed store, looking for a certain poison, the clerk told her it was no longer present.  “The government won’t let you have it any more,” the man said,

“We are the government,” my wife replied.

The reason for not selling the poison is that we discovered that mice killed by it became food for raptors, which died after eating the carrion.  We banned DDT in 1972, because it concentrated in the fat of eagles, made their eggshells thinner, breaking before hatching.  After we stopped using DDT, the population recovered.  You didn’t think manufacturers of DDT were going to voluntarily stop selling it, did you?  That’s Ayn Rand’s world, not mine.  We took lead out of paint in 1978 because it is a neurotoxin, especially in children.  We used to have leaded gasoline.  Cars back then ran better with tetraethyl lead, but they run better now with unleaded gas.  California banned lead in gasoline in 1992, the rest of the country in 1996.  The percent of children with high lead levels has decreased from 7.6% to 0.5% since 1997.  That’s not due to the oil or auto industry demanding the removal of lead from gasoline. That is we the government, we the people, telling them to do so, improving public health.

Oh, Robert Kehoe, medical head of the Ethyl Corporation, helped keep lead in gasoline for 40 years.  In 1943, when research showed that children with elevated blood lead levels had behavioral disorders, the powerful corporation threatened to sue and the research stopped.  Kehoe argued lead occurs naturally, the body could deal with it, and thresholds for lead toxicity were far above what body levels were. That sounds a lot like arguments I hear against global warming.  In fact, Kehoe’s upper limits for lead toxicity were 80 micrograms/100ml, when current upper limits survived Reagan’s anti-regulation policy and are 10 micrograms/100ml.   We have smarter kids and maybe less crime, since there is a remarkable correlation between per cent with high lead levels and crime rates.

In 1937, S.E. Massengill Company marketed Elixir Sulfanilamide without alcohol.  Their chemist dissolved the product in diethylene glycol (DEG) (similar to antifreeze) and added raspberry flavoring.  DEG causes kidney failure, but in 1937, few, including the chemist, knew that. One hundred seven died, many of them children, and the outcry caused Congress to pass the Food, Drug, and Cosmetic Act, which required companies to perform animal safety tests on proposed new drugs and submit the data to the FDA before being allowed to market the products.  Massengill said, “We have been supplying a legitimate professional demand and not once could have foreseen the unlooked-for results. I do not feel that there was any responsibility on our part.” The chemist felt differently.  He committed suicide before trial.

A young researcher, Frances Kelsey, was involved in the DEG studies.  Dr. Kelsey later stopped the use of thalidomide in the US, saving untold numbers of American children from being born with phocomelia, or no limbs.  Government meddling again. Just let the pharmaceutical company put whatever they want on the market.  People will make the right choice.  Right, Ayn?

What would happen, pray tell, if we trashed all the “onerous regulations” that we have in place, removing second hand smoke, stop marketing cigarettes to children, mandating child seats, seat belts and air bags, vaccinations, dangerous toys.   Do people really want to do away with government regulation?  Do we want people to die from something preventable?

In 1979, failure of companies to have an adequate amount of chloride in new soy-based infant formulae led to 130 infants developing chloride deficiency.  The new product was faulty, despite company claims. How many have to die, be made ill, miserable, hospitalized at great cost, before we get things right?

In 1989, the number of new foods introduced annually was so large that there was concern people had no way to decide the safety, cost, and nutritional value of what they bought.  One may say, “the market” will decide, but “the market” requires people to decide based upon facts, not ads, and honest numbers, rather than slick commercials.  The change did not come from “voluntary action,” for it never does.  In 1990, after the Nutritional Labeling and Education Act, we started seeing all those numbers on food we buy at the store, and now even at places like Starbucks, where the other day, I had a cup of coffee in one of those red “Satan sippers.”

I wanted something nice with my coffee, but everything that looked good under the glass had 300+ calories, and even if I jogged home, I might burn a third of that.  I ended up buying Vanilla Bean Scones, 300 calories for 3 of them, figuring 100 calories a day extra for 3 days I could handle.  Everything under the glass looked great, for 400-600 calories.

What else did the Nutritional Labeling Act do for me?  Ten years ago, when I suddenly found my profile not to my liking, I stopped peanut butter, which I love, and olive oil, diminishing my intake 600 calories a day.  I read the labels. The change was slow, but over six months, I lost nearly 4 kg or 9 pounds.  On a trip to Oregon, preparing for the move, I ate at a coffee shop every morning, enjoying a Marionberry muffin, which must have been 500 calories extra.  A little of this, a little of that, and the weight came back.

For the past year, nothing changed, despite a lot of hiking and running, remaining 5 pounds heavier than I wanted.  Obviously, I was eating as many calories as I was burning.  That’s thermodynamics.  I then took a hard look at my grocery shopping.  It turned out to be an easy look:  I found two items of note: yogurt I bought was 60 calories more than a comparable amount, which tasted the same.  That isn’t much, but the fancy vegetarian hot dogs I had two days a week were another story.

I was stunned.  Each was 280 calories a pop, 1120 total when I had them for dinner twice a week. By going back to the traditional type, I saved 720 calories alone every week.  Added to the yogurt I was eating, I could eat essentially the same for 1140 fewer calories a week.  Within six weeks, I had lost 1.5 kg, more than 3 pounds.  I couldn’t have done it without the Nutritional Labeling Act.

For every “onerous” regulation, there were a large group of people who once said, “somebody ought to pass a law”.  That’s what politics should be, doing good for people.  I’m not out to trash capitalism, but I’m damned if companies should get away with….murder.  Their fiduciary responsibility is to their stockholders.  We the government have a fiduciary responsibility to we the people, not we the stockholders.

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A TENNER AND A RED CUP

November 10, 2015

After finishing graduate school, I returned home to become a medical statistician.  At 51, I knew people in the community, I was a statistician, I knew medicine, medical administration, was trained in quality improvement, and a decent writer.  I had it all.

Except for the course on marketing.  I bombed, completely failed, one of the biggest failures of my life. I was bitter for at least 5 years, maybe longer, until time and dealing with the deaths of my parents both shoved me into another direction.  I often blamed my failure on the fact that I had pissed off the medical community.  War on Mike, I could have called it, sort of like the War on Christmas.

Except for a few vocal detractors, perhaps four, the medical community could have cared less about me.  They were too busy getting on with the stresses of their own practices, families, and other matters, not trying to think how they could screw me over.

Sometimes, I wonder if I will ever become an adult.

After being executor of my father’s estate, I moved on. I’ve been fortunate.  Nah, I won’t be famous, but I am content in my own skin.  I have discovered that there are some good things about growing old and there are things that just plain suck.  In short, I am alive, and a lot better off than most.

That brings me to Starbucks, which has a plain red cup for Christmas, and now accused by many so-called Christians as “hating Jesus,” being anti-Christian, and has Donald Trump calling for a national boycott.  I think the country has more important matters to address then the color, which I like, on a Starbucks cup.  To those who now hate Starbucks, I say, “get a life.”  Re-read the second, third, and fourth paragraphs above, especially the fourth.

My solar eclipse video in 2010 got 1000 views, yet the Starbucks customer who said that the company hated Jesus has a video with over three million views.  Sort of says something about Americans.  You know what?  I’d rather be a quiet guy who taught people about solar eclipses, volunteered teaching math, taught English online to people in 90 countries, donated to animal welfare in two countries and four cities, and on my own dime led hikes in the Cascades than a guy who had three million people listen to his stupid rant.  For the record, I decided not to add to his count.  If he looks at my video, I’ll look at his.

The holidays are a time I now look forward to.  Formerly, when in practice, they were a time I dreaded:  most of my partners took time off, patients who went to the hospital usually had a horrible reason, services at the hospital were often slow, because people were “away for the holidays,” and I usually came down sick with something.  Additionally, I had to do Christmas shopping, because my late mother made a big deal about Christmas. Oh yes, night call was really depressing when somebody with a Grade V subarachnoid hemorrhage or irreversible anoxic encephalopathy had to have the plug pulled on Christmas Eve.  I disliked the season.

These days, my wife and I go to the mall on at least one December Monday (more if we can) and watch people in line with their pet animals wait to get a picture with Santa.  What a hoot.  A woman last year had a Siamese cat perched on her shoulder for at least 45 minutes while she stood in line.  She had another half hour to go.The best we could do with any of our cats is about 4.5 seconds with the silver one, and maybe 4.5 milliseconds with the semi-feral 5 year-old.  I’m not exaggerating.

Yes, that is a Siamese on her shoulder. Valley River Mall, 2014

Yes, that is a Siamese on her shoulder. Valley River Mall, 2014

Christmas Eve Day, we go shopping for things we want, have lunch somewhere, and return home early.  After dinner, we walk the neighborhood looking at lights, then turn on the 24 hours of “A Christmas Story,” which we love.  Hell, two of our cats are named Red Ryder and Black Bart.  We use quotations from that movie often:  “The line ends here.  It begins back there.”  “Soooooaaap poisoning.”  Christmas Day is vegetarian; we do just fine with fake turkey and all the trimmings.  I put on some Christmas music, pick up the tree that the cats have knocked over and enjoy the day.

Who is declaring war on Christmas?  Well, the nightly progress reports about how well merchants are doing this year compared to last is a little counter to the message Jesus preached, if I understand the Bible.  I don’t think Jesus would like our constant war since 2003 and our troops overseas since 1945.  I think Jesus might have preached something about gun violence, but I’m not religious, so I may be wrong.

It is a goddam red coffee cup for Chrissakes!  It’s not Satan jumping over the counter.  Get over it!  Bring in your own decorative cup or mug and save the planet.  Starbucks lost $3.2 million last April when their computers crashed, so they gave customers free coffee.  It was April, not December, but isn’t there something  about keeping Christmas in your heart the whole year?  Saturday,  Safeway had $1, $5, and $10 coupons to donate food to the needy. On impulse, I threw in a five spot.  My heavens, the clerk started ringing the bell as if I were a breast cancer survivor in October at Starbucks in the MSP airport.  Yes.  That Starbucks.  Where the manager comes out and hugs a survivor.  I don’t cry easily, but that sort of stuff brings tears to my eyes.  Yes, that Starbucks.  The one that wants to increase hiring of veterans to 10,000 and provide free tuition to get a bachelor’s degree at Arizona State University.  And a red coffee cup is all the talk is about, rather than helping veterans to attend college?  I’m a veteran, and helping vets trumps any complaint about coffee cups, which I happen to like.

Anyway, the cashier asked if I wanted my name on the coupon.  Embarrassed, I declined.  She thanked me three times.  It was just $5.  But no, that’s not the point.  I was making this cashier and some unknown recipient happy.  That’s what Christmas is about, not politicizing the event to make it sound like we are trying to defeat the 70% of Americans who call themselves Christians.  Can’t we just have Christmas, Chanukah, Kwanzaa, and any other holiday this melting pot of people celebrate, without claiming there is some sort of war?  Can’t we do good things for others? Are these people Dementors or Ebenezers?

The very next day, I went right into Starbucks that’s part of Target, although I personally prefer Dutch Brothers, and by God, I got me one o’them red cups for my decaf.  Yeah, I have to drink decaf. It’s better for my heart, especially when I am dealing with damned idiots who think we’re having a War on Christmas. It’s repetition, and repetition doesn’t make it right.  It’s wrong, and I am by nature argumentative against wrongs.

Take it from me, you poor Christians who feel persecuted.  I thought the medical community was persecuting me, and I just didn’t do a good job marketing myself.  It took me a while, but I got over it.  Start marketing yourself.  Begin with following Jesus’s teachings.  Ya know?  Love, caring for the poor, he who is without sin….

Be big boys and girls.  This War on Christmas is bogus.  Get over it, you hear?  Go to Safeway, stick a tenner coupon in with your groceries, which I will do the next time I’m in, and you will be doing the Lord’s work.   The next time I might even put five of them in.  It will make the clerk’s day.  Then, this non-believer, who likes pagan holidays like Christmas, will say to her:  “Merry Christmas.”

And walk out of the store with a big smile on his face.  Won that war.

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DEAD END

November 8, 2015

When I moved to Oregon, I volunteered for organizations I didn’t even know existed, and I didn’t volunteer, but thought I would, for others. Such is life, and I predicted this experience before the move. When I learned there was a state-wide reporting system for medical errors, I wrote them, eventually being invited to their offices to meet with the staff. I was optimistic.

But not surprisingly, nothing came of it. I knew that when I walked out the door after that meeting. I read body language well. I saw the expression, “I’m really busy and need to get back to work rather than talk to this guy.” What I brought, they didn’t need, and that is OK, just unfortunate for me. I later wrote an opinion piece about the need for pharmacies in the state to do more analysis of the errors they made, so that we could improve state-wide systems. Seven hundred pharmacies in the state generated only 20 reports last year. That’s disappointing, but again not surprising, either. Nothing came of my article, but I didn’t expect anything. I’ve gone down a lot of dead-end roads. I turn around and try others. Occasionally, I find a path that leads to interesting places. I don’t find one often, but if I don’t try, I won’t find it at all.

After a few problems obtaining my medication, which I recently wrote about, I sent a letter about my experiences to the head of the Patient Safety Commission. I didn’t know what would happen, but again, if I didn’t write, nothing would happen. I received a reply, saying my letter was forwarded to the staff as a reason why the Commission exists. I found that Interesting. A few days later, a staff member wrote me saying she knew a man who taught pharmacy students, and he might be interested in talking to me. This road was going a little further than I thought. After exchanging a few emails, the pharmacist called me and we spoke about medical errors, pharmaceuticals, and other issues.

It wasn’t a fit, and before I heard the words, I knew this wasn’t going to work out. I can read body language over the phone well, too. He wanted somebody “downstream,” a patient who could come to his class and explain how a medication error affected them. That’s asking for a lot, and I think is unrealistic. I sure couldn’t provide it. I saw the Dead End sign, but we had an interesting talk. I think his class would benefit from one who had seen a lot of errors in other fields, studied them, and could advise his students about system design and learning from errors. Somebody like me.

For a couple of hours after the call, I had the usual down in the dumps feeling, which happens when I encounter a dead end sign. Maybe something will happen. He might talk to other people who are interested in what I have to say. But I strongly doubt it. It almost never happens. Networking to me has led only to my giving free advice, almost never receiving anything in return. Still, I keep trying, although I am running out of time.

I might have told the students about the error in a Bend hospital, where a lady after recent brain surgery came to the hospital and had fosphenytoin, an anti-convulsant, ordered. For some reason, she was given an IV bag containing rocuronium, a paralytic, but labelled as fosphenytoin. She might have survived had there not been a Code Red, for fire, and was left unattended for 20 minutes. She died a few days later from anoxic encephalopathy. It’s like a plane that has a landing gear problem that consumes the pilot’s attention so much that the plane runs out of fuel and crashes. That happened in Portland in 1978, killing 10. It spawned CRM, Crew Resource Management, which essentially considers everybody in the cockpit an equal resource in an emergency. The concept worked a decade later on a United jet and to perfection in 2010 when a Qantas A-380’s port engine exploded and the plane had to be nursed back to Singapore. The video is worth seeing, as an example of how teamwork in the cockpit saved the plane and all aboard. The investigation is worth reading, as well, as to how a seemingly minor quality assurance problem at Rolls-Royce had catastrophic results. Oh, it wasn’t a miracle that everybody survived. A miracle would be not to have had a problem ever occur with anything we make. Everybody survived because of redundancies built into the aircraft and skill of the crew. Medicine needs that kind of dedication to safety, where pharmacists are important resources who can find errors in drug choice, dosage, or interactions.

Instead, I read online that there now needs to be a safety zone where those mixing drugs will not be interrupted. I’ve been harping on that for 15 years. Sterile cockpit means that nobody talks about anything but the aircraft when the altitude is below 10,000 feet. In 2013, exactly four cases of incorrect medication being given were reported state-wide. Whatever the number, we aren’t learning from them. I later read that up to 440,000 deaths in the US occur from medical errors annually, and I don’t believe that number, either, because if we can’t even track something simple like the wrong medication’s being given, we can’t possibly know the number of medical errors. I offered a solution a decade ago, one that uses random sampling of hospitals, but I hit a Dead End sign.

I could have spoken to the students about our needing to count the number of prescriptions filled improperly, the number of prescribing errors made, and the number investigated, not to shame anybody, but to understand how many errors and what kinds of errors are made, so we could refine systems and know whether or not we had refined them successfully.

I think with examples compared to aviation, which I find compelling, we could start educating students the need to have a safe, effective, voluntary way to report safety issues. Maybe that generation would stand on my shoulders and see further than I.

No, I have spoken out on the topic enough, maybe too much. I’m out of date, but there are things still happening that shouldn’t be. A patient was recently awarded over $12 million from being given the wrong dosage of Amiodarone during a procedure. He is now brain-damaged for life. This was a preventable error. For him, normal life hit Dead End.

That’s far worse than the Dead Ends I’ve had.

Cummins Creek Trail, Oregon Coast

Cummins Creek Trail, Oregon Coast, 2014

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