Archive for the ‘GENERAL STUFF’ Category

I REALLY SHOULD HAVE STAYED HOME

December 8, 2017

I really should have stayed home that Tuesday evening and not gone to the German Stammtisch at Track Town Pizza.  I go there most Tuesdays to practice my German, to listen, speak, and to talk to people there.  It’s good to get out.  I only stay an hour, because the place has low ceilings, serves alcohol, and gets noisy fast, so that I have difficulty enough understanding English, let alone German.

Last Tuesday, I got into a political argument, first one in a long time.  It was my own fault.  Oh, I can blame the other individual, but I shouldn’t have taken the bait.  Unfortunately, however, a lot of things that have stewed inside me for some time came to the surface.

Normally, I try to steer clear of these arguments, with the exception of climate change, where I immediately put out my four rules: no pejorative attacks, required p-value, confidence intervals or margin of error, what happens if one side is wrong, and verifiable predictions locally, nationally, and globally.  That has always ended the discussion.  I need that approach for politics, although I admit difficulty these days in avoiding pejorative attacks, since my default mode when I get angry is a severe case of sarcasm.  It’s one of my huge flaws.

Anyway, the initial trigger was discussion about an upcoming lecture being given by a German official about immigration.  The individual with whom I was talking—an immigrant himself, I think—was saying how the speaker from Germany was lying.  I had no facts, so I let it go. I’m a grandson of an Irish immigrant, and I believe are that if more countries were problem solvers, rather than problem causers, there would be fewer immigrants. But the fundamental cause of immigration woes is overpopulation,  and unless we control population, immigration, with its attendant problems, will increase.  There are two major realities: one, we can’t grow indefinitely and two, we must control our numbers.  Unfortunately, population control is not on the agenda of The Other Side—or for much of my side, either for that matter.  A lady recently profiled in Sierra, the Sierra Club magazine, had three children.  I almost wrote a letter about it then thought better.

We then got into a discussion of weapons, after the individual mentioned a recently deceased friend of his who had several machine guns and a half million rounds of ammunition in his home.  I was shaming myself silently for being secretly glad his friend—63, massively overweight—died suddenly at home. Half a million rounds of ammo and at least one machine gun.  Wow.  Another listening to our conversation asked why the dead man—or anybody else—needed a machine gun.  We got the usual Second Amendment response, and that is where I started getting angry.  I wasn’t going to argue the wording, but I wagged my finger at him—something I inherited from my father—and said “I hope some day you feel the same kind of pain those who have lost people to gun violence feel.”

I’m not a Christian, and while I don’t have to be a jerk, I don’t have to be nice, either.

I’m not honestly sure what else was discussed, but the individual blamed Obama for the drug trade in this country. I was a bit stunned, saying that we have had a war on drugs that began when Mr. Obama was a child, and that he hardly was the person responsible.  I mentioned the Bush years, which seem to have vanished into the murky morass of 21st century history so far, the two wars and one recession have been blamed mostly on his successor, but while the man said he didn’t like Bush, he had absolutely no use for the Democrats.  Social programs, he said.  That was the reason.  So I asked him what sorts of social programs were a problem.  Unlike Mr. Obama, who is a centrist, or Ms. Clinton, who is center-right, I’m a liberal, but I can find wrong with some social programs.  I couldn’t get an answer, and as angrier I became, the quieter my voice was. I kept asking which social programs he was against.  I could have said that Social Security should have means testing.  I certainly would limit the tax deduction for children, in a somewhat feeble attempt to try to decrease population, and limit the mortgage deduction to $500,000.  This man couldn’t come up with anything, despite my quietly asking him “Which social programs?” five times.  All he could come up with was disability: “I see people getting disability who are better off than I am.”  OK.  That’s an issue, but it is hardly budget busting, and are we going to end disability payments because some cheat? The answer to some is yes. The Other Side wants to restrict voting because some cheat, which I believe was fewer than 10 in the last election, the first one’s documented being a Republican.  I am ignoring the almost certainty of one party’s involving the Russians and the definitive asking by the nominee for the Russians to publish every email they had.  That’s illegal and treason.

I didn’t mention my relief that a person with a half million rounds of ammunition was dead. When the individual stated with some outrage that the ATF (Alcohol, Tobacco, and Firearms) was in the house and planned to destroy the weapons, not give them to the dead man’s heirs, I didn’t know the law, so I kept quiet.  Destroying them sounded like a good idea, like beating swords into plowshares, but I’m no expert on Isaiah.

I remember that during a break in the arguing, the other man said that he wished the conversation hadn’t gone on because “I don’t want you to think badly of me.”

“I already do,” I replied.  And I suddenly got up and left, walking out, not turning back to look.  I cared not a whit for what he thought about me.

Several days later, it’s difficult for me to remember what it really was that pissed me off so much, and I’m ashamed I spent so much anger accomplishing almost nothing.

I should have quietly exited the conversation, rather than getting into a pissing contest with a skunk.  It’s difficult these days to read the news, see the direction of the country, and not be worried, lose sleep at night (unless this is age), and feel powerless to do much about it.  I’m frankly weary of dozens of emails clamoring for money for some candidate, promises to impeach (which doesn’t solve the problem; conviction is then necessary, and I also know who the second, third, and fourth in line people are), and the continuous surprise that things turned out the way they did. I find it stressful that I wish for bad things to happen climatically so I can say “I told you so,” and I hope those who voted for this government get hurt.  That’s petty, considering these people won’t vote Democratic even if their candidate is a pedophile or groped women.  We already know that.

I walked outside into the pouring rain.  Wonderful. I love the rain.

NIGHTSTANDS AND CLOSETS

April 3, 2015

About four years ago, I came within six inches of never being able to hike again.  I was at a holiday party given by an acquaintance who was a retired field grade officer in the Air Force.  We had a mutual interest in astronomy—he became an amateur-professional whereas I remained an amateur.  Indeed, he once told me that my eclipse chasing wasn’t really astronomy, so I stopped mentioning it to him.  Then again, back in late 1991, he said the annular eclipse of 4 January 1992, visible from San Diego, was “no big deal.”

Annular solar eclipse 4 January 1992.  It ended before it reached the coast, but from a 300 m high hill, we could see well out into the ocean.  Two hours later, it was pouring rain.

Annular solar eclipse 4 January 1992. It ended before it reached the coast, but from a 300 m high hill, we could see well out into the ocean. Two hours later, it was pouring rain.

Seeing the “ring of fire,” the Moon inside the Sun, set into the ocean, ranks as one of the best natural views I’ve ever seen.  He missed it.  My acquaintance had made some public statements that offended the fringe who believed in odd celestial occurrences.  For that, he told me at the party that he had received death threats.

“Want to see my weapon collection?” he asked.

I didn’t want to, since weapons bother me.  When my father died, we found a handgun in his nightstand and couldn’t get rid of it fast enough.  Fortunately, we knew a deputy sheriff.  My host showed me a laser guided gun on his nightstand, ready to fire in case anybody broke in and tried to kill him.  Wow.  I looked at the gun and saw instant death, oblivion, cessation of existence. Then he showed me his closet with as many weapons as clothes, several different kinds of firearms, any of which probably could have taken out the neighborhood, had he been crazy.  At that point, a samurai sword, unsheathed, dropped from a hanger on to the floor.

Six inches from my left foot.

This is a smart person, but where were the safety checks?  No, this wasn’t a gun, “only” a sword, that could also kill, and a lot faster, had it been grabbed, than a nearby firearm. Had it been a loaded gun and discharged, I could have died instantly.  I never went to another party there again.  It just freaked me out.

Gabby Giffords, who four years ago was shot in the left parietal lobe by a crazy gunman, 4 miles from where I lived, at a store where I almost went that day, was recently at the Capitol to support a bill expanding background checks before firearms are bought.  Such checks are espoused by an overwhelming majority of men, women, Republicans, Democrats, and firearm owners themselves.

The NRA wasted no time tweeting how Giffords’ own shooter passed a background check, omitting the fact that the individual complained about the difficulty he had.  The NRA proffered other examples where background checks were done and firearms were later used in homicides.  That’s like saying somebody in an accident wearing a seat belt died, so we shouldn’t wear seat belts.

We have gun shows where people purchase firearms with no background checks at all.  Video recordings are amazing.  They show things occurring that people still deny, be it buying a gun at a gun show and leaving, without any checks, to denying that one ever said Iraq clearly had weapons of mass destruction.

Will background checks prevent all murders?  Of course not.  Will they make them fewer?  I believe they will, a verifiable prediction.  If I am correct, would not the prevention of one murder be a good thing?  Exactly how are people’s rights to own a firearm infringed?  We don’t have unbridled freedom of speech; why should we have unbridled right to bear arms?

I made the mistake of reading some of the comments at the end of the article.  One guy basically swore at Ms. Giffords; another, while extolling her courage, wanted to make sure his right to protect his family was not infringed.

Does this man think his family is under siege by robbers just waiting to kill him?  Does he not know that the presence of a firearm in a house nearly doubles the likelihood of a mortality there?  It increases the likelihood of a suicide of a man living there thirty-fold.  Could a gun protect him?  Sure.  But a bigger problem is the number of deaths in this country from domestic violence.  Three women a day die here on average from domestic violence. Want to end it?  Make it a lot more difficult for stalkers and people within 2 years of a divorce to own firearms. Why two years?  Not sure, frankly.  It seems like two years is enough time to get over the fact that a relationship is over.  If I am wrong, that could be changed.

Exactly how many people need firearms to protect their families?  Truthfully, I DON’T KNOW.  One of the reasons I don’t is that we don’t have research on this and other issues dealing with gun violence, because the National Rifle (read: Gun) Association has prevailed upon Congress not to allow this to be done by the CDC.  If gun violence isn’t a disease that needs to be controlled, then I’m missing something.  Over ten thousand people a year in this country die from it, triple that if you count suicides; seven times that number are injured.  Had Ebola killed this many, we would have shut the country down.

I’m worried, too, not of being gunned down, but that my car will be vandalized if I put a sticker on it saying “Americans for Responsible Solutions.”  Sam Brownback has signed into law that allows Kansans to carry concealed firearms without a permit and without requiring a gun safety course.  There is a sense that Kansans will do the right thing, and they don’t need the government to tell them how much training or responsibility they need.  There won’t be a blood bath in the streets, they say, this isn’t the Wild West.  Perhaps they are right.  What if they aren’t?  Where is the evidence?  Who is counting?

Each day I read of people gunned down, of children taking guns, pulling the trigger, killing their mother, sibling, friend, or themselves.  I’m not scared I will encounter a situation like that; although it is certainly possible, it is improbable. As one who thinks firearms need to be better controlled, I am unpopular, at least among a vocal, scared, hateful group, not a majority, who nevertheless control the agenda for firearms.

Guns are too slow and too quick.  If you are a teacher with one in your desk drawer, and a mass shooting breaks out, you may well be gunned down before you get it.  If you have one available, and you shoot at what appears to be an attacker, but who isn’t, which almost happened that day in Tucson, then it’s too quick, too final.

After 9/11, we talked about arming pilots.  How does that sound now?

PASSING IN A SCHOOL ZONE

March 10, 2015

The sign said “20 mph between 7 and 5 on school days.”  Oregon has two types of 20 mph school zones: that and “20 mph when children are present.”  I was doing 20, when a guy behind me pulled into the center turn lane, accelerated, passed, pulled in, driving far more than the 35 mph speed limit after the zone.

I caught him at the next light.  So, to save a few seconds, the guy broke a few laws, wasted gas and brakes.  For nothing.

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“Why didn’t you call a neurosurgeon?” The plaintiff’s lawyer asked me in a deposition, back in 1978.

“I and my attending did, Sir,” I replied.

“Why didn’t you hurry and do it sooner?  The patient might not have been paralyzed.”

“He already was when I first saw him, Sir.”

The patient, with ankylosing spondylitis (AK), a bad disease that fuses bones of the spine, had fallen and had cracked his spine.  Unfortunately, an orthopedist tried to move the neck, producing spinal cord injury and partial paralysis.  I resented being blamed for the catastrophic outcome, and it would be the first of a long number of bad encounters I had with the legal profession.

Technology now allows non-radiologists to view many images before the radiologist.  This increase in speed of transmitting information occasionally comes with a cost.  Recently, an individual with AK and a neck injury was felt to have a normal C-spine X-Ray, according to a physician’s reading in a trauma center. The reading was wrong but fortunately did not cause a similar catastrophe.  Radiologists should read these images before anybody moves the spine of a patient with AK.  I’d make it mandatory.  It doesn’t guarantee a good outcome, but it improves the probability of such.

*************************************

A Chance Fracture has nothing to do with luck.  Or maybe it does.  Formerly called seatbelt fractures, before shoulder harnesses, they occur with violent forward flexion of the thoracolumbar spine.  The anterior or front part of the vertebra flexes and compresses, the posterior elements fracture.  It is highly unstable, and the proximity of the fracture to the nerves in the spinal canal means paraplegia may occur.

A patient was seen after an automobile accident, and a physician noted free air under the diaphragm on one image.  This means a perforated viscus, usually the bowel.  The patient was quickly taken to the operating room, for speed matters, and the “bowel was run,” meaning that all of it was checked.  The radiologist, in the meantime, looked at the images, noting no free air but saying there was an Chance fracture.

Oops.  In 100 yards, the speed limit will be 35. Did you have to pass?

The patient now has an abdominal scar, is at increased chance for adhesions and a bowel obstruction as a result, and was fortunate not to be paralyzed after having been moved.  Waiting a few minutes for the radiologist’s reading would have avoided an operation.  Free air requires immediate attention, but surgery may be delayed until the diagnosis is clear.

*****************************************

A third patient had a dislocation of the hip, a bad injury, and was taken to the OR before the radiologist reported a clot in the iliac vein.  Such clots are a risk for pulmonary emboli and complicate surgery, something the surgeon must know pre-operatively.  There was time to think; fifteen minutes wouldn’t adversely have affected the outcome.   Like the guy passing me, hurrying may save time, waste time, or cause a bad accident.

I don’t practice any more.  I wasn’t a trauma doctor, but as a neurologist I saw plenty of trauma long before we had Level 1 centers.  I am out of date.  But I know the ABCs, airway, breathing and circulation, which were and are essential to deal with immediate survival.  Here, seconds and minutes count.  Otherwise, I palpated the entire patient, looking for injuries that weren’t obvious, but might become significant problems.   It’s easy to see an obviously fractured femur and immediately want to fix it.  A wise radiologist said, “The first thing you must do in an emergency is take your own pulse.”  By that, he meant to stop and think for a few seconds.  If you don’t have a few seconds, it’s probably too late.

Time.  It is about time.  Knowing how much time one has matters.  Knowing how much time one has to think matters more.  Time.  Is it worth doing 45 in a 35 zone?

Technology has revolutionized medicine.  Improved communication would as well, if we actually did it.  If several people with significant injuries arrive at a trauma center, they must be triaged.  Some need help more quickly than others.  For some, it is sadly too late.  Many may require the same test; the order in which they get it must be established.  Communication means telling the radiologist the history of the patient, what the clinical concerns are.  It improves the reading of the image.

Ask a radiologist sometime how good clinical histories are.

Today, we do whole body scans.  These take time to perform, valuable time. Taking extra minutes to scan the entire body may delay doing an important test on a second patient. These scans deliver much ionizing radiation and are expensive.  Neither of the latter two is an immediate concern, but they are issues.  Radiologists read hundreds of images quickly, and that requires…..time.  Anything that limits the number of scans is good.  Clinical evaluation does just that.  Patients with free air under the diaphragm likely have a rigid abdomen.  Chance fractures produce severe back pain.  This information helps the radiologist immensely.

When I was responsible for caring for many sick patients, I triaged them, trying to make best use of time, an important commodity in my life.  I needed time to eat, sleep, think, see patients, and summarize my thoughts.  I had only so much of time, and only I could prioritize it….until the day came when I realized I could no longer fit what was expected into what time I had.  Hurry is both dangerous and stressful.  Kids suddenly jump out into the street.

Television makes it appear that speed saves save thousands of lives, that everything must be done in a hurry, and that death is prevented with seconds to spare.  That simply isn’t true.  Time is important, because waiting can be deadly.  But there must be time to think, to reason, and to plan approaches, too.  Or people will die.  We all make mistakes.  We can prevent many with better standardization, lessening fatigue, fewer interruptions, ordering only what needs to be ordered, giving information to radiologists, allowing them time to read images before people are rushed to surgery.

Once one is beyond the ABCs of resuscitation, there is time to think and plan care.  That time must be used.

The next light will likely be red, anyway.

MACK AND JACK

March 4, 2015

Former Arizona Sheriff Richard Mack is asking strangers online to pay medical bills he and his wife have incurred.  The Constitutional Sheriffs and Peace Officers Association, which Mack founded, is paying some of them.  Mack is LDS;  I was surprised that the Church wasn’t passing the hat.

I actually wish Mr. Mack good health, hoping he gets coverage under the Affordable Care Act, which he was ardently against.  I guess that makes me a liberal, whom Mr. Mack detests, because I think part of my job as a citizen is to help other citizens.  If my taxes support people on Medicare, for which Mr. Mack will be eligible in two years, assuming the program isn’t gutted by his fellow Libertarians and Republicans, then so be it.  Medicare is a good program.  It helps the elderly.  Some in Congress think that is a free ride.  Well, all Americans get a free ride, be they Ted Cruz, Mitch McConnell, or Mike Smith.  My college education was subsidized, I get more from SSI than I paid in, and I can access for free things the government requires be open source.  Oh, I had to give a couple of years of my life to the military, but that is national service and something people used to do.  Ted and Mitch did not serve. Besides, I got paid for it.  The idea that successful folks are self-made, without help, guys like Jack Welch for example, is pure baloney.  We all benefit from being Americans and from what our government does.  Research that improves medical care is tax supported, roads, infrastructure, the National Weather Service and Hurricane Center, the Coast Guard, plows during snowstorms, FEMA, all benefit us.

Passing the hat was once helpful when medicine couldn’t do much, or if somebody’s barn burned down.  It doesn’t cut it today, when a house is lost, a child has leukemia, or if you are 62, like Mr. Mack, and have had a heart attack.  After passing the hat a few times, there isn’t much money; people can’t chip in that every time there is another needy soul.  That is sort of why we have the Affordable Care Act, which covers people for whom the hat isn’t large enough to hold say $10,000, which isn’t much for a hospital stay.  Most of us don’t have that kind of money lying around.  Jack Welch does.  He got about $400 million when he retired from GE, after cutting 100K jobs and research.  He’s on his third wife, by the way, but at 79, his time has passed.  He won’t be around to see what his denial of climate change has done.

Back to Mack.  He supported Cliven Bundy, the rancher who refused to pay for grazing his cattle on public (that’s my and your) land at $1.35 per animal per month eating an average of 780 pounds of foliage, and got away with it, because to have thrown him off would have been akin to the attack at Waco in 1993.  Mack got the Supreme Court to weaken the Brady Gun Bill, and he ran for a Congressional seat, getting 11,000 votes in the primary.  That’s about 10,950 more votes than I would have gotten had I run in a primary in Arizona.  I got 50 votes in the last election I ran for, Secretary of the Arizona Medical Association, which I lost.  I wasn’t too popular in the medical community.  I told the truth.

I wish Mr. Mack good health, because ill health sucks.  I haven’t had a heart attack, but I have been very ill, and it isn’t fun.  Mack doesn’t deserve it.  Nobody does.  He deserves to have insurance, and when I supported the ACA, I hoped that all uninsured would be covered.  Many of those I may not have liked, but they deserved coverage.  Frankly, single payer, like Medicare, would have been simpler, but it was never put on the table, which to this liberal is unfathomable.

Some would say that wishing good health on somebody who supports views you detest is Christian.  Or LDS.  Well, I’m neither, and I can’t stand the latter, which has probably made a bigger mess of Arizona than other single group I can name, since their influence has packed the legislature and certainly helped Jeff Flake, a nondescript House member, win a Senate seat over Richard Carmona, a Vietnam Veteran and former Surgeon General.

My feeling about Mack is not dissimilar to that towards a woman who posted on Facebook “we ought to use the guns we have to shoot liberals.”  I pointed out that I was a liberal, a veteran, probably paid more taxes than she and her husband made, and volunteered in my community.  She apologized, one of the few I have ever received in my life, saying she and her husband had fallen on hard times when he lost his job and got sick.  The only thing they really wanted, aside from being out of debt, was to be able to hunt deer for meat they needed, without people’s deliberately scaring off the deer. I felt a little badly being right with my financial assessment. It was a cheap shot.

I’ve been a Life Member of the Sierra Club since 1983, but I wished her well, both with hunting and with her husband’s problems. I don’t believe in hunting, but hunting for food, when one needs to eat, and has no other choice, is not a sin.  They’ve been dealt bad cards, and while we can’t help everybody live great lives, we ought to help people get off the floor.  That’s what this liberal believes.

Many things I support help people, and my liking them is not a precondition.  It is not my place to judge whether only nice people get help; every citizen deserves to have affordable medical care and education.  They don’t deserve a free ride through life, but education is essential to our success as a country, and medical care costs are one of the biggest reasons people become bankrupt.

Don’t get me wrong.  I worked hard to get what I got.  In high school, I studied when other kids partied.  Did the same in college.  Worked damn hard in medical school and post-graduate, often being on call every other night. Served two years in the Navy on a ship, so I started my medical practice when I was 31, after many had been making good money for a decade.  I didn’t go abroad in high school or college.  Would have been drafted.  I’ve done a lot in my life, I worked hard to get it, but I got a huge amount of help along the way, without which I wouldn’t have gone anywhere.  I’m grateful.

It’s time to give back.  Way past time, so others may get the same shot at success I’ve had.  But I won’t donate to Mr. Mack.  He deserves medical insurance, and I’ll vote for that.

Maybe Jack Welch will help out.  Or his second wife.

She had a good pre-nup.  Does my heart good.

“IF I AM STILL AROUND”

March 2, 2015

I just know the man was younger than I.

And early last summer, he was healthy, or at least so he thought.

Today, I read his obituary in the paper.  He had been diagnosed with “brain cancer” (a glioblastoma, likely) six months earlier.

It gave me a moderate jolt.  These sorts of things do.

There is death, and there is death.  For those who are demented, death is a release for them and their families.  It is sad, but it is a release.  Society often doesn’t allow us to say that, but many of us think it.  When my mother-in-law died at 94, one niece cried for hours.  My wife and I just said, “It’s finally over.”  My mother-in-law had been widowed twenty years earlier, was never the same, moved out of her house to assisted living 8 years later, had become slowly demented and had been ready for death for years.

I have seen too many who did everything they could to forestall death, when it was not only going to be the outcome, it needed to be the outcome.  I wasn’t popular, but I had the respect of nurses who dealt with these issues first hand.  When I practiced, I once had eight dying patients simultaneously in an ICU.  I had to deal with eight families, each of whom had members who were dealing with a family death for the first time.  I don’t remember what I got paid for it; suffice it to say that my total bills for the entire 8 were less than an average inpatient surgery at the time.  Surgery takes skill; dealing with death?  Well, that is another story.  That’s just talking to patients or families, not taking a knife and curing them.  Talk is cheap, and talking about death isn’t paid for at all.  Remember Death Panels?  That was just paying for the discussion with people about how they wanted to die.  You’d think from the uproar that elderly people had never thought about the concept before.  I submit talking about death is far more important ultimately than a good deal of procedures Medicare does pay for.  Perhaps if it were reimbursed better, the discussions would be better, but I am out of date.

Here in Oregon, people who are competent and terminal can choose the time of their death, not passing, for passing is a euphemism that makes us think that the non-existence of a former sentient being is something other than non-existence.  About seventy-five people choose that option here every year, not many.  These individuals know full well what they are doing.  They know they are dying soon, and they don’t wish to go through the indignity, often painful, to reach the end result—death.  Some use “assisted suicide” to describe this law, but suicide has a different connotation in our language, and “planned death” is a better term.  The individual is dying soon from a disease, not a medication, and they don’t wish to go through the whole disease process to the bitter end.  There are strict controls, and people die when they are ready, having had for some time the knowledge that they could choose or not to choose to use the drugs that would allow them to die.  A third never use the drugs.

A death from a bad disease in a younger person is a particularly bad tragedy, even if it is were not preventable.  It is a message to those of us who hear about it to be sure we are doing what we want with our lives.  It is a message to end estrangements, if possible, to fight only those battles that are meaningful, to leave behind something good, to live and to be able to say to yourself or even aloud, “I am alive!!!!”

I don’t live in a perpetual state of angst about death, but I find myself discussing events in the next 1-2 decades with the caveat, “If I am still around.”  Mind you, accidents, which can occur at any age, can cause sudden, unexpected deaths.  In one’s 60s, however, there are a lot more things that can kill.  Pneumonia is suddenly not just a minor inconvenience; it is life-threatening.  One nurse told me a two years ago that a cardio-thoracic surgeon we both knew developed leukemia at age 60 and was dead 6 weeks later.  I probably had my mouth open for a couple of minutes.  Suddenly, the problems of the world don’t seem so pressing.  Indeed, Oliver Sacks, who recently admitted he has cancer metastatic to the liver, has stated just that.  He no longer watches the news.  I can’t say I blame him.  I don’t watch it much, either.  I try to deal with the things I can control, not worrying about the many over which I can’t control.  I wish I could stop worrying about the weather and climate change.  I can’t change it, but it still hurts to see it happening.

That means I support the Humane Society, but I turn off commercials and don’t look at posts that show animal abuse.  I simply do not have the time, resources or energy to deal with every needy individual in the world.  Further, the sheer volume of these requests overwhelms me and shuts me down.  I feel like a failure that I can’t fix the world. I am not going to try, and if that makes me a bad person, so be it.  I try to choose my battles, decide where my money, time, effort should go, and am glad I am in a position to do all of these.  I have my own list of things to do; another list, much shorter, are those few things I have done in life that I believe have defined me as a person who existed and which have mattered the most.  The first list is written down, not ordered.  I discuss it should people ask and make it a point to do the things on it when I can.  The second is far more private, and it is very much ordered.  I am deeply clear what those items are.  Others may have seen me as a different person, but this list describes how I see myself.

I don’t know how much time I have.  I just know that every year needs to count for something, and something on one of those two lists needs to be part of every year.

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.

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.

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.

STREET SMARTS

January 25, 2015

Back in ’86, I had just arrived at the canoe outfitters east of Ely, Minnesota, and used a pay phone to call my wife, before soloing in to the Boundary Waters for a week.  One of our cats had just died, and we were both grieving.  I asked her about “Tribble,” a small grayish- white stray found in a fast food parking lot, whom we had just taken in.  My wife’s voice changed immediately when she started talking about the kitten who would become pure white when clean and grace our lives for a decade.

One never can replace an animal, but one can give a new one a home, helping the grieving process immensely.  I don’t use the relative pronoun “which” with animals, only “who” or “whom.”

*********

I got the text from my wife while I was running north from Knickerbocker Bridge on my way home.  “We just put Patience down.  It was time.”  When I got home and called Arizona, the other end of the line was full of silence punctuated with tears.  What could I do?  Nothing but listen.  For an animal person to lose an animal is tragic.  We are animal people.

Patience was a horse born into my wife’s arms 17 years earlier one night.  She was a demanding creature, and while I don’t normally visit my wife’s horses, I once had to do the feeding, and Patience was not.  She was queen of the herd and had to eat first.  She was not big, 15 hands 1, maybe 2 on a good day with windage, but she more than made up for her size with her personality.

Sadly, as the years passed, Patience developed leg problems, which ultimately led to her foundering, a painful condition where there was a real possibility the Coffin bone will come through the hoof. While there was initial hope that the hoof would grow back, a later check revealed that she would not survive without a great deal of pain and no guarantee she would ever walk normally again.  She was euthanized before my wife’s eyes.  I wasn’t around to be there; her best friend, whom I will call Babs, was, and the veterinarian suggested the other horses in the herd be brought up to see the corpse.  Several sniffed at her, then started eating her hay.  Mind you, I didn’t hear the last part, or the next part, for several days; it was too painful for my wife to discuss.

Horses are something we don’t talk about much.  My wife is a different individual at the barn.  I seldom ask, but the few times my wife opens up, she vocalizes a torrent of equine-related words:  “When you euthanize a horse, they are standing up.  Patience fell, as she lost consciousness, and the bang, when she hit the ground, startled the rest of the horses.  They knew this was not an ordinary fall. They called out in a most unusual way.”

I never knew this stuff occurred.

My wife came back to Oregon for 2 weeks, still grieving and stressed out about having lost two horses in the past 10 months.  Babs’ daughter, who lived in another state, happened to see an advertisement in a journal for a horse.  “She looks really nice,” was relayed to her mother.  “Then I saw she was for sale in the Phoenix area.”

Babs decided to drive up to Phoenix and check out the horse on a weekend my wife was working there.  It would take me 2000 words to describe Babs properly.  She is a generation younger than I but probably a generation ahead me in street smarts, and I’m no dummy.  The thought of driving 3 1/2 hours to Phoenix to check out a horse was entirely consistent with her character.  She and her husband once picked up several horses in Colorado, a 13 hour drive one way.  Or was it 15?  Their property is full of dogs, cats, horses, ducks, chickens, and once “Miss Piggy,” a pot-bellied pig.  Babs knows everything that is going on in the county, on 2 or 4 legs, on the opposite side of the political fence from me, except where stupidity is involved.  Neither of us suffers fools gladly, and we’ve helped each other with serious stuff that I wouldn’t do with many others.

Babs and my wife planned to meet for dinner in Phoenix that weekend and see the horse, who was called Ally.  Both agreed that Ally looked good, the price reasonable, and they decided to get her vetted. I got a picture texted to me.  Sure the horse looked fine, but what do I know?   My wife was not optimistic, but it got her mind on something else, and that was good.  But, on the following day, the vet called with bad news:  the agent was a deadbeat, we might not be getting a fair deal, so Babs decided not to go ahead with the vetting.

Funny thing was, the vet also said, “She looks like a nice horse.”  That made 4 who had said that, 5 counting me, but I don’t count.

Nonplussed, Babs texted my wife and said she still wanted to move ahead.  Turns out Babs already had a grain bucket with “ALLY” written on it.  The vetting was moved to Friday, and I was about as curious as my wife what would happen, although I thought I knew.  A good vetting may ferret out that many give a horse Ace (Promazine) or Bute (butazolidine, an anti-inflammatory) before a sale, so if the horse is arthritic, may not appear lame to a buyer.

I also learned some mares are given progesterone because when they are “in season,” they can be unmanageable.  Progesterone prevents ovulation.  Three months after the sale, the progesterone is gone, the horse goes into season, and there is an issue.  We didn’t need that.

With all of those caveats, Babs wanted this one.  I didn’t mention that Babs negotiates like the main character on Pawn Stars.  I don’t know what she offered, but in the end we got the horse for a whole lot less.  She and my wife were texting constantly.  For Babs’ SMSs, my wife has a train ringtone on her phone; I kept expecting to see a Union Pacific locomotive in the driveway.  She seemed a lot less depressed, too.

Ally wasn’t easy to get into a trailer for the trip out of Phoenix. I believe Babs used the word “turd” to describe her. That would be about right.  Babs has a doctorate in Street Smarts; her ability to find the right word is uncanny.

“We’ll fix the trailer issue quickly,” was the next text.  Yeah.  No doubt.  Maybe in a day.  If that.

My wife is a lot happier than I’ve seen her in awhile. Think Babs is, too.  When I heard there was a grain bucket with “Ally” on it, I knew what was going to happen.

I’d never dream of telling my wife that, however. Street Smarts.

CALCULATED RISK

January 19, 2015

“Well,” I said, looking at the student’s math problem, “everything is fine until here:  you have (-14/23) + (15/23), which is correct, but you wrote they equaled 18/23.”

“What should it be?”

The student paused.  I continued,  “What is minus 14 and plus 15?”

She took out her calculator.

“No,” I said.  “No calculator.  What is minus 14 plus 15?”

She thought for a few seconds. “One”.

“Exactly.”

“I must have pushed the wrong button on the calculator.”

I tried not to cringe.  “You don’t need a calculator to add minus 14 and plus 15.  By using a calculator, you run the risk of pushing the wrong button and believing what comes out.  Use your head.  You knew what it was.”  The woman nodded.

We tutors sat alongside a wall at desks, and students, who sat at one of many tables, working on math problems, would come to any of us if they wanted help.  I spend four hours, sometimes more, two days a week as a volunteer, and I am usually busy the whole time.  A fellow tutor about my age commented how we once had main-frame computers (the adjective has now almost disappeared from the language) that took up a whole room, required air conditioning, and needed punch cards to do simple calculations.  I can remember learning BASIC, written by John Kemeny, mathematician, teacher, entrepreneur and president of Dartmouth College for 11 years, including the year I graduated.  Kemeny was a genius.

In 1969, Wang calculators appeared in a small room in the chemistry department, where I was a major.  These were slightly smaller than a laptop keyboard, and we could then do exponentials and natural logs.  We used to use log tables to do calculations. Our generation knew the word “anti-log” and the term “9.xxx-10”. If you know what I mean, you are at least 55.  We thought these new calculators were incredible.  We could put away our slide rules.  Imagine, cube roots by pushing buttons! We played with [ln (0)], to see how the calculator handled undefined numbers.  It was fun.

Now my TI-83, a rather old calculator, can graph any polynomial I want in any size graphing window I want.  It can give me the values of derivatives, intercepts, z-values for proportions, t-tests, Chi Square values, raise numbers to the 100th power or more, which makes interest calculations easy, store numbers, do linear, quadratic, cubic, and exponential regression, has a built in z- and t-table, does binomial calculations, take n th roots of things, and fits in my back pocket.

What it cannot do IS TELL ME WHAT TEST I SHOULD USE.   Nor for that matter, can it square any number with 25  digits, all of which are 9, as fast as I.  I think I can multiply any pair of two digit numbers as fast.  Squaring three digit numbers ending in 5, I can also come close to beating it.  But graphing y= [sin x/(x-2)]^2]?  No way I can come close.  I can do logs to the base 10 of 2,3,4,5,6,8,9, and 10 to 5 decimal places faster, but I can’t do the log of 7 or larger primes. I can’t do them to six or seven places.  Nor can I do trig functions other than the simple 30, 45, 60, 90 and multiples.  But I can estimate them quite closely, which surprises people, when I say the tangent of 35 degrees is about 0.7.  The tangent of 30 is √3/3=0.5773, and the tangent of 45 is 1, so I just interpolate.  Many times, that is all I need.  I am metric fluent, but I can’t use polar coordinates well.  The TI-83 does that and shifts to radians with a couple of key strokes.

These calculators are great.  BUT THEY CAN’T THINK.  They take your thoughts and input and give the result.  They don’t say whether you asked the proper question.  They don’t tell you that a quadratic function might fit the data better than a linear function, They will tell that you inputted an incorrect formula but not a wrong number.

Nor will the calculators say if you violated the assumptions with linear regression, something that many people who argue against global climate change, for example, fail to recognize.  One cannot simply make a scatterplot, draw a line through the points, or even have a calculator do it, and conclude nothing has changed in the last decade.  A calculator can minimize the sum of the squared vertical distances of the points from the line, showing the best “fit”.  It can do it faster than I, although it can’t prove why the formula works, and I can.  A calculator can show whether the line is going up or down, even how much, and if one asks for more, the p-value for the line, the probability the occurrence is different from a fixed number’s being a chance occurrence. The calculator, however, cannot cannot tell you whether the distance of each of the points from the line follows a normal distribution with mean 0 and the same variance, without some work and judgment from the user.  Nor does it tell one whether a point should be an outlier.  That also requires judgment.

Calculators have to be used for the right things, just like computers, and one needs to have an idea when the answer makes no sense.  If I Google “East Pacific Ridge,” wondering why the Jet Stream Wave #3  has stayed stuck for so long, which is devastating the American West, I might read something that says only warm moisture from south is getting through, because of the radiation in the water at higher latitudes from the 2011 tsunami can’t, which is nonsense, akin to pushing the wrong button.  We push wrong buttons sometimes, or we forget to erase something in the calculator.  We look at an answer and should realize it makes no sense.  That ability has been greatly diminished, and in some places has disappeared, along with my slide rule.  I am not a whiz with a calculator.  But I have the ability to look at an answer, a graph, say about what things ought to be, and whether the answer makes sense.  I agree that Common Core is teaching estimation, but there are multiple ways to estimate, and children need to be taught multiple ways to do math, because they learn differently.  I estimate differently from the way Common Core does.  I learn differently.  Indeed, discovering how an individual learns is one of the most important things education should do.

A 10% increase in the likelihood of a rare disease is not 10% likelihood you will get it.

Decrease in the rate of growth does not mean the total is declining.  It is not.

Four different outcomes do not mean they all have equal probability.  They usually don’t.

There’s a place for the mean and another place for the median.  A person who uses them interchangeably to describe a set of data is either lying or doesn’t know the difference.

Finally, (-14/23) + (15/23) can’t possibly be larger than (15/23).