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UNCOMMON MANIFESTATIONS OF COMMON DISORDERS

October 24, 2012

A 28 year-old woman comes to the hospital with significant left-sided abdominal pain, and the imaging study is read as showing a small left-sided inflammatory process felt to be diverticulitis, despite no diverticulae being seen.  No comment was made about the appendix. Diverticulitis with perforation in the large bowel may occur in the young, but it is an older person’s disease.  As a former clinician, I would be bothered about that diagnosis.

But, four days later, the patient was better.  A repeat study was performed just to be certain nothing was awry.

Something was.

The patient now had an abscess in her left side of the abdomen, and there was inflammation throughout the peritoneum.  This time, a different radiologist looked at the scan in a different plane.  There are 3 anatomical planes for viewing: sagittal, coronal, and  transverse.  In the coronal plane, it was clear that the appendix had ruptured.  In the sagittal plane, where the prior reading had been made, the appendix wasn’t visible.  Radiologists don’t always look at all the planes.   They get paid by numbers of cases reviewed, just like most physicians, and there is a lot of pressure to take care of many patients.  Before you say this is wrong, remember that many people complain of emergency department waits.  If a radiologist takes a lot of time to read a scan, people wait.

But the appendix is on the right side of the abdomen.  What gives?

I have a book from my late father-in-law called “The Early Diagnosis of the Acute Abdomen,” by Sir Zachary Cope, the 8th edition, written in 1940.  It should be required reading for every medical student.  The appendix is attached to the cecum, and the cecum is on one side of the iliocecal valve, leading from the ilium to the large bowel.  The first radiological report did not mention the cecum.  This was a major oversight.  Unless the cecum is identified, the appendix cannot be identified, either.  If those two cannot be seen, appendicitis as a cause of the problem cannot be excluded.  In a young person with significant abdominal pain, appendicitis is always a consideration until proven otherwise.  When I was a shipboard doctor, I had read Cope’s book 5 times, because diagnosing appendicitis meant either an operation on board (I did two, one by myself) or an expensive Mede-vac, with a helicopter landing on the small flight deck of a ship.  I’ve done that many times, and it requires skilled pilots.

The cecum can be not only in the right side of the abdomen, but in the middle or other parts.  The appendix, therefore, can be anywhere in the lower abdomen, the pelvis, in the middle, and even in the right upper abdomen, mimicking gall bladder disease, should it be retrocecal, or behind the cecum.  The appendix can irritate the bladder, mimicking urinary infection.  If the appendix is pelvic, ruptures, and forms an abscess, the abscess will move up the left side of the abdomen, the path of least resistance, exactly what happened here.  Two of the best medical adages are: first, uncommon manifestations of common disorders are more likely to occur than common manifestations of uncommon disorders; second, when you hear hoofbeats, think horses, not zebras.

The woman will be operated upon and should survive, but she will have extensive scarring in her abdomen, which will likely lead to future bowel obstructions and multiple operations.  If she has children and needs a C-section, it will be a very difficult procedure, since bowel may adhere to the uterus and perforate during surgery.  She would have had future problems had she been diagnosed promptly, but not nearly to the extent that she is likely to have now.

It just isn’t the fault of the radiologist, however.  Where were the clinicians?  Why would a clinician accept diverticulitis in a 28 year-old with no other diverticula being visible? Why was there no statement why this could not be appendicitis?  Such a statement would show that the clinician had at least thought of the diagnosis.

I made a lot of mistakes in practice, but any time I was bothered by a diagnosis, I either kept looking at the patient or asked a colleague what he or she thought.  I also wrote a provisional diagnosis on my reports for X-Rays, not just “headache” or “abdominal pain.”  I wrote, headache, slight left sided weakness, glioma a possibility,” or “abdominal pain, left-sided, high white count.”  The radiologists loved having the information I provided them, and I got better reports, too.

I recently learned from a pathologist the astounding fact that with the advent of imaging procedures that supposedly allow us to look inside the body without surgery, that autopsies, the few that are done, show NO CHANGES, repeat, NO CHANGES in the pathology that was MISSED by the clinician and the radiologist during life.  This is scary.  It means that our assumption that we know what is going on with a patient on the basis of an imaging test may not be correct

This is the second time I have discussed a major problem with appendicitis in a young person.  The first patient died.  This person walled off the abscess, which the body used to do fairly successfully, in the days before good diagnosis and good surgery.  My grandfather had unoperated appendicitis and survived.  It can happen, and it did in 1940.

I would like to think in 2012 that we might be a little better.  I’m not really so sure we are.  And that bothers me as much as a diagnosis that doesn’t make sense.  It makes me worry and think, “What else could be going on?”

There is one other adage we would do well to remember, the most basic rule of all:  “Listen to the patient.  She is trying to tell you what is wrong with her.”

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DOUBLE STANDARD FOR WOMEN….AND A SCARY LOOK TO THE FUTURE.

October 14, 2012

While substitute teaching recently, I saw a large poster on the classroom wall showing 4 famous women mathematicians.  Two in particular struck me as interesting.

One was Grace Murray Hopper, a Navy programmer until she retired at 60.  She was so important that the Navy recalled her to active duty 4 months later, and she retired for good at 80, the oldest officer serving on active duty in the armed forces and the first woman admiral.  She was instrumental behind the development of COBOL.

Amalie Noether, a German, received her Ph.D. in 1907, but prejudice against women kept her from anything other than volunteer jobs until 1929.  She taught in Germany for 4 years as a full professor, until the Nazis came to power, when she emigrated to the US, taught at Bryn Mawr and worked nearby at the Institute of Advanced Studies at Princeton.

She died in 1935, and 22 years’ of skills were lost to the world due to prejudice against women.  Today’s Germany is far different; I know two physicists whose work is unbelievably good.  I was asked by one to check the English in her Ph.D. thesis.  Imagine, writing a Ph.D. thesis in a second language.  I’ve had a lot of math, but ich war im Kindergarten mit der Mathematik. I received a picture of the X-Ray Telescope she is helping build that will be launched from Baikonur in 2014 to L2, the second (of 5) LaGrangian Point, where the Earth’s gravity equals the Sun’s.

Here in the US, women may flip the ratio of men:women in science and math.  I like seeing a lot of women in these fields; as a past boy, I wonder what’s happened to the guys.  Hopefully, they will return; perhaps the President’s initiative to hire 99,999 math and science teachers (he said 100,000; I will work for free), may help.  We lost too many mathematicians to Wall Street, where some modeled the housing market with the incredibly stupid assumption that prices would never fall.  I once bought into the notion that the stock market always goes up, until I realized we had about 70 years of data.  We have a lot longer and better climate data saying the Earth is warming, but I don’t hear these same people saying the Earth will always get hotter, even as the Arctic ice pack this year shrank far below previous records, worse than experts predicted.  Oh, yes, that appears to have an effect on the jet stream’s waves, which affect ridges and troughs, high and low pressure.  I wonder if the 112th Congress knows that.  I doubt many; one on the House Science Committee believes women’s bodies can fight off “legitimate rape”; another thinks the Earth is 4000 years old.

I don’t worry that we will require women to teach without pay.  No, we will only forbid them to choose how to deal with their bodies.  Make no doubt about it.  The US is well on its way to making abortion illegal, including for rape or incest, which even Saudi Arabia allows, although like prohibition, it won’t be eliminated.  There are coat hangers and now Mexican drugs, which are given by non-licensed people, that will abort but desperate women who take these may bleed to death.

But that’s God’s will, right?  By the way, if you happen to believe that, what happens to the guy who made the woman pregnant?  Was he just “sowing wild oats” and the woman promiscuous?  Just curious, because there seems to be a double standard.  Wouldn’t it be nice if we had DNA testing to find the father?  Maybe, we could give him a choice:  support the baby equally or have him wear a large “F” around his head, for “I fathered a child out of wedlock.”  It could stand for another word, too, the 21st century version of The Scarlet Letter.

What particularly disturbs me, in addition to the lack of care of the unwanted child that is ignored by the far right, many of whom want to dismantle Medicaid (“block grants” sounds better than dismantle, don’t they?), is the assault on birth control, which prevents many unwanted pregnancies and therefore abortions.  I saw this coming, with attacks on Planned Parenthood.  Funding for PP, should Romney get elected, would be removed, and other services, like STD testing, curtailed.    The Church is against birth control, but did nothing about pedophilia for years.  It’s too bad boys can’t get pregnant.  I also find it interesting that the late Strom Thurmond, a racist senator from South Carolina, had a child by a black woman.  Wow, I can be hypocritical, but if hypocrisy were track and field, these guys would be Usain Bolt.

Perhaps I will be wrong.  On the other hand, five readings of The Rise and Fall of the Third Reich and studying the Challenger disaster taught me that small problems may become catastrophic if nobody speaks up.

Mankind is capable of unspeakable horror:  the Holocaust, Srebrinca, Katyn Forest, Rwanda, My Lai, stoning, and Maharashtra (a state in India, where an unwritable-by-me horror was committed upon a pregnant woman, and the perpetrators were not punished).

When a country is coming closer to banning abortion even in the case of rape or incest, what is the next step, forbidding women to have certain careers?  Oh, one says, this won’t happen.  Really?  Why not?  In 1925, Hitler wrote Mein Kampf.  Eight years later, he was Chancellor.

To me, the ultimate irony would be for women and others emigrating from the US to countries where their skills would be welcomed, and their bodies respected.  Think that is impossible?  Then you probably believe the stock market always rises, people don’t need regulation, we should be on the gold standard, the climate is just fine, and that many countries are as strict on abortion as is the Republican platform.  There are only 5: Malta, Dominican Republic, El Salvador, Nicaragua, and Chile.

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THE WAR OF 1812

October 6, 2012

A friend of mine in Bosnia, whom I help learn English, has a 16 year-old daughter who is an exchange student at a high school in southern Illinois.

Her daughter got the best grade in her class on an essay about the War of 1812.  She knew that part of American history better than her American classmates.  They would not be expected to know much about Bosnia, although I was shocked at two of the questions they asked the young woman, when she arrived at the school:

  1. Did you come here by train?
  2. Do you take showers?

I often say there are no dumb questions, except asking one that was just answered.  Questions reveal a great deal about the one who asks them, and the above two questions revealed a shocking lack of education or curiosity.  Personally, I would have asked, “What is it like to live in Bosnia?” or “What languages do you speak?”

I don’t expect most Americans to be able to accurately find Bosnia on a map, although the 1984 Winter Olympics were held in its capital, Sarajevo, and there was an horrifically devastating war and genocide there in the early 1990s.  Considering that the US was part of ending that war (the Dayton Accords), it was at the time the first instance where air power alone was able to end a war, that is something worth knowing.

Instead, we have a large number of people who can’t find important countries on a map, countries where geography determines history, and history determines behavior.

Indeed, at a time when many Muslims in the world do not like America, to put it mildly, it would not hurt to remind them that we were helpful in ending the genocide against Muslims in Bosnia.  The mother and her daughter are Muslims, and the former has taught me a great deal about Islam.  She is one of best, purest, nicest people I know, who lives her religion.

She taught me that “Balkans” is a word that means “blood and honey,”  probably one of the best descriptors of the region.  This area will likely explode again.  There is no Tito, no Yugoslavia, now Serbia, Croatia, Bosnia/Herzegovina, Kosovo, Montenegro, Slovenia, and Macedonia.  I tell many of my European friends that one thing many Americans cannot understand is why Europeans appear to lean towards dividing into smaller groups.  We now have Moldova and Romania.  The USSR was divided into 14 different countries. People in Dagestan are Russian, but they call themselves from Dagestan.  (It’s west of the Caspian Sea.)

I often have discussions with my wife about what American students ought to know, and she says, probably correctly, that I am too strict.

But, given student loans and credit cards, students ought to know something about debt.  They ought to know the Rule of 72, which says that the doubling time of debt is 72 divided by the interest rate in %  (not decimal).  Debt at 8% interest doubles in 9 years (72/8); at 24% in 3 years (72/24).  That is why credit card debt is so deadly.  Yes, and students ought to be able to quickly convert decimals to percentages and vice versa.  I am not asking that students be able to derive the Rule of 72, which is P=Po[(exp(rt)], which is [P/Po]=exp (rt), and since P=2Po, we have 2=exp (rt), ln 2=rt  and t = ln2/rate (decimal).  ln2=0.693) so if I multiply numerator and denominator by 100, I get 69.3=t .  Seventy-two is a much easier number to deal with than 69, so we use that.  I do expect knowledge that 1/4=25%  and 0.62 is 62%.  Yes, really.

I think American students ought to know the difference between a billion and a trillion.  Politicians discuss money figures of this magnitude frequently.  There ought to be a simpler way to explain, and perhaps this would be a good debate question to ask politicians, along with the age of the Earth. The Earth has existed more than a trillion days, assuming, of course, we are teaching that the earth is 4.5 billion years old.  A billion is the number of seconds old we are in our early 30s.  A million is the number of miles the Space Station travels in about 2 days, 40 trips around the Earth, the number of miles a busy driver will drive in a lifetime.

I think American students ought to be able to name nearly all the states without looking at a map.  I think they should be know Canada is our biggest trading partner, and that it and Mexico border the US.  I think they should be able to name most of the original 13 colonies, know when the Declaration of Independence was signed, and the Constitution ratified.  I think at least half of the Bill of Rights should be known, at least 3 Supreme Court justices, and the last 5 presidents.

We should require more writing, more research projects, more math and science.  Students ought to understand the basic concepts of statistics, such as means, variance and the concept of error.  They might then recognize the chance they could be wrong.  Music and art should be studied, care of animals, the mistreatment of which is a red flag for sociopathy.  The students ought to periodically go outside for exercise and learn about the plants, water, and sky.  They should spend one evening under a clear sky and see the Moon and stars.  They should learn at least one foreign language, and if they already know one, to learn another.

Students should be taught that being unique and being special are not the same.  One is given, the other has to be earned.  Wow, we have a lot to do in a short time.

Fortunately, we have a lot of retirees who could help, and it would be great for them and great for the schools, too. The War of 1812 is not particularly difficult to understand.  It’s not like when it happened is a mystery.

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SPAMMED ON JACKFISH BAY

September 27, 2012

My wife and I got spammed on Jackfish Bay on our last canoe trip.  No, I didn’t have a computer; I saw a plastic bag in the forest behind the campsite, and it had three full cans of SPAM, the real deal.  Minnesota is the Spam capital of the world; for those who don’t know the etymology, it is shoulder of pork and ham.  When I first canoed, 50 years ago, Spam tasted pretty good.  Then again, in the woods, most things taste good, even pine needles.

On the same campsite were two empty beer cans and a burned out can in the fire area.  We carried all of this garbage out, along with our trash. The white pine in the center of the campsite had dozens of scars from people who had to chop at it.  Despite that, the tree was tall and had no signs of blister rust, unusual for a tree this age.  White pines are the most beautiful tree in the woods; the wood from them is prized.  Why anybody would deliberately chop at a tree that was likely a sapling when the Voyageurs came through 225 years ago is beyond me.

White pine (Pinus strobus), scarred by prior campers.

But, give a guy (usually a guy) an axe, and everything in the woods becomes fair game.

On the way out of the woods, we passed a campsite where somebody had cut a few dozen balsam pine boughs for a mattress.  There was a time, half a century ago, when we cut balsams down for tent stringers, used their boughs for mattresses, put cans in the campsite can pit (or in the lake), and threw axes at trees.  These days I thought were gone.  Having cleaned some 500 campsites in the Boundary Waters, those days are not gone.  Note to campers:  aluminum foil does not burn completely in campfires.  No, it does not.

The Wilderness Act of 1964 establishing the Boundary Waters (BW), made most of it, except for a few lakes, including Basswood, non-motorized.  Cans were not allowed, green trees were not allowed to be cut (they don’t burn, and there is no reason to do so), permits were required (and were free for more than three decades), and the number of people who could congregate at one spot was limited to 9.  The BW was and is the largest roadless area in the contiguous states.  This did not sit well with some, and Sig Olson, one of the first great wilderness writers, was burned in effigy in his hometown of Ely.

Sig knew, far before many, that wilderness was no longer something to be conquered or to be lived off but something to be protected.  It was a massive shift in thinking that many still have not embraced.

We now have lightweight and safer gear: air mattresses, chairs, small saws, rain suits, good tents, barbless hooks, food packaged in plastic, but not metal, that it ought to be easy to travel in the wilderness without harming it.

I write this to those who do not know the rules but wish to abide by them; I hope maybe a few of the others might think about what they are doing as well.  The BW is not pristine America post-glacial era.  Most has been logged, about a century ago, and it has been burned by natural and human-caused fires.  I’ve seen a third of the campsites with hot ashes or frankly burning fires and no inhabitants.  I’ve seen many other fires built outside the fire area.  Given the dryness of the soil–dig a latrine, as I have and you realize this fact–fires can spread underground.  Fire is a natural phenomenon, lightning sparked fires, such as the Pagami Creek Fire last year, clear the forest for new growth.

The debate should be about whether we let naturally caused fires to burn.  There should be no debate whether somebody should be allowed to leave an unattended campfire.

The BW is open to fishing and hunting.  Fishing has to change too, from a half century ago.  Catching large stringers of fish–or one huge fish, a breeder–has to stop, and catch and release, except for a meal, with barbless hooks should be done.  Is this inconvenient?  Sure.  But what about the upcoming generations?  BW lakes are not sterile, but the northerly climate makes them far less productive of fish than many lakes at lower latitudes in the US.

The world changes.  We are no longer voyageurs with canoes in an unmapped wilderness.  We are a quarter million annual visitors in the wilderness the size of Rhode Island.  While there is much room, large numbers of people put pressure on the wilderness with human waste, human trash, and other impacts.  Humans belong in the BW, but as our numbers increase, our impacts must lessen.  Even the best camper may break rules when caught out in severely inclement weather.  I’ve seen hundreds of pounds of abandoned gear.  The late Mike Manlove referred to this as “being out of one’s comfort zone.”

Wilderness is not only subject to attacks from within but from without.  Fish have mercury, lakes become acid.  Water quality may deteriorate from sources far from the wilderness.  Careless boaters can transfer invasive species from one infected lake to a previously normal one.   Heavily log or burn much of the forest, and streams and lakes will become muddy.  This affects fishing.  Eventually, such damage may clear.

Mining, on the other hand, is forever.  A sulfide mine, planned near the wilderness, is a huge concern.  Communities need jobs, but sulfide mines are particularly toxic to watersheds, and the BW is a watershed if ever there was one.  Another pillar of the local economy is tourism.  Destroy the watershed, and tourism will disappear.  I am told the mine will be safe; things tend to be “safe” until they are suddenly not safe.  Then, everybody is sorry, the money made, the rich folks gone.

One hundred fifty years ago, the virgin pine stands of northern Minnesota were thought to be inexhaustible.  Forty years later, the state was importing lumber.  Log enough, and the jobs eventually end, along with the forest.  Mine enough, the jobs eventually end, along with the surrounding area.  If we have an unemployment problem, one good solution would be for many families to have a lot fewer children.  The US population has more than doubled in my lifetime; we have one of the highest birth rates in the industrialized world.

This is the 21st century, and we need natural resources, wise use of land, and a lot fewer people than we are producing.  If we continue to act the way we did in the 18th century, nearly exterminating the beaver, the 19th century (the buffalo and the forest), and the 20th (treating wilderness like a playground), there will be a large emptiness in the 21st.

Nature can recover, but within limits, and often with very different outcomes than even the best biologists can predict.  Enjoy the wilderness, carry out what you brought in, and maybe a little stuff that others brought in, too.

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SEASONS OF THE CANOE COUNTRY….AND LIFE

September 25, 2012

“Come on in,” called Dorothy Molter, as I had paddled up to shore on her island home on Knife Lake and knocked at the door.  Dorothy was a legend on Knife Lake.  She left nursing and Chicago around 1930 and lived on an island in Knife Lake, which straddles the border between Minnesota and Ontario.  Called “The loneliest woman in America,” Dorothy had hundreds of visitors every year.  She was grandfathered (or mothered) and allowed to live the rest of her life on Knife Lake after the Wilderness Act of 1964 required resorts to be taken down, power boats removed, limits on numbers of people who could go in, and even how low planes could fly overhead.

Dorothy was a legend.  She gave me some of her famous root beer, and as we talked, I commented that it was a little more difficult to canoe trip when I was 32 then it had been when I was 18, guiding canoe trips in Algonquin Park, wearing the coveted red neckerchief that only guides wore.

“Yes,” Dorothy replied, completely straight-faced, “I don’t paddle and carry as well as I once did, either.”  Dorothy had forty years on me and she would live for 5 more, her statement a lovely put down to my complaint about age.  I never forgot that.

In the ensuing 31 years and twice as many trips I have taken into the Quetico-Superior, not exactly easy from Arizona, I can count lots of things–wildlife sightings, fish caught, bear charges (1), aurorae seen.  What has fascinated me the most, however, has not been the three seasons in which I have paddled, but the changing seasons of my life with the canoe country.

I first put a canoe on my head 50 years ago, in the spring of my life.  I was an apprentice guide, and I carried wooden Old Towns, slept in canvas tents or under a canoe.  Nobody practiced Leave No Trace camping.  We had can pits, cut live balsam for tent stringers every night, and washed dishes in the lake.  I carried up to 140 pounds, dragged reluctant canoes down rivers, and fought waves so large they hurt, when the bow crashed down on the other side.

In my 30s and 40s, in the summer of my life, I discovered and then explored the Quetico-Superior, covering as much distance as I could.  I had a map on the wall in my office, and after each trip there was new ink on the blue and green splotches.  Miles mattered, new routes mattered, single carrying portages mattered.  I was up early, paddled hard all day, and slept well at night?  Rain?  I got wet.  Headwinds?  I worked.  Portages?  They were a chance for me to show what I had.

When I was 43, I volunteered in Ely for the Forest Service, spending six months away from my medical practice and 100 days in the woods between mid-May and mid-October.  I was a third again older than the guy who visited Dorothy Molter, in far better shape, but I now learned about the trees and the plant life that I had walked by, cut, and burned.  I learned that giving back to the wilderness was more important than having my own personal proving ground.

As I approached 50, I brought my wife along, a previous non-camper, and taught her how to travel.  She in turn taught me how to enjoy the woods–together.  I stopped single carrying portages in 2001, when I was 52.  I had nothing to prove and a lot I could hurt.  I enjoyed walking back in the woods for a second trip.

When I was 56, I soloed into Kawnipi Lake one more time.  Many of us who ply the canoe routes of Hunter’s Island feel Kawnipi is the most beautiful lake on either side of the border.  I may go back again, but it doesn’t matter now whether I do.  I have been there six times, love the place, and am thankful for what I’ve seen there.

“Bowling alley.” Kawnipi Lake.

The northern sweep of Agnes Lake, on the way to Kawnipi.

The year after, my wife and I sponsored a scholarship at Vermilion Community College (VCC).  We have no formal tie to the school, but Ely has given both of us a great deal, and we get great pleasure from helping the next generation of wilderness enthusiasts, many of whom not only live at the edge of wilderness but at the edge of poverty.  These young–and older–men and women are doing great work, and each year at the spring banquet, I meet them and hear their stories.

After 2003, my wife and I started base camping in Lake Insula.  I never thought I would base camp, but I enjoy the day trips where we explore side bays, sometimes finding trails that lead to interesting views.  It is nice not to have to set up camp every night and break it down every morning.  Do I miss the long days and the multi-lake trips?  No, I look back on them with fondness.  My pictures have faded; neither the diaries nor my memories have.

We’re now well into our 60s, the autumn of our lives, and every autumn we come up and base camp somewhere else.  We find a nice place, explore, relax, and forget about the “road, steel and towns” that Sig Olson wrote about.  We are in his “back of beyond.”  We enjoy canoeing and we work well together.  The lakes are old friends; the campsites second or third homes.  Every year we can come up is a gift–one more chance, one more trip, a few carries, the automaticity with which I put a canoe on my head, or deal with a 2 foot chop.  I have watched with great joy my wife become an excellent canoe tripper who also loves the woods, and helps me make a comfortable camp, in all sorts of weather.

Fall colors on Jackfish Bay.

We established a second scholarship at VCC and contribute to a third.  VCC has become family.  I come up for the banquet in April and take a solo trip for a day or two.  I don’t go far, I just want to be out there, alone, thankful for those who saved this wilderness from damming, clear cutting, and roads.  In the autumn of my life, I get to see others in the spring of their lives and canoe in spring, too.

We don’t know how long we will be able to canoe.  The autumn is a brilliant time in Ely, and it is a brilliant time in our lives.  This past trip, I saw Lesser Sandhill Cranes fly high over me on Pipestone Bay.  Next March, I will be in Nebraska, at Rowe Sanctuary, showing people these same birds during their spring stopover along the Platte, one of the two great North American migrations.

We will camp as often as we can in the Boundary Waters.  We know there are no guarantees reagarding ability or longevity.  We hope to canoe into our 70s.  I dream of going out in the winter of my life when I am 80; I took my father into the Quetico when he was 78.  We hope there will be enough of those with sense to guarantee the future of this region to those whose lives are not only drawing to a close, but those whose lives have yet to begin.

Eventually, we will die, like every living organism we have seen in the wilderness.  Our ashes will be spread in the area, finally being part of the wilderness we have travelled, loved and supported.

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GOLDEN PEARLS AND DIE LIBELLE

September 15, 2012

One of the interesting experiences about learning is a new language is the new world that opens up to one who can read books written in that new language and listening to videos narrated by speakers of that language.  Translations are important, but there really is a difference when one reads a book written in the original language.

Reading several German books has nearly doubled my vocabulary in the past six months, for while I can understand the meaning of a book, it is essential to look up specific words I do not know.  This flies in the face of some advice, to learn words in context, but when I took my PSAT exam years ago, my contextual definitions were often wrong.  From that day forward, if I am uncertain what a word means, I look it up.  I have multiple different lists, and I memorize….daily.

I am not going to use all those words, but if I am to understand German–.and now Spanish, too, for I am learning that — I need to know what those other words mean, for while I may not say them, others will.  I am continually amazed by words I thought I would never need to know that were said a few days later.  I learned “die Libelle,” dragonfly, and wondered when I would ever to use it.  A week later, on German radio, there was a description of research done about die Libelle, and I immediately thought “wow, something is going on about dragonflies”.  The something was how they caught die Stubenfliege, fly.  Every word that I can understand gives me more pieces of the puzzle that is called conversation.

My experience with German is one person’s.  I am mostly self-taught, because there have been few with whom I have been able to speak or write on a regular basis.  Good grammar books are not common.

German videos have shown me all parts of the world.  Many are from Germany itself, so I have seen the large cities and the northern coast–North and East Seas–separated by the Danish peninsula.  I have seen parts of Bayern–Bavaria–that I did not have time to see when I was in München.

Still other videos have shown me, narrated in German, apricot harvests in Turkey;  nomads in the high arctic of Russia, dealing with the “gas rush”; salt mining in Bolivia; tree houses for research in Costa Rica; research on the Andean Condor in the Argentinian Patagonia; a women’s co-op in Yemen and water filtration in Peru.  One was about Portland, Oregon, describing the lifestyle.  Another in the US showed homeless eking out a living in the California desert, living in conjunction with snowbirds.  A third showed Detroit beginning to turn into a farming city, using empty neighborhoods to grow crops.  I miss some meaning, but I don’t miss much.  A lot of the translations are slow, and I know enough Spanish and French to know when there is not a full translation into German.  That is a lot of fun to recognize.

A recent video was about harvesting pearls in the Philippines, off the coast of Palawan, the long island at the western end of the Archipelago.  I never saw Palawan, but I have spent a lot of time in the Philippines.  I was struck by not only the way pearls were harvested, but the science being used to run genetic crossing of the mussels, trying to produce the most valuable golden pearls.

There are other problems, too, that I hear about.  Virtually every video that discusses the environment comments on climate change, viewed from the local perspective. On these videos, I have not heard one word saying that climate change is a hoax.  Perhaps the videos are biased; perhaps not.  Coral reefs are bleaching, which is not news.  The northern end of Palawan is too warm (32 C., or nearly 90 F.) for growing mussels.  The oceans are getting warmer.  This is a fact, not fiction, not a hoax.  They are also growing more acidic, which is also a fact, due to carbon dioxide.  For those who say that man is not changing the environment, ocean acidification is the smoking gun that says we are.  This has made the news in the last several months; I knew about acidification in 2006.

Water vapor is, of course, the most prevalent greenhouse gas.  As air warms, there can be more water vapor present, because warming makes gas molecules move faster, keeping them from condensing.  Air at 31 C, all else equal, may contain 2 grams more water per cubic meter than air at 30 C.  The amount of air over the tropical ocean would best be measured in millions of cubic kilometers.  Does it prove anything?  Perhaps not, but there is a lot of circumstantial and non-circumstantial evidence to suggest we have a problem.  Water expands with heat, with a coefficient of expansion of about 0.0002/degree C.  Warm water 1 degree C. and the worldwide 110 million square kilometers of ocean surface plus a significant depth expand a lot, when multiplied by 0.0002/C.  Add glacial melt, and we get ocean rise, which is well documented to the tenth of a millimeter per year.  This rise will be at least 70 cm this century, but some think maybe a meter, and can easily flood a coastline where there is a shallow angle from sea to land.  In addition, salt can easily contaminate the water table.   If you live in Kansas, that is no big deal, unless we prove that the drought of 2012 was due to climate change.  It may not be.  Or, it may be.  The question goes back to Clint Eastwood in “Dirty Harry”:  “How lucky do you feel?”

What continues to interest me is how nearly every place these videos are shot has an environmental overtone.  Water in Peru is a problem because of the receding glaciers.    Drought in Yemen is the cause of decreasing biodiversity, which is important both for the planet, and for humans, because many of our ideas for new medications or molecules come from natural compounds.  There are just too many of us, and the planet is showing signs of big signs of wear.  I haven’t heard much about this in English, but I sure am hearing about it in German.

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ALL MODELS ARE BAD; SOME ARE USEFUL

September 10, 2012

On a recent science podcast, climate models were being discussed, one conclusion of which was that droughts like the 2011 one in Texas were 20 times more likely to occur today then they were 50 years ago, and that this was due to climate change.  However, floods that devastated Bangkok recently were felt not to be due to climate change, but rather a cyclical issue that was worsened by the way Bangkok had built since the last such flood.

There was a call from a listener, and as soon as I heard the tone of voice, I said to myself, “Uh oh.”  Some listeners call in with questions, some give speeches.  This one did both.  He wanted to know if the models were so good, what the temperature was going to be in a certain city in the Midwest next July 4 and for the following 3 July 4ths.

He had a very angry, challenging tone of voice.

Climate models are not the same as weather prediction.  We cannot predict the weather accurately more than a few days in the future.  Does that make the GFS, ECWMF, NAM, AVN and other models wrong?  Yes….and No.  As a statistician, I learned the following:  “All models are bad.  Some are useful.”  Weather forecasts are based on atmospheric models, which differ according to initial conditions and the relative weight of the known variables.  I remember 50 years ago, when weather forecasting was done by a non-meteorologist on television, and the forecasts were not very good.  We have gotten a lot better; short-term forecasts, in the 24 hour range, are exceptionally good; I use the GFS 9 day model as a rough idea of what to expect in the coming days, but I know matters will change.

Climate forecasting is another science altogether, taking into account different long range variables.  From 40 years ago, when climate scientists, unaware of key variables, thought there might be cooling, to now, where virtually all believe warming is highly confident (95% being considered highly confident), there has been much research and ability to get information about the past.  The fact that a confidence interval is used means that statistical techniques have been taken into account, and while the conclusion may be wrong, it is highly unlikely that it is.

Let me explain a confidence interval:  it is NOT a probability, or it would be called such.  It is a range, based on the evidence, of where the parameter (the true measurement) is expected to be.  The parameter is unknown and unknowable, so that the interval either contains or does not contain the parameter.  This makes no sense with probability, so we call it confidence.  If we are able to repeat the experiment 100 times, we would expect 95% of the intervals generated to contain the parameter.  We would not know, of course, which 95 would.  The fact that models are not perfect is taken by far too many to allow them to take the other view, that they are wrong.  One may, of course, choose to do so, but it behooves those who disagree to come up with their own margin of error, p-value, and confidence interval, so the data can be appropriately discussed.  To say,”models are wrong,” is inappropriate for a scientific discussion.  Of course they are.  Statistics as a predictor is wrong, but good statistics state the likelihood an error of a defined amount will occur.

Probability is forecasting the future.  There is almost nothing complex in our world that we can forecast perfectly.  There must be some error.  Every responsible scientist quantifies that error in some manner; to do otherwise is to say that one can predict with absolute certainty what the future will bring.  We don’t do this with temperatures in Iowa on July 4th, where the next hurricane will form, or even its 10 day path.  Nor do we say, with absolute certainty, that the Earth is warming.  But the range that the models are giving us does not include zero or a negative number with high confidence, and that means the conclusion is, based on the current data, that the Earth is warming.

While correlation does not equal causation, there may be factors that make such causal.  Because we know that one greenhouse gas has increased (carbon dioxide), that another, in the face of warming, has increased (water vapor), a third and fourth (nitrogen oxide and methane) are increasing, we have reason to believe that the conclusions are not in error, and that there is a causal factor.

Anybody who follows hurricane forecasts is familiar with the cone of uncertainty, and the fact that the cone changes with time.  We saw this with Irene last year, and we saw the gradual westward shift of Isaac this year, as the initial forecasts showed Isaac to strike Tampa.  With time, the models showed a westerly drift of the hurricane’s expected path, and for it to ultimately strike New Orleans.  The models were constantly updated, and the gradual change was noted.  What did not happen was that the hurricane dissipated, it curved into the western Atlantic, or it went south into the Caribbean.  The models were good.  They were not perfect, but they were very good, and three days before Isaac made landfall, it was predicted to hit very close to where it eventually did.

Nate Silver says that the cone of uncertainty for hurricanes was 700 miles in diameter 25 years ago and 200 miles in diameter today.  He is studying models to understand why some work and others do not.  But the poster child for good models is weather and climate science.

Models to some have become the new “Bad Boy” of climate science.  Every responsible scientist develops models, if it is all possible.  Indeed, the dawn of simulation was about 15 years ago, and I remember running simulations in graduate school in 1998.  We are now able to do this so much better than we once did.  Debate should be over what models are used, their initial factors, the variables, and the conclusions, not whether or not we should use them.

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SWIFT BOATING VACCINATION

August 13, 2012

On a science podcast I listened to a few months ago, the moderator interviewed an actress from a well-known television series.  She had a Ph.D. in physics from UCLA.  The moderator himself was on the show one time, and that may have colored his viewpoint of what happened in the interview.

The woman had not vaccinated her children, saying,  “There are a third more vaccines now than there were when I was growing up, and I thought that was too many.”

She thought that was too many?  Based on what science?  Her statement appalled me, and I was equally appalled when the moderator did not call her out on her actions.  So what if there are a third more vaccines?  I haven’t seen a measles case in years.  A measles cluster involving about 7 people occurred here a few years back, and it made the newspaper.  Fifty years ago, only 7 cases of measles in a neighborhood  would have made the newspapers as real news.  Measles kills and is extremely contagious:  1 in 1000 die from measles encephalitis.  It is a nasty, nasty disease.  Does this mother want to spin the roulette wheel on her children?

Or rubella, the disease we kids loved to have, because we felt fine but had to stay home from school.  Unfortunately, pregnant women may catch rubella–and may not know it–until too late.  Does she want her daughter to have a child with congenital rubella syndrome, like a cousin in my distant family?   He is deaf, retarded and partially blind, and he lives with his mother.  What happens to him when she dies?  What happened to his life, and what happened to his mother’s life?

What about polio, where most cases are asymptomatic?  Perhaps if her children never leave the US, they will be fine.  What if they go to Bangladesh, Paraguay, Uganda, or even Mexico?  Does she want to take the chance they will get polio that is not asymptomatic?  Perhaps they will not be allowed in, because some third world countries actually believe that vaccination is important, even if some in a First World country don’t.

Mumps orchitis (testicular inflammation and a chance of sterility), pertussis, and H. influenzae meningitis are not benign diseases. This is the worst year for pertussis in decades.  What is this woman thinking?  Does she believe these diseases no longer exist because a higher power took them off the Earth?  Does she not know the Salk Trial was stopped early, because the vaccine worked so effectively?  I was part of that.  I was in the first cohort who got the Sabin vaccine.

When I was a medical student, forty years ago, we wrote “UCD” in a patient’s history, meaning “usual childhood diseases.”  I have no idea what they are now.  If we did as a country what we should do, and mandate vaccination for those who clearly have no contraindication, we would not have many “UCD” at all.  In Arizona, half of all children in charter schools are not vaccinated; 15% in public schools are not.  It’s bad enough we are destroying public education in this country; now the kids are going to be at higher risk for bad diseases, too, in addition to no solid proof in Arizona that charter schools deliver a better education.

Regrettably, all it takes is for a few vociferous people who will not believe sound science to convince many that white is black, and black is dangerous.  There are many people convinced vaccines cause autism and vaccines are bad, when good science has not shown that.  There are many who don’t believe we landed on the Moon, that astrology is meaningful, who can’t find Polaris, don’t know why we have seasons, don’t know metric or English measurements, think 9/11 was a US government plot, and the Marfa Lights are UFOs. Even more believe that the climate is not changing, and that we can continue to grow economies infinitely using finite natural resources.  The latter beliefs are unfortunate; not vaccinating when there are no contraindications is child endangerment.

Before 2004, not many people had heard of Swift Boats.  Today, the term is an English verb: “To Swift Boat somebody”.  You take a fact, say it isn’t or discount its worth, repeat the lie over and over again, and you can get a lot of people to believe it.  Swift boat ads helped defeat a decorated combat veteran by turning his Vietnam service against him. We have Swift Boated vaccines, and at some point we will pay the piper.

I wish I could have had the measles vaccine in 1956.  I did get the mumps and shingles (zoster) vaccines.   The zoster vaccine decreases the risk of neuralgia by half and cost me $200. I thought that was a good bargain, since post-herpetic neuralgia is a miserable, poorly treatable disease.

For most of history, disease, not hostile action, was the biggest cause of battlefield casualties during war.  Small wonder that the military believes in vaccinations.  It would be nice if the rest of the country did.

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THE DEMENTORS AMONG US

July 22, 2012

On 5 June, I took my telescope, a camera, and a videocamera, all with solar filters, to the local medical society, and showed about 100 people the transit of Venus, at the same time shooting video, taking pictures, and answering questions.  This exceedingly rare event occurs in pairs, 8 years apart; the next pair will occur 105.5 years from now.  Only Venus and Mercury, inner planets, can cross the Sun as viewed from the Earth.  Of the 100 who came, nobody knew it would be the last time I would be involved in a local medical community event; from now on, before our move next year, I will be only a patient, and hopefully not too often.

The transit was not as beautiful as many astronomical events I have seen, but it is so rare that nobody alive today will see it again, including the baby who looked through the eyepiece of the telescope; his grandchildren, should they live long enough, will.

TRANSIT OF VENUS, 5 JUNE 2012, WITH SUNSPOTS VISIBLE

A picture I took of the transit appeared on the Society’s magazine where I was once a columnist until I resigned last spring, because of reasons explained in the link.  It was a beautiful picture, and it was a good way to leave medicine, as a volunteer, who took a good photograph of a rare event, and shared it with the members.

Everybody who came was nice, except for a few comments, that while were not nasty, I could have done without.  One man, whom I know well for his right-wing beliefs (even as he gets AHCCCS, Arizona’s Medicaid) asked me the distance it was to Venus, and I said about 26 million miles.  He said, “Wow, that is less than the national debt.”

Why does politics have to be brought up during an exceedingly rare astronomical event?  The distance to alpha-Centauri in miles is greater than the national debt.  So what?  We have the national debt for a lot of reasons, some of which I think are important (Medicaid, Social Security, Medicare, FAA, FDA, NIFC (National Interagency Fire Center, which saves lives, towns, and houses) FEMA etc.), some of which are not (Iraq, Afghanistan, aid to dictators, farm subsidies, tax breaks for millionaires).   But it sucked a little happiness out of me.  Dementors do that.

Another person came whom I consider a true enemy.  The person has never once laughed in my presence in the 35 years we have known each other.  Not once.  The individual does not believe in evolution, vaccination, climate change, and thinks there should be no government involvement in medical care.  Just seeing this individual depresses me.  That is a  Dementor.  I was polite, and while that person asked good questions, there has been “too much history,” and too many hateful comments from that individual for me to let down my guard.  Since this is likely the last time I will likely ever see this person, or anyone else there, I sucked it up for 2 hours.

A few months back, my wife and I had dinner with a neurologist friend and his sister, a retired nurse.  She had worked in emergency departments, and was vehement about those who misused them.  This happens.  I was up in the middle of the night a lot, caring for drunks, helmetless people who had motorocycle accidents, people who had not taken their anticonvulsants, and were in a state of continuous seizures.  Most of these people did not have insurance, and I didn’t get paid, although I could have been sued for everything I had, were I wrong.  That is part of a physician’s life–caring for many people come to EDs for conditions that they do unto themselves.

This woman we had dinner with felt that those patients wasted time, money, and effort, should have not been rescued, but left to die on the street.  Really.  A nurse said that.  My wife was shocked; I had missed that part of the conversation.  Well, Ron Paul also said that, too, and was loudly cheered by many, who if they have no insurance, are only a drunk driver, appendicitis, a kidney stone, or viral meningitis away from being in an ED without money and 5 figure costs.  My wife said if we again had dinner with the neurologist, and his sister came, I would go alone.  We left the dinner depressed.  Dementors do that.

Last March, in North Blind on the now dry Platte River, I was in my third year as a volunteer tour guide for the Sandhill Crane migration.  I was in the lower level of the blind; my co-guide had never been there and wanted the upper level, which had better views.  I had a family of four with two tweens, who were bored.  Their mother wasn’t interested, and only the father was taking a few pictures.  It was a good show–not spectacular–but good, and the kids obviously wanted to be elsewhere.  I couldn’t teach about Crane behavior, because they weren’t interested.  I guided 20 times during my stay, and this was the only time I left the blind depressed.  In a place where you can see cranes in fog, snow, close up, or 50,000 in the air above you, darkening the sky, with a haunting call that I simply love, who have been on Earth for nearly 10 million years, where it is one of Jane Goodall’s top 10 sights, and where the governors of Colorado, Nebraska and Kansas came one night, to have a bored family was a real downer.  They were Dementors.

EVENING ON THE PLATTE, MARCH 2012.

Twenty years ago, I helped a man on the Fall Lake portage in the Boundary Waters.  It was his last portage before returning home to Miami.  He had had rain, poor fishing, bugs, and not a good time.  I thought the weather had been fine, the fishing good, and the bugs non-existent.  I helped him get his gear across the portage and wished him well.  He was a Dementor, too, but the beauty of the Boundary Waters was strong enough for me to ignore his complaints.  Indeed, I parried every one of his comments; when he came to insects, he said “And the bugs!!!” He then looked at me and said, “Or are you ‘in’ to them, too?”  No, I am not “in” to bugs, but I recognize their presence, and I realize that they limit the number of people in the wilderness certain times of the year.

I’ve had my Dementor moments; many of us have.  But there are some who are always Dementors, and I try to avoid them if possible.  If they persist, I change the subject.  I had buttons made commemorating the Transit of Venus.  I didn’t make one for myself, for I only wear solar eclipse buttons,   The Dementor at the viewing got a button and liked his.  I almost wished I had seen that.  Harry Potter had the gift; maybe briefly, I had it, too.

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UNCOUNTABLE AND COUNTABLE COSTS

July 12, 2012

I needed a prescription refill for a medicine I have taken for 3 years.  My prior physician allowed calls to be made by the pharmacy to refill the prescription, so I didn’t have to go to his office to get one.  Unfortunately, he left practice to do concierge medicine.  I didn’t wish to pay $1500 annually for 24/7 access to a physician.  For years, I thought that went with the territory, along with not charging for the thousands of telephone calls I returned.  I can’t tell you how important it is as a patient to get a physician’s call.  I can’t put a dollar value on it, other than to say a big “Thank You” to the physicians who have called me back.  That has no dollar value, either, but I think they appreciate it.

Physician #2 left practice to become a hospitalist, because he was unable to afford continuing the practice he was in.  Physician #3 required a visit to refill this particular prescription, which is neither addicting nor dangerous.

We don’t have standardization in medicine for those things that need to be standard.  We disparage it as “cookie cutter” medicine, when in fact, cookie cutter approaches ensure good cookies.  “People are different,” I hear. No, we really aren’t as different as many would like to think.  Most men have similar anatomy; most women have similar anatomy.  Our physiology is the same, and our bodies react to insults in predictable ways.  That is why we study pathology.  Surgeons take out gall bladders the same way, and as a neurologist, I had a standard history and “cookie cutter” neurological exam.  I seldom forgot anything important.  What does differ is how we personally react to disease, and in a short office visit, time spent on that is virtually nil. I practiced for 20 years, so I know the difficulty in trying to diagnose, treat, and understand the patient’s reaction to an illness in a short office visit.

I drove to the physician’s office and asked for a prescription for 2 pills twice a day, 120 pills in all, with 5 refills.  I had my request written on a piece of paper.  I had to come back 2 days later to pick up the prescription.  The office could have sent it, but that requires something to be done by somebody else.  If I do it myself, it is more likely to get done right. Prescriptions can be lost and not sent.  It is only 45 minutes round trip, so it is nothing important, only my time.  When I returned, two days later, I was given my prescription, written for 1 pill twice a day, not 2, as I had asked for, but 120 pills in all, with 3 refills, not the 5 I had asked for.  I could have asked for the prescription to be written the way I had written it down, but the 120 pills a month was right, so I took it to the pharmacy, explaining carefully that this was a new prescription from a new doctor, who would be henceforth refilling future prescriptions.

The pharmacy normally calls me when my prescription is ready.  They didn’t call.

So, I walked to the pharmacy, 10 minutes fortunately, and was told that I could only get 60 pills, not 120, because the prescription was written for 1 pill twice a day. They said they couldn’t reach my doctor, but they mistakenly had called my previous one, who was no longer in practice, despite my having told them I had a new doctor, whose name and telephone number was on the prescription.

The pharmacy said they would call the doctor’s office.  I left the pharmacy empty-handed, because if I got 60 pills, I would have to explain to the insurance company why I needed a new prescription, should I again want 120 pills, which I do. The next day, the pharmacy said nobody picked up the phone.  I drove to the office, handwritten note again, and asked for another prescription, either to be called in or given to me to pick up.  While there, I asked if they had been called.  They said no, and they answer, so I am not clear whom the pharmacy was calling.

The following day, I got the prescription filled, a week late.  What would have happened if I did not have extra medication?  What would happen if I were 85, no medical background, not thinking clearly, because I was 85 and in ill-health, and on several medications?  I might end up in the hospital, which would be a five figure cost, because of breakdown of a really simple system.

I ask:  what is so difficult about writing and filling a prescription correctly?   Frankly, insurance companies should be trying to fix bad systems in medicine, which would save them far more money, than worry why a 63 year-old is taking 120 pills of Drug X every month, the same amount, and is doing just fine.  I am unable to refill a week in advance, should I go out of town during the time the refill is “allowed.”

No, insurance companies should fix bad systems, like ensuring antibiotics are given in a certain time window before elective surgery, which would save them far more money, as would standardizing the antibiotic. When I was medical director, we met the time window only a quarter of the time, and we had a post-op infection rate 4 times higher than Salt Lake City.  That amounted to about 20 extra infections a year, or a few hundred thousand dollars.  Those are all facts.  We had one doctor use a very expensive antibiotic for his patients, increasing the possibility of resistance, and I was unable to get the Surgery Department to deal with it.  We also had 3 wrong-side surgeries: on the head, knee, and bowel.  The first one was not communicated to the internist following the patient, who resigned from the case, he was so angry.  Bad systems cause trouble.

My pharmacy experience is is one reason why so many of us are so angry about medical care today.  It doesn’t work properly.  Systems are broken, and it costs money and time, and makes people frustrated and angry.  While time is supposedly money, it isn’t to me.  It has uncountable worth.  Unnecessary anger and frustration are uncountable expenses.  Being uncountable does detract from their importance, a fact lost upon many today.

Thirteen years ago, I bet my career on becoming one who taught people how to fix bad medical systems, and I lost.  Here is how medical errors have affected my small family:

My mother’s final illness began with a fainting spell.  She was taken to the hospital where we were told her CT head scan was normal. Five months later, 1500 miles from home, her rapidly progressive dementia led to a fall, breaking her hip, and she was delirious after surgery.  I had to fly to Portland, put my abulic (more than dementia, destruction of personality) mother, recovering from a broken hip, on a plane, and bring her home.  At the same hospital, we discovered she had refused the initial CT scan, and nobody had told us.  Worse, the attending physician later changed the note on the chart (the note that said “CT normal”), which is illegal.  Three more days (uncountable cost) were spent in flying to Portland (countable), to bring my parents’ car home.  My mother died soon after, so the error probably didn’t matter much, although the way she died still bothers me (uncountable cost).

My oldest brother’s meningioma was misdiagnosed until he went blind in one eye.  He is a professional photographer, so this is a significant issue (uncountable cost).   I am hoping the meningioma doesn’t grow further and kill him, because he refused surgery.  That might not have been a bad idea, given the location of the meningioma and given how complex medical procedures are.  After all, if we can’t deal with prescriptions properly, what is the probability of a successful operation?  Are there data? Or is it just anecdotal?

During my father’s final illness, he had low protein and edema so extensive that it literally wept through the skin on his legs.  Despite that, his nurses said he had heart failure.  I tried to explain to the head nurse that a lab test to measure protein was overdue,  that I was not the enemy, only wanting to ensure my father got the care he needed (uncountable cost, except for the lab test).  The response from the head nurse was “Let doctor take care of it.”

In my language, doctor takes a definite article.  For an unknown reason, omitting it annoys me.

I had a significant mistake made in my own medical care which led to 2 months of the worst misery I have ever experienced.  The medication for this condition is the one I have been trying to get at the pharmacy.

We argue about insurance reform, but we waste countable billions on bad systems;  suboptimal care, unnecessary deaths, and the uncountable cost of unnecessary frustration.  A family member of mine may need chest surgery and stay overnight in the ICU.  I will sleep there.  Many doctors would agree with my decision.  If you can possibly afford the time, and remember, my time is not important, you need to check everything that is done.  Medicine is complex, although we have other complex systems in society which work a lot better.  “We’re different from them,” say my colleagues.

Yes, we are different.  We don’t fix our bad systems, and we marginalize those who try.  I am proof of that.  Once I left medicine, I heard horror stories from just about everybody I spoke to.  Many of these may not be true, but tell me:  how many people each year die from medical errors?  We have estimates, but they are poor, which to me is a travesty.  With sampling or a census, ability to keep the findings from discovery, we could review each death from each hospital and sort it into:  definitely caused by medical error; significant, but not fatal, medical error; not significant medical error; no medical error.  Each chart could be reviewed, and we would have a superb estimate of the number for a calendar year by January 31 the next year.  Additionally, we would know what the errors were, and we could learn from them.  Legislation to do this was written by me, had 10 co-sponsors in the Arizona legislature, which was 8 more than the number of doctors who supported it.  The Hospital Association killed the legislation.

We physicians want malpractice reform, yet we act as if bad outcomes are just bad luck.  They are usually due to a concatenation of bad systems that can be fixed, not tolerated.  How many and what kind need only to be counted.  To people like me, who live and breathe numbers, “count” is always modified by the adverb “easily”.

Instead, I have encountered verbs: to marginalize, to ignore, to frustrate and to fail.

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