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SAVE EDUCATION BEFORE SAVING PAR

April 18, 2010

Last week, I volunteered to teach an adult education course at Heritage Highlands.   Regrettably, few people showed, because a golf tournament occurred simultaneously.

That epitomizes Arizona’s attitude towards education.  Sports matter.  Schools and learning don’t.  Look at the space devoted to each in the media.  Compare salaries of coaches and teachers, then ask who influences more individuals.  Having been both a substitute teacher and a classroom volunteer on successive days in the same school, I know what teachers do.  Rich retirees need to volunteer in the schools, teach reading or otherwise give back to the community, in addition to playing golf.  Make no mistake, nearly all of us receive more from America than we give, Social Security heading the list.  The exceptions are those public servants and military who risk and give their lives.  And only 7% of us are veterans.

If ever a time to prove it takes a community to educate a child, this is the time.  If ever America needed an educated citizenry to compete in a fiercely competitive world, this is the time.  If ever education needed money and volunteers, this is the time.  If ever we needed parents to make education a priority for their children, motivating them to study, dress, speak and write well, this is the time.  The teenage brain matures later than the body.  We must recognize that fact and understand that teachers alone cannot mandate proper behavior.

We need to pay for education with money and time.  An educated society wouldn’t have tolerated keeping Iraq war spending off budget.  I don’t recall the anti-tax crowd, most of whom supported the war in 2003, serving or demanding fiscal honesty and responsibility from the previous administration.  But suddenly they are using precisely that reason to destroy public education.   How many dollars we need for education depends upon how many of us are willing to volunteer.  Regardless, I want my taxes go to education rather than to unwinnable wars and impossible nation building started by old men who never served one single day abroad in uniform.

It’s time to embrace what Horace Mann wrote 172 years ago:  the public should no longer remain ignorant; education should be paid for and controlled by an engaged society; classroom diversity is important; schools should be non-sectarian; children should be taught the values and spirit of a free society; and there must be well trained professional teachers.

Sales tax raise?  Absolutely.  Triple it for luxury items.  Income tax?  We need a marginal tax rate of 90% for income over $3 million, comparable today to the 90% rate over $400,000 under Eisenhower, a Republican.  It might decrease greed.  Saving Arizona and America is more important than saving par.  We must spend whatever required to ensure we graduate students who meet reasonable standards to move to the next level.  Cutting education funding is about as stupid as it gets.  But that’s Arizona.  And that is why we’ll leave.  Enjoy your golf.

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TOUCHING OTHERS

April 8, 2010

I never knew Jamalee Fenimore or Stephne Staples.  Nobody who reads this knew them, either.  Both of them loved the Sandhill Cranes, as do I.  Both have a viewing blind named for them at Rowe Sanctuary in Gibbon, Nebraska, at the southern bend of the Platte River.

Every spring, the Sandhill cranes and the Whooping cranes, the most and least common of the 15 worldwide crane species, begin their 5000-7000 mile migration to the subarctic in North America and Siberia.  Their final staging area is on the Platte River.  They go to the Platte because there is food nearby–formerly small animals but now mostly corn–and because of the safety that one of the largest braided rivers in North America offers.  They feed in the adjacent fields by day and roost in the river by night, where the shallow water allows them to hear predators approach.  Before the Platte was dammed and water used for irrigation, recreation and drinking, it was a mile wide and an inch deep, too thick to drink, too thin to plow.

Now, the Platte in many areas contains less water and has invasive species and many trees growing nearby, limiting the habitat to 50 usable miles from the formerly 200.  Rowe Sanctuary owns 4 miles of river and 1900 adjacent acres, which has been preserved as habitat.  Every night in March, up to 600,000 Sandhill cranes, 90% of the world’s population, roost in the river.  And every morning, they leave.  It is a spectacle that Jane Goodall has called one of the world’s best.  I’ve been fortunate to have seen many great sights in nature.  This one is in my top three, seeing a solar eclipse and a wolf in the wild being the other two.  I love seeing it so much that I volunteer at the Sanctuary, along with dozens of others, helping the full time staff of four–that’s right, four–show visitors the cranes from viewing blinds, for cranes are hunted in every one of the 17 states they pass through except Nebraska.

Many talk about the cranes that migrate to Arizona.  I just say, “You don’t understand.”  And you can’t, until you witness the occasional flocks of fifty thousand cranes, darkening the sky.

Stevie Staples mentored one of the Rowe Staff and lived 74 years, dying in 2006 from cancer.  She was a former canoe racer and a real character.  I once raced canoes, and I would have loved to have discussed racing with her.  She touched the people at Rowe.  She knew that, for she did live to see a beautiful picture of a Sandhill Crane in flight with her volunteer tag with “9 years of service” on it, because a picture of her receiving the picture is on a desk of the person she mentored.

Jamalee Fenimore grew up in Nebraska and practiced veterinary surgery in Washington state.  She died of cancer far too young at 49, donating her estate to Rowe.  Nobody at Rowe knew or remembered her being there.  But obviously, she was touched by the river, the cranes and the sanctuary.  We volunteers learn that we may touch visitors in ways we never know.

When I volunteer at Rowe, I work 17 hour days, sleeping on the floor in the sanctuary so I can hear the cranes on the river in the middle of the night.  I guide people to the viewing blinds, I clean toilets, paint, greet people, and now am setting up “Nature by the Numbers,” where we hope to show teachers and students how math and science are used in the real world, so we don’t lose our connection to nature.  The escaped, illiterate slaves used the North Star on the Underground Railroad.  How many of you readers can find the North Star?  How many of you have slept under the stars, how many bird species or constellations can you identify?  What is the Moon’s phase tonight?  How many large mammals, excluding deer, have you seen?

On my last tour, I took a disabled person to Stevie’s blind in an electric golf cart.  Had he been able to walk, all of the group would have gone to Strawbale blind, which was the plan.   But we still saw many cranes, American white pelicans, and unusual behavior.  My rider loved the view and tried to tip me, which I of course refused, asking him to put the money in the container at the sanctuary.  I planned to talk to other clients, because as the lead guide, I hadn’t spent time with them.  But I spent time with this man.  He was originally from Singapore; when I told him I had been there twice, his first comment was “Thank you for saving my country.”  I’ve never heard that before, and it did me good.  I hope I and Rowe did him good.

We touch each other in ways we may never know.  Good people spread kindness throughout their world.  The lucky ones receive that kindness or are those who live long enough to discover that their kindness was deeply appreciated and honored.  But all who spread kindness are fortunate that they have the ability to do so.  Stevie knew in her final days that her kindness was appreciated.  I hope Jamalee Fenimore did, too.  But if not, I know she knew she was doing the right thing.  I deeply appreciate what she did.  And every time I guide people to either of the two blinds, I tell them the story. Both women deserve to be remembered.  And to have a viewing blind named for you on a river where a half million cranes visit every March is a wonderful honor.  It also reminds me of my duty.

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SANDHILL CRANES+2 WHOOPERS, 2010, PART II

April 7, 2010

This site is still under construction, but the You Tube videos are worth seeing:  the first shows a brief version of a pair dancing.  This is to release stress, to bond and to release hormones.  I can’t help but think it is just pure joy as well.  The second is at http://www.youtube.com/watch?v=vLQTOIt_gBM and shows the first plus about eight more minutes of the birds calling.

I went to Rowe for the beginning of the crane season, but it was a very cold winter and the birds didn’t show up until March 1.  I had a few great views, but left before the season really got going.  I felt like I had unfinished business on the Platte and went back at the end of the month.  I worked 17 hour days, slept on the floor in the gift shop (so I could hear the cranes on the nearby river when I woke up), cleaned toilets, led and assisted on viewing blind tours, washed dishes, and basically did whatever needed to be done at Rowe Sanctuary.  Even ran the Crane cam one night, which is on Rowe’s home page.  I haven’t felt so alive in a long time.  Rowe has a full time staff of only 4; there are many local volunteers and folks like me who come from a long way off to help in any way they can.  I felt blessed and very fortunate.  Also saw two whooping cranes at a long distance, so the pictures aren’t great.  But I saw them.

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IN ANOTHER LIFE? NOPE, GOTTA BE THIS ONE.

March 11, 2010

“In another life, I would have been a good math teacher,” I once told a teacher friend.  I don’t believe in another life, but I still have this one and realized I can become a good math teacher.  I now substitute; based on my training and experience I ought be allowed to teach full-time.

I’ve often felt I never belonged in medicine.  Indeed, looking back on what has given my life meaning, medicine ranks a distant fifth–yes, fifth–behind my wife, allowing my parents to die the way they wanted, the companion animals I’ve taken in and my experiencing the beauty of nature all over the world.

I did belong in medicine, just not here.  I belonged in medicine where physician training was geared towards dealing with patients typically seen in practice. Surgeons are trained in and do surgery; radiologists interpret images; ED physicians field emergencies; dermatologists treat skin disorders.

I mistakenly thought that neurologists were consultants who treated neurological disease.  Nearly half of my new patients had limb pain, spine pain, dizziness and headache.  I counted.  In my training, I learned little about headache and spine pain and nothing about dizziness and limb pain.  Yes, we need to learn rare diseases, but we also need to learn how to treat the common ones.  I had learn it myself.  Too many patients with carotid artery disease were sent directly to surgeons, bypassing me.  Yet, in 1984, I had city-wide data showing a 15% major complication rate for carotid endarterectomy (CEA), much worse than medical management.  I sent my referrals to the only surgeon whose outcomes beat medical treatment.  Locally, the complication percentage didn’t change during the next decade.  I counted.  I used outcomes data years before it was a buzzword and got blasted by my colleagues for using it to help my patients. I diagnosed and successfully treated depression a decade before it was mainstream, when still equated with being “crazy.”  Got blasted for that, too, by patients, expecting a deadly neurological disease (which it is).

Much of my practice consisted of patients with normal tests, post-surgical disasters and chronic pain; the last I was unable to help.  I was not taught how to diagnose irreversible brain injury, discontinue support and deal with families.  While I was trained to treat epilepsy, most of the seizures I saw were psychogenic.  I counted.  In 1982, I proved statistically that perceived I’m-not-at-fault injuries dramatically increase the likelihood of chronic pain.

I belonged in medicine where counting was valued, not mocked, and we tracked important matters, like CEA morbidity and clean case surgical wound infections.  I developed a non-discoverable reporting system for errors, so we could learn from and not hide mistakes.  More legislators backed my bills than doctors; had the bills passed, we would have advanced the cause for liability reform, because they were primarily about helping patients, not decreasing premiums.  Ironically, four immediate family members have suffered consequences of medical errors.

I was frequently asked “Are you busy?” but never “Are you happy?”  Yes, I was busy–and no, I was not happy, because I was rushed, interrupted, and chronically tired, three classic setups to make errors, in order to pack in another “emergency,” an overused term increasing stress, cost, shortcuts and mistakes.  Some ED clerks were instructed to call every neurological consult “stat.”  I accepted that many neurological conditions couldn’t be helped; I grew weary of the many conditions neither diagnosable nor treatable. It took me too long to realize I could quit.  I never regretted doing so.

In a better medical world, we would fix the numerous faulty processes that decrease quality, increase costs and suck the fun out of life. We would review every hospital death to see if a medical error occurred.  With appropriate sampling, we would have a decent estimate, not the old, inaccurate infamous “100,000 deaths.”  I once thought my experience in practice, administration, quality, statistics and writing would make me a valuable local resource.  I was as mistaken, as those at GM who pushed for Japanese style quality outside of NUMMI.

My local and state medical societies should demand real-time data on breast and other cancer incidence, not difficult, rather than 4 year-old results (look it up).  We should have city/state-wide standardized checklist approaches to central line insertion/care, ventilators and pre-op antibiotics, to name just three.  Public health committees should discuss important issues they could influence: obesity in the young and annual motor vehicle deaths, the latter unnecessarily killing more local teens than Mad Cow, West Nile, mercury, terrorism, autism or kissing bugs combined.  My challenge to the committee to change its approach received one letter of support; I resigned.  Surveys, which I randomized for free, should take a quarter of a year, not a quarter of a decade, to complete.  Yes, 2.5 years.

My solutions aren’t perfect, but every one is better than what we have.  Waiting for perfection is like waiting for Godot.  I’m not a shaker but a mover, moving so far ahead I’m no longer visible.  In my lifetime, I will teach math, but in my lifetime I will neither develop nor see the medical changes that would have been so easy, effective and necessary.



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SANDHILL CRANES, ROWE SANCTUARY, 2010

March 3, 2010

After missing the 2009 season due to illness, I came up here on 25 February.  It was cold, snowy, and the Platte was frozen.  The only cranes I saw was a flock of 20 over Lincoln.  What they were doing over there is anybody’s guess.  Bet they wondered, too.

But the weather has changed, and here are some YouTube videos.  If you go to mrqssm, you will see all the videos I took.  The audio is outstanding, and the last was the best.

http://www.youtube.com/watch?v=inYeOS_Gm6k

What does a volunteer do?  Just about anything!  Rowe is part of Audubon, but they get NO funding from the national.  Everything they spend they must raise.  There are only four staff members–Bill, Kent, Tony and Keanna, and they are all very different people who work very well together.  They are the engine, but the volunteers are the fuel that make the place run.  Rowe needs people in the gift shop, showing people the birds outside during the day, somebody to run errands, to run the crane cam, to give crane lectures, to clean the place, sweep, clean the bathrooms, re-stock, greet people in the parking lot, do maintenance work, etc. etc.!!

I was early season, so there were few visitors.  What did I do?  Hauled a box spring through the upstairs window, since it wouldn’t fit going up the stairs.  I set up camouflage at two blinds, using drills and staple guns.  I re-hung 19 windows in one of the blinds, using drilling and various boy scout knots.  I made beds, cleaned bird poop off the building and the sidewalk, knocked down old nests, which led to the former.  I built an analemmatic sundial by the parking lot.  I got a complaint that it was slow, but that is because the Sun is running slow.  Or our watches are running fast!!

I helped Tony set up the Crane Cam upstream.  I got to play with great power tools, drive a beat up but serviceable pickup through rural Nebraska, saw Sun reflect off snow geese (yes, they are incredible pests, eating their way out of their habitat–like humans, I might add–but they are pretty) and had the blinds to myself morning and evening before season opener.  I hacked down weeds around three blinds with a retired Kearney math teacher, so we could talk math.

Oh yes, I got to meet Mike Forsberg, the renowned wildlife photographer, and was able to give him some information about moonrise azimuth.  I talked to him in a blind one night, just the two of us, the same day he signed a book he authored for me.  He then sent me five lovely pictures he took.  Was that cool or what?

And I got to meet loads of great local Nebraskans who come to volunteer there as well.  They were all great, and while a couple thought I was the Energizer bunny, it was only because I kept forgetting stuff and was running all over the place.  Want to do something good with your time?  Rowe needs volunteers!  Want to contribute to something worthwhile?  Rowe Sanctuary is a place to do so!

Some other pictures:

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‘No Child’ law undermines public education and must be reformed

February 23, 2010

When I was 18, I guided four canoe trips into the wilderness of Ontario’s Algonquin Park. I was in charge of several other teenagers for six days, paddling, carrying a canoe and a pack, navigating, choosing the campsite, cooking and first aid, one to two days travel from the nearest adult.

Today, at 61, experienced and competent, I cannot teach full-time with the nearest other adult a few yards away. For eight years, I have been an active volunteer in math at two high schools. At least 20 times, I have taught when a substitute did not know the material.

I want to do more, and there is great need. My father was a public-school teacher, principal and superintendent. I believe in public education; with liberty and national parks, it is one of three gifts America has given the world. If public education fails, and many legislators hope it does, we will destroy the middle class that is America’s strength.

I now have a substitute certificate. But I want to create a statistics course at a high school that needs one. I have a master’s degree in statistics and taught many semesters at New Mexico State, Pima Community College and other venues.

For four years, I graded the free-response portion of the national Advanced Placement Statistics exam; only three of nearly 400 graders were Arizonans. I have created a syllabus, prepared lessons, taught and graded. I’d teach the course for free if necessary, because I can afford to, and high school students should learn basic statistics.

But I can’t, because of No Child Left Behind (NCLB), even as children are being left behind in droves. I encounter them every day I tutor. I don’t see the many others who need help or mentoring and don’t get it, and those who drop out.

With appallingly inadequate funding, many schools nationwide remove problem students, gaming the system to survive. NCLB is like Clear Skies, Healthy Forests and Clean Coal: the intent of each perverted the name. I believe NCLB’s original intent was to close public schools, outsourcing education to for-profit charters.

Public schools need money, volunteers, evening and weekend hours, and an end to promoting those who aren’t ready. Teacher certification should mean demonstrated competence; demonstrated competence should allow certification.

A former neurologist, I saw many who practiced in my field with nowhere near the eight years of post-college training I had. But to teach full-time, I must return to school despite two advanced degrees and teaching experience using both. Where is the America I served as a shipboard Navy physician, the country that found innovative approaches to solve problems?

Public education, an American invention, needs help. The Iraq war was funded by an off-budget emergency authorization. Public education needs an emergency authorization. I don’t want to hear politicians say “children are our future.”

All I ask is to serve young people and America to my fullest potential. And make NCLB a literal reality.

Michael S. Smith has taught statistics, neurology, reading and astronomy. E-mail him at michaelspinnersmith@gmail.com


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LILLIPUTIAN LESSONS

February 7, 2010

Foregoing the elevator, I went to the stairwell at the Nairobi Intercontinental, ascending to my third floor room.  When I reached the spacious second floor, there were a dozen hotel workers taking a break.  When I appeared, an old white western guy, the scene got–shall we say–awkward.  Their conversation stopped.

I smiled and said, “Jambo,”  an all purpose Kenyan greeting, one from the heart, my guide, Danson, told me several days later.  I heard several “Jambo’s” in return, and tension left the stairwell like air from a popped balloon.  I continued up the stairs, and they continued their conversation.  Trying to speak the language in another country is a sign of respect.  “Jambo,” told the men that I was cool with the situation, I knew a little KiSwahili and was a guy who respected Kenyans as people, not former colony inhabitants.

One of my big regrets in life is never having learned any foreign language well.  Still, within 12 hours of arriving in Nairobi, I could count, say please and thank you, and “Jambo,” which I used a great deal, along with “Hakuna Matata,” the Kenyan version of “Don’t sweat it.”  My French in France was not appreciated.  But my Spanish worked in Spain (and not badly in Italy, either), and the Filipinos absolutely loved it when I spoke Tagalog, 35 years ago.   I blew one vendor away with my “Hindi ako kumakain nang barbeque dito,” essentially stating I wasn’t interested.

At Lake Nakuru, I showed several lodge staff the annular solar eclipse through solar filtered binoculars, the eclipse being the reason I traveled to Kenya.  I love eclipses, and I love showing them to people and explaining the phenomenon.  Many were flat out amazed a guest would take an interest in making sure they could see something that almost certainly they will never see again (the November 2013 eclipse will be partial in Kenya).  In the short time I was there, many called me “Mr. Mike,” an appellation I particularly like, since it simultaneously shows respect and liking.  I told one waiter my age was sitini na moja, (look it up!)  It took him a few seconds, but he got it, and later (in English) talked to me at length about the lodge.  Danson later told me that I had made a big impression on the staff, one of the nicest compliments I received.

People are people.  Just like me.  The Kenyans have a life, a far more difficult one than I can imagine, but they are still people.  Unlike us, they have a beautiful memorial site for their disaster of 7 August 1998. Also unlike us their cellphones work everywhere.  I texted the eclipse phenomenon in real time back home. My text immediately went through from Jomo Kenyatta airport; it didn’t from Houston’s Intercontinental.  Not infrequently, I get “No Service” from Campbell and Skyline.  So who is Third World?

When I left practice in 1992 to take a leave of absence, I received many notes, cards and letters.  The one I remember the most was from a dietitian, who was also leaving to go to pharmacy school.  She said, “You respected the little people.”  I tried to.  I was taught at a very young age not to beat up on those who can’t defend themselves (nurses, custodians, aides), which I have done and for which I have been ashamed.  I’ve seen too many physicians and others in power who beat up on people, and I remember taking the brunt of it when I was an intern scrubbing on a bypass case.  It was difficult to hold the retractor properly when my eyes were filled with tears.  I was thanked only 5 of the 12 times I scrubbed with those two surgeons.  I was the little people, and I never forgot that treatment.  It was so bad, I got blisters on my hand from learning how to take a hemostat off a piece of wet kleenex with one hand without tearing the kleenex, so I wouldn’t get yelled at in the OR.  And I mean yelled.

I finally got some revenge.  On a later case, with the pair, I had my thumb too far through a hemostat.  “Don’t hold your instruments like that, Smitty,” one yelled (a term I detest), “you don’t hold your silverware like that, do you?”

“I don’t use silverware,” I retorted.  “I use my fingers.”  That was the end of that conversation.  When they quizzed me on anatomy, which I happened to know cold, I spat the correct answer back at them.  After three correct answers in a row, they left me alone.  One later had a nervous breakdown; both must have been incredibly unhappy people.

I always thanked nurses for helping, I tried to clean up after myself, and if you read Code Team on my blog, you will discover what other things I cleaned up in the hospital.  But occasionally I lost my cool.  We all do.  I just tried to remember to apologize when I did.  And if one is polite most of the time, he or she can easily be forgiven for a lapse.  There just can’t be too many of them, and an apology,must be coupled with a change in behavior.

When you’ve been at the bottom as many times as I have–undergraduate, medical school, internship, residency, graduate school and now teaching, you understand a lot better what it’s like being the little people.  That gives you two choices:  to haze those below you or to break the cycle.  I’ve tried to choose the latter.

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WEARING RED

January 7, 2010

“For them is sweat and toil, hunger and thirst, and the fierce satisfaction that comes only with hardship.” Sigurd F. Olson (1938)

Forty-five years ago, after three summers at Camp Pathfinder, a canoe tripping camp in Ontario’s Algonquin Park, I became staff, “third man”  on canoe trips.  Being staff was different.  I no longer knelt in the bow, looking for rocks and setting the pace; I was in the stern, responsible for steering, orders and keeping up with the other canoes.  When we reached the portage,  I flipped the 90 pound canoe over my head, carrying it anywhere from a few yards to four miles.

I no longer had to wash dishes, only chop wood and help cook.  But I had difficulty with my new role.  I abused my new power by excessively bossing campers.  So, on my second trip I was third man under a second man who had never been a camper with my experience.  That hurt.  On my third trip, 14 difficult days, I struggled so much that I didn’t ask what my rating was.  Instead, I snuck in the cabin one night where the ratings were kept, and saw mine:  “He needs a LOT more tripping experience.”  I never forgot the pain of seeing those words by flashlight.  They were true.

The next year, I was 17, stronger, and vowed to do better.  I was sent out as second man, paddling and carrying well, kinder to campers.  I realized that my job was to ensure they had a good time on the trip, even as they worked hard, for hard work is what makes a canoe trip so satisfying.  On the first day of one trip, the head man and third man were hung over from a previous day off, and I had to keep telling my two canoe mates to slow down so we wouldn’t lead the trip.  When we reached the dreaded 1 1/2 mile Iris-Alder portage (named for the lakes it connected), I was allowed to go first.  I blasted over the wooded, rocky, swampy, hilly trail in 20 minutes, canoe on my head, well ahead of everybody.  I was second man for 3 more trips that summer.

There was a hierarchy of neckerchiefs worn by the staff.  It was an unwritten rule that nobody but a head man wore red, second men blue.  Pathfinder was and is known for its challenging trips and its red canoes, which today are part of their e-mail address.  That summer in 1966, I wore blue.  To entertain the campers, I thought up games like tree golf (I won’t describe it) and told scary ghost stories around the campfire.  When a camper’s asthma flared up on one trip, the head man and third man took him to help, several hours away.  I was left in charge, nervous, but thrilled to have the responsibility.

My ratings were good, and my last summer, I was promoted to head man on short trips.  I bought my red neckerchief, proudly put it on, and at 18, took 8 other lives under my care into South Tea Lake.  I navigated, carried canoe and a pack together, chose the campsite and cooked the meals.  The trip was only three days, and I was familiar with the area so that navigation wasn’t a problem, but I was in charge of two other staff and six pre-teen boys—no adults anywhere.   Even today, I am amazed that I was given such responsibility at my age.

Command changes one’s perspective.  When the campers swam, I counted heads, over and over again.  If I didn’t see one, I got everybody to stop playing until I was certain.  As head tripper, I had to decide the menu, time the meal right, and make special goodies, like fudge, which was how everybody rated a head man.  And every night in the tent, I listened to every sound, anybody crying out, responsibility weighing heavily on me.

Back in camp, I wore the red proudly, the way an airliner captain wears four stripes, or the commander of a naval vessel wears the five pointed star in a circle on their right chest pocket signifying current command at sea (left pocket for former command).  I took a second trip as head man, the responsibility still weighing heavily on me.  Two days after that trip, I went out as second man on a better trip, just like a pilot of a 737 becoming a co-pilot on a 747.  I put my blue neckerchief back on, helped outfit, did my job well, and made sure the campers had a good time.  I never wore blue again.  In late summer, my fourth trip as guide, I took six men six days on a super trip to Pine River farm and Big Trout Lake.  I didn’t remember all of these trips, but Pathfinder’s Web site lists them going back to my era.  My fondest memory of my final trip was a day a camper couldn’t carry his pack, so I carried it and my canoe—at least 140 pounds—a half mile with no trouble along the slippery shoreline of the Tim River.  To this day, I have worn the red neckerchief on nearly all the 60 additional canoe trips I’ve taken. Occasionally, I put on the blue as a reminder of the days I wasn’t in charge and what I had to do to earn red.  I have no other colors in my collection of neckerchiefs.

I practiced medicine for 20 years, a hierarchy if ever there was one, but I never once thought about the red neckerchief.  I wish I had.  For the past eight years, I have been a volunteer math tutor at two high schools, never being as busy or as in demand as I had hoped.  So this year, I set up a program to be an on-call volunteer substitute math teacher, teaching when the substitute was unable to do so.  I have taught twice, and that is a huge step up from tutoring, like being staff.  But I still felt I was wearing blue, not red.  I wanted to be in charge, to take full responsibility for running a class, even if only for an occasional day.  I got my substitute certificate and waited.  One day my call came from a statistical colleague, wanting me to teach AP statistics, sports statistics and his algebra 1 class.  I looked at his lesson plans, made modifications that I felt might help, and went to school to teach–by myself, no certified substitute in the room.  I put my red neckerchief on the desk beside me.  No student noticed it, but I looked at it frequently.  As expected, I made some mistakes that first day, but one of the students left the class saying, “You’re the best sub we’ve had all year.” I won’t take the neckerchief every time I’m called, but I will take it often, to remind me of what being in charge means—the responsibility, the worry, the challenge, the chance to do well.  Most importantly, I will remember where I have worn red:  on the lakes and rivers of the Canadian Shield, from Algonquin to ANWR, and many places in between.  I will remember the rain and sun, bugs, moose, fish and loons.  I will remember those days at Pathfinder, the eyes of my fellow travelers reflecting the light of campfires from Little Island Lake to Big Trout, my being in charge of the whole trip.  I earned the red once, and I have earned it again, doing different work, once again in charge.

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Posted in 2010, COLUMNS IN "REALITY CHECK", MY WRITING, UNPUBLISHED OUTDOOR WRITING | 3 Comments »

AFTER ALL, THESE THINGS HAPPEN

January 3, 2010

A 52 year-old woman lies in extremis in ICU following a gastric perforation discovered after contrast is put through an NG tube. So what?  These things happen.  Yep, they sure do.  Here’s how this particular one happened.

The woman had an Upper GI four months earlier showing a paraesophageal hernia, where the esophagus went through.  The report mentioned the hernia, it didn’t mention its prediposition to gastric volvulus.  While one can’t mention every possibility in a report, it might have been useful to mention this particular fact.

Four months later, the woman presented with abdominal pain.  Her initial CT of the abdomen and pelvis mentioned the hernia and an ovarian cyst, but no comment was made about gastric distention or the type of hiatal hernia.  Unfortunately, the prior study wasn’t re-evaluated during the reading.  That was unfortunate, but many studies today contain a thousand images; indeed, a radiologist may encounter 100,000 images a day.  An NG tube was passed, and a second scan, with contrast, showed the perforation – really well.  Fatigue, the volume of images, hospital and referring physician demand for quick reads, compensation for number of studies (not images) viewed, make errors more possible.  Reviewing past studies is not compensated, so there is less of a  tendency to do so.  What do clinicians do if they receive a huge chart when a new patient arrives, inconveniently booked into a follow up slot?  Compensation is based on a numbers game; what game is played dictates what gets done well, what gets done, and what doesn’t.  Having been on both sides of the medical fence, I can easily spot a distracted, harried and hurried physician.  All three of these are a setup for cognitive errors, the single biggest type of mistake a physician can make.

The patient developed peritonitis.  Perhaps if fewer CT scans were ordered, it would be easier to routinely evaluate prior studies as part of the reading process.  Once having practiced neurology, I believe, and the literature supports, a person with intact cortical function, no neck pain, no tenderness to palpation and no neurological deficit doesn’t need a cervical spine CT after an injury.  Whole body scans are often done when clinical judgment would suffice.  Besides being a radiation issue, it is a time issue affecting emergency department throughput (we patients call it waiting), a money issue, because these studies are expensive, and a quality of care issue.  After my bicycle accident, I had several studies, but nobody took off my shirt to look at the road rash on my back.  Nobody palpated my entire body, since severe pain in one place may mask a significant injury elsewhere.  Those additions take perhaps thirty seconds.

Worse, if little clinical history is provided, it affects the type of study and the radiologist’s approach.  Differentiating PE from dissection makes a big difference in timing of the scan after contrast.  “Chest Pain” is not helpful to the radiologist.  Yes, you are in a hurry.  I was too.  But I always put clinical information on my neuroimaging requests.  The radiologists appreciated it.  I got better reports.  It helped my patients.

This woman survived.  The medical community ought to learn from this, rather than copping out and saying “these things happen,” “nobody’s perfect,” or “who made you the quality expert?”  “Nobody’s perfect” doesn’t cut it if a person dies from something preventable, either in or out of medicine.  You don’t hear the civilian or military aviation community say that.  They learn from the mistakes, and they publicize them.  Read a few sometime, and you would be surprised how much we could take away from their field, rather than the mantra, “We’re doctors.  We’re different.”

Rheumatic fever, polio and gas gangrene used to happen; 30 years ago auto accidents killed twice as many people per capita, anesthesia deaths were once far more common.  Sean Elliott and Alonzo Mourning would have died from uremia the way actress Jean Harlow did.

Excessive workload increases the likelihood of a radiologist’s not reviewing past studies and not dictating, “Paraesophageal hernias can lead to gastric volvulus.”  What does workload do to you in your field?  There ought to be a way that physicians can do a decent job, make decent money, learn from their mistakes and those of others, have a life and not fear lawsuits.  Here are a few thoughts:

It’s time we had community standards for common, high risk procedures that lend themselves to standardization: hyperalimentation, ventilator management, pre-op antibiotic delivery and central lines.  We can standardize and still respect individual differences.  It’s time disciplines who function together, like emergency medicine and radiology, work together.  It’s time to have legislation mandating a free from discovery error reporting system which I proposed in 2001 and which failed the legislature in 2004 and 2005; the hospital association worked to  kill it.  It’s time to have liability reform so physicians aren’t treated like criminals when they err.  Maybe if we did the first two and supported the third, we could get the fourth.  Along the way, we might additionally work towards complete medical coverage for childhood up to at least age 18 – with real-time data on outcomes and costs.  We might start having a better system.  Maybe we could expand age 18 to all.

And perhaps see fewer cases of preventable peritonitis.

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GOING NATIONAL! ON CAROLYN HAX, NO LESS!!

December 30, 2009

The scan didn’t come through well, so here it is the old way (goes with the old guy).

29 December 2009

On another such marriage–a.k.a. ” a couple of thoughts from an old guy.”

Here are a few rules I try to live by, and believe me, I’m no husband of the year.

1.  In relationships, the little things are the big things.  I say please and thank you a lot to my wife when she does the dishes I usually do or takes care of an errand I usually do.  If I clean the litter boxes (which she usually does), she thanks me.  It shows respect and appreciation, which are essential for a marriage to last.  I don’t say “I love you,” a lot; neither of us does.  But we do thank each other often and “please” is part of our house vocabulary.

2.  Take 100% percent responsibility for your part in any conversation.  That means instead of, “I didn’t say that,” you acknowledge that you did say that (maybe you really did–we all misspeak), not in a passive-aggressive manner, but that you truly believe that you did.  Then you can add, “What I should have said was….”  I’ve learned this defuses a lot of hot issues.

3.  I’m a “have to fix it” guy when my wife has a problem.  One day, long ago, I had no fix, so I sat there and listened.  Afterward, my wife thanked me profusely for just listening.  I didn’t think I did anything.  But I did a lot by keeping my mouth closed and my ears open.  Such a concept!

4.  When I mentioned that I was going to write you, my wife commented that when she came in at the end of the day,  I got up from the couch and kissed her.  Just that.  I never really thought it was a big deal, but to her it really is.

I wish I had known all this stuff 38 years ago when we got married.  Then again, I did learn it and, obviously, I’m still learning.  Makes me wonder what else I’m missing!  But at least I try.

I tell teenage guys to marry women smarter than they are; fortunately for them, that won’t be difficult.

Tucson

Posted in MY WRITING, OP-EDS | 4 Comments »

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