Posts Tagged ‘A different side of medicine’

DRUNK WITHOUT ALCOHOL: SLEEP DEPRIVATION

April 14, 2016

After the second long flight on the trip, from Tokyo to Singapore, we arrived in the Lion City about 1 a.m.  Fortunately, we had booked a hotel at the airport, and all we had to do was find it.

Biologically, it was about 10 a.m. the next day for me, and I had not slept well on the plane.  I seldom do.  Usually, my head flops over and wakes me up, and I couldn’t find a way to rest it elsewhere that worked.  Yet, I felt surprisingly sharp, as we walked through the terminal.  The terminal wasn’t quiet; indeed, the world isn’t quiet, even when it ought to be.

I wasn’t sharp,  although I didn’t realize it.  I had trouble finding the right tram, and the “T2” sign didn’t click with me as meaning “Terminal 2.”  I thought it meant “Tram 2.”  Nevertheless, we got to the hotel and slept a little.

The next morning, I realized how much clearer I was after even 5 hours of sleep.  There was so much I had missed in the airport the prior night.  I didn’t realize the shortness of the tram and the various shops present.  It wasn’t like I was totally stupid the night before, but I thought I had been functioning well, and instead I had acted like I was mildly drunk.

Exactly.

Being sleep deprived for 24 hours is akin to being drunk.

When I learned German online, I was often teaching English to people all over the world.  I was amazed at the hours when they were awake.  No, not the hours in my time zone, but hours in theirs.  People were up at 2,3 or 4 a.m.  I can’t fathom this.  I have often wondered if the one of the big problems in the world is that a good share of humanity is functioning half or fully drunk because they aren’t sleeping enough.  It sure would explain a lot of the world’s problems.

If I am separated from the felines who live with me, like when I take a canoe trip, I find I sleep even more than the 7 hours I usually get, although eventually I return to that number.

I knew sleep deprivation was bad when I was a physician.  I felt awful, the telephone’s ringing jarred me, I occasionally dozed, and I often sat writing a note on a patient, only to realize I was staring at the paper and nothing was appearing on it.  Had I been drinking and practicing medicine, I would have been thrown off the hospital staff.  Instead, they tolerated me for years functioning at a sub-optimal level, called “not enough sleep,” and actually expected it.  My partners did, my colleagues did, my teachers did, for the “giants” of medicine, those who in my view made the mess American medicine is, were purportedly able to function without eating, sleeping, or vacations.  They were held up as paragons of medical virtue.

The only bad evaluation I received as a medical student was when I gave the wrong order at midnight and fell back asleep.  The next day, the patient needed a ventilator.  I felt badly, for good doctors give the right order any time day or night.  I obviously was not good.

Eventually, medical programs recognized the need for doctors in training to get enough sleep.  Pilots have known about sleep deprivation for a lot longer.  The airline disasters in the Marianas and Colombia were in large part due to pilot fatigue.  Pilots take brief naps on long haul flights, for a nap has been shown to improve performance.  I wonder sometimes how many errors I made because I was too tired.  We all gave orders over the phone at night and had in the future to sign off our phone orders.  There were always orders I gave at say 3:27 a.m. that I had no recollection of  giving.  No recollection.  That’s scary.

More than one has teased me for the brief 10 minute afternoon nap I often take and have taken for years.  Because I have animals, I am up at 5.  I am in bed by 9, when most I know go to bed a lot later.  Indeed, I often wonder if they go to bed at all.  There appears to be a gap between 2 and 5 in the afternoon on the US West Coast, when the rest of the world is quieter.  Three hours.  Then in the evening the messages start, and when I awaken at 5, there are often messages sent to me at 1,2,3 a.m. as if I were awake at those hours.

Nope.  I’m not.  I can’t function awake at 24 hours.  Nobody can.  Oh, people can be awake that long, but they are kidding themselves if they think they can function.  They are missing things in life, because we just aren’t able to function normally.

TEASING

April 1, 2016

One Saturday night early in my internship, I was called to the cardiology floor to evaluate a patient with a fast pulse.  I walked into the room, today still able to remember what room and which bed he was in.  The man’s heart rate was about 150, and while he was tolerating it, he needed to have something done.  I hooked up an EKG, both confirming the rapid pulse rate and the diagnosis, atrial flutter, with 2:1 block, so the atrial rate was 300 contractions a minute and half of them were getting through to the ventricles.  Back then, before the anti-arrhythmic drugs we have today, massaging the carotid artery was one way to stimulate vagal tone and slow the heart rate.  Thinking I could see the EKG well, I started massaging the patient’s right carotid artery.

I can still see the patient as he had a seizure about twenty seconds later.  I took my finger off the carotid and he quickly woke up.  I looked more closely at what I thought I had been watching.  The vagal tone I stimulated was so strong that I blocked all atrial conduction, no longer 2:1 but rather 300:0, so that not one beat passed through the atrioventricular node to the ventricle.  I had put him into cardiac arrest.  Great job, Doc.  No pumping, no blood.  No blood, no brain function.  When the brain suddenly gets no blood, one of two things may happen: coma, which is the most common, or a sudden burst of electrical activity, a seizure. I once seized when I fainted.  A lot of “near death” experiences may be due to excessive brain stimulation due to severe hypoxia.

The attending showed up an hour later, looked at the patient, then the EKG, and finally me.  He held up the EKG, looked down his glasses, and quietly said, in a British accent,  “Are you the author of this?”  I was embarrassed beyond belief.  The patient was moved to ICU and fortunately made an uneventful recovery.

My misadventure with a patient’s neck was the butt of many jokes for the rest of my internship. For days afterward, every one of my fellow interns, when they saw me, would rub the side of their neck. Even today, I would be willing to bet money if one of the interns I knew saw me, the first thing he would do is put his hand on the right side of his neck and act like he was rubbing it.  He did that every time he saw me for the rest of the year.

The first few times it was tolerable.  Then, it became annoying and finally hurtful.  I admit it.  I screwed up.  Do I have to be reminded of it every time you see me?  What do you want?  Should I admit to being the worst doctor in existence?  Would that help?  Should I quit? Would that help?  Why are you doing this to me?  Have you never made a mistake?

Later, in practice, I saw a psych patient whom I was convinced didn’t have anything neurological going on.  A nurse disagreed, and she was proven right; the CT scan I ordered showed a large, benign brain tumor, which had caused the person’s problems.  I might add while this is always a consideration, I only saw twice a benign tumor causing psychosis in all the years I practiced.  Oh, I diagnosed the other tumor.  For years afterward, the nurse reminded me of my mistake.  Stuff like that hurts.  It starts to eat away at a person.  OK, I missed a tumor.  I am a bad person, a bad diagnostician, a bad doctor, and on and on up the ladder of inference.  Do you continue to  have to remind me?  Does anybody remind me, I wondered back then, about the diagnoses I did make correctly, the patients I did help, the times I was right and others were wrong?  What about the case of Wilson’s Disease that I diagnosed on the first visit in the office?

Teasing is toxic.  Maybe in small doses, it is fine, but only in small doses.  Let the individual poke fun at himself or herself.  And perhaps that is why I behaved the way I did last February 2, when the hike leader gave me a stuffed toy of a groundhog and told me quietly to start hiking before everybody else and put the groundhog on the trail somewhere where it could be seen.  About fifteen minutes up the trail, I stopped and placed the groundhog on the edge in the sun, because frankly I wanted six more weeks of winter.  I like rain; I haven’t seen enough of it in decades.

I waited, and when the first group of hikers arrived, one looked at the groundhog and pulled out his camera.  He was dead serious.  “Wow, a groundhog is up here!”

I thought he was kidding.  He had to be.  But the furry thing did look kind of real.  I quietly walked over and put my hand down on the stuffed animal.

“Oh my God,” the hiker said. “I fell for that.  I can’t believe it!!”  I didn’t say anything.

And I haven’t since.  The individual has mentioned the groundhog event to several people, but I have stayed quiet.  Sure, I could have teased him about it, but a long time ago, I learned what I should have known all along:  a good deal of teasing is toxic.  It hurts, and it isn’t appreciated, no matter what people say.  “Can’t you take a little teasing?” I heard as a kid.  I should have replied, “Can’t you take a little poison?”

EERO, EPOR AND THE 577R ALLELE

March 2, 2016

It did me good to read that Finnish skier Eero Mäntyranta’s success in winning seven Olympic medals in cross country skiing was likely due to a genetic mutation that increased his oxygen carrying capacity 25-50%.  He wasn’t the only Finn who was this fortunate.  I wondered at the time why Americans never were on the podium in those events.

It also did me good when I read in Outside about a man who could hold his breath six minutes—yes, six minutes— and used that skill to dive to tag threatened hammerhead sharks.  A comment was even made by Laird Hamilton that this man was unique.

Hamilton, one of the great big wave surfers, is unique, too.

It did me good to read that virtually every Track and Field star has the 577R allele in some form, enabling them to do things that the rest of us can’t.  It isn’t a matter of training harder, as some have told us, or “mental toughness”; nope, it’s genetics.  Now, that doesn’t mean one can’t train and improve.  There was evidence that Lance Armstrong improved his muscle performance 8 per cent through training.  Unfortunately for the sport, he improved it another smidgin by taking drugs, although he was far from alone.  All Tour de France riders are genetically exceptional, and at the top of the top, a fraction of a per cent advantage matters.  Some argue that genetic mutations don’t make for a level playing field. Well, we aren’t all created equal.

For years, reading about all these guys and gals who could do everything from surf to big wall climbing made me feel inadequate, despite my wondering that these skills were genetic.  Now it’s clear.  You either are born that way or you aren’t.  Nurture is essential, mind you, but nature creates a few special people every generation.  I am not one of them and never will be.  On the other case, I’ve never taken performance-enhancing drugs.  I was drug-free.  Maybe there is a genetic mutation for that, too.  Or maybe good nurturing teaches one not to cheat.

For most of my life, I tried to play sports well.  I am competitive.  But I have a modest ceiling.  My medal in 1966 for the third place 400 yard freestyle relay at the Delaware state swimming championships was my being a moderate size fish in a puddle, since Delaware, besides being the first state, is the second smallest.  I played baseball but never thought to try out for the team.  Basketball? I played third string in the city league, although one fabulous day I hit 20 free throws in a row at a schoolyard.

In cycling I was in the top 14% of the El Tour de Tucson 109 mile finishers.  That meant I placed about #736.  I trained long hours and had done all the right things; my result wasn’t bad, but hardly noteworthy.  In only one sport—skiing—was I good, and that was because I started young, took lessons, and had a lot of days on snow.  I was an excellent technical skier, but I couldn’t race well.  As a kid, I dreamt of being a pro baseball player; I never once dreamed of being a top skier. I was neither.

I feel better knowing that when I watch a track meet, or a good basketball game, I am watching people with chromosomal genetic code that I and nearly all others do not have.  More importantly, I understand the pain of those who train and train and train, but they didn’t have the right 577R allele to be part of the U.S. Olympic Team.

I feel better knowing that I was right when I argued with my cycling friends that it was genetics that made top riders.  All the training I did made me better and faster, but I reached a low asymptote.  I do believe I have a slight genetic advantage for endurance. I did a 200 mile bike ride once in just over 12 hours. In the 2002 Cochise County Classic, I was part of a small group that had our own support, and from mile 100 to mile 160, the end, I was pulling at the front two-thirds of the time, stamping out a solid pace, seven riders in my slip stream,  as we finished in about 8 hours, averaging 20 mph.

I was sixth out of 20 finishers.  Not even podium.

I was right when I argued that if I could be a top cyclist by training, anybody could multiply three digit numbers in their head, the way I do, simply by training.  That stopped most arguments, because people knew then that my skills were genetic.  Sure, I practiced math a lot, but I had this stuff in my genetic code from day 1, just like Yo-Yo Ma and cello;  Laird Hamilton in big wave surfing, Chris Froome in cycling, or Stephan Curry in basketball.

We should celebrate these people, and we do, paying them good money and cheering for the the ones we like to succeed.  No doubt they eat right, they train right, they do everything they can to reach their potential.  Some do it better than others, and they are household names.

I no longer feel inadequate when I read about these people who grace the articles in Outside, Sports Illustrated or Golf Digest.  I am reading about genetics, what how random mutations can positively affect performance, and—I think—to a lesser extent what training does.  Training is what we can control, and allows us to do reasonably well, be it learning a language or hiking up a mountain.  None of us will be noteworthy except maybe in our small group.  Nope, it is the mutations who make the stars, the names we know.  They work hard, to be sure, to separate themselves from other stars, but they are in a league of their own.

Now all we need is a mutation that leads to idea generation that would fix the rest of the human race, so we wouldn’t trash the planet and drive ourselves to the brink of extinction, which we will.

Maybe it’s time for better nurture.

THE DIFFERENCE BETWEEN FAIR AND FAIRLY

January 24, 2016

I travel all the time but have not paid the $100 for the TSA pre-check. However, I get selected for this line in LGA more often than not. I think that they (Delta) know the frequency that I travel and do not consider me a risk. I will tell you that it ticks off the people on my team that have paid for the service.

This was a recent Facebook post from one who was randomly chosen to use the TSA pre-check line. TSA does this to encourage more to be pre-screened.  It cost me $84 to get mine, and I had to drive to Roseburg to be fingerprinted, but the few times I fly,  I don’t wait in line.  I am at an age when convenience is worth a lot, even if I can’t attach a dollar value to it.

“It ticks off the people on my team that have paid for the service.”  In other words, somebody got something for nothing, They had to pay for it, IT IS NOT FAIR, IT IS WRONG, AND IT MUST BE CHANGED.

Fairness is an American obsession.  Many want to end Food Stamps, now SNAP, Supplemental Nutrition Assistance Program, because a few have abused it to buy things they shouldn’t have. Food Stamps is one of the least abused, most useful of all federal programs.  Still, any unfairness bothers people.  In Kentucky, able-bodied adults between 18 and 50 with no dependents must work, volunteer, or take classes for 20 hours a week for SNAP.  Heaven forbid somebody get something for nothing.  Many can’t find jobs, and I know first hand the difficulty to find volunteer opportunities. If we want “must work programs” let’s have mandatory national service for the young and able-bodied on welfare with an organized list of thousands of jobs, thousands of supervisors, so that we can fix infrastructure and support the three gifts America gave the world: liberty (military service), the national parks (build trails, fix the backlog of jobs), and public education (help in the schools).  Then let’s pay them by giving them a reasonable stipend followed by four years of education in a field of their choice after completion of their duty.  Such work gives people dignity, and I can’t attach a dollar value to dignity, either.

Because somebody cheats on welfare, many want to disband it. One should pull himself up by his own bootstraps, by golly.  This is difficult if one doesn’t have shoes, let alone boots. If we tried to enhance family planning, rather than trying to destroy it, we would have fewer children, less poverty, and require fewer jobs.  Freeloaders are employers who come to a city lured by tax breaks, not single women with children on welfare.  Every corporation that skirts IRS laws is a freeloader.

In college, I discovered for the first time in my life that hard work didn’t bring success and good grades.  It wasn’t fair, but life isn’t. When asked whether it was fair to call Reservists up for duty in Vietnam, JFK replied, “There is always inequity in life. Some men are killed in a war and some men are wounded, and some men never leave the country, and some men are stationed in the Antarctic and some are stationed in San Francisco. It’s very hard in military or in personal life to assure complete equality. Life is unfair.”

Want to know something that wasn’t fair?  Read Paul Kalanithi’s “My Last Day as a Surgeon” or “How long do I have left?”  He was, the past tense a sad way to refer to a remarkable human being, a neurosurgical resident, diagnosed during his training as having Stage IV non-small cell lung cancer.  He died two years later at 37.  As a resident, he was a skilled communicator and physician.  He learned in his last two years of life to enjoy the simple things as realizing his reassurance of a patient mattered.  He was a physician-scientist who could have been a writer, too.  It wasn’t fair that he died so young.  He quoted his chances of getting his disease: 0.00012%

As a physician, a lot of my stress was seeing people who had medical problems that weren’t fair.  I saw the 55 year-old at 2 a.m. with a sudden onset of a Grade V (the worst) subarachnoid hemorrhage, who was going to die. Not fair.  I saw a colleague develop a glioblastoma multiforme, which killed him at age 52. Not fair.  Or the 41 year-old man who in the ED at midnight, with a big stroke, whose wife said, “He’s going to die,” and I remained silent, because I knew she was right.  Not fair.  The 25 year-old woman devastated by MS.  Not fair.  The 28 year-old who broke his tibia, who coded one night at 3 a.m.  He didn’t make it.  I can still see the ugly, huge pulmonary embolus at his autopsy.  A gifted classmate, hiking by a Colorado river, falling, hitting his head and drowning.  He was 27.  Not fair. Notice that four of these were sudden.

This is life, or maybe death.  Bad things happen.  Some we can prevent, and some we haven’t a clue how to prevent.  I try to think that I must make each day count in some way, because we don’t have forever, and time is passing.  Atrial fibrillation was my game changer.  My probability of having a stroke has significantly increased.  Not fair that I inherited some bad genes, but biology doesn’t really care how I feel.  It just is. I’m moving on. The clock is really ticking now.

One question we must address as a society is how much unfairness is…for lack of a better word…fair.  The other is how to treat people fairly.

The tax code is unfair and could be changed.  It is not a malignancy.  I don’t think it is either fair or appropriate to pay women less who do the same work as men.  I don’t think it is fair for a child to die of a preventable disease because the parents didn’t believe in vaccination. I don’t think it is fair that people should go bankrupt because they had a medical condition that nobody could have foreseen.

We aren’t born equal, we don’t have equal opportunities and life will never be fair.  We can, however, treat people fairly who end up on the wrong side of the luck scale.  Any of us could be one of them.

Any time.

WEARING ANOTHER’S STRIPES

December 31, 2015

“Everything is going to be OK, Mr. Roberts!”  the young man ran in to the hospital room where I was examining Mr. Roberts and just as quickly left.

My first thought was, “Who was that guy?”  My second thought was that Mr. Roberts was most assuredly not going to be “OK” for the near future, maybe never.  I was just an intern, years ago, and had to evaluate the unfortunate man who had a large stroke involving the dominant hemisphere, middle cerebral artery territory, affecting expressive and receptive speech and paralyzing his right side.  At least Mr. Roberts didn’t understand the optimistic words.

The “intruder” was a physician’s assistant for a well-known local internist and was busy writing orders when I returned to the nursing station.  Because he worked for a senior physician, he made himself important by association.  Stripes are what nautical and airline officers wear on their sleeves or shoulders. Stripes should not be transferrable, but a lot of people think they are.

I stayed quiet that day; as an intern, I was at the bottom of the hospital pecking order, and the PA was “wearing the stripes” of the doctor for whom he worked.  My training was more than his, I was working longer hours than he (nobody worked longer hours than interns in those days), but length of training, knowledge and hours worked stood little chance against a forceful, sure of himself individual.  I would see that in spades with the surgeons with whom I would deal.  There was no way I would have told the PA that Mr. Roberts had a long, difficult road ahead of him.

A month later, that longest year of my life, I found that the OR Nurse for cardiac surgery wore the stripes of the two cardiac surgeons for whom she worked.  Every intern had to spend time on the cardiac surgery service. The pair made my 24 day rotation hell.  The two fed off each other, driving me to tears on one occasion, classic physician behavior back then that is slowly dying out as the old guard finally moves on.  I was a physician, not yet licensed to be sure, but I didn’t deserve to be treated as the “hired help,” either.  The two were equal opportunity nasty to everybody; they threw instruments, hit me on the wrist with an instrument if I weren’t holding it properly, demanded I hold a retractor better, when I couldn’t see what I was doing, and thanked me only 5 times on the 12 multi-hour cases which I helped them.  I found I could fight back with my intellect, because I was able to correctly answer every anatomy question they posed during a case, often with a bored tone of voice that was my passive-aggressive way to say, “Can’t you do better than that?”

One day, I finally had one of those rare moments in life where I said exactly the right words at the right time, the “Perfect Squelch.”  I was holding a hemostat, a clamp, and my thumb was too far through the handle.  “SMITTY!” the senior surgeon shouted.  (I hated that name).  “DON’T HOLD YOUR INSTRUMENTS LIKE THAT!!! YOU DON’T HOLD YOUR SILVERWARE LIKE THAT, DO YOU?”

I quietly replied, “Dr. Maloney, I don’t use silverware.  I eat with my fingers.”  Other than Dr. Maloney’s unsuccessful attempt to comment, the room remained silent the rest of the case.

Their nurse treated me as the hired help, too.  While I didn’t like how she looked at me, her mannerisms or her tone of voice. I just told myself that my time as an intern wouldn’t last forever.  Every day was another 0.27% gone.  I wonder how she was treated by the surgeons themselves.  One subsequently had a nervous breakdown, and I actually felt sorry for him.  He was an arrogant jerk, but his life was going south and mine was not.

Wearing the stripes literally came to pass the following two years, when I was in the Navy.  The concept of the wife of the Captain being in charge of the other wives was “wearing his stripes.” Some women used their power well, however, perhaps supporting a pregnant wife of a Navy Ensign, her officer-husband overseas for 8 months, and needing help.  Others tended to act as their husbands, only that backfired if a wife was a professional with her own career and quite capable of living independently from her husband if she had to.  Like mine.

Over the years, I have seen others wearing the stripes.  I’ve seen them on the face or heard it in the voice of an Executive Secretary or a doctor’s nurse.  It was a very clear, “my boss has a lot of power, so therefore I have it, too.”  Had I more interpersonal skills, I would have learned to cultivate these people so that they would look forward to hearing from me and do things that I wanted.  Alas, I did not have such skills.  I called things as I saw them, and that wasn’t always popular.

I came by my attitudes honestly.  My father was once superintendent of schools, responsible for everything in the district. Not everything he did was popular; indeed, we frequently got phone calls at various hours, since our number was in the directory.  One night, I heard my mother on the phone in my parents’ bedroom, a place I never went.  Sound travels, however, and I couldn’t help but overhear her say something along the lines of “That’s not my job, and I am not going to listen to your tone of voice any longer.  Good-by.”  She hung up.  When she left the bedroom, she saw me.  I don’t remember the look on her face, but I never forgot her words.

“Your father is getting paid to do this.  I’m not.”

She might easily have said, “He can wear his own goddamn stripes.”

THE DEMENTORS IN OUR SYSTEMS

October 24, 2015

I don’t speak out much any more about quality of care in medicine, mostly because I am out of date.  But I am not out of data.

Last July, I had a sudden dysrhythmia.  I was minding my own business one evening, checking  a sunflower, when I stood up and started noticing my pulse pounding irregularly.  I had no pain, and at first I thought it was a bunch of PVCs, premature contractions, although they were a little different.  I was alone, didn’t want the animals to be uncared for if I were admitted, so I did the next best thing.  I went to bed.  I awoke at 1 am and felt fine.

I saw my PCP the next morning, who had had a cancellation, and my EKG looked fine.  She recommended a Holter Monitor, so I wore one for 48 hours, during which time I hiked and had no symptoms.  The monitor showed a few supraventricular rapid beats, nothing solid, but not normal, either, so I was told I would need to see a cardiologist, and a referral sent.

Ten days later, I had no appointment. On my own, I stopped all caffeine and chocolate, and the few funny sensations I had had vanished.  Unfortunately, so did my referral.  An email to the office went unanswered for a week, until my PCP replied, asking me what the cardiologist said.  Well, I wrote, maybe he or she had said something, but not to me, since I had no appointment.  She apologized and within a few days I had an appointment 5 weeks later, nearly 8 weeks after my event.

I saw patients as emergencies the same day who had a 10 year history of the same headache with several normal CT scans. I have a dysrhythmia as a 66 year-old and it takes 8 weeks to see a cardiologist?  It’s a different world today.

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

Later, my wife needed a GI evaluation.  A referral was faxed to the specialist’s office, and we were to get called back.  The office of the referring physician was about 150 meters away, as the crow flies, from the office of the new physician.  Two weeks later, we had heard nothing.  My wife called, and nobody knew where the referral was.  This sounds familiar.

My wife and I are not mildly or moderately demented, we are educated, knowledgable about medicine, and can afford our care.  What happens if one is demented, uneducated, or unclear about the medical system?  Most people are unclear.  I certainly am, and I practiced medicine.  Perhaps these people think (1) nothing needs to be done, (2) the physician wants money up front and they hadn’t paid in advance, (3) somebody had changed their mind, or (4) they might not have assumed anything, just forgotten about the referral, since they didn’t have it on our mind and didn’t follow up.

Sort of like what happened to those who sent the referral.

A phone call was answered pleasantly, and my wife was told the referral would be faxed over to the other physician’s office that day, there would be “three business days” to set up a future appointment, and then she could have the procedure.  With all due respect to electricity, I can walk a referral over almost as fast and with complete certainty deliver it to the right person.  With all due respect to the fact my style of practice isn’t done today, “business days” is redundant.  Every day was a “business day” for me.  I told my wife that we were going to go to the physician’s office that day.  It was a 15 minute drive, and there is something about a face-to-face interaction that gets things done quickly.  It’s far more difficult to ignore a person, unlike a call, e-mail, SMS, or some other electronic medium of communication.

We bypassed everything possible and had the appointment 46 hours later, one business day, to those who count such things.

The same week, I discovered my monthly medications had no refills.  I sent an email through the online patient portal and waited a week to hear.  Nothing.  I called the pharmacy, and they had received nothing but would call the physician’s office.  I waited another week, now two weeks late in getting my medications, and called the pharmacy to see if my prescriptions were ready.  I heard a “prescription” (indefinite article, singular) was ready, and when I stopped by, indeed, one was.  The second one?  Nowhere to be found.  The pharmacy tech was pleasant enough, however, saying she would call it again to the doctor’s office. Before she called, I asked to see the dose, having changed it several months earlier. It was the original amount.

Fortunately, I had plenty of the medication at home, since the pharmacy had not changed the dose, despite my having asked them to do so.  Two days later, I got a call from the pharmacy, telling me that they had been unable to reach the physician’s office.  So much for pharmacies’ calling physicians successfully.  I called and talked to an answering machine.  I would have walked over, but I figured I had a week to burn.  I still haven’t received the drug.

None of these three issues was serious.  Sadly, none of them is rare, either.  These sorts of things on a daily basis are Dementors, for they suck the happiness out of people.  Time spent fixing these problems is time that can’t be spent doing something more important, like promptly scheduling a patient, rather than have them wait on hold, which we all do.

There needs to be a better way to track referrals.  I can log on to Amazon, UPS, or USPS and immediately know the status of a package that I ordered thousands of miles away, yet I can’t find out in my own small city whether my referral has been seen by the specialist or where my medications are.  What happens if somebody is elderly, infirm, doesn’t hear or see well, and needs specialty care?  We are up in arms about the Affordable Care Act, yet virtually everybody is silent about the many broken systems in medicine that affect everybody in the country who seeks care, which is about all of us.  Am I just incredibly unlucky?  I doubt it.

As for pharmacy issues, I find it ironic I am having the same problem that my op-ed in the local paper addressed: pharmacies must start using the state error reporting system.  Oregon is the only state that includes pharmacies, but the 721 last year reported exactly 20 errors.  I alone have had three, and there are nearly four million people in the state.  I don’t think I am incredibly unlucky. What happened after my op-ed?  Choices: (1) few read it, (2) pharmacies jumped on board and are reporting like mad, or (3) nobody really cares, because we have high quality care.  A=1; B=2,C=3, D=1,3.  You choose.

Every broken system has countable and uncountable costs.  The countable ones are hours spent doing things twice, looking for something, fixing what is wrong, and spending time apologizing.  The uncountable ones are Dementors: annoyance, unhappiness, feeling of powerlessness, the wondering why, after so many years of stating what we need to do in medicine, why it still hasn’t been done.

NEEDLESS, PREVENTABLE DEATHS

September 3, 2015

“I don’t think it’s about more gun control.  I grew up in the South with guns everywhere and we never shot anyone.  This (shooting) is about people who aren’t taught the value of life.” (Samuel L. Jackson).

I’m not Mr. Jackson, a famous actor.  I’m Mike Smith, a nobody, but I have training in analysis of data Mr. Jackson doesn’t have.  Words like his get read by millions.  My words will be read by a couple of dozen.  Maybe.  But mine are worth more.  Here’s why: Mr. Jackson talks of a time that never existed.  I know, because I am 16 days older than he (fact 1), and we grew up when 7 people per 100,000 died from firearms (fact 2).  Back then, the population was 150 million, not well over 300 million today (fact 3), so there were fewer than half the deaths.  We didn’t have 24 hour a day rehashing of many deaths due to firearms, either.  There were no social media to post information, making it sound some days like we are in a free fire zone.  Teaching “the value of life” is a platitude.  It sounds good; it doesn’t give details exactly what is supposed to happen. Lot of good churchgoing young boys raped girls and did bad things where I grew up, Mr. Jackson. Let’s leave anecdotes and go to a few more facts.  I like facts.

Deaths from firearms per 100,000 peaked in the 1970s and 1980s (fact 4), and have declined significantly since 1993 to a number not much different from the 1950s (fact 5).  Back in the 1950s, there were 3 TV channels.  The news was on at 6 and 10; there was no other TV news.  There was no Internet; we heard about major events on the radio, TV, or newspaper.  Gun violence, incest, priest pedophilia, unwanted pregnancies were hushed up, lynchings were common, people died at more than twice the rate they do now in motor vehicle accidents, children died from acute lymphoblastic leukemia, rather than being cured, poliomyelitis and other infectious diseases were a scourge.

To the anti-gun crowd, gun violence deaths are not increasing per 100,000 people.  Fact.

To the pro-gun crowd, gun violence is a problem.  Fact.

It is a major public health issue, and it was politicized enough to hold up the Surgeon General’s nomination, because he agreed.  When I looked up information about gun deaths, I saw one link that said that “knifes” (sic) cause more deaths than rifles.  Note the misspelling of the first word and the use of the second, rifles.   Yes, for a few years knives killed a few more than rifles.  However, handguns cause 20 times more deaths than both knives and rifles combined. (Fact 6).  Handguns have a bad connotation, which is why we have the National Rifle Association, not the National Handgun Association.

Comment on knives:  Against a knife attack, I have a decent chance to escape without death and maybe without injury.  Knife attackers have to TOUCH their victim, significant.  With firearms, one may inflict death from hundreds of yards, never touching the individual. One might be talked out of using a knife, whereas with a handgun, it is a quick twitch and cessation of existence for the other person.

Shootings with assault weapons get the public’s attention.  Less attention was given that in the last two days, three people in Eugene died from handguns, two murders, one suicide, associated with a murder.  You won’t read about this in upstate New York, but the people are just as dead.  The murder-suicide was over a woman, who at least wasn’t killed herself, although three women die daily due to violence from men they know.

Background checks aren’t perfect.  So?  Neither are seat belts.  That doesn’t mean we don’t wear them.  They improve the probability that if we are in an accident, we will survive.  One less gun where it doesn’t belong and saves one life would seem to me to be worth it.  We need liability insurance to drive a car.  We ought to have it when we own a gun.

Fact 5 is that the death rate from firearms has fallen compared to two decades ago.  Indeed, crime has fallen in every major category (there are 9), not just per 100,000, but ABSOLUTE numbers, in the last two decades.  (fact 7) Here is the link: http://www.disastercenter.com/crime/uscrime.htm In other words, we are safer.  That doesn’t mean people aren’t dying or being robbed; they are.  We need to do better.  But, we are safer than we have been in our history. Yet people still buy guns, believing in a myth that we aren’t safe.

Suicides, however, are a major problem.  Sixty per cent of firearm deaths in the US are suicides, the highest percentage ever (Fact 8).  Why can’t we do research into this issue to try to prevent nearly 20,000 of them annually?  http://www.hsph.harvard.edu/news/magazine/guns-and-suicide/   Depression is treatable.  We can’t cure everybody, but that doesn’t mean we shouldn’t try.  Keeping guns out of the hands of those prone to depression is difficult, but rather than use it as an excuse that “they aren’t murders,” we ought to try to address the problem of controlling guns in the hands of seriously depressed people.  Easy? No, but let’s stop saying “fix mental health” and actually deal with it as a country.

A friend commented 390 children drown each year, and the 60 to 100 children who die accidentally shot by another child is a smaller number.  Actually, the number is at least 1100, (fact 9) and the fatality rate in hospitals has fallen from 0.5 per 100,000 to 0.3, a statistically significant drop. (fact 10). It’s easy to look at a link that says something you want to hear, but it is a lot more work to delve into the link to see what it says.  More than a thousand children under 14 die each year in automobile accidents. Should we therefore ignore drownings? Why do we tolerate this carnage?  Drownings are completely preventable and safety mechanisms must be enhanced, not “Be careful”.  TV ads help, but we need a system that makes it impossible for a young child to drown.  Why are guns available for children to accidentally shoot their parents?   One death a year is too many.  We require special car seats for infants and toddlers, and they decreased deaths by 71% and 54% respectively.  Perfect? No, but the 8-14 age group death number fell 50% in the last decade.   What about firearm deaths? Between 2006-2012 the number fell 20%.  Why not 50%….or 100%? Children’s curiosity about guns outweighs their parents telling them “don’t touch them.”   Yeah, it was a convenience sample, but it’s worth reading. http://www.ncbi.nlm.nih.gov/pubmed/11389238

To those who misuse statistics to prove everything they can to that gun violence isn’t bad, I say loudly, ANY unnecessary death is a loss to society.  Suicides are a special case of gun violence.  Can’t both sides agree that maybe this is one area we look at controlling access to firearms? Depressed people with firearms present at home are at high risk for death.  Difficult to control guns here?  Yes.  I thought America was good at dealing with difficult problems.  It used to be.  Want a dollar cost?  For children alone it is $8.4 billion in medical costs from firearms.  I am ignoring the “loss of enjoyment of life” and lost wages, which would increase that number 13-fold, I am told, but I can’t put a dollar cost on it.

Enough is enough.  Children shouldn’t drown, they shouldn’t die in MVAs, they shouldn’t die from leukemia, they shouldn’t die from child abuse, and they and depressed people shouldn’t die from guns.  We have made great progress in all of those areas but only modest progress on guns.  I don’t accept that. Mr. Obama has not taken one gun from one law abiding citizen.  Murder rates are down; let’s keep working to understand why and make them fall further.

To paraphrase Jimmy Carter, I’d like the last child to die from gun violence before I die.

CONCATENTATION AND EXPECTED VALUES

July 18, 2015

A bloody picture of a cyclist adorned my Facebook page.  The writer was succinct:

How I joined the walking dead:

1. Rented a bike with defective brakes.

2. Started riding through a long dark RR tunnel.

3. Encountered a multi-family group with very small children in tow coming the other way.

4. Wiped out trying to avoid scattering kids like bowling pins.

This is a classic description of a fortunately not tragic accident.  Each one of those incidents alone might not have been sufficient, but together they caused a bloody rider. There was a concatenation of events.  Sometimes, we have a concatenation of errors.

I had my own sixteen years ago this month:

  1. Took part in a long distance bicycle tour only a few months after starting to ride a road bike.
  2. Ended up on a rainy day wet, tired after crossing 3 Colorado passes, and eager to get to the school where we were going to be camping.
  3. Saw a car in the turn lane headed towards me.  I had limited experience riding a bicycle in traffic.
  4. Assumed the driver saw me.
  5. The car suddenly turned in front of me.
  6. Too late, with wet brakes, I skidded and landed on my right hip, trying to avoid him.  I wasn’t the walking dead, but I didn’t walk normally for several months, and I’m lucky I can walk today.

It’s worth discussing the concept of the expected value of an event, like the lottery.  People see 2 winners in the last lottery and buy tickets, because after all, they could win.  It has to be somebody.  This is usually true.  If not, eventually the probability becomes so high that when the lottery has an unusually large payoff somebody (or several people) almost certainly will win.

If the probability of an occurrence is extremely small, invariable, and not zero, and the number of times the occurrence may happen is very large, the expected value is their product.  A probability of 1 in 110 million of winning x 440 million lottery tickets sold has an expected value of 4 winners.  It’s that easy.  Low probability events, like automobile fatalities, occur every day, because so many people drive. Expected values are just that.  They are expected, but they are not necessarily going to occur.

Aviation, perhaps more than any other endeavor, has taken safety to heart, because aviation is so unforgiving of errors.  Additionally, aviation has a large number of events, called flights, where there is a low but non-zero probability of a crash.  Aviation has tried to improve the probabilities and in commercial aviation, there have been multiple years, often consecutive, without a fatality.

Non-commercial aviation isn’t as safe.  Nearly two decades ago, a 7 year-old was trying to be the youngest person to ever fly across the country.  Being the youngest, oldest, first, most disabled, fastest, —st is often the first cause in a cascade of events that leads to tragedy.

A 7 year-old had no business being at the controls of an aircraft.  Period.  One of the last things to mature is judgment.

  • They took off to try to beat a thunderstorm, poor judgment, because wind shear is unpredictable in thunderstorms.  One must wait.
  • They were overloaded.
  • The runway was at a higher altitude where there is less lift for aircraft.
  • Rainwater on the wings diminished lift.  Airfoils are delicate; distortions of shape diminish performance.
  • They turned to avoid part of the thunderstorm.  Turning decreases lift.  The overloaded, slow moving, distorted airfoil plane stalled and crashed, killing all aboard.

Remarkable finding of evidence and piecing it together led to understanding why Air France 447 crashed in the mid-Atlantic in 2009.  Here’s a root cause analysis:

  • Why did the plane crash?  It stalled.
  • Why did the plane stall?  It was in the nose up position for the last part of the flight, reducing lift.
  • Why was the plane in the nose up position?  Because the co-pilots had taken control and saw that the altitude was low.
  • Why did the co-pilots take control? Because the autopilot had shut off.
  • Why did the autopilot shut off?  Because it wasn’t getting useful information from the pitot tubes, like altitude and speed; the altitude reading was faulty.
  • Why didn’t the co-pilots keep on the same course as the autopilot? Because they trusted the instruments.
  • Why weren’t the pitot tubes sending useful information?  Because they were faulty and needed to be replaced, but the airline was phasing them in.
  • Why was the airline allowed to phase them in?  That ends the questions.  That’s where action needed to occur.  Additional causes included the pilot’s napping (not wrong) so he was not in the cockpit when called.  There were other crew miscommunications.
  • What could have been done?  As soon as the “stall” alarm came on, the crew needed only to push the nose of the aircraft down.  Planes stall when they climb too rapidly.

**********

This root cause approach to errors is what medicine needs.  When a surgeon operated on the wrong side of the head, he got a letter telling him not to do it again.  Nothing changed.  Here’s what happened.

  • Patient in ED had a subdural hematoma and needed emergency surgery.  There are emergencies where one must act in a matter of seconds, and there are emergencies where one needs to act quickly, but can take a few minutes to think about the necessary approach.  A lot of people in and out of the medical field don’t understand that there is a huge difference between the two.  Unnecessary hurry is one of three bad things in medicine (others are lack of sleep and interruption).  A subdural hematoma needs to be evacuated, but unlike its cousin an epidural, it doesn’t need to be done in the emergency department, and there is time to plan the procedure.
  • CT Scans were relatively new and had changed the left-right orientation opposite to traditional X-Rays.  I practiced when CT scans showed this orientation, and it was extremely confusing.
  • Many people have trouble distinguishing left from right.  It isn’t a personality flaw, it is a biological issue, akin to being shy.  Approximately 15% of women and 2% of men have this problem.
  • Nobody spoke up to tell the surgeon they were concerned upon which side he was operating.

Without going into more detail, I reiterate the comments I made to the head of the operating room, who assured me that 99.9% of the time they did it right.

“No,” I replied.  “You get it right 99.99% of the time, and that isn’t good enough.  Counts matter, and wrong side surgery cases must be zero.”

We need better system design to decrease the probability of the wrong thing’s happening.  The stronger our systems, the more events will have to occur for something to go wrong, and that means people will be safer.

We will never know if a better system saved a life.  But probabilistically, it will increase the expected value of success, and I trust expected values.

TO ERR IS HUMAN; TO LEARN FROM THEM ESSENTIAL

June 29, 2015

In the movie “It’s a Wonderful Life,” George Bailey saved pharmacist Gower from mixing poison into a prescription.  Gower’s son had recently died from influenza, and Gower was thinking of his son, not the prescription.  Here’s the root cause analysis.  Why was poison there?  Because it always had been.  Why had it always had been?  The movie doesn’t tell us.  Why didn’t Gower notice it was poison?  Because he was still grieving his son’s death.  Why was he working?  Because he had to.  He had no choice.  Why had he no choice?  Because you worked or starved back then.  Why?  Because we had no safety nets.  Why not?  Because it had always been that way. Why?  I don’t know.  End of analysis.

Did Gower want to err?  Of course not. But he almost did.  Poison has always been present in pharmacies.  It’s called the wrong drug, the wrong dosage, or an unexpected interaction. None of us is immune from making errors.  “Be more careful” isn’t the solution.  We need systems robust enough to make errors impossible, for people may be preoccupied, sleep-deprived, hurried, interrupted, multi-tasking, under pressure to produce may all combine to produce errors. None of us is immune.  “Be more careful” isn’t the solution.

Compare how improvement doesn’t and does occur, respectively.   I once got a letter from the quality committee castigating me, because a nurse asked me, a consultant, if she could have an order to get a blood gas analysis.  I gave the order, the blood gas was mildly abnormal, and I neither got a call nor followed up on the result, which was wrong.  I felt worthless, a bad doctor.  Good doctors are perfect, and I wasn’t perfect.  Nobody asked why these results didn’t go to the attending physician, or weren’t even called to me.  Indeed, the idea of quality in medicine was to assign responsibility and blame.  It was my job to follow up on this blood gas, and I failed.  Don’t do it again.  You are reported.  What did I do after that?  I never ordered another blood gas as a consultant again.  Was that optimal care? Nope.  But I wasn’t going to be nailed again for not doing what the attending should have.

Here’s an example of how root cause analysis helps.  The columns on the Lincoln Memorial were eroding from power washings, and this was becoming a concern.  Rather than just replacing the marble, very expensive, somebody actually talked to the people doing the work, an amazing idea, since while management traditionally makes decisions, the people on the ground really know what is happening.  Asking why learned of frequent power washings, which came from bird poop.  Why?  Birds came to eat insects.  Why?  Because insects were attracted by floodlights.  Solution?  Shine the lights, not for two hours after sunset, but only for 30 minutes, which didn’t attract insects.

Oregon is the only state where pharmacies are included in the confidential error reporting system.  I was disappointed to learn how few errors are reported here with a full “root cause” analysis. The first pharmaceutical report was in 2012, a few years after the program began.  Of 200 total reports, only 28 were last year among 721 pharmacies state-wide.  I’m a retired physician, I take medications, and I have considerable knowledge of medical errors, having been on both sides of the error divide.  I regret my errors, but what has additionally bothered me was that I could neither unburden myself of my guilt nor could I allow anybody to learn from them.  Silence does not improve systems; it allows the same error to recur.

Thinking on one hand I might have something to offer, despite my age, I contacted the Commission, whose staff were most kind to meet with me.  I wasn’t seeking employment, hoping only that my passion for improving medical quality and safety might allow me to contribute.  I am willing to help in any possible way at any interested pharmacy or health care facility in the state.  Reiterate. No charge, free.  Every person in my small family has suffered from medical errors.  This isn’t surprising.  Nor would I be surprised if every pharmacist who reads this knows that he or she has made errors or had close calls.  And didn’t report them. Shame, fear of reprisal, no time, no harm no foul. Which one?

I was wrong about numbers of reports.  I expected that was crucial.  It is not.  Pennsylvania has a quarter million reports annually, but “fall” without knowing why doesn’t help, not even if you knew the numbers state-wide.  How do I know?  I asked that question.  A few thoroughly investigated reports, learning why something happened until the question can no longer be answered is effective.  The Commission has people who can and want to help with this. I could, too. However, the culture of medicine and management must also change, away from punishment, excuses, fear, shame, ridicule, silence and hiding, to one of openness, learning, sharing information and power, the goal being to improve systems to cause less harm.  I am pleased that the Commission has done so much.  I am disappointed that 14 years after I proposed a similar program, how far we still have to go.

Were each pharmacy to perform one thorough analysis on a mistake every other year, this volume would have vast potential to improve systems that currently hurt patients and shame those who make errors.  The information could be shared state-wide.  Far from desiring to punish well-intentioned, hard-working people, I want them and others to learn from errors or near misses.  We make mistakes.  The days of hiding them must end.  Top management must vigorously support reporting by encouraging front line people to talk candidly to the Commission about what happened, with absolutely no fear of reprisal.  That’s a tall order.  I do not want to hear about percentages of successes, because counts of serious mistakes must be driven to zero.  In 2001, 99.999996% of all domestic flights were safe, and I doubt anybody believes that was a good percentage.  One mistake that is investigated is not going to cause long waits in Eugene, Portland or Bend.  Mistakes are made.  That is a fact.  We need to understand thoroughly why they occur and how to prevent them.  “Double check” and “education” don’t cut it.  We don’t tell people to put their foot on the brake when they back the car.  Cars are designed so that people can’t shift into reverse before their foot is on the brake.  Repeating “we believe in safety” does not establish validity.  “You mean you once didn’t?” I want to reply.

For reporting the error, George Bailey was initially slapped on his bad ear by pharmacist Gower, who later embraced George, when he realized the scope of his error.  It’s time to end both the slapping and the fear of it.

For reporting an error, George Bailey was initially slapped on his bad ear by pharmacist Gower, who later embraced George, when he discovered the error.  It’s time to end both the slapping and the fear of it.

INATTENTIONAL BLINDNESS

June 26, 2015

I was relaxed and would soon arrive at the meeting point for our weekly Wednesday hike up Spencer Butte in Eugene, 6 miles, 1000 feet vertical.  It’s a good weekly workout, and I like the other hikers.  I came to a 4-way stop, looked left then right, focusing on the car to my right.  I let him turn; he was there first, and he was to my right.  I started to go, but for some reason, looked left.

I had NOT seen the bicycle just to my left.  I hit the brakes and stopped immediately, quickly enough that I didn’t get a dirty look, but still shaken.  Where did SHE come from? It was possible when I looked the first time, the cyclist wasn’t visible, but I doubt it.  I think I looked for a car, not a bike, didn’t see a car, so I then looked right. There’s a term for that, and it’s called inattentional blindness*.  We see what we expect to see.  If you are watching a video of a basketball game, asked to count the number of times people in white shirts pass a basketball, you might not notice the person in a gorilla suit that comes out, thumps her chest, and walks away.  Half the people viewing the video didn’t. Yes, really:

We operate on faulty assumptions, too.  Last year, I was driving east, when a cyclist on a cross street to my left made a right turn, heading west.  I didn’t give it another thought.  Slowing to make a right hand turn in heavy traffic, I eased over, fortunately not quickly, as I suddenly had this “where the hell did he come from?” moment.  The cyclist had made a U-turn behind me and came up faster than I was driving.  I almost hit him, and it would have been my fault.  On the other hand, had the cyclist, who gave me a very dirty look, realized how I interpreted his move, he might not be so quick to do that again.  Or he might, since he wasn’t wearing a helmet, and that to me is a strong sign of ignorance.  Helmets save lives, and they are a “go to the mat” issue for me, one upon which I will not compromise.

I bring this up because of a TED video about Dr. Brian Goldman’s experience with medical errors.  His video is nearly five years old, a decade after I proposed a system for dealing with doctor imperfections and system design failures, wanting what Dr. Goldman wanted—ability of doctors to come clean.  I approached it from the standpoint of reporting anonymously, he from the standpoint of allowing doctors to stop hiding what shouldn’t be hidden and admit what is normal:  people aren’t perfect.  Both of us agree that better system design is the answer, so that when errors are made—for they will be—there are backups in place to make it impossible or at least highly unlikely that the errors will propagate or concatenate into worsening problems.  Dr. Goldman is a young man, compared to me, so he doesn’t know that three decades ago, I knew that sleep deprivation, hurry, and interruptions were rampant in medicine and were wrong.  I was told by my colleagues to put up:  good doctors didn’t make mistakes.

Yes they did, but back then I believed the contrapositive—if you made a mistake you weren’t a good doctor.  Being sued for missing an acoustic neuroma was the first step that ultimately would lead to my leaving medicine.

I’ve mostly gotten beyond the bitterness of the lawsuit, but my wife tells me I take insults personally too long.  She’s right.  I do, although the lawsuit was personal.  It took me years to realize my not being a successful consultant in medical statistics was not entirely my fault.  Or that my medical safety reporting system, introduced 14 years ago, had no chance of passing in the state in which I was living. Dr. Goldman is personable, has a radio show, and is a somebody.  I was an average doc who hadn’t the personality, the drive or ability to convince people something is a good idea. I swore I’d never deal with medical quality again.

Moving to Oregon changed that.  Or maybe I grew up a little.

Oregon has a patient safety commission here that deals with doing root cause analyses on voluntarily reported errors.  I did a little reading, emailed them with my experience, and was invited to talk to them up in Portland.  It helps, if one is a volunteer.  Yes, you may get what you pay for, but you may get wisdom for free.  Or not.  It was interesting to talk about things I haven’t talked about in a long time.  I’m a bit rusty about how medicine is practiced today.  In some ways, there has been great progress.  In the matter of errors and patient safety, I haven’t missed a lot in the past decade since I left.  The head of the commission and I were both a little discouraged.  I had expected more progress, frankly.

I doubt I will do much for them, because I can’t make doctors and nurses report errors and investigate them.  Everybody is busy.  Too busy.  Too busy doing things to get by, too busy to fix systems that rob their lives of time to do other things.  I could tell the woman was in a hurry, although she was polite.  I recognize all the signs.  I kept a cautious eye on the clock.  Time is important.  Most people are important.  I’m not.

Twenty years ago, I made a list of things to do “if there is only a little time left.”  That’s the bad cancer diagnosis list of things to do, like take my wife to Hawaii or England, as promised.  There are also things to do while I can still do them, like one more time in the Refuge.  That’s ANWR.  That’s the “you aren’t going to be healthy forever,” list.  There are also things to do because I like them.  That’s the, “you are alive, and you have an opportunity. Do them” list.

If my  latest ventures don’t work, well, I can keep providing answers on algebra.com.  Look me up, under “Boreal”.  I’ve taught English, reading, and math.   I know English well, I taught myself to read when I was 2.  Math is just natural.  And fun.

*For inattentional blindness, the observer must (1) fail to notice a visual object or event, (2) the object or event must be fully visible, (3) observers must be able to readily identify the object if they are consciously perceiving it, and (4) the event must be unexpected and the failure to see the object or event must be due to the engagement of attention on other aspects of the visual scene and not due to aspects the visual stimulus itself. Individuals who experience inattentional blindness are usually unaware of this effect, which can play a subsequent role in behavior.