Posts Tagged ‘A different side of medicine’

« Older Entries
Newer Entries »

SOME THINGS DON’T COME WITH A PRICE TAG

January 21, 2013

Because my wife works in the Phoenix area on weekends, I often hear of unusual cases.  A 60-ish woman developed hemoptysis, coughing up blood.  While a strong  sign of lung cancer, hemoptysis is also a hallmark of tuberculosis.  Now, it is often MAC disease, Mycobacterium aviae complex, a non-contagious cousin to TB, often affecting lungs previously damaged from pneumonia, where the bronchioles, the small airways, dilate, a condition called bronchiectasis, a nidus for such pathogens.  We used to say hemoptysis was a manifestation of bronchiectasis; I wonder today how many of those people in retrospect had MAC disease.

MAC can be treated with “triple therapy”–3 antibiotics, many used for TB.  If  widespread, the antibiotics have to be taken for life.  If localized, then part of the lung containing the disease may be taken out, and the disorder cured.

That’s pretty nice, to take somebody who is coughing up maybe a cup of blood periodically, and curing them.  Surgery can cure many bad problems.  I have three pins in my right hip after a car turned in front of my bicycle in 1999. Without surgery, I’d be limping or not walking at all.  Since surgery, I’ve backpacked Alaska five times, climbed mountains, canoed, and traveled all over the world, walking normally.  My surgeon gave me back my life.

The downside is that surgery is expensive.  So is anesthesia.  And hospitalization.  There are a lot of people employed in hospitals to check you in, care for you, get your medicines, your meals, get you out of bed, clean your room, and so forth.  But what is the price of good health?  Until you’ve had bad health, you probably don’t think much about good health’s being worth something.  It’s just that we can’t put a price tag on certain important things in life, like no longer having a condition that makes life pretty miserable and limits activity.  A lot of people no longer die quickly from conditions that may not be curable, but can be controlled for many years, like COPD, CLL (Chronic Lymphocytic Leukemia), CHF (Congestive Heart Failure), HIV, and many others.

Being poor is both highly correlated and likely causative of ill health.  There are a lot of poor people in this country, a whole lot, for whom a lot of medical advances simply are too expensive for them.  They hope…..the abdominal pain will go away, the chest pain on exertion isn’t their heart, the recent onset of headache isn’t a brain tumor, or the recent fever isn’t something bad.  I hope, too, when I get one of these problems, but I can get it checked out and either be treated or reassured.  I don’t know what reassurance is worth, and I don’t think the Republicans in Congress think it is worth much either.  I can look up the price of Raytheon stock; I can put no price on my ability to be able to walk normally.  Most of us take our health for granted.

Until something bad happens.

The woman with MAC had insurance.  What if she didn’t?  The antibiotics are expensive in their own right–$60-$100 a month.  I know many people who need that money for other things, and not booze and cigs, either.  They have kids who need things, their cars break down, they need a new heater in their trailer.  Yes, trailer.  What if she can’t afford it?  She might be a great candidate for surgery, but she doesn’t have $25,000 or more to pay for the diagnostic tests and surgery.  So what does she do?

Coughs up blood and hope it goes away.  Maybe pray that she doesn’t exsanguinate.  There is a place for prayer, but not here.  We have the ability to treat these people.  Not to do so is betraying the ideals this country was founded upon.

In America, many believe that is the way it should be.  If you don’t have insurance, well, you don’t have insurance.  The market will deal with you.  Maybe you are lazy and on the dole, not doing real work like moving money around, which has been shown not to add value, unlike the minimal wage Nurse’s Aide who has to clean a patient who soiled himself (crapped in bed and was lying in it). I’ve done that, by the way, hundreds of times.  As a doctor, too.  Some weren’t born to wealth, had bad genes, parents who didn’t read to them, had a husband leave (after fathering a few kids, perhaps), and don’t have “connections”.  Or, they are unemployed, because unregulated fools believed in stupid models, made bad bets, got bailed out and were paid nice bonuses for doing it.  That is basically why our unemployment rate is so high.  You are out of luck, and there are 50 million “you’s” in America today.  The thought of insuring somebody, called the Affordable Health Care Act, derided by many as “Obama Care,” is an anathema to many.  Let the market take care of it.  Really?  We aren’t talking pork futures here; we are talking about people’s health.

What I find ironic is many who were angry about the AHCA were elderly and retired military, both of whom were getting government subsidized medical care.  The military earned it, although how much longer we as a country can afford to pay it remains to be seen.  If Medicare is going to be on the table, then so must defense spending.

The millions of poor people here don’t have the loud voices that Bill, Rush, Ann, Mitch, John and Eric have.  The Republican Party, who has voted in the House more than 33 times to repeal the Affordable Health Care Act, appears not to realize exactly how many poor people there are  It’s easy to forget, when one has insurance and can get any medical condition taken care of without worrying about bankruptcy.  But these 50 million are mostly silent, and not in the news.   I don’t see that cutting medical safety nets will do these 50 million much good.  Indeed, I see that expanding the safety nets to cover these people is a better idea, and I am willing to be taxed to do it, even though I already pay double the percentage of Mitt Romney.

There are conditions I saw as a neurologist that are totally devastating–like an anterior communicating artery aneurysm that blows out the frontal lobes, leaving somebody permanently in a nursing home physically intact but with the judgment of a 6 year-old.   That could happy to anybody–Republican, Democrat, rich, poor.  I’ve seen devastating strokes, infections, trauma, rapidly aggressive cancers ravage people or kill them outright, often with no warning.  A former colleague of mine was practicing cardiovascular surgery and was dead 10 weeks later from leukemia.  I can get T-boned by a red-light runner tomorrow, or run over by a distracted driver, when I am out for a walk.  I was almost at my Safeway store, the day of the Tucson Massacre.  My congresswoman is paralyzed and partially aphasic for life; her replacement was shot that day, too, uses a cane and now has to defend the 2nd amendment to get re-elected.  While there are scathing attacks on abortion, I haven’t seen legislation pass to ensure every child under the age of 18 gets covered for medical care.  This to me is right to life, which ends at birth.  There are those who espouse Christianity who call fetuses children but who are against covering all children’s medical care.  Since that passes as Christianity in this country, small wonder I am not religious.

Should people be responsible for themselves?  Well, it depends.  In the Ayn Rand world, every human does the right thing, and there is no cerebral palsy, no devastation from herpes encephalitis, no people tied to ventilators or oxygen tanks.  Ms. Rand was no saint, with a personal life that made Bill Clinton’s look normal.  I’ve read her books; they sound fine until you suddenly realize that she writes about a different universe from the one you live in.

To Rand Paul, and the others who think we should just care for ourselves, illness is our problem.  According to Mike Huckabee, God is punishing you, just as God punished Newtown.  Yes, godlessness in the schools caused Newtown.  I wrote Mr. Huckabee about that and never heard back.  I’ve seen thousands of lives devastated, families in pain, and many who have gone bankrupt. You?  Maybe some day it might be you in the bed looking up at somebody, hoping for relief of your misery, and being able to resume the life you took for granted.  That assumes, of course, that your brain is not the source of your being hospitalized, in which case you may not recognize anybody.  This stuff happens, you know.  I worked for 20 years in a small city caring for people with these things, and I was really, really busy.

Those of you who called paying for end of life decisions, derided as “Death Panels,” might walk a few meters in my shoes (that’s a few yards for Americans who read this), and think about those derogatory comments.  Here’s my op-ed four years ago 

You see, we can decide to be rugged individualists, which is really romantic, until other rugged individualists assert their rights over ours.  That’s a problem.  Or until we need help in a hurry, be it a flood, a fire, an earthquake, a horrible illness, or a car wreck where we are trapped in a vehicle with leaking fuel and a hot engine.  When that happens, most of the money you’ve got, the gold in your safety deposit box, the few bucks on your money clip, the spare jewelry you think will be worth a lot won’t be worth a tinker’s damn.

And then, just maybe then, you will learn that health insurance, Obama Care, clean nursing homes and freedom to die the way you choose, may be more important than you thought.

Finally, you might understand why it is worth spending taxpayer money on medical care.

Tags:
Posted in MY WRITING | Leave a Comment »

“OH CHRIST, SMITTY, YOU CONTAMINATED THE TUBE. DAMN YOU!”

December 18, 2012

The words might not be completely accurate, as this happened in the operating room of Presbyterian Hospital, when I was an intern, 37 years ago.  I spent the worst 24 days of my internship helping two cardiovascular surgeons during my surgical rotation.  I scrubbed on 12 cases, and was thanked on only 5.  That 41.6% rate is entirely accurate.  I am formal when it comes to thanking people, I count things, and I would bet any amount of money on those statistics’ being accurate.

I despise being called “Smitty.”  The older of the pair was in his 50s, and I got some perverse pleasure out of the fact that he had made a pass at the most beautiful ward clerk in the hospital and had been politely stuffed.  I knew that, because she told me.  She also told me one night, “It’s a shame you’re married, Mike, or I’d take you home with me.”  She was gorgeous, but I had been married 3 years to the same person I am married to today. Besides, I was chronically tired.  If I had been “taken home,” I would have certainly have slept …..and done nothing else.

The partner was in his late 30s, equally irascible, and ultimately had a nervous breakdown.  It was foreseeable, and it was to my credit that when I heard the news, I felt sorry for him.  The two surgeons beat up on me, as did their scrub nurse who, as we said in the Navy, “wore their stripes.”  They drove me to tears one day, and a visiting doctor from New Zealand, who wanted to become a cardiac surgeon, not only left the OR in the middle of the case, but I heard later he said he would never be a heart surgeon.

The only thing I could do well in the OR was answer their questions about anatomy.  The two would point out vessels and ask what they were, or where they came from, and I would spit out the answer like it was the easiest thing I had ever heard.  There was nothing they asked about anatomy I didn’t know.

I was a “Little Person.”  Oh, I had potential to earn money, power and influence, but as an intern making $10,000 a year, on call every third night (worse in the Denver General Emergency Room, I was a little person.  These guys had power over me, and they intimidated the hell out of me.

And that’s why I contaminated the tube.  They were going to put a chest tube in a patient in an unusual manner, and I was shown how the tube was to be held.  I didn’t understand completely, but I was too scared to admit my ignorance.  So, the tube was handed to me, and WHAP!  The sterile tube hit me in the nose, a most definitely non-sterile area.

This is why in 1978 a plane crashed in Portland, out of fuel, killing 10.  There was a problem with the landing gear, and while the pilot addressed it, the co-pilot noted the fuel situation.  Rather than forcibly confront the pilot, who was known for being….unsavory….the co-pilot chose to stay silent, and the plane crashed.  Aviation has addressed this problem in 1980 with Crew Resource Management and it has saved lives.  Medicine would do well to do it, too.

The Little People are the ones who can’t defend themselves, and I learned early in life from my mother that I was never to beat up on those who couldn’t defend themselves.  We were well off enough that once a week a black cleaning lady came to the house.   This was in the 1950s and early 1960s, when being a black woman was a whole lot different from how it is now.  If they knew that in my lifetime Michelle Obama would be in the White House, they would have dropped dead from shock.

Florence and Tillie were to be called that, and I was to treat them well at all times.  I was to say “Please,” “May I?” and “Thank you.”  They were “Little People.”  I could have told my mother lies about them, and they would have lost their job.  It never crossed my mind; my mother had power over me.

As a Navy doctor, I had to keep space between me and my enlisted corpsmen and chief, because I was an officer.  Still, I did well enough that the few times I went to the Chief’s Club in Subic Bay, in the Philippines, I never had to buy a beer.  I usually had 2 or 3 put in front of me.  I outranked them, and we all knew it, but I respected them for who and what they were, and they appreciated it.  We helped each other.  And we had a good time doing it.

During my residency, I “lost it” one stressful night in the Emergency Department.  The next day, I apologized to the nurse.  She appreciated it.  Like most, I don’t like to apologize, but deep down (or not so deep down) I knew I was wrong.  It only hurts for a little while.  I learned that apologizing defuses a lot of tough issues.

In my practice, I wasn’t always the greatest guy, since I was chronically tired and too busy.  But I thanked people.  I said “Please,” and I asked nurses often what they thought of the patient. I treated them as …. people.

I cleaned up after myself after spinal taps, and if one reads  Code Team, one will understand that I wasn’t afraid to clean up after patients, either. That astounded nurses.   I realized that social workers, dietitians, PT, and OT could help my patients.  I talked to all, and asked them what they thought.  I learned a lot, including the notion that people like to be asked what they think about something.  It is flattering, respectful, and makes one feel wanted.

Because the nurses weren’t afraid of me, they told me things I might not have been aware of. They learned about neurology; I learned about nursing.  I learned that abnormal cardiac rhythm strips were destroyed, because the nurses were afraid of telling the doctor on call, for fear they would be shouted at.  How does that make you feel about cardiac care?  Bad heart rhythm, throw away the evidence!

In 1992, I took a leave of absence.  I had an outpouring of good wishes from the hospital staff, which frankly surprised me.  I received several cards, which I still have today.  But there is one that I treasure most of all.  It came from a Dietitian, a young woman who was going to leave the hospital too, to go to pharmacy school in Washington State.  She wrote a simple note:  “You were always good to the ‘Little People.’ “

Tags:
Posted in GENERAL STUFF | Leave a Comment »

UNCOMMON MANIFESTATIONS OF COMMON DISORDERS

October 24, 2012

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

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

Something was.

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

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

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

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

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

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

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

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

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

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

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

Tags:
Posted in MEDICAL ERRORS/SAFETY WRITING, MY WRITING | Leave a Comment »

SWIFT BOATING VACCINATION

August 13, 2012

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

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

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

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

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

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

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

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

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

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

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

Tags:
Posted in GENERAL STUFF, MY WRITING | Leave a Comment »

THE DEMENTORS AMONG US

July 22, 2012

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

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

TRANSIT OF VENUS, 5 JUNE 2012, WITH SUNSPOTS VISIBLE

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

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

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

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

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

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

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

EVENING ON THE PLATTE, MARCH 2012.

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

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

Tags:
Posted in GENERAL STUFF, OUTDOOR WRITING, PUBLISHED | 1 Comment »

UNCOUNTABLE AND COUNTABLE COSTS

July 12, 2012

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Tags:
Posted in MEDICAL ERRORS/SAFETY WRITING, MY WRITING | 1 Comment »

RESIGNED TO MY FATE

May 1, 2012

I just resigned from my column “Reality Check” in the medical society magazine, Sombrero, after nearly a decade of writing.

I wrote about 80 columns during my tenure, and it is sad that I will write no more.  The writing made me better, for one needs to practice to write well.  And that is the primary reason I left.  There is now a counterbalance column, so to speak, to my  column.  The primary issue is not that the writer has a far right wing perspective, but that he writes poorly.  The magazine deserves the best writing possible.

This individual had his first column published a few months ago, and I was not told, as an invited columnist, that he would be a regular.  That was unfortunate.  The first column  was about climate change being not true, using evidence from 3 cold days last winter and a cold winter in Iceland as examples.  This to me showed an inability to distinguish climate from weather.  At the same time he wrote, northern Scandinavia experienced temperatures nearly 13 degrees F. (7 C) above normal throughout the autumn, and while I won’t say the presence of Sandhill Cranes over winter in Nebraska is due to climate change, any more than 3/5s of the bird species in the Christmas Bird Count have the center of their range at least 160 km (100 miles) further north, it is suggestive. Nearly every climate scientist thinks manmade climate change is occurring, and most of those who don’t believe the Earth is warming.  Those who believe neither are truly on the fringe.  Of course, the fringe might be right, but everything we are seeing suggests under predicting of the effect.  It isn’t just warming, it is the rapidity at which it is occurring, that is an issue.

Conrad Anker, the world famous climber, who is going to take a group of physiologists up Mt. Everest, says the change in the high altitudes is incredible.  Routes that were snow covered 35 years ago no longer are.  I can speak to changes in the high latitudes.  As Mr. Anker put it, if one plays golf in Kansas, one doesn’t see climate change.  But if one is at high latitudes or elevations, or happens to live in the Seychelles or Bangladesh, where the oceanic rising is occurring, it is another story.

The writer was in favor of drilling in the Arctic National Wildlife Refuge (ANWR), calling it a “god-forsaken place” where only “Birkenstock clad hikers go.”  I have been to ANWR twice, I think it is one of the most beautiful places on Earth, and I fail to see what hikers wear (I don’t have any Birkenstock outfits) has to do with climate change.  How much oil is in ANWR is a controversial subject; what is clear is that we should use every conservation method possible before even beginning to consider drilling in what many call the “American Serengeti.”

The editor of the magazine is libertarian-right wing, and has consistently argued many times about what I have said, yet he did not check these climate statements out.  The heat island effect is the simplest proof of manmade climate change; the rapid acidification of the oceans (pH has fallen 0.1 unit, which is nearly a 30% increase in hydrogen ion concentration) is a quiet problem that is going to devastate world food supplies, should there be an interaction between acidity and oceanic warming, which many scientists feel there is.  An interaction means that the sum of two variables is greater than simple addition.

Today, the new writer’s fourth column appeared; 8 column inches longer than mine, rambling, and with false statements, such as he paid $500,000 into SSI, when the current rate is about 5% on $106,000.  He said it would take him until age 137 to get that money out, when in fact if he started at age 70, it would take him 17 years to obtain $500,000.  This shows a lack of attention to detail, unwillingness to check important numbers for validity.

Edmund Burke once said, “All that is necessary for the triumph of evil is that good men do nothing.”  I have done plenty, without much to show for it.  In any case, it is up to the medical society to decide whether they want a writer who writes 1200 words of vitriol and doesn’t check facts.  It is not up to me to respond.  I will continue to post on my blog, where I will fire salvos when I think necessary, but pay attention to detail as well.

Would I return?  It is difficult to say.  I would have several requirements, and I don’t see any of them being met.  I am leaving quietly, with no fanfare, no final column, no goodbys.  It is the same way I will be leaving Tucson, when the time comes, now getting sooner.  I will leave quietly with no fanfare and goodbys to perhaps five people.

There are few things worse than staying too long, be it as a guest, a writer, a worker, or a sports star.  The best stop sooner, rather than later.  I won’t say I am the best, but I think I made a few people think.

Tags:
Posted in COLUMNS IN "REALITY CHECK", MY WRITING | 3 Comments »

MUST WE DEBATE EVERYTHING?

April 4, 2012

1983:  I am in court testifying that a woman post cardiac arrest is irreversibly brain damaged.  Her husband wants to discontinue support; her sisters sued to keep her on the ventilator.  Nothing I said in the hospital had changed the sisters’ mind.  I knew the science and the outcomes of persistent vegetative states after cardiac arrest, and I agreed with the husband.  Eventually, he prevailed.

February 1988:  I show a nurse the conjunction of Saturn and Uranus in the morning sky.  She said they were in Capricorn (the proper name is Capricornus), but the two planets were visibly in Sagittarius.  I argued with her for 5 minutes before realizing nothing I said would change her mind.  Their next conjunction is in 2032.

Later, a man got a great deal of publicity for supposedly having discovered a new planet near Neptune.  I got a call at home from the man, who told me the planet was moving rapidly.  I stated that at Neptune’s distance from the Sun, the planet would move about a finger breadth at arm’s length every year among the stars.  No matter.  The man was convinced.  Nothing I could say would change his mind.

A physical therapist took me to lunch and told me that manipulation of the bones in the skull got rid of headaches.  I told him that skull bones were fused in adults.  No matter.  “It works!” he said; nothing I could say would convince him otherwise.

1984-1994: I said that the science underlying asymptomatic carotid artery stenosis meant that operations should be done only if the surgeon had a complication rate of less than 0.5%.  No matter.  Many were done at the hospitals I practiced; the major complication rate was 14%.  I got screamed at and threatened a few times, for intimidation, repetition, and reputation often trump facts.  I did not prevail.

2005:  Terri Schiavo.  Senator Frist, a physician, said she had cognition, despite clear evidence she was vegetative (smiling is part of the vegetative state).  Congress intervened briefly, an example of government’s dictating medical care if ever there was one.  Fortunately, science (amicus curiae brief by the American Academy of Neurology) and the court prevailed; indeed, the 600 gm brain with large ex vacuo hydrocephalus at autopsy confirmed what we neurologists knew.

March 2012:  I am in Tower Blind at Nebraska’s Rowe Sanctuary, guiding people to a suitable place to see the Lesser Sandhill Crane migration, one of Jane Goodall’s top 10 sights in nature and one of my top three.  As we waited for the cranes to land, my co-guide, an elderly woman, told me how she saw an egg stand upright on the recent equinox.  I said that can happen any day of the year.  The equinox is an instantaneous point in time, like the tangent to a function, with no influence on egg behavior.  No matter.  She was convinced.  Nothing I could say would change her mind.

More people believe in astrology than know why we have seasons.  Many believe we didn’t land on the Moon, that strange lights in the sky are aliens, who may abduct us.  A woman doing the luge at the Olympics held her neck in a certain way to “increase vertebral artery blood flow to the brain”; holding her breath would have been better.  Each of us has heard some remarkably odd ideas from people, totally convinced, totally wrong, about how the body functions.  Laetrile and colonic cleansing come to mind.

Our Sun is at least a second generation star, for elements heavier than iron must form in supernovae.  I believe in evolution and that vaccines are several orders of magnitude more helpful than harmful. I wish in the above instances I asked a simple question:  “Is there anything that you could learn that would convince you that you are incorrect?”  If the answer is “nothing”, then I am wasting my time.

We should change our beliefs when sound science shows that our beliefs are wrong.  When I learned that anticoagulation did not help vertebrobasilar insufficiency, I stopped using it.  When physicians at the University of Western Ontario discovered EC-IC bypass didn’t improve outcomes, they discontinued the operation.  They discharged four patients that very day.  There are many issues in medicine that we should study, in order to do the best for our patients; after all, each of us will be a patient.   We should discuss, not debate, the way we need to change American medicine, because I believe few are happy with the current situation.  We need to listen to and understand other points of view.  We must be willing to try new approaches, in order to learn from and modify them.  We need leaders able to convince people they can do great things that they never thought possible.  We need to use the best science available, even if it shows that our beliefs are wrong.

Children are born curious; alas, too many have it drummed out of them.  Perhaps if more were curious, we would look for answers, discover what we thought was true wasn’t.  That to me is moving forward.  Could I be wrong on climate change?  Yes. I don’t think I am, but yes, sound science could change my mind.  But I would rather discuss how we are going to fix medicine, locally and nationally.  My error reporting system has languished, unused, for 11 years.

I hope I am wrong about human-caused climate change; if I am, I will admit it.  Promise.

Tags:
Posted in 2012, MY WRITING | Leave a Comment »

TOUCHING OTHERS

November 13, 2011

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 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 affords.  They feed in the adjacent fields by day and roost in the river at 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, has invasive species and many trees nearby, limiting the suitable habitat to 50 miles from the former 200.  Rowe Sanctuary manages 4 miles of river and owns 1900 adjacent acres, preserved as habitat.  Every night, for 6 weeks in March and April, up to 600,000 Sandhill cranes, 90% of the world’s population, roost in the river.  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 are the other two.  I love the cranes 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 shy birds and will not let people near them.

Many talk about the cranes that migrate to Arizona.  I simply reply, “You don’t understand.”  And you can’t, until you witness the a flock 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 staff at Rowe.  She knew it, 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.  The picture hangs on the wall in the hallway of Rowe.  A picture of Stevie’s receiving the picture from the Rowe staff hangs in Keanna Leonard’s office.  Keanna is the dynamic educational director at Rowe.

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 at the time.

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, and I teach them everything I know about cranes.  Mostly, however, I let people look at the sight, staying silent, so they can hear the birds.  I clean toilets, paint, greet people, make a noonmark, build a sundial, do whatever needs to be done.

On one 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 had better views at that time.  But we still saw many cranes, American white pelicans, and unusual crane 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.  To have a viewing blind named for you on a river where a half million cranes visit every March is a wonderful honor.  I really can’t imagine a better one, frankly.

Tags:,
Posted in 2012, COLUMNS IN "REALITY CHECK", ECLIPSE CHASING, HOT SPRINGS NP, MY WRITING | Leave a Comment »

ON THE MEDICAL-SURGICAL FIRE LINES

August 14, 2011

In 1984, I had data about surgical outcomes by surgeon for carotid endarterectomy (CEA) in two Tucson hospitals.  There was a 14% major complication rate and a 23% overall complication rate, clearly worse than the results that we knew about medical management of the condition.  I referred my potential surgical cases to only one surgeon, whose outcomes were comparable to medical management; many patients, when told that the local outcomes, refused surgery altogether.  I took a great deal of heat from my colleagues for my stance.  So be it.  My patients mattered more.

I saw far too many complications post-operatively when I had not been involved pre-operatively.  In my view, many of these procedures, especially every asymptomatic CEA, were not indicated.  Some agreed with me.  Not many.  That of course, isn’t the only turf battle in medicine.  There are many. Patient care quality is often mentioned; I wonder today how much outcomes data is collected, how well it is collected, and whether decisions are made based upon it.  I would hope so.  However, as a physician with advanced training in statistics and quality, I never was called upon in this state to offer my opinion.

Before last summer’s fires, I wondered how many in Sierra Vista, a conservative city, had decried big government, only to realize that they needed the resources of the National Interagency Fire Center to save property, lives and indeed the city.

The National Interagency Fire Center was created by combining of three governmental agencies to cut duplication (waste)–the US Forest Service, the Bureau of Land Management and the National Weather Service.  Eight different federal agencies are now part of the NIFC, which has no single head. That isn’t to say that firefighting is done without an incident commander.  There is one.  But the organization itself has no CEO.

Aside from cutting waste, the NIFC did one other remarkable action: they coordinated nationwide firefighting.  Instead of each state having its own cadre of firefighters, on duty only for that state, the condition of the COUNTRY was looked at, so that wild land firefighters in Oregon might be called upon to fight a fire in Utah, because the latter was more severe than any fire burning in Oregon at that time.

This approach required that firefighting managers in a state give up local turf for the good of the country.  Incredibly, they did.  And we are better for it.  Congress would do well to follow that example.

That isn’t to say that the NIFC always gets it right.  The Fire of 1910 colored our wild land firefighting thinking for decades as sure as a missed diagnosis often colors a physician’s thinking for the rest of their practice.   Sometimes fire fighters, in spite of their training, do the wrong thing, as in Colorado’s Storm King fire in 1994 or the Thirty Mile Fire in Washington in 2001.  But there were no calls to dissolve the NIFC, to hand it over to the states, or worse, to local people, to handle matters themselves.  The fire deaths were investigated thoroughly, and the mistakes publicized, in hopes that they would not be repeated, although the Storm King fire deaths unfortunately paralleled those of the Mann Gulch fire in Montana in August 1949.

Without the NIFC, Sierra Vista, Alpine, Greer, Springerville, Pinetop/Show Low would not exist as we know them.   To me, that smacks as government doing something right, something that government should do, that individuals on their own, no matter how motivated, simply cannot do.   It is quite easy to set government up to fail.  I see that today.  It is far more difficult, but far more rewarding, to set government up to do good, to step in where individuals simply cannot deal with circumstances that are overwhelming, like severe poverty, catastrophic medical emergencies, education, or natural disasters.  Katrina was bad; the gutting of FEMA prior to that put the US on world-wide display as an incompetent country.  How many died because of that?

How much government we should have is a matter of opinion.  Frankly, I am willing to pay taxes, and a lot of them, to ensure we have a country that properly helps lead the world.

Like the NIFC, government won’t always get it right. But I am incapable of defending myself from wild land fires or knowing if my food, water or an aircraft are safe.  I depend upon somebody in government to have firefighters in place, mandatory food safety inspections, oversight of the financial system, and an aircraft control system, so that the results of unpreventable disasters are minimized and we prevent what can be prevented.

I want to know which physicians are best for me, should I need a bronchoscopy, colonoscopy, back surgery, or have a carotid event.  I hope my colleagues have sorted this problem out by now, but I don’t know, despite bringing a wealth of skills to the table.  Perhaps we need a National Interagency Medical Quality System, assuming we can find enough people to give up some turf and do what is right for the patient.  Like the NIFC, they wouldn’t get it right all the time, but it would be a step in the right direction.  Heck, I might come out of retirement to serve, should anybody ask.

 

Tags:
Posted in 2011, COLUMNS IN "REALITY CHECK", MY WRITING | Leave a Comment »

« Older Entries
Newer Entries »