Boreal B[l]og

“In nature, there is no right or wrong, only consequences.”

An Alaskan cruise ship happened upon several deer swimming across an inlet.  Suddenly, several Orcas appeared, attacking the deer, killing the whole group.  The passengers screamed, begging the captain to “do something.”  There was, of course, nothing the captain could do.  Or should have done.  This is how nature works, predator and prey, survival of the fittest.  It is terrible to see it, but deer feed other animals as well as to breed and make more deer.  It is the way of the world.

Unfortunately, I didn’t like the way of the world when lightning caused Minnesota’s Pagami Creek Fire,  It was monitored, because wilderness fires are beneficial phenomena to the ecosystem. Jack pine seeds can only open after a fire, and I’ve seen large forests of young jack pines 10 years after a major burn. Unfortunately, one day the fire exploded, running 12 miles, ultimately burning 92,000 acres.  Regrowth has already begun, but I will never again travel my favorite route to Lake Insula.  It is the way of the world.

Large fires have burned huge swaths of Minnesota, the last big one in 1918.  That fact has not stopped many on the Iron Range from blaming the fire on the Forest Service or “radical environmentalists” like me. Scientists know fire belongs; if there is anything “radical”, it is the idea that forests, like life itself, are immutable.

Often, those who decry big government are first to ask where government is when there is a disaster.  FEMA was decimated in the name of smaller government, until Katrina, proving the adage to some that government can’t do anything right. I might counter with “Lehman Brothers.”  Wildland firefighters, who save so much property and risk their lives, are part of “big government”.  A PCMS member once made a pejorative remark to me about “government doctors.”  I think those of us who were medical officers, including the VA physicians who trained all of us, might feel differently. The previous Vice-President, who never wore a uniform, referred to those 16% of us against the Iraq invasion as traitors.  I want every president to succeed, because if they fail, we are in big trouble. If being against a war is treason, wishing a president to fail is the same, unless there is a double standard.

Big government cleaned the air (under Nixon) and the rivers, because corporations would not do it voluntarily. Accountants do not factor environmental costs in the bottom line.  When free markets fail because of greed or poor planning, big government must step in. If government is bad, then it must not interfere in the bedroom, marriage, and how I should decide to die. Drowning government in a bathtub would appear, in my world, to drown national defense. I don’t want that.

We did canoe in Minnesota, just not where we had hoped. While the fire was beneficial, we are likely to see more of these as boreal rainfall patterns are changing to a savannah-like ones with floods and droughts, rather than even, a phenomenon ascribed to climate change.  The oceans are more acid, the Ksp (solubility product) of calcium and phosphate will now, with 30% more hydrogen ions, cause deterioration in shell formation.  This is a major concern, since the oceans are acidifying at a rate 100 times faster than ever recorded during the past 20 million years.  Carbon dioxide + water=carbonic acid.  Nearly every glacier is retreating, and the volume of cubic kilometers of fresh water entering the ocean will further change the climate.  This isn’t bad, it just is, unless you are human, live on a coast, eat seafood, or get your water from a glacier, as do Peruvians and Indians, in which case it is a huge concern.

Every prediction of the future must quantify uncertainty; to do otherwise is unscientific. Not one argument I have heard against climate change has stated a p-value, confidence interval or margin of error. The late Sen. Moynihan said “you can choose your opinions but not your facts.” The IPCC is 95% confident, which we statisticians consider high. Using a cold week or a record low as a counterexample shows an inability to distinguish between local weather and global climate, which is basic to understanding climate change. For the record, in Tucson there have been 6.5 times as many record highs than lows since 2001 (142/22). This is a fact.

Not one argument I have heard against climate change has been free of personal attacks.  These attacks, having nothing to do with science, obscure the issue, ironically diluting and degrading the writer’s thesis. The subject is climate change, not what hikers wear.  I have discussed the science using statistics, which may be confirmed.  To clarify, I have been to ANWR twice, hiked 120 miles in three of its major river valleys, including 1002, and I find it and Antarctica among the most beautiful places on Earth.  I strongly disagree with those who disparage ANWR or climate change without having ever seen or understanding each respectively, and I have considerable knowledge of both topics.

Of course, some scientists, ever fewer, do not agree, but the vast majority of reputable scientists believe manmade climate change has occurred. Per cent occupancy of the globe is statistical misuse: 70% of the planet is water, and vast stretches are desert.  Fukushima is 0.0003% of Japan’s area, but radioactive Cesium contaminated 10% of the country. It is the way of the world that as a statistician, I frequently see statistics misused (99.999996% of aircraft flights in the US were not hijacked in 2001).  Mankind has never encountered CO2 levels this high.  We are running an uncontrolled experiment; worse, models are under-predicting the consequences. The average temperature has risen, overall weather patterns have changed and the higher sea level has already caused problems. These are facts.  It is the current way of this world.

When I was a neurologist, I often delivered bad news.  I do so again as a scientist and writer.  As a physician, I changed my patient management in the face of convincing evidence.  I believe I have convincing evidence about the world’s climate. I believe if nobody speaks out against those who disagree, and I continue to be polite with my word choice, misinformation will continue. I am calling them out; I will not be silent.  It is the way of my world.

The voters who elected this Congress believe that they will benefit from smaller government.  Ironically, many of these voters will need SSI and Medicare, which may be cut.  They are deer, and they actually want to swim with the Orcas.  It is, sadly, the way of their world.

Twenty-five years ago, I went to trial for alleged malpractice.  During the trial, the plaintiff’s lawyer kept quoting a neurology book, trying to make it appear that I practiced below the standard.  Each time, I asked to see the passage, and each time, I read the paragraph before and after the lawyer’s quotation.  He was quoting out of context.  He was lying, to make a point.  The third time I asked for the book, he literally threw it at me, on the stand.  Several jurors actually gasped.  For the first time, I thought I might not lose.  I didn’t, but of course in a malpractice trial, a physician never wins: it is lose or not lose.

I question whether the U of A’s new to promote civility will be successful.  I will try to be civil in my comments.

I find it difficult to be civil to those who did not serve this country in uniform, but are quick to support our military in our many misadventures that have cost hundreds of thousands of lives and trillions of dollars.  I was among the 16% of Americans in 2003 who thought invading Iraq was a bad idea.  I was right.  I am often right on the big issues, not that it matters much.  The bullies and the jerks usually win.

I find it difficult to be civil to bullies who use ideology, rather than facts, to call those who disagree with them unpatriotic, and sold a war that has been so costly.  These bullies polarized the country.  Worse, the media supported them in the name of “balance.”  We allowed the debate on health care to be uncivil, allowing words like “death panels” into the national discourse.  My opinion piece was entirely civil, factual, and appropriate, since I have dealt with death and dying many times when my colleagues were quite happy that I, and not they, would.

During the last total lunar eclipse, CNN interviewed two astrologers, no astronomers, because the eclipse happened to occur near the solstice.  Is this what America has come to?  I will ask:  what does a total lunar eclipse require, and why does it occur?  Can you tell me why we have seasons?  Can you tell me how you would determine the number of square feet in an acre and how many square kilometers equal a square mile?  Can you tell me what case follows the word “between”?  Do you know where Guadalcanal is, why it was important and what Marine Division has it on their emblem?

I find myself difficult to be civil to those who disparage science, want to take us back several centuries, at the same time enjoying their cell phones, cars, food and water so safe we don’t think about it.  I find it difficult to be civil when I am in a minority of Americans who believe global climate disruption is occurring and man caused.  And I will not argue this with anybody, unless they (1) avoid all use of pejorative language, (2) use statistical terminology and (3) state the consequences if they should be wrong.  I have yet to find anybody who can do this. I find it difficult to disagree so without being disagreeable, for I see these people and others destroying a country that I served as an officer in uniform, and at least 98% of Americans have not.

I find it difficult to be civil, when 10 years ago I proposed a reporting and counting system for medical errors, which failed.   And do we know the scope of the problem in 2011, and have we improved our care?

I find it difficult to be civil to those who received complete data on 6^th grader obesity–from 5 middle schools–promised to help, and didn’t.  Tucson has a grant to deal with this problem, when with a few volunteers from PCMS and the school of nursing, we could have obtained data from every middle school in the county–free, since I would not have charged for my data analysis.

Do we have any data this year?  None that I know.  The principal at one of those middle schools yelled at me, uncivil, although we were helping him meet his mandate.  What is happening in his school?  Is the median BMI still at the 89^th percentile, rather than the 50^th?  Are 14% of his students still above the 95^th percentile and 7% above the 99^th percentile, 3 and 7 times the expected values, respectively?  Is his school representative of the county?  Does anybody care?

What we need in America are volunteers, service, ideas, hard data, willingness to say “I was wrong,” and polite, respectful discussions with willingness to listen.   It is time we say “no more” to those who deliberately lie to push an agenda.  It is time that we and the media gasp, like the jurors did in January 1986, call these bullies out on their lies, because equal time requires equal facts.  Bullies must be stopped, whether high school students, lawyers or fat old non-veterans who deliberately lie on the public airwaves.

I took my skills out of medicine to other fields.  I now wonder whether I take myself and my skills out of this country, which I see as in major decline, because of lack of MY “family values”:  education, politeness, population control, caring for the Earth and all its living beings.

When I saw a familiar ship steam into Subic Bay and moor, I decided I ought to visit to check out their sick bay.  It would be the only time in our 8 month WESTPAC deployment my ship and theirs would simultaneously be in the same port.

It was a wise decision.

The other ship had a corpsman, and it had been one of my ancillary duties to ensure their medical readiness for deployment to the Western Pacific.  Before boarding, I had received a list of their deficiencies:  instruments still wrapped in cosmoline, poor record keeping and outdated supplies were the worst.  On my first visit, I additionally discovered their Executive Officer (XO) was a Type I diabetic, who apparently varied his insulin depending upon how he felt (this was before blood glucose monitoring). The ship was a floating medical mess, and I told my shore-based medical boss my concerns about the XO.  He ordered me to ignore the diabetic and do whatever else it took to get them ready.

My adoptee vessel would spend time training at sea when my own was in port, giving me opportunity to ride her and fix deficiencies.  So, the following week, I boarded for three days of steaming 50-100 miles off southern California.  After morning sick call, where the corpsman was thrilled to have me, we got to work cleaning instruments, removing outdated supplies, ordering new ones, re-organizing the department.  We had a lot to do; unfortunately, their ship rode a lot worse at sea than mine.

Later that morning, I took a break to the bridge wing, watching California recede, when the Captain came up beside me.  I saluted, he returned it, promptly ripping me a new one:  “I don’t appreciate your trying to torpedo the career of my XO.”

Stunned, I replied,  “Captain, what are you talking about?”

“Your concerns about his diabetes went to the Commodore, and I had to answer to him.  My XO sees a full Captain at Balboa (the Naval Regional Medical Center), who knows far more about diabetes than you do.  So stay out of this, doctor.”

He walked away, not returning my salute.

The Captain at Balboa did know more about diabetes; I was 3 months out of internship.  But I was a shipboard doctor, and he almost certainly never was.  We had shore based physicians who sent sailors back to the ship with instructions not to climb, when we dealt with ladders dozens of times a day.  Another said a sailor couldn’t return to a ship because of exposure to salt spray, as if we were a catamaran, not a 14,000 ton vessel where I stayed drier on a Pacific crossing than a 5 year-old at the beach.

I felt relaxed that December day in the Philippines when I went to the other ship.  I had made their medical department ready for deployment.  I taught the corpsman everything I knew about diabetes and on a routine physical of a crewman discovered an abdominal mass that was lymphoma.

I asked permission to come aboard, saluting the colors and Officer of the Deck (OOD), saying I could find my way to sick bay.  As I walked down the passageway on the 1 deck, the corpsman practically ran me down.  “Quick,” he said, “The XO.”

Surprise, surprise.

We rocketed up 3 ladders topside to the XO’s stateroom, where I found him sweaty, uncoordinated with slurred speech, a vial of insulin and a glass of orange juice on his desk.  Fortunately, I had ensured the emergency kit had an amp of D50, 50% sugar.  I told the XO to lie down, found a vein, and injected.  Within seconds, he was normal.

We had the OOD call the local Naval Hospital and the Chief Staff Officer, (CSO), the squadron’s troubleshooter.  The CSO was superb; he and I took the XO to the hospital for admission, his sea career finished after 14 years.  He would never command a ship.  Worse, the ship needed a new XO immediately, difficult in mid-deployment.

I had been proven right but felt like hell.  I wish I had been wrong, the XO having no further problems, eventually wearing the 5 pointed star in a circle signifying command at sea.  But I knew he never should have been aboard.  I occasionally wonder why I went over to their ship that day.  Like the lady and the tiger, I wondered had I not been there whether he would have taken/given insulin or orange juice. Not surprisingly, I never heard from the Captain; the CSO, however, thanked me profusely.

We all like being right, dreaming about revenge upon our detractors.  I was right, not because of brilliance, but because common sense, my medical training and probability dictated a brittle diabetic had no business being second in command of a deployed warship.  I’ve been right on many other issues for decades:  climate change, too many carotid endarterctomies, diagnosing depression in patients who thought I was saying they were crazy, chronic pain being highly correlated with not at fault injury, the need for a medical error reporting system.  I wasn’t brilliant; all I did was to observe nature and people, be realistic, use science, probability and tried to avoid magical, irrational, ideological behavior I and all of us are prone to. I often wish my conclusions were different or I was wrong, but I try to follow the facts.

Whenever I want to say “I told you so!” I remember that time in Subic Bay.  Being right often brings no joy; it only means that one’s observations and conclusions are correct.

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

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

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

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

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

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

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

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

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

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