Monday, May 30, 2011

The American Economy as a fatal illness

Terminal illnesses entail a grief process.  We all know the 5 stages of grief: denial, anger, bargaining, depression and finally acceptance.  Most people, looking at our economic future, are  in this process somewhere.  It is perhaps too early to definitively say that this illness is terminal, however, as with medical diseases, the longer the denial and anger stages last, and the later the treatment,  and the more dire the outcomes.  I am reminded of a patient I had once who had seen every surgeon in the city, and put off getting her breast cancer treated because, "God would not allow a minister's wife to get breast cancer; the doctors must be wrong."  This level of denial is everyday life in our capitol.  It is exactly what is going on when big Ben says, "I can print as many federal reserve notes as possible (I will NOT call it money; words have meanings!) and there will be no inflation."

Denial, the next stage is a favorite pastime of socialists.
(Aside: my definition: anyone who advocates government solutions for economic problems.) 
This denial takes a slightly different form.  More like, "we are doing so much good with our programs that karma, God, etc, will surely see us through.  All these people need help.  We cannot let a little thing like bankruptcy derail our great society!"  But it is certainly not something that conservatives can gloat over.  Their denial is even more expensive than the socialists.  They maintain the insane position that we can bomb anyone into oblivion that we so desire without ever having to pay attention to costs.  Our self-righteousness will see us through.  Moderates take a little from column A and a little from column B.

But many on both sides of this political slug  have gone on to the next stage of grief; anger. 
(Aside: a coin has intrinsic value from the metal it is made of.  A slug (our current, "coins" do not. )  In a similar fashion for political factions to have any intrinsic meaning, there would have to be some significant differences between advocated policies.  Our current political "parties" have none. So there are only two sides of the political slug, not the coin)

This anger can be seen acted out in our political theater.  The socialists decry businesses and "the rich" (by which they mean the rich who did not get rich via government) who do not pay their "fair share" of taxes, and are looting society.  The conservatives roil against the unions, government pensions, and other government shenanigans and give-aways.  Here, at least they both are approaching reality.  The tax code is so biased and convoluted that anyone with a good lawyer and political connections can avoid a lot of taxes; and this is almost always the rich.  And the figures are clear, government spending on all levels is what caused this fatal disease in the first place.  Government is like a crack addict; it cannot kick its habit of giving away other people's money.  The rush they get from this power is, as a past secretary of Education told me,  "an insatiable lust."

On to the next stage: bargaining.  This is the budget process that is going on right now.  "If we give in $100 million, will you gauranty us another few years?" ask the Democrats.  "If you cut $100 billion can we be granted another few years?" reply the Republicans.  In truth, this is like the lung cancer patient promising to cut his two-pack-a-day habit down by one puff(Democrats) or by 1cigarette (Republicans.)  Much more aggressive treatment, will be needed; and soon!!

Depression is not seen in D.C. so much.  Politicians are always too busy doing, "something" to have time to get depressed.  However this is the stage that the majority of the country is in.  The average American is not as stupid as the leaders in D.C.  He or she knows, often from personal experience, that overweening debt is a disaster waiting to destroy lives; and countries.  Looking towards the professionals to provide answers, and seeing only, "take two Q.E's and call us in the morning." creates a mood of certain doom.  There are millions in this country who feel like dead men walking.

The final stage is acceptance.  Those of us who have reached this stage are surely to bear the wrath of all the others.  We are unpatriotic, speculators, cold, calculating, evil.  How can one give up on America.  "Land of the regulated, home of the groped!"  Oh dear, I think I got that wrong.  Or maybe not.  Acceptance. unlike with an individual's fatal disease, means accepting that your country is on an inevitable road to ruin.  It means recognizing the parallels between what is going on in D.C and what has happened many, many other times in history when government hubris caused it to become completely divorced from reality.  It also means recognizing that no individual is required to go down with the ship.  And it is this recognition that angers all the others so much.  By god, all us frogs are going to boil, and we ain't letting you out!  Time to jump out of the pot!

Sunday, January 30, 2011

Idiot-Proofing Vehicles – or Making Them 'Safe'?

Well, Eric Peters has got me riled this evening. While I cannot disagree with his arguments against government meddling, like many Libertarians he fails to distinguish between government meddling and sensible behavior. I have a good friend, who drives his wife, an ER doc, crazy, because he won't wear his seat belt as a protest against the state. Mr. Peters seems to fit into that category. I guess he doesn't realize that he is trapping himself in ideological silliness as much as the government meddlers do. Kind of reminds me of all the kids these days with their face full of holes and metal; as trapped in their "uniform" as much as a military man.
His arguments regarding the idiocy of government mandated backup cameras are eminently logical; as are all arguments against government coerced "safety." But to extend that argument to conclude that the cameras themselves are wrong, is just intellectual laziness. He has done this before with his arguments on drunk driving. just because the government rules regarding penalties for having alcohol in your blood stream are ridiculous he avoids the fact that the majority of highway deaths in this country involve people with a good deal of alcohol in their blood, and that this chemical impairs judgment across the board. While it is true that the majority of people with low, but illegal amounts of alcohol in their blood drive more slowly and carefully, this is in large part, if not primarily, due to fear of the draconian, life destroying penalties if the cops find them.

I started putting seat belts in my father's cars in 1960, and in the cars of any of my high school friends that I could convince. This saved the life of one of my best friends, when 6 mo. later he had a head-on collision. Yet, I was incensed when the government started mandating seat belt installation, then use, in the '70's. I am still incensed. However, the mandating of seat belt use has not dissuaded me from the logic of their use. As a trauma surgeon, I have seen first hand their life-saving effects.
In 1960 it cost $2.50 for a set of seat belts. If we did not have government mandated airbags and three point harnesses, I could purchase decent restraining devices for not only my car, but likely a dozen others. My choice at present would be the airbag seat belts used on small planes, along with a 4 point harness. I survived a bad airplane crash a number of years ago, but suffered 6 broken ribs in large part because, at the time the FAA forbade the retro-installation of shoulder harnesses in older planes.* How many millions of dollars have been wasted for the only borderline safe system in modern cars. Think of the Nascar racers crashing at 200mph and walking away. Markedly safer systems would be available were it not for government mandated "safety."

Now Eric extends the installation of rear view cameras as not just another example of government meddling, but an instance of the idiocy of trying to be safe. I never gave much thought to cameras until 3 years ago when I rented a Toyota Prius. I was going skiing at Big Mountain, and it was the only car available at the Bozeman airport. I was surprised that not only did I enjoy the car, but that the back up camera was really useful As I get older, I find my neck does not turn as well as it did 30 years ago, and being able to see behind me was very useful.
I currently have a van conversion for long trips, and the camera in this is very useful. Backing boats down a ramp, especially when your car is still level and the boat is going down the ramp and disappears from view is another use for these devices. Anything that makes my life easier, and allows me to concentrate on more important things is a benefit.

Then Mr Peters starts off on a rant about kids being left in cars, and other things that seem to bother him tremendously. It seems his distaste for government intrusion overrides his common sense. I am certain he, like myself, suffers from the newly discovered mental condition O.D.D.** Though in my case, I consider it a highly honed survival skill. We all suffer from the human condition of imperfection, and forgetfulness. Not to mention the all too frequent, "wtf WAS I thinking," problem. Anything that can help us with these human foibles should not be so lightly dismissed. Life is complex, and anything that makes it easier should be embraced, not dismissed. In fact this is the ultimate argument, at least practically, against ALL government action. It without fail always makes life more difficult and painful

His final question, "where will it all end" makes me laugh. twenty five years ago I was a panelist on the Portland show, "Town Hall" during a debate on mandatory seat belt use. They liked the ratings they got having a surgeon opposed to these ideas. I also argued against the sin tax on cigarettes, but that is another story.
My argument of course was that this was not a legitimate function of government, and I concluded, "Where will you draw the line? Are you going to mandate helmet use for kids riding bicycles? "Oh, no!" they assured me, "that would never happen!"

*Actually they didn't ban it, just made getting an "STC" to allow installation extremely expensive ($20,000)
** (O)ppositional (D)efiance (D)isorder. One of the latest of "diseases" used as an excuse to drug kids.

Tuesday, January 18, 2011

Go Not Gently Into The Night

Go Not Gently Into The Night

Just read an article about a survey that shows surgeons at high risk for suicide. This does not surprise me much. It is a lonely and demanding profession.
Lonely because often nurses and support personnel either fear you (or fear their image of a surgeon) or are just looking for a chance to take you down. With the current “snitch” laws which allow for anonymous reporting of almost any behavior, just walking through the hospital can be grounds for being reported, if you are not sufficiently, “friendly,” or, “engaged.” Never mind that you are intensely focused on that pt. in 301 who is not doing too well.
Lonely because it is a competitive business, and your colleagues are often waiting for you to make a mistake. And lonely because when you do make that mistake, and the pt. suffers, so do you, with little, if any support.
Lonely because even mentioning what you do puts most people off;. I suppose it is like being a priest, no one wants to let their guard down. And if you do mention what you do, the price of every service doubles.

Not much need to say anything about the demanding aspects of this life. Patients’ lives in your hands daily, and the buck stops with you!

I do not know if my personal experiences with suicide are abnormal, though they seem that way to me. I do know they are very painful to think about, and something I have only, after many years, been able to discuss at all.

My first experience with suicide struck like the proverbial bolt out of the blue. I was between my junior and senior years of medical school. I was on the West coast searching for internships; I was more than ready to bid adieu to the East. I received a letter from my parents that the police in Syracuse wanted to talk to me, with a number to call. When I called, they wanted to question me about my best friend, an architect student who lived in the apartment next to me. It seemed that he had hung himself in the bedroom of my apartment; his wife found him the next day. The cops wanted to talk to me because there was no note, no fight with his wife. He just went over to my apartment to practice his guitar, which he liked to do, and for which I gave him keys so he could indulge his passion in the middle of the night without disturbing his wife.

This guy was one of the few people I have ever met that I truly envied. He seemed to have everything. From his Norton racing motorcycle, to a command of classical guitar, to his monstrous tennis serve, there was nothing that he was not extremely good at.Even his method of suicide demonstrated his ability and ingenuity. It is not easy for a 6’4’ man to hang himself in an apartment with 8’ ceilings. He cantilevered a 2x4 using the closet rod so the end of the beam was at 8 feet, and using his knot tying skills constructed a very short noose to do the job.

I was so stunned that I did not talk about it to anyone for 20 years. The first time I spoke publicly about it was at a eulogy for another friend who had blown his head off (with his wife’s gun) because she was having an affair. He staged it to make sure that she would find him when she returned home. This was certainly more understandable, though again, this was a very talented, brilliant, and well traveled person. Of course his act was much more clearly what most suicides are; the ultimate, “fuck you!”

In between there were two more suicides that were at least a little more removed, though painful. It was My wife’s best friend’s husband’s ex-wife (whew, all those possessives!) She responded, after the all-knowing court awarded her the children (after all mothers should always get custody,)* to the voices again; those of God telling her to kill her children before they went to hell. She shot her two kids and herself in the head. The other was a surgeon who, though a partner in the large group I was working with, was no friend of mine; I knew he was nuts, and tried to convince the chief not to hire him. His wife was also cheating on him so he shot them all, the wife, the three kids, and himself.

The most poignant suicide was a friend, who was also Dr. Kevorkian’s first patient, Janet Adkins. Janet was a wonderful lady, in her mid 40’s with rapidly progressing Alzheimer’s disease. She was with it just enough to realize how bad she was getting, and knew that her life would not be worth living without a brain that worked. Of course, this made headlines around the world, and resulted in an hour long television show (Town Hall, Portland, Or.) where her husband and I took on the religious zealots and the medical do-gooders who would, if given the chance, have denied her this opportunity, and forced her continued existence; not a life, just an existence, to satisfy their own inner turmoils.

I have no moral, nor conclusion to this story. I will say that, barring a terminal illness, I could not do this to people who admire or love me. It is just too painful, even after all these years.

* At my divorce, in 1981 the judge told my lawyer, "I don't care what the law says, as far as I am concerned the mother should always get custody." It was at this trial that I first became aware that court recorders skipped those passages that reflected badly on the judge. At least they used to, might be harder these days with all the recording devices available.
PS 01/18/11

Tuesday, January 11, 2011

The joys of being a landlord

Our renters, Jeff and Melissa Miller, of Orofino Idaho have quite obviously not taken any garbage out since they have rented the place. This barn was spotless when we left. Of course, since they haven't paid any rent in 6 months, this is not surprising. Wonder who the next landlord for this disgusting family.

A Surgeon and His Son Meet The Medical Establishment Head-On

A Surgeon and His Son Meet The Medical Establishment Head-On

NOTE: this is quite long and has some technical language.  It was sent (without the names redacted) to the Washington State Medical Board, along with a formal complaint.  This accomplished nothing.  The peacock surgeon is still plying his deadly trade.

On December 5th my 25 year old son, Andy, was involved in a head-on collision with a semi-truck.  His injuries were horrific, and life-threatening.  But his medical care was almost equally so.  I am writing this both as a father and as a trauma surgeon for 32 years.
I was called about 1 hour after his accident, and informed that he had a broken leg and was being transported to a small rural hospital in Northern Idaho.  Given my history, I jumped in the car and headed up there ASAP.  But first I suggested to the nurse that she make sure he had two IV’s started.  I have seen too many trauma victims succumb to shock from inadequate fluid replacement, especially in small hospitals.
When I arrived, he had had a CT scan, and x-rays of his left femur.  The CT scan showed multiple fractured ribs, sternum, back fractures, but no severe internal injuries.  They had ignored the right leg, but this turned out to have not one but two fractures of his femur.  His BP was in the 80’s and the FP said to me, “it can’t be too bad, his blood count is still normal (39)  Since with three breaks in his femur, he had a minimum of 6 units of blood loss (half his blood volume) I  knew that he was in deep trouble.  His blood count should have been ½ of normal, if they had replaced enough fluid to compensate for his blood loss.  Therefore they were at least 3 liters behind, and losing ground!
By this time, an orthopedist who happened to be at the hospital had diagnosed and stabilized the femur fractures; the life-flight from Spokane was there, and off we went. In the Spokane ER, he was completely re-evaluated.  By this time it took 6 liters of fluids to bring his pressure up and start his kidneys functioning.  The damage had been done though, and because of the inadequate fluid replacement, he could not have any IV dye, and so working up his internal injuries was limited.  It was found that he had internal injuries in the area of the duodenum (this is critical later.)
He had to have an ultrasound done through his esophagus to make sure that he had no aortic injury (because dye was contra-indicated as above.)  Since he was too unstable for anesthesia, I had to talk him down and hold his head steady while this was done awake.  He was a real trooper though and did great. 
Then it was off to the OR where the orthopedist put rods in both his femurs.  He was then taken to the ICU and kept on the ventilator, because by this time he was in fulminant Adult Respiratory Distress Syndrome
Over the next three to four days, his temperature was never below 102 and often up to 104.  Along with this was a white count of 23-25 thousand; three times normal.  I asked the trauma surgeon what this was due to (I was suspicious that he had intra-abdominal injuries, as there was no other logical explanation for this.)  It was ignored.  He said it was normal; yah, right!
Eventually after a week on the ventilator, his temps came down, his lung function improved, and he was able to be taken off the ventilator.  During this period of time his fluid retention was extreme, even for a trauma case.  He gained more than 70 lbs (sic) from his pre-injury weight.  This was another indicator of something seriously wrong.
Shortly after this, he was transferred to a surgical ward, and physical therapy came up to start getting him up.  At about the same time the wound on his left leg, where the femur had poked through began oozing several hundred cc’s of fluid a day.  The next day a, “wound care specialist” came up, opened up the superficial part of the wound, and said that it was just superficial and nothing to worry about,  He packed it tightly (a big no-no) and said he would be back the next day to change it.  He never came back.  Two days later, I knew that if I wanted to get this wound taken care of, I would have to get him out of that hospital, so we took him home. 
My wife had made arrangements, including a hospital bed, commode, walker, and wheelchair so we could do this at home.  As soon as I go him home, I opened up the wound.  The tract was all the way down to the femur; a depth of at least 6 inches (the length of a medical q tip) and it drained large amounts of fluids over the next few days.  I changed the dressing, and cleaned out the wound four times daily and eventually it. If it had been left alone and not opened, the femur would almost certainly have become infected.
He was on antibiotics, and these were stopped after a total of two weeks.  When this happened, the diarrhea he had had, and which we were attributing to the antibiotics, stopped.  Unfortunately so did all bowel activity.  His abdomen became progressively more distended, with severe cramping pain.  When, a day later, he developed a mass in his right side, with peritonitis, I knew that he was in serious trouble.  I took him to the local hospital, where a CT scan showed a ,”markedly dilated right colon with large amounts of stool, and a thickened transverse colon and meso-colon consistent with either diverticulitis, or more likely an injury from his prior accident.”
He went back to Spokane where he sat in the ER all day from 0800 until 5 in the afternoon.  At that time, Dr. X (names redacted to protect the guilty) decided that there was nothing wrong with him, and he was just having trouble dealing with the pain. 
I should note here, that two days after he came home, he stopped his narcotics, began physical therapy including working on a stationary bicycle.  This despite two broken femurs, multiple fractured ribs, and multiple back fractures.  As I said, he is a trooper.
So he was given laxatives, with minimal results, and attempts were made to wean him from the narcotics he needed to control his pain.  His abdominal mass was still present. Eventually he decided that since nothing was being done, he would go home.  However he was unable to tolerate  the severe pain, and had to return the next day.
Again Dr. X  insisted that there was nothing wrong with him.  When Andy and I commented to the resident that we were in a bind, because we knew something was wrong, and that Dr. X would not believe us, Dr. X came in and, there is no other way to put it, had a fit.
He stated that he was insulted that we went behind his back;  there was no need for a second opinion, and that we were welcome to take him anywhere in the country for one. 
I briefly toyed with the idea of putting him in the car and driving to Seattle, but was not sure he would survive the trip; he was that sick!  Instead I asked if we could have a GI consult.  Dr. X reluctantly agreed to this.  However when the gastroenterologist scheduled a colonoscopy, Dr. X called him up and told the gastroenterologist that he was risking his career because he, the all knowing Dr. X, felt it was neither necessary nor a good idea, and he, Dr. X would bring him before the peer review committee if he dared to go against his exaltedness.  He was still so insulted that anyone would dare question his judgment that he was willing to let my son die to defend his, “honor!”
Andy, a coach of junior-high football players, summed up this confrontation accurately and succinctly.  “My kids don’t act that immature!”
At this point I demanded to speak to administration; demanded someone be found to take care of my critically ill son, and this was done.  Dr. Y came and saw him, colonoscoped him the next day, and found a severely damaged transverse colon with almost total obstruction.  The pediatric scope he used; about the size of a sharpie pen would not fit through the small opening.  That is how tight it was.
The next day his right colon was removed.  He was found to have a perforation in his cecum along with an abscess due to the length of time it had been obstructed, .  Another day or two and he surely would have died!
During this entire time, ever since the second hospital admission, I had been telling Dr. X, the nursing staff, and anyone who would listen that my son was in terrible nutritional state.  No one would listen to me.  All they saw was a fat kid.  They would not believe that he had lost 60+ lbs (sic)  Even the second surgeon, when I mentioned this to him, laughed and said, “You can’t have lost much weight.”  When I said he had lost 60#, I was ignored.  At no time did a dietician see him; no nutritional workup was done, and this despite lab values that clearly indicated starvation (albumin of 2.1-2.4; prealbumin of 6-7, and BUN of 3.  All indicators of Dachau-like starvation state.)
After his second surgery (colectomy) his pain improved, but he continued downhill.  He had no high calorie feedings, his nutritional status continued in a downward spiral.  The first day after surgery he walked all the way around the surgery ward.  By three days after surgery, he was so weak he could walk no more than 20 feet without stopping to rest.
The surgeon wanted him to go home.  When I suggested that he was getting weaker, and I was very worried about his general well being and especially his nutritional status, the surgeon’s response was, “We cannot have this kind of relationship!”
What does that mean?
I can’t be a concerned parent?/ Or I can only be a concerned parent if I act like an obedient idiot, kowtowing to the all-knowing surgeons??
Eventually he relented, put a feeding tube in Andy and started him on high calorie feedings.  After this he improved quickly, and dramatically, and went home, still on the tube feedings two days later.
It is now three months since his accident, and he is progressing, though slowly.  He goes to physical therapy daily, and can be up and around for several hours a day.   The last round of delayed surgery and a week of living with a perforated bowel and abdominal abscess have set him back at least 2 months.  Fortunately he is young, and should eventually recover from this whole episode.
This entire episode has given me a whole new light on medical care.  I myself have been a patient, and have had several major orthopedic surgeries, and know the frustrations of being a hospitalized patient.  But never have I seen the total fragmentation of care, and disregard for the patient that occurred.
The nurse daily reported that Andy had a distended abdomen with severe RLQ pain and guarding; all signs of peritonitis; but evidently they were too afraid to say anything to the surgeon.
I say afraid, because there was an episode that brought this all out.  When Andy was in the ICU, the attending decided to put in a PICC IV, and remove his central line because of his high fevers, thinking the central line might be infected.  I was asked to leave during this procedure.  I came back later and noticed that he still had his central line in.  When I asked the nurse why he had both his PICC and his central line still in, I was told it was because there were no orders to remove the central line.
When I told her that the attending had discussed with me that the ONLY reason for putting in the PICC, was so they could get out the possibly infected central line, I was told again that there were no orders.  When I suggested that she call the attending (it was 6 PM) to get an order for this, I was told that under no circumstances would she do this.  The potentially infected central line was left in until the next morning.
So it seems, at least at this medical center, the old fashioned system of, “fear the physician and the hell with the patients,” rules.  The idea of teamwork, check systems, and cooperation just never happened.  I have only described the most egregious events, but on a daily basis the attitude was, “I take care of my sphere, and don’t ask me to do anything else.”  This was true whether it was asking for water, another pillow, a clean gown, etc.  At one point we waited an hour for a wheelchair so he could be allowed outside for a short time.  Once the nurse had called transportation, her job was done, and she was off taking care of other patients.  All to be expected in a busy hospital with overworked staff, but frightening when you are sitting watching your son die day by day.  The lack of caring by most of the hospital personnel was made more obvious and poignant by the opposite extreme, of the good nurses and aides who put their all into their jobs.
What lessons have I learned from this tragic and almost fatal melodrama?  We in the medical profession cannot be too careful, and must leave our emotions and egos at home, where they belong.  When caring for critically injured people, we need all the help we can get.  more important, people like this should NOT be supported by the medical establishment. The medical board reminds me of the police "investigating boards." whose sole job seems to be to protect their colleagues from having to answer for their acts.