Map of life expectancy at birth from Global Education Project.

Tuesday, August 31, 2010

Next Episode of As the Colon Churns

This post is not going to be particularly meaningful, but I have to advance the narrative. So what happened after I suffered that horrific bout of paralytic ileus?

I couldn't have any narcotics, because they sedate the bowels, and of course that was the opposite of what we wanted to happen. And I couldn't have any aspirin, or tylenol, or ibuprofen. Those all supress fever. The doctors had to keep track of my fever so they could tell if something disastrous was happening. So I could have no pain relievers at all.

Peter told me to ask for atavan, a tranquilizer, which might help me sleep. He told me I could put a pill under my tongue and dissolve it. Dr. Huang agreed to my request, but things didn't work out the way I expected. Nurse Huang came in a few minutes later with a big, ugly syringe, and gave me a very painful shot in the ass. It might have done some good, but I didn't sleep that night.

I wasn't idle, however. I had developed diarrhea. My nurse -- Nance now, there was a shift change at 4:00 -- gave me a plastic device she called a "hat" that would hook over the sides of the toilet to catch a stool sample. But I didn't produce anything that could arguably be called stool for many days. Instead, I would stagger into the lavatory every half hour to expel a pint or two of pale yellow fluid.

I had to report every one of these episodes to my nurse, and I had somehow to try to catch my urine too so it could be measured. It was a real challenge. I had to urinate standing up so I could use the blue jug with the cubic centimeter markings, but it was far too dangerous to try to urinate before I had relieved my bowels. At the same time, it was a feat of hatha yoga to hold back my urine while my bowels were gushing.

That was not my only problem. Every time I went into the lavatory, I had to push the IV pole in ahead of me and get it positioned correctly so I could wrestle the knee-length smock out of the way and get my pants untied. Then I had to reverse the process on the way out. Every time, the IV got yanked around inside my vein.
In the next two days, I went through four or five IVs. They would stop running completely, or the arm downstream from the needle would get painful and swollen. Now I was more dehydrated than ever. Just because I couldn't stand the thought of drinking anything didn't mean I couldn't, at the same time, feel just as thirsty as a dying man in the desert.

There was never an IV nurse after 5:00 in the afternoon. Once the IV stopped running at night and I lay there desiccating for five hours before someone came to put a new one in. She didn't know what she was doing. First she blew a vein in my left hand, then she tried to put the needle in the crook of my left elbow, in the big vein they take blood samples from, and she blew that one as well. She finally gave up. During business hours, I was considered a windfall instructional resource. The IV nurses would bring students around to jab at me, until I insisted that the butchery stop.

Once, while I was lying in bed, I looked down to see the line full of blood and then I saw that it had somehow come apart. I pushed the call button. When Nance came in, she gasped and said to me, "don't look at the floor." A man came in with a mop a few minutes later and he just said, "Oh man." I didn't look, but from the way the man worked the mop, I figured the puddle of blood must have been at least five feet in diameter.

I said to Nance, "Look, the reason this is happening is the way I have to manipulate my clothing every time I go to the toilet. I have to get this damn nightie out of the way so I can get my pants down, and it keeps getting tangled in the IV line. Can't you give me a regular short pajama shirt?" Well, they didn't have any. The long johnnie was the only upper garment in stock. But she improvised. She got me a surgeon's scrub top. Not only did that put a stop to the repeated torture of blown IVs, but it immediately gave me back a measure of dignity I hadn't had since the night I walked in. I was now the only patient in unit 7B who was not humiliated by his clothing. The scrub top had a flattering cut and was an attractive blue with tan piping; it was closed in the back; it ended appropriately at the waist. I was now dressed like an adult instead of an infant.

That was definitely a win, but I had other problems. Remember I still had the diarrhea. And the fever. And the cramps. The day after the episode of the intubation and vomiting, not having slept for 36 hours, I determined to put an end to the cramping which I thought was doing permanent damage to my guts. I closed my eyes and concentrated on the deranged bit of flesh below my navel. I tried to communicate with it. Every time a spasm began, I would talk to it softly in my mind. "Relax, relax, don't fight your fellow intestines. Go with the flow. Accept the contractions as they come your way. Accept them and let them pass through you." Between attacks, I would visualize the waves of peristalsis flowing smoothly down through my bowels. With astonishing quickness, I gained voluntary control over the spasms and, within 20 minutes, they had stopped.

That was not the whole cure for what ailed me, however. I had gas pains worse than ever, and something new: an occasional sharp stab near the incision that would make me gasp. Whenever I walked, as I did often now, I would feel at least a little pain in that same place, and once in a while it would flare up and stop me in my tracks. The doctors could feel a hard lump there, and I could feel that lump inside me without even touching it. Another development which did not improve my mood was that my right testicle was sore all the time. You tell me why. Having to measure and describe every secretion of my body for my nurses was humiliating. I still could not sleep through all the pain, the diarrhea, the tornados of bells, the stench of burned popcorn, Mr. Karakov talking in his sleep ...

The Second Coming

I wonder if the anywhere from 87,000 to 1 million people (consensus estimate: 87,001) who showed up on Saturday for the world historical event at the Lincoln Memorial didn't go away disappointed. Here they were expecting to get the inside dope on the imminent plan by the Communist Fascist Islamist Terrorist Anti-American Anti-Christ who has seized state power to confiscate their guns and round them up into FEMA concentration camps so that Mexican drug gangs can take over the U.S. as the vanguard of the UN One World Government leading ultimately to imposition of Sharia law. Then they were going to get the details on the massive grassroots mobilization to use Second Amendment remedies to thwart the conspiracy, followed by everybody being issued an automatic rifle and given their personal deployment orders.

Instead they got a lot of religious claptrap and some stale jive about honoring The Holy Troops of blessed name. It is entirely unclear how this reclaims the Civil Rights movement on behalf of middle aged middle class white people obsessed with their own victimhood. Nor is it clear how this restores America's Honor, nor is it clear what exactly is supposed to have happened to America's Honor in the first place. It seems to me that if Glenn Beck continues to morph from a purveyor of right wing paranoia and white resentment into a Mormon prophet of Christian dominion, he's going to lose some of his fans.

Just sayin'.

Monday, August 30, 2010

One man's ceiling is another man's floor . . .

And your taxes are my income. Massachusetts has typically weathered recessions a bit better than many states because we have a bigger than average health care sector, which has just kept on growing through hell and high water. Not so much this time.

On the one hand, I've been ranting and raving ever since I've been doing this blog thing (BTW this is my 2,007th post, I didn't even notice the 2,000th) that our medical industry is too large and much of it is waste. That's still true but that waste is also income for people -- medical underwriters need to eat. And those anesthesiologists making the 300K employ a lot of nannies and gardeners as well as keeping the Mercedes Benz dealer in business.

BUT, the contraction we're feeling right now isn't actually such good news, because it isn't accompanied by a rational re-allocation of resources. People who are avoiding appropriate medical services because they can't afford the co-pays, or can't find a physician who will accept Medicaid, aren't making us better off in the long run. Massachusetts has few people without insurance, thanks to Romneycare, and I doubt that whatever effect the recession is having on undocumented people has much of anything to do with the aches and pains of the health care industry. So yeah, there is probably a little bit of efficiency and beneficial belt tightening by the highly paid going on here. But without radical reorganization and reform of payment policies we aren't going to get a better, cheaper industry, we'll just get more injustice.

However, if we do ever achieve those radical reforms (not that I'm holding my breath) we will have a substantial workforce whose skills and experience are made obsolete, including many wealthy executives. This why it is so difficult to achieve meaningful social change in a democracy. All of us may have some interest in reform, but most of us are a) unlikely to understand our real interests and b) even if we do, reforming health care isn't going to be the most important thing in the world to us so long as we do have decent access.

But the people who would be out of work, and the rich people who might actually have to find honest work for the first time, care a lot - more than they care about anything. And they will donate to candidates, buy attack ads, and pay for massive disinformation campaigns if they must in order to protect their sinecures. That's political science.

Sunday, August 29, 2010

Doing Good

The anniversary of Martin Luther King's famous "I have a dream" speech reminds us that the Freedom Movement was originally organized by churches and led by preachers, MLK foremost among them. I certainly can't deny that religion has often inspired people to do great things. But just because a belief system can produce benefits has no bearing on whether it is true. To argue for a belief based on its alleged utility is called the pragmatic fallacy.

In any event, I need hardly point out that religion can equally be a force for evil, from the ancient history of sectarian violence (read the Bible if you really want to see how God can inspire hatred and gore -- and he hasn't gotten the least bit sweeter either) to oppression of women and sexual minorities, to torturing dissenters to death in Jesus' name, to the depredations of European colonialism (fully justified by Christian leaders), and oh yeah, slavery and white supremacy, the very evil King's movement was organized to overcome. The problem with claiming religious belief as a force for good is that it is arbitrary, and can just as easily, probably more easily, pivot in an instant to become a force for evil. Just consider the rally that happened at the Lincoln Memorial yesterday.

Still, apart from its large scale role in society, religion creates community at the local level. Religious congregations do charitable work, they help neighbors meet each other and they knit together small towns, and in many societies they perform other essential services. I don't mind admitting that I miss that. I don't have anyplace to go on Sunday to meet up with old friends and make new ones. I've known people who were down and out at one time and slept in the church basement. Support groups and youth programs and voluntary organizations and all sorts of down home institutions meet in churches and are nurtured by congregations.

So, like a lot of people, I can see an argument for trying to replace all that with some form of secular community. People have tried, with humanist associations and that sort of thing. Some Unitarian churches manage to keep the mysticism to a minimum, although others are still pretty heavy on the Jesus. But for the most part attempts to replicate the secular functions of religious communities with non-religious organizations haven't been very successful.

There are plenty of important secular charities, obviously, but they have little or no connection to local communities, they just ask you to mail them checks. There are all sorts of clubs organized around a specific interest, from theater to stock market investing to bicycling to smashing imperialism, but you have to be heavily into the particular to take part and they aren't likely to branch out into succoring the needy or being a way for new folks in town to meet up with everyone.

So I agree, without religion there can be some social goods we haven't quite figured out how to replace. Any brilliant ideas?

Oh, and BTW: I am going through some major changes in my own life the next couple of months, it's possible there will be some disruption in blogging as there was on Friday. I hope it won't be the case, but if it is you'll know why.

Thursday, August 26, 2010

Moral Idiocy

You won't be surprised that sitting as I do within a clinical research institute I get e-mails regarding the injunction against federal funding of embryonic stem cell research. I'm not a lawyer (thank FSM) so I don't know whether the judge is playing with a full deck, but I am hearing about the consequences.

Our own director of grants and contracts (who is a venerable Juris Doctor) writes "I would just like to pass on the following information regarding the Stem Cell Court Order, whereby pursuant to a court order issued August 23, 2010, NIH is not accepting submissions of information about human embryonic stem cell lines for NIH review. All review of human embryonic stem cell lines under the NIH Guidelines is suspended. In addition, the February 23, 2010, proposal to revise the Guidelines is also suspended."

Researchers at Children's Hospital, George Daley and Leonard Zon write:

The injunction forbidding the use of federal funds to support embryonic stem cell research threatens the progress of our work and dashes the hopes of patients and their families facing illnesses who will someday benefit from this research. As of today, experiments and studies currently being supported with federal grant dollars will now depend upon support from private donations, and in these difficult economic times, philanthropy is not a viable funding source for research. This decision is a tragic setback not only for patients but for the whole field of stem cell research.

We hope that the injunction can be rendered moot by an act of congress that removes any ambiguity in their support of federal funding for human embryonic stem cell research.

Now, I've always been one to dial back the enthusiasm on this, not only because effective treatments are a long way off if they ever come, but also because our development of ultra-high technology and comparably ultra-high cost medical technology has run way ahead of our ability to pay for it, which means that medical breakthroughs are mostly about benefiting the wealthiest people on earth while doing nothing for the people most in need who can't get access even to pretty cheap stuff that we already have.

More people die of cancer worldwide than from HIV, tuberculosis and malaria combined, most of them in poor countries where, as David Kerr and Rachel Midgley write:

Currently, a cancer diagnosis in the developing world is likely to mean a painful and distressing death. Although there is growing awareness of the magnitude of the increasing cancer problem in low-income countries, the challenges of producing comprehensive national cancer plans are substantial; not least of these is the need for financial prioritization. The estimated amount spent on health care through Britain’s National Health Service in 2008 was approximately $3,000 per capita — considerably more than that spent for health care for citizens of Kenya, about $8.30 per capita annually.

Obviously, that isn't going to pay for even the most basic cancer treatment, let alone for growing new organs in vats should stem cell research pay off. Still, as long as we're funding research into cutting edge biomedical technology, excluding use of embryonic stem cells is ethically preposterous. Thousands of embryos are destroyed every year that are overproduced in fertility clinics. I don't see any religious fanatics objecting to that. What they object to is taking cell samples from a few of those in order to advance scientific knowledge and perhaps, one day, curative technology.

To equate these nearly microscopic balls of cells with human beings is just asinine. They are created in petri dishes and they have no differentiated organs of any kind. They are indistinguishable from slime molds unless you happen to sequence their DNA. The religious right got itself into this trap of illogic by claiming that abortion is identical to killing babies, when what they really don't like is sex. There's no sex going on here but they can't afford to be inconsistent so here they are, condemning actual living children to death and disability without even trying to save all those blastocysts anyway.

But they aren't really that stupid. They are really that evil.

Wednesday, August 25, 2010

Oh yeah, my time of strife and woe . . .

I know I'm supposed to tell the rest of this story so I'll get on with it.

When you have your intestines cut apart, they shut down for a while. The anesthesia and the morphine also contribute, so getting off the morphine is helpful, but it still takes at least three of four days for things to get going again. That's why I had the nasogastric tube sucking my stomach dry all the time, and that's why I couldn't eat or drink anything. Hence the IV hydration. You don't want the stomach trying to send anything on for further processing and causing a backup. The way you can tell the guts are starting to operate again is pretty simple -- you fart. So passing gas, as the nurses more delicately put it, became my principle goal in life.

So, Saturday morning, taking my early walk, I farted, just a little puff. What a joy! I felt fine, except that I was thirsty, I still had some pain from the incision and from gas, and I was tired beyond words of being in the hospital. The Chief Resident told me that perhaps I could try some liquids the next day and, if all went well, go home on Monday. He pulled off the dressing, ripping out a good chunk of pubic hair in the process. The incision, it turned out, ran from directly below my navel to just over the point of my right hip. It was closed with big steel staples, like railroad ties.

Then the Chief of Service came and told me I could start eating immediately. He put me on what is called a Full Liquid diet. He gave me his card. "After you're discharged, I'll want to see you in a couple of weeks. In the meantime, if you have any problems or questions, just call." The card read: "Beth Israel Hospital, a major teaching hospital of Harvard University. Andover G. Knozall, Instructor in Surgery." Leah, my wondrous primary nurse, was off that day. Nurse Chris Huang, who I did not know well, gave me a lunch menu. Mirabile dictu! I could order tomato soup, vanilla pudding, cream of wheat. I lustfully circled my choices. Then Chris told me I could get juice from a referigerator across the hall.

It turned out the juice came in a little container that looked like a urine sample. I drank some apple juice, trying to be cautious, but it was gone in a minute. I will not try to describe this experience; I'm sure you can imagine what it meant after nearly a week with nothing getting past my front teeth except a wet sponge on a stick.

I waited a half hour or so and still felt okay, so I went for a urine-sample container of orange juice. I was on my way out of there! I got a little anxious, though, the next time I got up to walk and discovered that my abdomen had blown up into a hard, geometric hemisphere. When my lunch came, I was too bloated to eat.

I had begun to feel surges of pain in my abdomen, always in the same place directly below my navel. As each one subsided, my diaphragm would spasm and acid would burn through my chest and into my throat.

My friend Peter, who is a psychiatrist, came to visit with his eight-year-old son. JJ had brought me his electronic baseball game, to help me pass the time.
In the end, that people care for you is the meaning of life. But pain, in its time, is the whole universe. The cramps now came every minute, stronger every time. They would start in a tight focus just below my navel. Then pain would swirl through my belly and explode into my groin and up through my chest and neck like a cluster bomb, trailing acid fire into my throat. After every attack, I violently gulped the air I would need to make it through the next one. My memory of this whole episode is a blur of agony, but my nurse knew that I was in serious distress before Peter and JJ came. She paged the intern on duty on my team right away, but he didn't come for more than three hours. By the end of that time I thought the spasms would break me in half.

Peter did everything he could to help. Even though he is a doctor, it was not his place to intervene. He tried to talk me through a meditation exercise to conquer the pain, but I could not concentrate. I was not simply in pain: I was possessed. My body was no longer my own. I wanted JJ to leave, afraid he would be hurt and disturbed by what he was seeing, but I didn't want to send him away either because I wanted him to know that I liked having him care about me. It was up to Peter, anyway, and Peter let him stay.

Peter urged nurse Huang to page the intern, again and again. She argued with him, defending her own conduct although it was the system Peter was resisting, not her. Finally he threatened to call Andover Knozall at home. Five minutes later, the intern came. His name was Dr. Huang. No relation? I don't know.

"Ileus", he said to Peter, who agreed with him. That's a fancy word for paralysis of the bowels. Peter had explained to me that the cramps came from the bowels starting to work, but without coordination. One section might start a wave of contraction that met up against another section that was locked up tight. The problem came, ultimately, from the apple juice I had drunk that morning. My stomach was trying to send it on down to intestines that just weren't ready.

Dr. Huang said he was going to pump out my stomach. Peter and JJ left the room. Dr. Huang had a little roll of thin orange tubing. He cut off a piece and dipped one sharp looking end in some vaseline. Then he stuck it up one of my nostrils. It felt exactly as though he had stuck a burning match up there. "Don't do that don't do that don't do that" I yelled. I couldn't yank my head back because it lay against the mattress. I couldn't struggle with him because I was paralyzed by the cramps. The match burned back through my skull. "Where is it?" Dr. Huang asked.
"My throat my throat my stomach my stomach take it out take it out." Then I gagged and vomited onto Dr. Huang's shirtfront. I vomited again, and a third time. By then, he had a bowl under my chin. The tube came up with the brown glop in my stomach, and I pulled it out of my nose. The cramps eased.

Peter came back in and he helped Dr. Huang change my smock. "Actually," Dr. Huang said, "I'm more concerned about his fever. It should be going down by now. It's still 102." I was lying back exhausted. Peter and Dr. Huang left. I still had cramps, but they stayed in that tight little focus under my navel, no longer exploding through my vitals. Every minute, a little surge of pain. But no more cluster bombs, no more back arching and throat burning.

Nurse Huang came in. "I did everything correctly from the standpoint of nursing. Your friend was wrong to say he was going to call the attending." She leaned over to lecture me. How could she would berate me in my present condition? But I found the strength to answer. "My friend wasn't criticizing you. He said so. He was surprised that you took what he said so personally. He was just upset with the system," I told her. But she wasn't satisfied. "I did nothing wrong within the responsibilities of nursing," she insisted.

There are a couple of lessons here. The first concerns the hubris of the surgeon. Even though the residents and nurses knew that I wasn't going to be ready to eat anything for another day or so, he is such a great surgical genius that his patients get better a day earlier than they are supposed to. Actually I later learned that he should have put a stethoscope on my abdomen to determine if the bowels were working, but he didn't even bother.

The second lesson is that it was impossible for me to get any help because I had the bad fortune of already being inside the hospital. If I had been out on the sidewalk and somebody called for an ambulance, I would have had help in three minutes. But inside the hospital a guy with ileus and abdominal cramps is way down the list of things to worry about. Presumably it was only going to torture me, not kill me, so nobody gave a shit. Not only that, they were angry at me for causing such inconvenience. I'm pretty sure they are more attentive in your typical veterinary hospital.

Sorry, but 19 years later, I'm still pissed off about it.

Tuesday, August 24, 2010

A few more thoughts on Marc Hauser

Perhaps I've said enough already, but this sad, painful story has additional dimensions. Hauser's specialty was evolutionary psychology, and his essentially fraudulent experiments were purportedly telling us something about the cognitive capacities we share with some of our primate cousins. In the context of the cause of science, and the barbarians at science's gate (such as the very interesting visitor to my previous post on Dr. Hauser), there could not be a more sensitive subject.

Biologists claim that our minds and our consciousness are the product of evolution, inseparable from the physical substrate of the brain and created over the eons by a process of random change and selection by reproductive success. I would venture to say that this single claim infuriates the religious more than any other. And I can see that is intuitively very difficult to accept. Our own consciousness seems transcendent. It is awesome and baffling to contemplate the awareness of self, our apprehension of the world, and our own joy and pain. This is just obviously something beyond and outside of the material world. "Delight is to him- a far, far upward, and inward delight- who against the proud gods and commodores of this earth, ever stands forth his own inexorable self," wrote Melville.

And yet, however hard it is, however much it may threaten the meaning we find in ourselves, we have to accept the fact of our evolutionary origin simply because the evidence for it is overwhelming. It doesn't matter whether it feels right, or it's satisfying, or conversely whether it feels humiliating and depressing. It's the truth, and we know it is the truth because so many people have worked diligently for 150 years to understand that truth as deeply as possible and follow it wherever it leads. To betray them all, and offer an unrestricted gift to the enemies of reason and truth, is a failure I do not even know how to characterize.

Monday, August 23, 2010

Crime Against Truth

Yeah, it's really ugly when politicians and professional yackers make stuff up that isn't true. I've spent a lot of binary digits here wailing and moaning about our non-reality based political culture. But let's face it, we expect politicians and Glenn Beck to lie, that's their job, at least as they see it.

But if we humans are to continue our slow, painful climb out of the darkness, the scientific enterprise absolutely must be trustworthy. Scientists are human and they are often tempted by rewards other than truth -- prestige, money, fame, power. If they succumb to any of these at the expense of truth, it's a betrayal not only of the institutions where they work, and the scholarly community of which they are a part, but of all humanity. False findings and wrong conclusions can get embedded in the literature and take decades to expunge. Meanwhile investigators are led down false paths, funding is squandered, opportunities for important discoveries are missed, patients are mistreated - the consequences cascade endlessly.

That's why the case of Marc Hauser is so deeply disturbing. He was not only a prominent scientist and influential public intellectual, but part of a community of important thinkers and well-known champions of reason to which I personally feel a deep attachment, including Stephen Pinker and Noam Chomsky.

Arthur M. Michalek and colleagues (and no, Donald L. Trump is not The Donald) review the directly measurable costs to their own institution of a single case of scientific fraud, not nearly as important as Hauser's. They come up with a bottom line of $525,000, but that does not include the so-called intangible costs as falsehood stains the very fabric of the field. In fact, unlike the Hauser case, that didn't really happen here. This particular fraud was nipped in the bud, but Hauser has had three fairly important articles retracted or corrected, and his entire body of work must now be called into question.

Tom Bartlett's account (see my first link) suggests that Hauser may have been guilty more of wishful thinking than of conscious fraud. He coded the behavior of monkeys, but it turns out that only he could see the behaviors that supported his hypothesis. Graduate students who observed the same data saw the opposite.

However, that the design of his studies even made that possible is a grievous fault. The only legitimate way to do this is to have coders observe videos of the monkeys' behaviors while blinded to the stimuli being tested. It's just elementary that having the investigator, who has a compelling personal stake in the outcome, do unblinded coding in this way is invalid to begin with. It's a mystery how this work even got published if the methodology was accurately described.

So no, Hauser doesn't get off the hook as being sloppy or careless rather than deceitful. There's just no excuse for this. However, it is not a crime, and it won't even cause him to lose his job. Harvard has already determined that he committed scientific misconduct, and if NIH makes the same determination he will be disqualified from getting NIH funding for three years. That's it, that's the worst that can happen. To be sure, as a practical matter he's going to have a hard time convincing a study section to recommend him for funding even after three years, his reputation is in tatters, and he'll likely end his career as a tenured non-entity. But I'm still going to take this opportunity to scold him.

We have to pile on to make the penalty for this sort of thing not worth the risk. In my group, we agonize over getting every little detail right. We spend days and weeks going through our data and documenting everything we do, every time we touch it, who does what, and making sure that every case is labeled correctly, described correctly, and assessed correctly. When something gets screwed up -- and that will happen -- we make absolutely sure we have it straightened out before we move ahead. It's a major pain in the ass, it slows us way down when it comes to publication and grant writing, it's boring and it's annoying. But it's what you absolutely must do.

Sunday, August 22, 2010

Stranger in a Strange Land

As I might have mentioned, or maybe I didn't bother to tell y'all, I attended a funeral on Wednesday. (Not to worry, a friend of my parents with Alzheimer's disease, whose death was a long-awaited relief.) It happened at an old, very fancy Episcopal Church in an affluent Connecticut shoreline town. The pews were packed with elderly patricians, who collected at an old, very fancy yacht and country club for the reception.

The church (which is on the national register of historic places) is what they call High Church, meaning they lay on a lot of fancy rituals. It also happens to be the church I attended as a young child, where my uncle was the pastor and my mother taught Sunday school. It has been many years since I have experienced so much Christian folderol -- the last time was my uncle's funeral, in fact, in this very church, more than 20 years ago. What once seemed quite normal and perfectly sensible now seemed just plain bizarre and inexplicable.

People in medieval costumes came marching down the aisle holding useless but expensive objects -- a gold (plated I suppose?) cross and a crook on long carved staffs. They proceeded to wave around gold plated books and recite a whole lot of mumbo jumbo that was syntactically well-ordered but didn't actually mean anything. We all had to stand up and sit down and we were supposed to recite a lot of mumbo jumbo ourselves (although I did not), and then everybody had to line up to eat human flesh and drink human blood, although not really, it was just crackers and rotgut wine.

Making people assert beliefs or commitments out loud is a well-known psychological technique to cause actual belief. It really does work backwards from articulating the words to cognitive structure, I suppose because we don't want to make liars of ourselves. One of the incantations we were ordered to recite is called The Apostles Creed. For those of you who don't know it:

I believe in God the Father Almighty, Maker of heaven and earth.

And in Jesus Christ his only Son our Lord; who was conceived by the Holy Ghost, born of the Virgin Mary, suffered under Pontius Pilate, was crucified, dead, and buried; he descended into hell; the third day he rose again from the dead; he ascended into heaven, and sitteth on the right hand of God the Father Almighty; from thence he shall come to judge the quick and the dead.

I believe in the Holy Ghost; the holy catholic Church; the communion of saints; the forgiveness of sins; the resurrection of the body; and the life everlasting. AMEN.

Some of this, arguably, has actual meaning in that it has referents in reality. Most of it, however, is just words that mean nothing. "He descended into hell?" "He ascended into heaven?" These places do not exist. What the hell (pardon me) does it mean to "judge" the dead? I can form my own judgments, much better than Jesus, who is dead, but the dead don't care. It's all a lot of gibberish.

All you need to do is get away from it for a while, stop reciting it, and its power quickly fades. After a while, it's just laughable.

Saturday, August 21, 2010

There will always be an England

Just came across The Daily Mash, which may be summarized as the British Onion. You'll probably want to bookmark it.

Friday, August 20, 2010

Back with more gripes about the hospital

My home away from home many years ago, that is. One fact about hospitals that has changed a little bit since then, I think, but not yet enough, is that they are organized around the convenience of the staff, not the comfort or even the welfare of patients, except in the grossest respects.

Starting the first night after my surgery this became obvious. At irregular intervals there would be a storm of bells, three or four going off at once. It took me a couple of days to figure out that this happened when somebody hit the call button for a nurse. Usually they ignored them for several minutes, at least, so the people would hit them again setting off more bells. I believe many hospitals have gone to silent call systems now. There was an unpleasant odor that I interpreted as burned popcorn, which I believe was benzyl alcohol. With Mr. Karakov talking in his sleep and having the occasional crisis, sleep for me was pretty much impossible.

At four o'clock in the morning, a man came to take blood from my arm. He was efficient and skillful with the needle, but he caressed my forehead and shoulder for his own pleasure, and I was too weak to protest. That's right -- I was sexually assaulted twice in 24 hours in A Major Teaching Hospital of the World's Greatest University. At five o'clock, two nurses came in to weigh me. How can you weigh me, I protested, I can't get out of bed! Not to worry, they had a device which would jack me up in the air if they could get a sling under me. This involved rolling me back and forth. They counseled me to give myself a shot of morphine before they started. Hanging in the sling, I was bent back at the waist, and I yelled despite the morphine.

The nurses agreed that what they were doing was insane. The doctors had ordered it so that they would have the results in time for their morning rounds at 6:00. That also accounted for the pre-dawn blood-letting. Why the hell did they need to know my weight? They were concerned about my fluid balance. "Do you want to know if I'm dehydrated?" I asked. "Okay, I'm dehydrated."

This system has not been changed. The attendings or chief residents take the house staff on morning rounds at 6:00 am, and they need the biological data in advance. So patients are awakened in the middle of the night. This is so obviously wrong, in fact abusive, that I've thought of starting a political movement to end it.

I once interviewed a man who spoke only Spanish. The doctors would gather at the foot of his bed every morning and discuss him in incomprehensible gibberish. When his daughter got off work at 4:00 in the afternoon, she would come by and call his doctor on her cell phone, and then report to him, with whatever degree of accuracy, what he told her. They did the same thing to Mr. Karakov except that he didn't have a daughter to talk to his doctor for him, which is why he ended up with no idea what was happening. This is a fundamental violation of rights and human dignity, of course, but it still happens routinely. I don't think it occurs to anyone to bring an interpreter for morning rounds -- or for that matter to schedule them at a reasonable hour for the patients' sake.

Now, most of my nurses were absolutely wonderful. There were really only two exceptions -- the episode with Mr. Karakov, which I have already reported, and one other that happened to me, which I'll get to. A friend of mine, who is a nurse, refused to believe the story about Mr. Karakov. Nurses just don't behave that way, as far as she was concerned. Well, that one did. But she was an exception.

However, nurses don't run the hospital, doctors do. And too many doctors, as far as I'm concerned, are similar to airline employees, who view the customers as a major nuisance that they would be better off without. It would be better if the planes just flew from city to city, or the bowels got resected, without having to put up with those annoying human beings. Once I had a resident move in upstairs from me, and he actually told me that he preferred the people unconscious, so he didn't have to talk to them. (I only revealed my profession to him later.)

Wednesday, August 18, 2010

Lost in Space

I'll be in the Alpha Quadrant of the galaxy for the next couple of days, so I may not be able to get another post up till late Thursday or Friday. Meanwhile, another open door crashed through: Many children who are disruptive in school classrooms are misdiagnosed with Attention-Deficit Hyperactivity Disorder, when all they really are ... are young.

As I have noted here before, ADHD is a disease label that is applied more or less indiscriminately to children whose behavior adults don't like. I say indiscriminately because there is no diagnostic marker for the "disease," no physical manifestation, no test you can give. School demands something of children that evolution did not equip them for very well: to sit quietly in rows and concentrate on boring tasks for hours on end. Some kids just can't seem to do this. So we give them pills, which are literally and precisely the biological equivalent of the illegal drugs of abuse cocaine and methamphetamine, which stunt their growth and damage their hearts. It's a huge industry.

What this study tells us is simply that some kids who get this label are on the young end of the age distribution in their class so they haven't had the discipline sufficiently pounded into them yet to conform to expectations.

However, we have much bigger problems than this. In the face of multiple world-historical crises, cynical extremists have completely captured the political discourse with a campaign of religious bigotry. It is not only working on its own terms, it has silenced the urgent conversation we need to be having about climate change, the ongoing destruction of the oceans, the long-term economic decline of the United States and the very real short-term threat of global economic collapse, the possible dissolution of civil order and national integrity of both Iraq and Pakistan (very dangerous, either one) . . , oh, I don't know, pick your own nightmare. Meanwhile, nobody who isn't stark raving insane should give a fart whether people build an Islamic community center in lower Manhattan.

Tuesday, August 17, 2010

Ask a stupid question . .

You might get an intelligent answer.

Cheng Tsung-Mei for Health Affairs interviews Thomas Zeltner, former health minister for Switzerland. (You can't read this part except you can, because I'm reproducing it here.) The Swiss adopted a system in 1996 that's something of a model for the PPACA, only better, because poor people don't get second-class coverage.

Cheng: Many Americans bristle at the idea of being mandated to purchase health insurance and see it as a violation of their individual freedom. The Swiss are known for jealously guarding their individual freedom, too, yet they accept their own mandate to have adequate health insurance. As one such freedom-loving Swiss individual, would you defend the Swiss mandate?

Zeltner: That’s easy.We will not let people suffer and die when they need healthcare. The Swiss believe that in return, individuals owe it to society to make provision ahead of time for their health care when they fall seriously ill. At that point, they may not have enough money to pay for it. So we consider the health insurance mandate to be a form of socially responsible civic conduct. In Switzerland, “individual freedom” does not mean that you should be free to live irresponsibly and freeload from others, as you would put it.

Cheng: What if you do not have a job or are poor? How do you own up to the mandate then?

Zeltner: If you do not have a job, then, obviously, there are two options. Either you’re very rich or on a pension, and you don’t need public assistance. Or you’re poor—in which case you will get a subsidy from the government to help pay for the insurance.

There. Would that be so difficult for Democratic politicians to say?

Here's a little something I wrote for an encyclopedia

Just want to see if people have any comments.

Discussion of so-called “substance abuse” and addiction is vexed by ambiguity and disputes over vocabulary, which are caught up in equally vexing disputes about ideology and values. People may distinguish among substance use, misuse, abuse, abuse disorder, dependence, and addiction, but not necessarily in consistent ways.
The American Psychiatric Association defined drug abuse in 1932 as “the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state. . .” Note the oddity that not all drugs are drugs – the second sense meaning therapeutic compounds. This double meaning creates additional confusion. The definition went on to establish as essential conditions violation of cultural acceptability, social norms, or statute, in other words drug abuse was predominantly framed as moral transgression. This moral lens has continued to influence views of substance abuse, but the formulation of addiction or substance dependency as a disease has grown more influential.

Some question the concept of a substance abuse disorder or addiction entirely, claiming that these cannot be distinguished from other categories of voluntary behavior which may have consequences that most people would view as negative; while a contrary movement has extended the concepts of behavioral dependence and addiction beyond the use of psychoactive chemicals to encompass behaviors ranging from gambling to eating to sex to surfing the Internet.

For the disease model of substance use disorders the authoritative texts are the Diagnostic and Statistical Manual of Mental Disorders IV, Text Revision, (DSM) issued by the American Psychiatric Association; and the World Health Organization International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD10). Neither use the term “addiction.” The ICD10 focuses on harm to the individual from overuse of psychoactive substances, with difficulty controlling use and continued use in spite of harm defining “Dependence Syndrome.” The DSM uses a similar definition for “substance dependence.” However, its definition of substance abuse does not focus on damage to health, but rather on psycho-social problems such as failure to fulfill role obligations, and legal consequences. In this respect, the APA’s moral lens persists.

In the vernacular “addiction” may refer to any habitual overindulgence, but in neuropsychiatry it refers specifically to alterations in the brain’s dopamine signaling system centering on the nucleus acumbens region. This circuit is believed to provide rewards for behaviors associated with evolutionary success, such as sexual intercourse and eating. Addictive drugs increase the level of dopamine in this system, resulting initially in behavioral reward. Chronic overstimulation of dopamine receptors results in needing the drug in order to feel any behavioral reward and overwhelming other motivations. Note that the “reward” for using the drug is not necessarily euphoria or even pleasure, but merely the relief of craving. Additional accommodations by the body to chronic use of an addictive substance may result in various other physical or mental symptoms when the drug is withdrawn, creating an additional short-term challenge to cessation. However, craving may persist long after these acute withdrawal symptoms have ended.
Chemicals that affect this neural circuit include opioids, nicotine, alcohol, amphetamines and cocaine, although the effects of these compounds are otherwise dissimilar. Hallucinogens are considered drugs of abuse, but are not habituating. Cannabis targets a different class of neuroreceptors and is less habituating than chemicals that target the dopamine pathway. . . .

Habitual tobacco use is very harmful to health over the long term, dramatically raising the risk of lung cancer and some other cancers, heart disease, stroke, chronic obstructive pulmonary disease, and associated mortality. Tobacco use is considered the leading preventable cause of death in the United States and most of the wealthy countries. However, as tobacco is fully legal and does not produce acute impairment, other social harms associated with tobacco are minimal.

The example of tobacco supports a plausible argument that the harms associated with opioid dependency principally result from legal prohibition. Dependent users can be maintained with doses that do not produce euphoria but eliminate craving, with minimal consequences to health, and lead fully functional lives. However, as non-prescription opioids are very expensive and their sale and possession is subject to severe legal sanctions, habitual users must devote most of their waking hours to obtaining them or the money with which to buy them, often through illegal activity. They commonly self-inject to obtain maximum effect from small amounts, leading to risk of acquiring HIV and Hepatitis C virus from shared equipment, and injection site infections. They cannot count on the concentration or purity of the product they acquire, and may accidentally overdose or inject dangerous contaminants. They are subject to marginal existence, homelessness, and incarceration.

The Harm Reduction movement argues for a non-punitive approach to drug dependence which “Accepts, for better and for worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.” Preferred harm reduction policies include providing clean needles, teaching safer injection practices, and mandating users who commit non-violent crimes to treatment rather than jail.

The harm reduction approach is on weaker ground when it comes to amphetamine and cocaine abuse, as these substances have more profound inherent health and behavioral consequences. There is no medically safe maintenance approach to these chemicals – although weaker analogs are widely prescribed to children in the U.S. who have behavior problems. However, the social harm of prohibition extends beyond the users to the economy of illicit drug trafficking. Since drug traffickers obviously cannot call upon the authorities to enforce contracts and honest trading, the illicit drug industry is controlled by criminal organizations that use violence to control territory and settle disputes.

The case of alcohol is quite different. Alcohol used in moderation – typically defined as no more than 2 ounces of ethanol per day for men – may actually have some health benefits; whereas excessive consumption and dependency have many negative health and social consequences. Prohibition of alcohol in the United States during the 1920s failed to control alcohol use and abuse, but spawned violent crime syndicates. Most now agree that the social harm associated with alcohol is less under a regime of regulated, legal production and sale than it was under prohibition. In some Islamic countries with no cultural tradition of alcohol use, however, prohibition appears to be successful.

In the United States and western Europe there is increasing support for decriminalization of cannabis, which is held to be at worst comparable to alcohol in potential for harm. Cannabis prohibition is very costly in law enforcement, the incarceration of otherwise law abiding people, and the promotion of criminal activity. A caveat, however, is recent research suggesting that cannabis use in adolescence may slightly elevate the risk of later diagnosis with schizophrenia, which is a very serious disease. Use by adults, however, poses no such risk. Cannabis is held by many to have potential benefits for palliation of symptoms of many diseases and side effects of chemotherapy for cancer, so the movement in some states has taken the form of legalizing cannabis for medical use only.

Opioid drugs are a double edged sword of another sort. They are indispensable for relief of pain, are widely prescribed in short courses after dental procedures or outpatient surgery, and are given by injection in hospitals following major surgery or trauma. Such use rarely produces dependency. People with chronic pain may be prescribed maintenance regimens of opioids, which can be managed at a level which does not impair functioning. However, some people do develop dependency which continues after their prescription is withdrawn, or crave dosages larger than they are prescribed. This can lead to purchasing illicit supplies, or “doctor shopping” to obtain excessive prescriptions. Furthermore, diversion of prescription opioids to the illicit market is a principal means by which young people in the U.S. are initiated into opioid abuse.

Monday, August 16, 2010

Mr. Karakov

I did not exactly have a wonderful time while I was living in the hospital, but at least I could understand most of what was going on around me. My roommate, Mr. Karakov, wandered past my bed a few times on his way in and out of the room, pushing his IV pole. The pole has wheels on the bottom, so that patients can take it for a walk. Mr. Karakov would stop and talk to me brightly in Russian, holding the pole with one hand, gesturing expansively with the other. I would smile and indicate my incomprehension, but he was not deterred. I obliged by replying in English, not trying to connect in meaning, of course, but in affect.

"Yes, the latest red-shift survey certainly does imply a young age for the universe," I might have said, and "I am also concerned about the possible health effects of oscillating magnetic fields."

Mr. Karakov appeared to be in his fifties. He was rather fat. He wore the obligatory posteriorless smock, and paraded his naked and excessive buttocks without shame. Some exotic injury or disease had made his lower extremities pitted and darkly mottled. He seemed happy and healthy; he had not yet had his surgery.
I gathered from overhearing what Mr. Karakov could not that he was not in fact healthy. My doctors did not visit him on rounds; it was a different gang. The leader said, "This man is a pulmonary cripple." Mr. Karakov had Chronic Obstructive Pulmonary Disease. I have since looked that up. It's emphysema. He also was suspected of having bladder cancer. They brought in a translator to talk to Mr. Karakov about logistics, for example that he could have nothing to eat or drink, but noone told him anything about his condition or prospects.

Mr. Karakov had no visitors. He spent his days among gibbering incomprehensible strangers. He came back from his surgery making a lengthy discourse on what I took to be the subject of the intense discomfort he felt. Occasionally he would yell out in real pain. I could not see him as a curtain separated our beds, but I could hear more than enough. Nurses would rush in and grotesque activities would follow. One time, an experienced nurse was instructing a junior colleague in the procedures. They were somehow "irrigating his bladder", which from the sound of it caused gallons of water to drain into a bucket. The objective was to extract blood clots. It was the "long, ropy ones" that caused the major trouble.

Just after midnight Mr. Karakov had his worst attack. Nurses rushed in, followed in a few minutes by doctors. They shouted orders and vital signs at each other. More nurses rushed in pushing equipment. Doctors would ask Mr. Karakov questions, and when he didn't understand, they would ask again, louder. Then they would yell at him. Gallons, barrels, acre feet of water gushed. Mr. Karakov shouted in pain, discoursed angrily in Russian, then muttered and moaned. Someone cursed the hospital for admitting "these people" who could not speak English. Finally the crisis subsided. The Doctor in charge said, "I think he had pain from a clot and he vagled. He just vagled." (That basically means he fainted from pain. Not that I should even mention it but obviously all this commotion in the middle of the night is not conducive to my own restful recovery.)

He never vagaled again, but he started to piss all over the floor as soon as they took his catheter out. I didn't hear them warning him about this -- in fact, I don't think they brought in a translator all week -- and they certainly didn't do anything about it. I discovered it (the hard way) on one of my hourly trips through his half of the room. I called the nurse to see if we could get it mopped up, but apparently it was the wrong time of day to expect any mopping. When someone finally did come, she didn't mop the lavatory. "Oh, they won't go in there," said the nurse. I didn't blame them, frankly, but I had to go in there, twenty four times a day. (I'll explain later about my own situation at this point, which was not good.)

After a couple of days a nurse wandered over to Mr. Karakov's side of the curtain and started telling him, in English, that he was discharged. "You can go home now," she said. He answered in Russian, apparently indicating incomprehension. (Remember that I can hear perfectly, but I see nothing.)

She spoke to him more loudly. "You can go home. This is a taxi voucher. The taxi will take you home. Here are your clothes." As he continued, stubbornly, to refuse to understand English, she repeated herself more loudly. Finally concluding that deafness was not Mr. Karakov's problem after all, she strode out past me with the air of one who will sacrifice no further for the sake of the ungrateful.

Perhaps 30 minutes later she returned with a translator, an earnest young man. He was Russian born, but talked like a Certified Public Accountant from Alliance, Ohio. The dialogue which follows is reconstructed, but I have faithfully represented its essential substance and spirit. As I am ignorant of Russian, all speeches in that language, regardless of length or dramatic subtext, are represented by ellipsis in brackets, thus: [...]. Where not credited to a character, the ellipsis represents dialogue between Mr. K and the Translator.

Nurse: Tell him he's going home now. He can give the cab driver this, he doesn't need to pay for the cab. This is his prescription. He needs to get dressed and we'll take him downstairs.
Trans: He wants to know, will anyone tell him about his surgery, what was the result and what it will mean for him, and so on?
Nurse: Whatever the doctors have told him, I can't tell him more than that.
Trans: He says the doctors haven't told him anything, he really doesn't know what's going on.
Nurse: Oh for chrissake.
Exeunt nurse and translator. Thirty minutes later, they return, accompanied by an intern.
Trans: [...] Dr. Peachcheek [...]
Dr. P: Well, he has bladder cancer. We took out as much as we could through the urethra, but we just can't get it all that way.
Dr. P: Unfortunately, it will continue to grow. We think, in three to five years, it will be fatal.
Dr. P: We can't operate to remove his bladder because he has chronic obstructive pulmonary disease, and he couldn't survive surgery.
Trans: He wants to know, when the tumor grows, can't you scrape it out again as you did this time? They did it before in Italy, if you can just keep doing it...
Dr. P: (laughs nervously) Well, eventually he will run out of bladder wall.
Trans: You mean, every time you do this you use up some of his bladder?
Dr. P: Yes. I mean we could do it again but it would be futile. He will only live for so long, and we cannot get rid of the cancer ...
Trans: He says, what about the possibility he has an adenoma? In Italy, they told him it might be cancer and it might be an adenoma, that would be something different...
Dr. P: (surprised) An adenoma? Well, no, no it really doesn't seem to be an adenoma.
Trans: In Italy they told him perhaps it could be treated with radiation or chemotherapy, is there any possibility you could try some of these things they discussed with him in Italy?
Dr. P: Well, I mean those things could be tried, but I mean ... well, it just would be futile, we can't do surgery to remove the bladder...
Trans: He says for two days his right leg above the knee has been numb, he has no feeling here on his thigh ...
Nurse: Oh for chrissake.
Dr. P: Well, let me see. (sounds of bodies repositioning) Okay, now I'm going to touch him with my pen, like this. He just needs to tell me when he can feel it.
Trans: [...]
Dr. P: Hmm, Hmmmm.
Mr. K: Da......... Da.
Dr. P: Okay, I'm going to get a neurological consult on this.
Trans: [...]
Exeunt translator and medical personnel. Enter new Doctor, trailed by new intern, nurse and translator.
Intrn: I've been able to find out a little bit about him. He's a fifty-five year old factory worker, and lives alone. He says his legs have looked like that for twenty years.
Doc2: I understand from Dr. Glomerulus that he is a commercial airline pilot. Alright now, tell him this is sharp and this is dull. He is to tell me what he feels, whether it is sharp or dull.
Trans: [...]
Mr. K: (We learn the Russian words for sharp and dull)
Doc2: Well, this is something we see in patients with circulatory problems. You see it maps very cleanly here, this represents damage to the freeblemeyer nerve. It may have happened from lying on his side for too long. It may improve, in time, but usually it will not. He may feel some tingling or it may feel very cold.
Trans: [...]
Exeunt; Enter Translator and nurse.
Nurse: Alright, he's been discharged, he has to go now.
Trans: He says he can't hold in his urine. What is he to do, he can't get in the cab like this.
Nurse: Oh yeah. Well this is normal after the type of procedure he's had, it will improve in a few weeks. Uhm, we can give him absorbent pads, like diapers.... Excuse me.
[nurse goes and returns]
Nurse: Here.
Trans: He wants to know what he's supposed to do with them.
Nurse: They just fit into his underwear, he just puts them in his underwear.
Trans: He is concerned about going out, if he is out of the house for a long time will he be alright like this.
Nurse: Look, my shift is over, I've gotta get out of here. Oh alright. There's another system we can give him, hold on.
(Nurse exits and returns with apparatus)
Nurse: Okay, this goes over the end of his penis like a condom, okay? Does he know what a condom is? Then he has this bag around on the side of his leg, you see, with this garter belt-type arrangement...
Trans: He wants to know, won't there be a bulge, won't it show?
Nurse: Well it's up to him what he wants to do. Anyway, tell him he shouldn't use this when he doesn't have to. He needs to try to control his urine; if he relies on the apparatus he won't improve.
Trans: He says what about his drugs, can't he have his prescription filled here at the hospital before he goes?
Nurse: Oh for Chrissake. Look, we need the bed, there's somebody waiting in the ER for it and I don't have time for this, he was supposed to be discharged this morning. This is really getting ridiculous.
Trans: It's hard for him, he doesn't speak English.
Nurse: Alright, does he have his Medicaid card?
(nurse exits; returns in fifteen minutes with drugs)
Nurse: I had to lean on the pharmacy to get this sent right up. I'm out of here. Goodbye.
(exit nurse. Translator and Mr. Karakov exit a few moments later, conversing in Russian. CURTAIN.)

I withhold all comment. Res ipsa loquitur.

Sunday, August 15, 2010

God is one messed up cat

I regularly drive between Boston and Windham County, Connecticut. For years there has been a sign beside Route 20 near Worcester: "God Bless America. Office for Rent."*

You see God Bless America bumper stickers, politicians are required (apparently by the Constitution) to say it at the end of every speech, and people have even purchased billboards with the message. As far as I can tell, the logic is that the all powerful, all knowing creator of the universe probably wasn't going to bless America, but hopefully he'll happen to see the sign or the bumper sticker or hear the political speech and say to himself, "Oh what the heck, I guess I'll throw them a blessing," whatever that might consist of.

He is susceptible to other odd influences. I don't know what the deal is with the bomb threat, but it doesn't make any sense to me that the almighty only bothers to heal the sick and disabled if they happen to get a hold of some spring water in a plastic jug in the shape of a character known as The Virgin Mary. Remember, this dude is supposedly almighty and all knowing. If he decides whether to heal people based on whether they have the magic spring water, he's completely fucking nuts.

Another odd thing about God is that, in spite of his omnipotence, he is completely unable to defend himself. Apparently he magically turns crackers into human flesh in the mouths of worshipers, which is bad enough. It seems it really, really hurts his fee fees if somebody steals one of those crackers without swallowing it, BUT he can't do anything about it. He has to depend on equally affronted humans to try to get the guy kicked out of college and threaten to kill him and so on. In spite of his power to heal the sick, he can't give the guy stomach cramps. And then, when somebody intentionally abuses such a cracker, he needs a whole army to rise up and threaten to kill the guy, because God is just such a pathetic wimp.

Well God, I'm calling you out. You are just too weird to be Lord of the Universe, and I hereby demand your resignation. If you don't like it, you have thunderbolts available. I double dare you.

*The same guy recently put up a new sign: "General McChrystal for President." Apparently hanging out in a bar getting sloshed with a reporter for a hippie magazine and decrying the effeminacy of diplomats is the only real qualification for the job. This probably has something to do with Christianity as well.

Thursday, August 12, 2010

Sister Morphine

As promised, I'm going to try to organize this particular retelling around problems and issues, rather than chronology. So today's topic is analgesia. But you need a bit of chronology for context. There is a gap in my memory between the recovery room and my bed on the surgical ward. Whether I passed out, or they knocked me out again, or I just don't remember, I cannot say, but the next thing I knew I was in bed, unable to move my torso or my legs. I could not sit up or roll onto my side. There was an IV line in my arm. There was a tube going up one nostril and down my throat. It was connected to a machine that constantly sucked yellow brown fluid out of my stomach. Another piece of plastic tubing with two little nozzles blew oxygen into my nostrils. Another tube emerged from my penis, and it ran off to something on the floor. Wrapped around each of my calfs, from the ankle to the knee, was a long plastic cuff attached to a machine that inflated it every thirty seconds or so, squeezing and releasing unrelentingly.

As I wrote just a little bit later:

Thanks to morphine, I didn't care much about anything. My pain was still everywhere, now settling more and more into my throat and belly, but my body was scarcely my own. Let it be in pain, it was none of my concern. I would think for a moment that I cared about my drifting thoughts and dreams, but they would float away and leave no trace. Understand: this was not liberation from the illusion of self. It was exile in a solitude of polluted fog.

I could give myself an extra shot of morphine, as often as every ten minutes, by pushing a button pinned to my smock. I pushed it a lot. If I waited too long, the pain I always felt would start to matter. That was more than enough reason to wrap the fog around me. I very quickly got to dislike the morphine, however. It caused unbearable itching. It made me sweat. It made me stupid. It gave me weird, pointless, elusive dreams. They wanted to get me off of it too because a priority was to get my bowels working again and the morphine prevented that.

So, I asked them to stop it after a couple of days and I quickly felt a lot better. I am quite typical. The vast majority of people who receive morphine or other opioids for relief of acute pain simply stop taking it when they no longer need it. Whether I am typical in finding narcotics affirmatively unpleasant I don't know, but I'm certainly never tempted by them. I got a prescription for Vicodin after a tooth extraction a couple of years ago and all but two of them are still in my medicine cabinet. After minor surgery a few weeks ago, I got a prescription for 20 Tramadol and I never filled it.

But -- Prescription drug abuse is a large and growing problem. Lots of people get hooked on pharmaceutical opioids, and they are the most common path to heroin addiction for young people. (Heroin is actually much cheaper than diverted prescription narcotics, thanks to our heroic invasion of Afghanistan.)

This does pose a bit of a quandary. Opioid addiction is actually not nearly as harmful intrinsically as it is generally portrayed. That's why methadone maintenance works. Addicts suffer because a) they are continually going through incipient withdrawal; b) it is difficult and expensive for them to obtain the drugs so they end up devoting much of their time and effort to that single purpose, and often end up committing petty crimes to support their habit; c) if they inject, they are at risk of blood borne infections and other physical harm; and d) they are violating the law by possession and use and often wind up incarcerated and unemployable as a result. But otherwise, the worst actual physical side effect of habitual opioid use is constipation.

So yes, we could greatly ease this problem by decriminalization, expanded treatment and harm reduction approaches, but still, it's highly undesirable to create a lot of addicts. On the other hand, opioids are just the only thing that does the job when you're really hurting. Morphine is a double-edged sword that cuts both fair and foul. It's completely unacceptable to deprive people who need them of relief. But if they're around, they're going to get diverted and misused. There are technical fixes to reduce that risk, but it's always there. And, my own story aside, there are some people who receive prescription opioids for pain relief who do become addicted. That is the only point on which I will give Rush Limbaugh a break, except that he's a total hypocrite about it.

I was once addicted to nicotine and I may be a bit overfond of ETOH, but I don't have to worry about junk. I suspect that susceptibility has a lot to do with pain, of the psychic variety. Morphine isn't actually any fun, but it does make you indifferent to your pain. If you're desperate for escape, it's a way out.

Wednesday, August 11, 2010

Some crude exposition

There isn't necessarily any profound point to what I'm going to tell you, but we need to set the stage for the rest of the story. I now have a diagnosis of acute appendicitis. Mind you, I had no idea I had already rung up a bill for $450. I estimate (generously) that the three people who inserted objects in my rectum spent a total of ten minutes with me. When you do all the math, it turns out they make an average of $2,700 an hour -- this being 1991 mind you, so I suppose it would $5,400 today.

I had to lie on a gurney and be wheeled up to my room, even though I could walk just fine. The doctor handed me some paperwork to take upstairs with me.
I had the chance to read all about myself on the way up. There was a note headed "patient EP". "Pleasant gentleman," he had written. That made me feel good. But what is EP? Extrasensory perception? Effective persona? And don't obnoxious people get appendicitis? Or is it the policy to tag them for inferior service? Then there was a lot of gobbledykook and the diagnosis, "acute appendicitis". "Admit," it said. Then, "shave from the nipples to the thighs." I would have to stay out of locker rooms for months.

We came to my room, which looked to be up to code. My hostess was a very nice looking, friendly young nurse named Leah. I liked her. She didn't try to stick anything up my ass, which was just one sign of a generally more relaxed attitude.

I wasn't allowed to watch TV -- except for video of surgeons from A Major Teaching Hospital of The World's Greatest University performing ankle replacements -- until the next afternoon, when they would come around to collect the daily fee required for TV service. They also could offer me nothing to read. I sat there for four hours.

Finally some people came and rolled me into an elevator, then through some big swinging doors with bright red warning signs. There are lots of people around in blue pajamas and shower caps. The male anally obsessed doctor from the ER is there and he gives me a shower cap. "You can be just like us now," he says.
"Do I get a lollipop too?" I thought.

Then it was much later. My mouth was dry. I was in pain but the thirst was far worse. There were windows near the ceiling, as though I were in a basement, and there was daylight coming in the windows. That was wrong, it was the middle of the night. There was a beautiful woman looking down at me. Her face was gentle and her eyes shared my pain. The pain was nowhere in particular, it was a haze all around me or it floated in a ball somewhere above me or else it was in my throat thrust on down and through me like a rod of ice and I needed water.

It was a while before I was in any condition to understand what had happened but to jump ahead of my stream of experience, here it is. They had opened my abdomen and found a healthy pink appendix. But there was a mass on my colon "like a robin's egg." They thought it was cancer and that I was doomed. They performed a right colectomy. That means they removed half of my colon. Then they sewed the cut ends of my intestines back together. I had been in surgery for six and a half hours. Apparently the Chief Resident -- the same man who had sodomized me in the Emergency Room -- had found my innards to be not as advertised, so he called up his boss, the guy who teaches surgery to the residents. He left his card game or the barroom or whatever and rushed over to do the actual cutting and pasting.

While I was still in surgery, they had gotten the pathologist's report. I did not have cancer. I had a cecal diverticulum. The cecum is the place where the small intestine joins the colon; the appendix is near it, hence the mistaken diagnosis. A diverticulum is a little dead-end wrong turn in the wall of the colon. It had become obstructed, filled with putrefying material, and infected. That's it.

This is not a particularly enlightening post but we had to advance the plot. Meaningful stuff anon.

Tuesday, August 10, 2010

This is absolutely, 100% true.

I swear on a stack of On the Origin of Species.

So I present at the ER with symptoms of acute appendicitis. A nurse has me disrobe and put on one of those notorious backless hospital gowns, then insists she has to take my temperature rectally. Okay. She goes. About five minutes later, a female doctor arrives, or at least someone who appeared to be a doctor based on her blue scrubs. She said she had to give me a digital rectal exam.

While she's got her finger up my ass she asks me "Are you sexually active?"
I thought, "I guess it depends on how you interpret what's going on now," but that's not what I said. Then she says, "Do you have sex with women or with men?" Only when she's satisfied with my answers does she take her finger out of my ass. She tells me I have acute appendicitis and she goes.

But this was not actually the official examination and conclusion. Ten minutes later another doctor comes in, male, with some sort of junior club member hovering over his shoulder. He also pokes my abdomen. He taps on the left side, and I report pain on the right. "There is an eponym for this," he tells junior. "It is called Rolfsig's sign." Then he just has to stick his finger up my ass. I told him the first doctor already did that. Didn't he trust her? Apparently not. Anyway, although his exam was as negative as his predecessor's, he decided that I still had acute appendicitis, and that I should be admitted for surgery that night.

No doubt this seems bizarre to you, as well it should. In fact the first examiner was probably not there for any reason having to do with my medical care. She was probably a first year resident, possibly even a medical student, who was just there to rehearse. That she evidently had some strange attitude toward men is just incidental. The second doctor, I soon learned, was in fact the Chief Resident in general surgery and yes, his examination and diagnosis were the real deal.

So if you go to a teaching hospital, you will find that several people often line up to violate your bodily integrity in similar ways. It is the more or less official ethical standard that they are supposed to tell you they are doing it for practice, not to benefit you, and ask your permission. However, most of the time, they don't, because they are afraid you will refuse and then the youngsters won't get to practice. You will also find inexperienced people doing actual real stuff to you that matters, such as inserting IVs, and believe me, undergoing inept venipuncture is not the way to have fun. This is a problem, to be sure, because they have to learn somehow. But still. . .

Although academic medical centers may offer superior care, especially for complex or difficult situations, patient experience is usually poor compared with community hospitals. This is a big reason -- you aren't just a patient, you're a practice mannequin. And you may well come across some trainees who are truly incompetent, or even bizarre. As I did.

This has not changed even one little bit in 20 years, although people do talk about it. They make rules, but they don't enforce them.

I don't have a magic solution, I'm just sayin'.

Monday, August 09, 2010

Too many pills!

My colleague Dena Rifkin, ably assisted by someone you know, has interviewed people living with Chronic Kidney Disease, which ipso facto means taking ridiculous numbers of pills, about what that is like.

You won't be surprised to learn that it's a PITA, and that people often come up with reasons why they don't really need to take this one or that one, or not all the time, or even if they do think they probably ought to take them all they don't necessarily do it anyway. And oh yeah, this is not necessarily a fit subject for discussion with their doctors.

One reason this happens is because they have several different doctors, who don't talk to each other. Another reason is that they take pill B to counteract the side effects of pill A, and then they end up taking pill C to counteract the side effects of pill B, etc.

And the true fact is, some of those pills are indeed less important than others, but if the people don't discuss it with their doctors, they'll make their own decisions about which ones those are. Better for docs to have these discussions and prescribe fewer pills, which the people might actually take. I have a couple of very good ideas about why those discussions don't always happen -- what are yours?

Ch. 8 of my autobiography

I don't know for sure if it was a powerful influence on my present professional endeavor -- we tend to make sense out of our past but we might just be making up stories -- but nearly 20 years ago, in February of 1991, I very suddenly found myself in a hospital, a victim of major surgery. Some long-time readers suggest that I finish this story, which I started to tell here quite a while back. Rather than repeat the classic narrative structure of my previous attempt, I'm going to organize the discussion as best I can around issues. How far have we come since then, and what is unchanged?

Very Important Point #1: I had health insurance. I was an impecunious graduate student, and I probably would not have even thought about buying health insurance, but it was the law in Massachusetts that people enrolled in higher education had to have it. Brandeis could not have given me course credit if I didn't. This requirement, if I remember correctly, was about the only remnant of the failed health care reform legislation passed under the Michael Dukakis administration, and then repealed, because the business lobby refused to accept the requirement that medium to large businesses provide health insurance to employees.

As you know, the individual insurance market would not have offered an affordable product to many people. Lots of people with diabetes and other disqualifying conditions go to college and graduate school. However, the universities offered group insurance to students, at a good price. The product I had was actually catastrophic insurance. The idea is you can go to the university health service for routine care, with little or no out of pocket cost. But it was perfect for what happened to me. I was covered for hospital and surgical expenses, with only a small initial deductible -- or so the policy said.

To make a possibly interesting but not particularly relevant story short, I went to the Emergency Department at a Major Teaching Hospital of Harvard University (that's what they called themselves, on placards, business cards, bills and stationery) with what I believed to be acute appendicitis, which the physicians who saw me in the ED also concluded to be the case. But I did not have appendicitis, as I learned the very hard way.

To be continued.

Sunday, August 08, 2010


I was stuck in the Baltimore airport for several hours on Thursday -- the flight was canceled because I was supposed to be on it, is my theory. Anyway, although I had some reading material and even work I could have done, I went and bought The God Delusion by Richard Dawkins because I figured it would be more entertaining.

I don't usually bother to read that sort of thing because the non-existence of God has been obvious to me since I was old enough to think for myself, and indeed, I didn't really encounter any new arguments or ideas. But I continue to find myself befuddled by the difficulty we have in communicating with religious people. Dawkins was not writing for me, but for believers. He and I both know that few of them will read his book. Perhaps it will be helpful to some waverers or questioners, but the very definition of faith is to believe without evidence, or contrary to evidence.

As Dawkins points out, having unshakable faith is a badge of honor to believers, and he quotes several of them as proclaiming proudly that their belief will remain completely unaffected by facts or logic. Martin Luther, for example, condemned reason as the enemy of God. Under the circumstances, there isn't much hope for dialogue. That has been my experience in fact. I have tried many times to draw the faithful into a reason-based discussion of the nature of reality and they just won't participate. I suppose they know it is pointless because they already know that religion is preposterous, but they have chosen to ignore what they know and live a make believe life. So why waste time reviewing the obvious?

Nevertheless, I still feel we need to try. So I will return to my habit of long ago, of philosophical posts here on Sundays. For a time I was using another blog for the purpose but without the partners and interlocutors I once had there, I don't think it's worth maintaining on my own. But if anyone does care to join in these discussions here, from whatever point of view, you are welcome.

Friday, August 06, 2010

Oh yeah . . .

It may well be that I never did quite finish the story of my own experience of major surgery. It was a long time ago - February 1991, while George Bush the First was carpet bombing the retreating Iraqi army. But it's astonishing how little has changed since then. The basic problems I encountered -- cost shifting, overpaid specialists, lack of accountability (the physicians and hospitals billed me for the cost of their own mistakes, which is still the normal practice), underinsurance, overtreatment (they get paid to do stuff, after all), cultural incompetence (the treatment of my Russian roommate was appalling), the organization of the hospital around the convenience of staff rather than the comfort and recovery of patients, poor sanitary practices, nosocomial infection, reflexive lying to patients about medical errors, overworked nurses . . .

I could go on. The Patient Protection and Affordable Care Act actually begins to address some of these problems, and some important movements within the medical profession are beginning to address others. But here we are, nearly 20 years later, just beginning. Perhaps it is time for me to revisit the saga for the exercise of seeing exactly what is the same and what is different; and along the way, to consider why change has been so difficult to achieve.

Also along the way, I hope readers will weigh in about some of their own experiences, past and recent. This seems timely.

Wednesday, August 04, 2010

I know you definitely need one more thing to worry about

Those crazy environmentalists, they'll always find a way to harsh your mellow. Now it turns out that if we don't give you a receipt, you really ought to thank us. The thermal paper used to create cash register receipts commonly uses bisphenol A (BPA), an estrogen analogue that has been found to be associated with all sorts of health risks, from obesity to behavioral problems in children and heart disease. Not only that, but it can rub off on your fingers and then be absorbed into the blood stream.

This is probably not a big problem unless you work as a cashier, but still, who needs it? Especially when there are other sources of exposure and it adds up. This is a small matter but it is a cogent reminder that there are unintended consequences of all technological advances and we often don't find out about them until way down the road. Anthropogenic climate change is an example writ very large. We can replace BPA in thermal paper, although there is no sign of the EPA moving in that direction, but fossil fuel is the very foundation of our civilization, which is why it's much easier for a lot of people to deny reality than to face up to the developing catastrophe.

And here's a politician who achieves the impossible, setting a new standard for wingnut insanity.

I'm going to Baltimore this afternoon, for a short trip. Don't know if I'll have a chance to post tomorrow, if I don't, you know why.

Tuesday, August 03, 2010

Free Money!

As the 4 1/2 people who were reading this blog five or six years ago already know, a long time ago, in a galaxy far far away -- 1991 to be precise, in Boston, Massachusetts -- I underwent major surgery consisting of a right hemicolectomy. (They thought I had cancer but er, I did not. I would like my parts back.)

Anyway, the point of the story is, I had insurance, but the hospital and various physicians associated with my disembowelment didn't think the insurance paid them enough for their excessively superior services and sent me various bills amounting to -- seriously -- $25,000, which back in those days was a lot of money. Since the surgeon screwed the whole thing up and caused my extended hospital stay and expensive complications by his own incompetence, I obviously told them to TAFFOARD, which they did.

I was in surgery for more than 7 hours, so the anesthesiologist, who had already been paid about $150/hour by the insurance company IIRC, sent me a bill for an additional $250/hour, since he makes, you know, $400/hour. (The hospital had billed separately, about $350/hour, for the privilege of being anesthetized on its premises, so this was for personal services only.)

I wrote back and told the guy that he had already been paid by the insurance company, that the amount they paid was quite enough, that nobody deserved to make $400 an hour especially for a routine technical service that is commonly provided by a registered nurse making a modest salary, and that he was a disgusting greedhead who, as he sat on his yacht stirring a martini, should contemplate the many hard working people who he had ruined by his sickening avarice. I didn't hear back.

Well, I was right. Anesthesiologists nowadays make about $300,000 a year. Why? Beats the hell out of me.

Dulisse and Cromwell find (sorry, you worthless scum are only allowed to read the abstract) that in states where Medicare allows nurse anesthetists to work independently, there is absolutely no evidence of worse outcomes for patients or more adverse events. Nurse anesthetists make about $100,000 a year. They didn't go to medical school, but they have the exact same training in anesthesiology as physician anesthesiologists.

The bottom line for me is pretty obvious. There is no reason for the medical specialty of anesthesiology to exist. The whole thing is a ripoff. Or, they could settle for $100,000 a year.

Monday, August 02, 2010

The Land of Make Believe

Perhaps I spend too much time obsessing over the preposterous refusal of our political and media culture to distinguish between truth and falsehood. For some reason it just frosts my pumpkin when reporters give equal time to global warming deniers, creationists, and Republicans -- you know, people who believe that cutting rich people's taxes doesn't increase deficits, that the estate tax destroys family farms (there has never been a single example in all of history), and that covering everybody with health insurance will murder them.

But I'm not alone. I have mentioned Charlie Pierce's Idiot America here before, here's a nice review in Skeptical Inquirer. Pierce offers three premises which are foundational to our culture:

* First premise: “Any theory is valid if it sells books, soaks up ratings, or otherwise moves units.”
* Second premise: “Anything can be true if somebody says it loudly enough.”
* Third premise: “Fact is that which enough people believe.”

I would offer a fourth, which is that fact can be established by reasoning backwards from pre-established conclusions, e.g. the Magical Free Market™ makes everything and everybody happy. But that premise only applies to big important stuff. SI has a couple of open access investigative reports this month that show how people just plain like to be fooled, such as the case of the utterly fraudulent psychic Sylvia Browne. It makes for illuminating, if disgusting, reading.

As readers know I have been particularly contemptuous of the New York Times for it's consistent policy of being Fair and Balanced between truth and falsehood, whether the subject is global warming, budget deficits, or national security. Tim Lambert is all over them for a recent outrage, in which Virginia Heffernan, as is the habit at the NYT, confuses scientific objectivity with respect for conservative political ideology and religion.

Now, I agree it is a challenge to the cause of reason that the Bible isn't true after all, and there is no such thing as the Magical Free Market™ fairy, and yes, Virginia, burning fossil fuels is making the surface of the planet warmer even though that is highly inconvenient for our present civilization. People don't like hearing any of that, so they retreat into the chronosynclastic infundibulum,* where all possible opinions are true. But they aren't.

* Kurt Vonnegut Jr., The Sirens of Titan. Give it a read.

Update: Here's another good one:

One of the uglier strains of modern conservative thought is pervasive anti-intellectualism. As Faiz Shakir noted today, House Minority Leader John Boehner (R-Ohio) offered a rather classic example on "Fox News Sunday."

Host Chris Wallace noted that "a number of top economists" believe that the nation, right now, needs "more economic stimulus." Boehner replied, "Well, I don't need to see GDP numbers or to listen to economists; all I need to do is listen to the American people." . . .


If Boehner were facing a serious ailment, would he say, "Well, I don't need to see lab results or to listen to medical professionals; all I need to do is listen to the American people"? Maybe so, but at this point, the serious ailment is our national economy, and it affects us all.

When Wallace pressed Boehner on how he'd pay for trillions of dollars in tax cuts, the would-be Speaker eventually concluded, "This is the whole Washington mindset, all these CBO numbers."