Information Is Free

2012-01-26T19:48:00.000-05:00

eReadings - 7

History of Science

This is a series of 4 volumes starting in prehistoric times (yes, I said prehistoric times), and carefully covering the advances of science. I think there were 2 eras in which the accomplishments were quite amazing. Keep in mind that I'm reading out-of-copyright books, and this series was written in the late 19th century.

First, the Greeks. Their powers of reasoning and investigation are astounding, and there was very little to match them for centuries after the Greek decline. The Romans added very little to what the Greeks had already discerned. In spite of their limited knowledge about the extent of the world, the Greeks had determined that the Earth was a sphere, even though they had no idea as to where land was, where sea was on this sphere. There was the first notion of heliocentricity of our solar system, forgotten and discarded for many centuries. And of course we have people like Pythagoras and Euclid, who came up with important principles we still learn today. But we also get a sense of the attitude of some of these Greeks, a fair amount of hubris and jealousy, so this series is more than a recitation of dry facts.

In the 19th century, abetted by some very clever people in the 17th and 18th centuries, we see the beginnings of modern science as we know it, with careful experimentation, the discovery of new elements, the early development of the atomic theory, and again the various rivalries, co-discoveries, and they way that some became famous quite deservedly, some who did so less deservedly, and some who should have been famous but were overlooked.

It takes a while to go through these volumes, but for those interested in science and science history, it's well worth your while.

2012-01-21T22:00:00.000-05:00

eReadings - 6

The First Men in the Moon

by H G Wells

The title's "in" seems like a typo, but eventually you realize that it's very much intended by the author. We live now with the reality of space travel and men having actually gone to the moon, so keep in mind this book comes from the 19th century, when the moon remained a source of great speculation.

There are some inklings of the scientific knowledge at the time, as far as the lower gravity on the moon, the "thinness" of the atmosphere, but there are plenty of suppositions that are way off base, and if you can't separate yourself from what we now know about the moon, then you may find the book just silly.

There is the expected eccentric scientist, who comes upon some form of alchemy involving helium to create a substance which blocks gravity, much as an opaque object blocks light. Thus, we have a means of leaving the earth to arrive at the moon, with some curious, primitive means of survival on the way, yet Wells does manage a decent description of the implications of being in a state of zero gravity.

But there is an idea that the moon has a breathable atmosphere, and that at least as long as the sun is shining on it the temperature is such that one can walk on the moon without protection, and we might say the second surprise after that is that there grows a profusion of plants on the surface of the moon, at least while the sun shines. Somehow Wells had the idea the the sun shines on the moon continuously for many of our earth days, which figures in the events as the adventures on and in the moon unravel. Surprises continue as you read about the goings on beneath the moon's surface.

Of course, now science fiction and fantasy have to travel to distant planets and galaxies to give us believable stories of life outside of Earth, but if you cast away your prejudices about what it's really like on the moon, the story is nonetheless interesting to read.

2012-01-21T21:36:00.001-05:00

eReadings - 5
Hard Times

by Charles Dickens

It doesn't take long into this book to really feel the grime, grit, and bleakness of a small English manufacturing town, covered with coal dust and soot, where most people's lives belong to the factories and owners.

This is really the backdrop, though, for what is going on with the main protagonists, Thomas Gradgrind, and his friend, Josiah Bounderby, both wealthy, both in control of their lives and those around them. Mr. Gradgrind raises his children at home, filling them with facts, so much so that there is no allowance for dreaming, wishing, reading novels, anything not based on facts.

Mr. Bounderby is a self-made man, and reminds those around him incessantly of that fact -- abandoned by his mother, scraping out an existence, to finally make himself what he is today, a wealthy manufacturer and banker.

By the end of the book, each man receives his comeuppance in his own way, and at least Mr. Gradgrind is the better for it. Meanwhile, the story details the inequities of the rich and poor, part of which rests in the way the rich think of and treat the poor, yet at least some of the poor have qualities the rich will never attain.

Dickens is quite the creator of interesting characters, one of whom, Mr. Sleary, provides the challenge of reading through the depiction of his lisp, "Well, Thquire", he returned... "Ith it your intenthion to do anything for the poor girl, Thquire?" Some of Mr. Sleary's long-winded moments are a bit mind-numbing to read, seeming like a poor trick Dickens plays on his readers.

It may be a bit syrupy and sappy in the end, but overall very satisfying.

2012-01-08T21:49:00.000-05:00

eReadings - 4

David Copperfield -- Charles Dickens

Dickens writes in his preface that, at least of the time of the writing, this was his favorite book, since he really enjoyed the character.

My sense after reading it is that, interestingly enough, even though the story centers around David Copperfield and the things that happen to him as narrator of the story, it's not really about him. It's about all the strange and interesting characters in his life. There is much tragedy, various moments of happiness, sorrow as he tries to make his way through life, and the strange ways that people keep coming back into his life.

One of the most interesting families are the McCawbers, a family always on the verge of yet another financial calamity, going from one ruinous debt to the next, yet happy the whole while.

And now I see where the rock band Uriah Heep got its name, and quite a character he is.

Maybe the ending gets to be a bit of too much goodness, but this is a book full of enjoyable reading.

2011-10-30T14:21:00.000-04:00

Occupy Wall Street

I try not to have many political/social comments, mostly because it's something of a cesspool of negative thoughts, but I find OWS interesting, in that it doesn't seem to have a coherent message, or maybe it only seems so to some.

This isn't to say that everyone involved in it has the same idea of what OWS should accomplish, what its message should be, but there is some intelligence in not forcing that to happen. It's a complex intelligence that even though I might have dissatisfactions with the high-living economic world, it's not flavored by going through a foreclosure, unemployment, or various other disasters others are going through.

It's interesting to compare OWS to the Tea Party, as many have done, but the TP was long ago abducted by the rich to serve their needs. A Libertarian approach to things is great when you talk about not paying taxes, allowing anyone to make as much money as they possibly can, but it seems that strictly speaking, a true Libertarian would say that there is no reason to save the financial system, no reason to save the auto industry, anymore than we want to save someone from not having health insurance.

The message I think that OWS has to offer that needs to last is that it's time to temper the greed. It's time to not measure success based on how much money one can accumulate in the shortest amount of time. It's time to believe that, when you manage to benefit from wealth creation, that there is some payback to society for having a system that allows that to happen.

2011-10-29T13:50:00.000-04:00

Connectivity

There seems to be an increasing number of doctors carrying around iPads for various reasons, one being that they can connect to the hospital's system to get patient information. Our hospital has free wireless.

I carry around a laptop for the same reason, and while I have considered getting some sort of tablet, so far it doesn't make sense. There are a number of things I can do on the laptop that would not be feasible with a tablet. I have some custom software, like a database for example, that I would have to find some substitute for, and really don't want to bother.

The overriding issue, though, is that I have begun to see connectivity in the same way I saw TV some time ago: a great way to waste a lot of time, and realize hours later that you haven't seen anything worth remembering and have accomplished nothing.

This isn't some abstract mental exercise. It comes from having one or more computers running in my house so that I can as often as I want step up to and look up something, browse for random information on selected sites, check out blogs, or whatever. In the end it's not any more interesting, mostly less interesting than flipping through the hundreds of channels I could see on my cable TV, and I've already decided TV is mostly a waste of time. If I lived alone, I probably wouldn't have cable, and maybe not even a TV at all.

Here we are, in the 21st century, bombarded with uninteresting stuff, much of it propped up with advertising dollars to get us to go out and buy something we'll be unhappy with after purchase.

2011-10-19T13:08:00.001-04:00

eReadings - 3

History of the Plague in London

The first thing to realize about this book is its chronology. This is a "first person" narrative of the plague in late 17th century London, and if you check out the vagueness of Daniel Defoe's lifespan you realize he was at most a few years old during that time. His father is alleged to have kept some notes, perhaps a diary of the plague, so some have proposed that may have been in part the basis for this book. Others have suggested that Defoe used some other literary sources regarding the plague in other parts of Europe for his material.

So what you have is at best a second-person memoir, and when you consider the leeway one might see with a first-person memoir, at the outset you realize that there may be any number of distortions or exaggerations.

For a medical person, this is nonetheless an interesting book, showing as it does the profound effects on the infrastructure and the psyche of a large city faced with some medical epidemic for which no cure is known, yet a number of superstitions existed as to how to manage it, prevent it, most bordering on voodoo from a modern perspective.

Aside from the dubiousness of the factual information, this certainly seems more plausible than various movies about contagion we have seen. Some of the quite believable features are the accounts of people who took great precautions to avoid the plague only to succumb, and some who took none yet survived. Of course, there is ample evidence that taking unnecessary chances was generally a bad and fatal idea.

Will we ever face something like this again? The doomsayers predict it with regularity. If you ever wanted to think about coping with a very real disaster, this book is worth reading, and offers the safety of the distance of a few centuries when there was great ignorance about the cause of infectious diseases.

2011-10-02T20:27:00.000-04:00

eReadings - 2

Howard's End

I had not seen either of the movies made from this story, so I had no idea what it was about. For the most part, it focuses on two reasonably well-to-do young sisters living in London, due to an inheritance from their father, so neither they nor their younger brother would ever consider working. Nonetheless, the setting of the story is pre-WWI, at a time when at least some women are getting ideas about getting the vote, and speaking their minds even in the company of men.

Howard's End is a place which figures pretty early in the story, then manages to fade to the background until near the end. Meanwhile there is an interesting weaving in and out of various characters, with untoward if not disastrous consequences for some of them.

I found the story line the best part of the book. It's perhaps expected that one might have trouble connecting to the thoughts of young women about that time, but it seemed there was something missing in their characterizations. There certainly was a effort to show them as quite unsettling to the gentlemen of the time. I certainly would recommend the book as well worth the read.

2011-09-25T12:17:00.002-04:00

eReadings

Ever since I've had my Kindle, I've been doing more reading that I may have done all my life, perhaps excepting when I was going to college or medical school, but required reading is quite different.

The Kindle or some other e-reader lends itself, of course, to frequent reading, since you can switch it on and pick up where you last left off. It also allows you to easily skip from one book to another. At first I started out just reading a book, finishing that, then starting another. This is okay for some riveting novel like Moby Dick or Tale of Two Cities, but there's is only so much I can take of some others, with their thick prose, heavy ideas, or maybe they're just not so interesting.

Project Gutenberg

This is my main source of books. I've bought a couple from Amazon, but my personal view is that there needs to be a pricing shake-up with eBooks. They're way too expensive. These days they're hardly less expensive than a physical book, and all I really have is a license to read them. I can't give them to someone else or sell them, at least legally.

The good thing about Project Gutenberg is that there is a very large number of books to be had, and another good thing is that Kindle versions exist. On the other hand, unless you're looking at list arranged by author, you are staring at a veritable sea of titles. There seemed to be a fledgling effort by PG to make an area for book reviews, but it looks dead, with no updates since 2006. You are of course not getting recent books with PG, since they are by definition out of copyright.

The Magic Catalog

Until I found this, I was looking at books in HTML, then downloading the Kindle version, then uploading to my Kindle. With the Magic Catalog, I can turn on the wireless on my Kindle, then go through the catalog like any other book, click on a title, and have it directly downloaded to my Kindle (only take a few seconds at most). Usually I download them in bunches. This way I worry less about whether I might like them. If something is uninteresting, I delete it and move on to something else. The Magic Catalog is searchable, but in its raw state is a quite jumbled up list of books. At first I found this bothersome, but for someone who doesn't have such a command of information about authors and books, it's not actually bad on a practical level, but you do have to cultivate a sense of adventure and just try things out.

A Couple of Reviews

What I want to begin is to give some of my own impressions of things I have read, partly for my own interest, but also in case someone else might find these reviews helpful in some way.

The Communist Manifesto - Karl Marx and Friedrich Engels

I knew roughly what this was about, but since I never had it as a requirement in college I never read it. Back in the 60s there were a lot of references to it on campus, probably largely by those who hadn't read it either.

It's a book full of jargon, and I have to confess it took me a while to understand the bourgeoisie (bad guys) as what we might call the upper middle class, the shop owners, and in general those who were making the capitalist system work for them. The book is of course addressed to the proletariat, the peasants, the manual laborers who were paid and treated poorly, who generally had no property, living in some place owned by their masters/employers, with no hope of ever being able to climb out of this.

I suppose it's possible to read this book word for word, but I certainly found the repetitiveness led to tedium, and I could get the message scanning and skipping along. It's easy to see the appeal of the idea for its intended audience, the proletariat, even allowing for the fact that many of the proletariat were illiterate. The message was, "You have nothing, therefore you have nothing to lose. We will take the property and riches from the bourgeoisie and give it to you." Also quite specifically spelled out is that replacing capitalist institutions will be The State, and now that we have a century of Communism to look at, we understand all too well what The State became. Left out is any mention of what you might be allowed to do with your land once it's "yours".

Ten Days that Shook the World - John Reed

This was a serendipitous selection, picked out some weeks after The Communist Manifesto. I thought the title sounded interesting, so I downloaded it.

This is a first-hand account by an American Socialist journalist, who happened to be in Russia in late 1917 when dramatic upheaval there culminated in the Bolshevik revolution. Something which becomes readily apparent is the shallowness of the history of the Communist revolution as taught in this country. The number of different people, the number of factions involved, the number of plots and subplots, attempts at subverting someone else's plan are quite astounding. One can also see that a big part of what fuelled the revolution is that 80% of the Russian population were peasants. This is of course an outsider's point of view, but the access that he had to factions and leaders on various sides of the evolving quest for power is rather amazing. There is also a great battle of propaganda going on, which I suppose now we see as puny in comparison to what goes on with the media and the internet, but clearly one sees how absolute control of the press came about in communist Russia. We also can see the transition from the ideas the Bolsheviks had to have a peaceful transition of power led to armed conflict and bloodshed.

One of the things I've taken to doing, and that I would recommend, is online research about authors, usually after I've read their work. John Reed was born in Oregon, eventually sent East for his education, and became involved with the various unions' struggles of that time, in the process becoming a Socialist. Like a number of people in the Socialist movement, and the Russians themselves, there was this abiding idea that sooner or later workers of the world would rise up and follow the Russian communists' example. Even though ostensibly one needed governmental approval to travel abroad, especially during WWI, it apparently wasn't so hard to simply find a way to travel to Europe and go wherever you wanted. Finland was a way to get to Russia, and even though he was periodically held in custody on the way back, eventually someone would get him released and he'd be back in the US until the next time. All this travel through impoverished areas led to his death at 32 of spotted typhus. He died in Moscow and is buried in the Kremlin.

2011-09-23T19:59:00.003-04:00

Exercising will delay cognitive decline, or maybe not

We're seeing this sort of statement all around. Consumer Reports has said it. When I just updated my Epocrates, there was a little news item about this.

Here's the problem. This is not accurate. It's not necessarily wrong, but has yet to be proven, and this is a kind of research that many people don't understand, at least in terms of how to understand it.

What we actually have are a number of population studies, in which someone looks at a variably large number of people, and then analyses them by collecting data. One kind of data will be who has cognitive impairment and who doesn't. But also various lifestyle things might be looked at, like amount of exercise, how regular it is, etc.

So it has become clear that there is something of a match up between those who exercise and those who retain cognitive function better than their peers. So obviously, exercise causes a retention of cognitive abilities, right? Not necessarily.

All this really says is that there is some commonality, and it might work in the other direction, in other words, maybe people who exercise do so because they are more cognitively with it. How can that be? Well, why do people exercise? Have they been exercising because they knew it would keep them more cognitively fit too? Seems unlikely.

We actually already know that an early sign or marker of dementia can be social withdrawal.While I suppose that there are those who exercise in social isolation, exercising is very much a social sort of thing for the most part. At any rate the reasons why people exercise are not simple, and while there may be many who would like to exercise, there is something different about those who actually end up doing it.

The real answer to this question of the cognitive benefit of exercise would have to come from some controlled experiment, where you take one random group and force them to exercise, and another group where you prevent them from exercising. And I might as well add that we're not likely to see that happen, since you also have to do this for a number of years, since this isn't something that happens in 6 months.

So I'm not making an argument against exercise, I'm just trying to clarify some misimpressions that are floating around about it.

2011-09-10T12:50:00.002-04:00

Terrorism

Now that we're bathed in frequent if not continuous commentary regarding 9/11, it continues to be noted that we see little indication of any effort to reduce anxiety about terrorism. I guess it's because it doesn't sell advertising space.

What is terror about?

Terrorism is about inducing terror. Let's face it, this isn't so hard, and it's made easier in a world of instant, 24 hour news access, where one of the leading concerns is that if you're going to have news broadcast 24 hours a day, you have to have something to say, even if you have to manufacture it to some extent. Any time you don't have to manufacture news, you have a gold mine to use for content.

Terrorism is cost efficient.

This is true. You don't even have to actually do anything. All you need to do is create anxiety about what you might do, based to some extent on things you have done, but you can also benefit from some cockamamie thing that someone thinks you were trying but didn't happen. Look at that poor schmoe who sets his pants on fire on an airplane -- terrorism for Dummies -- but it works!

Fear

Really, this is a matter of dealing with the fears that we all have, that some have more than others, that some have so severely that there are psychiatric DSM-IV codes for. But what value is there in engendering fear? Very little. Even though there are logical, scientific explanations (not opinions) that the energy that a cellphone can generate, in the radio frequency energy level, are quite impossible of causing changes to DNA, we will probably never quash the idea that cellphones cause brain tumors. The main risk of cellphone usage comes from using it while you're driving down the road.

So the same people that have some abiding concern about some Islam-inspired terrorist continue to yack on their cellphone as they drive down the street.

2011-05-20T12:34:00.002-04:00

Out of Office Reply

Why is it that people think these are needed/useful? They are annoying on so many levels.

First of all, they're counterintuitive to the whole idea of email. I don't expect you to read and respond to my email instantly, it's the nature and the blessing of email.

Secondly, they're generic, meaning that most have no useful information. So what if it says, "I will be out of the office from X to Y"? Should I expect a reply on day Y+1?

Further, some of these people belong to mail lists. On a busy mail list, one getting a dozen or more emails a day, a dozen or more of these generic responses go back to the mail list. Just for one person.

Just because your email client has the capability of Out of Office replies doesn't mean you have to use it. Let's face it, you're not really that important to me, and if you were, I'd expect something more personal.

2011-05-20T11:12:00.004-04:00

Restaurant Cleanliness

One of the things I would like to see some day is that restaurants, like hospitals, like some hotels I've been in recently, like an airport I have been in recently, install hand sanitizers for their employees' use. They could, just like in my hospital be there with an invitation for patrons to use as well, but I would really like to see the day when, just before my server comes up to the table, they go to the sanitizer and rub their hands with alcohol gel before they touch anything on my table or take my order.

There is no reason not to do this, and I think the public esteem for restaurants who do this would surely improve. Maybe some employees use a private sanitizer already, but making it a public event says more than the same act performed in secret.

2011-05-01T13:08:00.005-04:00

Decline and Fall

One of the things I'm reading now on my Kindle is Gibbon's "Decline and Fall of the Roman Empire", the original written in the 18th century. It's a long story, with plenty of ups and downs, but overall one gets the sense of the decay of governmental institutions and secondarily of society as a whole. I've started thinking about some parallels with current times, not so much anticipating the total collapse of the United States as one might be tempted to propose, but certainly connecting with various ugly aspects of how our governments come about in succession.

I am not intending to be partisan with what I have to say, since to me the most worrisome features of our time affect whoever is in power and simultaneously whoever is not.

If there were some Roman times which seem exemplary, it was when there were monarchs who were simultaneously authoritarian in some way(s), yet saw the value if not need for there to be a diffusion of power, not just to the Roman senate, but also to the people. In those days, much like our own, the power the people enjoyed was a sense of security so that they could be productive, and enjoy the fruits of their labor. When times were good, there none the less came about great envy of various members of the nobility to have themselves elevated to being emperor, Augustus, or Caesar. But then as now power corrupts, and the some of the loudest voices against absolute power were from those who wished that same power for themselves.

If there was anything the Romans excelled at, at least in the early stages of the empire, it was in having a highly developed military machine. At first, the military was made up largely of those who had some ancestral connection to Rome and its central territories, but with time they became increasingly mercenary, with troops replenished with the youth of conquered territories, the creation of soldiering as a career, and these soldiers willing to fight for whoever paid them best. As time went on, more of the wealth of Rome came from pillaging. Agriculture, the main source of value at the time, became more fragile when faced with sequential conquests from barbarians, then recapture by the Roman empire.

And so productivity declined, with the result that the quickest way to riches was to steal from your neighbor. This happened both between the empire and surrounding non-Roman empires, but also internally, where one looked for a way to discredit some noble (or simply assassinate him -- and it might even be someone in your own family) and alleviate him of his wealth.

One might easily argue that assassination became part of the fabric of Roman society, with some Roman emperors lasting only days or weeks before they were killed and replaced by their assassins. The key to survival turned out to be some form of military might, either the "loyal" support of your own Praetorian guards, or the backing of your legion. So various emperors, anticipating real or imagined danger, found temporary safety in exterminating real or imagined enemies. But this loyalty of the troops quite depended on what you were willing to pay your troops, both now and later. Your so-called loyal troops might easily go to the highest bidder now, only to be swayed by some other higher bidder later.

The Roman senate, fearing for their lives, made it a practice to serially hail the new leader while condemning the last. Outside of brief exceptions, any power the senate enjoyed quite evaporated.

Here and Now

We have seen in our time assassinations and attempted assassinations, but my view is that while we have avoided physical bloodshed, we have adopted character assassination as the preferred mode to accomplish the same ends. The same motives are in the background, a mix of power and the riches associated with power, but instead of taking an opponent's approach and reasoning some improvements, it seems more expedient to attack the opponent, in some no-holds-barred attack on their character, their personal lives, their associates, any way to characterize them as evil personified. Afterwards, we elevate someone else to their status, and our opponents assassinate their character in turn.

Just as in Roman times, the reaction of the populace in general is a progressive loss of respect for anyone in the political realm. Yes we can be swayed by our own optimism and hope that this time it will be different, but as we see a series of contemptible politicians come into focus, we can only generalize that contempt for the whole mass of them. And always, the mercenaries, in our time not so much the miltary, but more likely the wealthy, will espouse their loyalty to the highest bidder.

2011-02-11T22:10:00.002-05:00

Sorry, Supplement Takers

The International Stroke Conference was on this week in LA, and I attended. One of the talks I went to was entitled "Is There Any Value in Vitamins, Fish Oil, or Food Supplements for Secondary Prevention?" (of stroke).

A raft of data was shown from various studies, but the end result: beta carotene, vitamin E, vitamin D, vitamin A, fish oil, omega 3 fatty acids, calcium supplements, all show no benefit in stroke prevention. Calcium may even increase your risk of cardiovascular events.

2011-02-01T11:51:00.005-05:00

Microcosm

Some years ago, I had an opportunity thrust upon me which has forever flavored my sense of the political process.

By some sort of default, I was suddenly a local representative to attend something called Buckeye Boys State (BBS), in which high school aged students came together, converged on Ohio University in Athens, Ohio (in the year I attended) as some sort of way for young people to gain some experience, some taste of the political realm. I can't recall how I got there. Since I don't remember my parents taking me, it must have been by bus, as intra- and interstate travel seemed to go at the time.

There was a Buckeye Girls State, too, so this was about separation of the sexes, not inequality of opportunity. The idea of sending a mixed-sex group of adolescents to some university campus for a week was not going to happen at that time.

So there I was, thrust into this, not really understanding it since I'm not sure I ever paid attention to anything about BBS before or after. It immediately became apparent that what we were there for, what we were supposed to do, was to set up a pseudo-legislative/executive body, and afterward make some attempt to fix the world as we saw it, at least on a state level -- we were charged with creating a state government. Since we were only there a week, the timetable was short.

So immediately it became apparent that certain individuals were primed, one might say pumped, for this. Immediately campaigning was going on, some identifying themselves as candidates for governor and other elected offices, and the guys vying for governor had their cronies to assist the process. There were two parties to which one might be assigned. I can't recall the other, but I was in the Federalist party (aside from the name, there was no assignment of ideology). So we had a party convention, selected candidates, I picked out some low-level office to run for, made some weak campaigning attempt, and lost the election.

After that, I managed some governmental appointment that in a week's time had no meaning, since it had no particular duties.

What I can still recall is the sense that I got of the political process, in which promises were made as if one were broadcasting wheat in a field of asphalt, more promises than could ever be kept as a whole since many were contradictory, but somehow people captured these promises, thinking that the promises they got personally were going to be kept. So in return for backing some particular governor candidate you were going to get support for someone/something else, but of course it didn't happen.

Then, as now, I see this as how government works. Those with influence can manage to convince others that if you do this for me, I will do that for you, but they have already made some other conflicting promise to someone else.

This probably wasn't the intended result (or maybe it was), but forever I will think of politicians in this way. Once you decide that for whatever reason you wish to pursue politics, you must work in this realm, in which handshakes, and tacit agreements, and understandings aren't really any of those, and not binding in any way.

2011-01-27T22:14:00.003-05:00

Electronics, Part 4

Smartphone
This continues to be a good thing, generally working well. I find that in spite of the wireless capability of the phone, I'm better off not turning on wireless connectivity at work. This is because, although the hospital has free wireless, the hospital's wireless connection is dependent on opening a browser, trying to use it, after which you have to "accept" the terms of use.

Not such a big problem, but if I forget to do this, I am not getting emails, since internet connectivity is blocked until I accept those terms. Best to stay on 3G and not have to think about it. There's hell to pay for missing pages for hours on end.

I have cut back services as promised. Since I was using something like 75MB of the unlimited internet usage, I cut that back to the lowest possible, 150MB per month. Also cut back on unlimited texting, since I was texting maybe 20-30 times a month. A $5 plan works well. And finally cut back on call minutes to the lowest number -- hardly ever use it for calling/answering a call.

I've started using my phone as my alarm clock when my little battery-operated one died. Very easy to set up, and I could find a quiet little tune to wake up to. A nice thing is that it can be set to work once, M-F, or 7 days a week.

Kindle
I've fallen off in use, but have read a few things since Moby Dick, like The Importance of Being Earnest, a quite funny play by Oscar Wilde. Am currently working on a German classic, Effi Briest to try to brush up on my German (slow going). I actually paid for a book from Amazon, Crucial Conversations, which I would recommend. I also have A Tale of Two Cities, The Time Machine, and an Agatha Christie novel lined up -- all downloaded from Project Gutenberg.

Lenovo Laptop
This continues to work well. Recently the hospital shocked (yes, shocked!) me by suddenly announcing that remote access to the system was now going to be through a Citrix client, and (drum roll please) there were clients available for Linux and even Android phones! I thought I was going to have to start breathing into a paper bag. As you might imagine, accessing a computer hospital chart on a phone is a bit cramped, but for selected situations, it could be useful, since I virtually always have my phone with me.

2010-11-21T11:15:00.007-05:00

Electronics, Part 3

This so far doesn't have so much to do with medicine. When my birthday came around this year I suggested to my wife a Kindle, and she agreed, no doubt happy to be off the hook figuring out what to get me. It took a while to get it, since they were on back order.

Now I've had it for a couple of months and it's cool. It's the Kindle 3, with just the wireless capability, good enough for me. Although I've used it a fair amount, I haven't bought much, just a German-English dictionary (two English dictionaries come with it), and one other book. So am I a slow reader?

Amazon has some free ebooks you can download, but they aren't so easy to find – takes a bit of searching. What I've found out is that you can download Kindle-compatible ebooks from Project Gutenberg, which is a project in the process of making available for free a large number of out-of-copyright books.

I've read Samuel Johnson's "A Tour of the Hebrides" (along with Boswell's "Journal of a Tour of the Hebrides"), written in the 18th century, and "Moby Dick" by Herman Melville. The latter was quite a surprise, as someone who had never read it, but thought I knew the story from the Hollywood version with Gregory Peck. For one thing, the book is BIG, and it takes quite a long time indeed to actually get to Moby Dick, with variably interesting diversions into whaling (a pretty gruesome thing in the 19th century). It occurred to me that if this book just came out, there might be compliments, but overall it would probably be panned as being bloated, with some contrasting styles of narration that don't necessarily go together. It's also said to be written by this Ishmael character, who alleges to have little education, but somehow spins a complex linguistic yarn with all sorts of references to classical and other literature.

I can recall from the movie version the scene where Ahab is pulled into the water by Moby, then resurfaces attached to the whale, his arm flapping as if beckoning the ship. Great scene, but not a part of the book – Ahab gets rather ignominiously yanked into the water, and that's the end of him. There are also very detailed descriptions of Queequeg's appearance and behavior that are nothing short of amazing.

Interestingly it was quite easier to read and understand Johnson's 18th century British English than Melville's 19th century American English. To say that it is flowery and obtuse is an understatement.

I took my Kindle on a trip lately, and tried out the idea of putting various reservation information on it, and it worked quite well, and so I had all of that in one place. When you don't need it anymore you just delete it.

I like the lightweight feel of it, and the physical size is about right. The battery life is great. They have what is said to be an "experimental" feature of a browser, but rather difficult to use, and legibility can be a problem, but browsing is not why I bought it, so for me not a big issue – after all, I have my smartphone now.

2010-11-14T13:12:00.004-05:00

Electronics, Part 2

On a more positive note than Part 1 is that I finally got a smartphone. It's not like I was just itching to get one for the longest time, I actually didn't feel I needed one until recently. What I had gotten by with was a simple phone, which most of the time was off, and some of the time wasn't even with me. The other part was having a beeper, yes the age-old beeper.

The reason for this was that, as I go through my day, I do not want to spend time answering the phone, to get messages, to answer questions about something or other. Even though some people had my cell number, it generally didn't do them any good, since I might not get a voice mail message for a week or two. Many doctors go on and on about not wanting patients to have their cellphones on when they're being seen, but at the same time, I've seen doctors interrupt conversations with patients to answer their phones.

Thus the beeper. Sends me a passive message, which might be about needing to call, but mostly not, but at any rate there isn't this expectation that I, personally, will be available to talk 24/7. The only bad thing about the beeper was the sound, which could be changed to one thing or another, but what couldn't be changed was the volume. The basic volume was Ok most of the time, but in a quiet room as you're resting, in the middle of the night sleeping, it was very annoying.

What finally happened was that, as part of the new world order of our group being bought up by the hospital, they agreed to continue our phone and beeper contracts until they were up, after which they would pay me $50 per month to get "whatever I wanted." There was no way that I was going to get a phone and beeper service, and hard to imagine I could pay only $50 in the process, so time to move on.

I had plenty of time to wait, see what's new with phones, with services. I had thought that surely I would want something with a keyboard, such as a Blackberry. But then there were iPhones, and later Android phones, which at first seemed not so good imitations of iPhones. But I'm not a fan of Apple and their business model, so I waited.

And then it becomes clear that the Android OS is rapidly evolving, and with the competition heating up between hardware manufacturers, things are getting better. Then this year as the switch comes nearer, Samsung comes out with their Galaxy S phones, and now I can see some sense in it.

Even so, I waited until I could figure out the transition from beeper-phone to smartphone. Finally I figure it out. I had already been having my office send an email about messages in addition to pages on the beeper, since there are missed pages, and missed pages are just missed.

The answer is smartphone and email, having a dedicated address for this phone, and dedicated just to office/answering service messages. Dedicated to keep the noise level down, noise being spam, and unimportant messages. And thankfully, when the email comes in, my phone chirps, just once, and I have control over the volume -- perfect!

It's been a little over a month now, and it's going well. I hadn't realized that my answering service could email as opposed to call or page (but they won't do more than one kind at a time), so that came as a great asset here. Meanwhile, I have gotten more familiar with other things like Epocrates, famous in the ranks of smartphone users. I'm also able to take advantage of other things, like the BMI calculator on my website.

The next thing I want to do is decide how to cut back on services. I started out with unlimited internet, but it's already clear I don't need that much, so we'll see.

2010-11-14T13:12:00.003-05:00

Electronics, Part 1

This is going to be a series of posts on electronics as I use them in practice.
First, a sad report on the netbook I blogged about last year. It looked promising, and at least for a time its promise seemed fulfilled. It did all the things I needed to get done, making EMG reports, tracking my patient charges, keeping up on messages and emails, and because of its light weight, was very easy to carry around everywhere.

Durability has always been the main long term problem with laptops I have owned. Usually, it's the screen - flaky connection, or in one way or another the LCD display just failing. One laptop still at home collecting dust has a failed CD-ROM drive, a killer when combined with the absence of any other way of upgrading the OS, since it was made before one could ask the computer to boot from a USB drive. I tried switching out the drive, but this didn't help, so it must be the drive controller.

So what happened to this Dell Latitude 2100? Not quite sure, but it seems to be a motherboard issue. Most often, I try to start it up, lights flash, and then the Caps lock key is blinking and blinking and blinking. After various shaking maneuvers were tried, it seemed for a while that lightly tapping the case on the counter would allow it to boot. But then, putting it into sleep mode, carrying it somewhere, and it would be frozen. Sometimes freeze up while I'm using it (grrrrr!).

With time, it took more "aggressive" tapping (aided by frustration), but somewhere along the way, I noticed that twisting the case could be enough to work sometimes, but anything that worked only worked sometimes. Obviously, surgery, or at least internal investigation was in order.

Comment: Sending one of these things back to Dell is of course an option. However, I was now in post-warranty land, and past experience tells me that a trip to Dell costs $150 (probably more now) just to have them take a look at your computer. So for a computer that brand-new cost me $400+, spending half of its brand-new cost is stupidity in action.

Next stop, Dell's website. I've bought a number of Dell products over the years, and while I am always game to trying to get useful info once again, they did not fail to change my bias that there is little if any useful support on the Dell website. What I was looking for was some help with understanding how to dismantle the 2100. I did find a site from a Dell employee about changing the SDD drive, but he gave no clue as to how to open up the case.

No help? No problem. After all, what I had in my hands was an electric-power-consuming paperweight. What good is a laptop that you might be able to get working by hammering on the counter, might quit in the middle of what you're doing, and will almost certainly not maintain its usefulness when you suspend and carry to some other place?

So I fumbled my way through opening the case by removing all identifiable screws, still found it impenetrable, and managed to eventually snap off some internal posts. Voilà! Case opened!

It would have been great to say that I found some loose part, some errant piece of metal debris shorting out some circuit, some obviously sick connection somewhere to instantly fix and resurrect this failed netbook. Alas and alack! No such luck. I mashed down on all he ICs I could see, brushed the motherboard from any unseen debris, no effect. And yet, twisting the motherboard could manage to allow this thing to fire up. [Disclaimer: you will see numerous warnings about disarming things you are taking apart, dire consequences of electrical shock, transmitting currents to various electronic components without adequate grounding. I'm careful, but I ignore such warnings. After all, to me this is a dead piece of electronics. Zapping the processor to some state of complete inoperability would actually do me a favor, allowing me to comfortably toss this amalgam of silicon and solder in the trash.]

Yesterday, I managed through googling to find some Dell information on disassembling the 2100. Still lacking in some important details, I was able to figure out that, as I had actually suspected, that the "key" to getting this sucker apart somehow rested in getting the keyboard dislodged. However, even after this revelation, I have learned nothing further. I can say that the motherboard problem lies somewhere in the region of the WLAN device, which seemed to be suspiciously loose, yet various maneuvers attempting to improve the WLAN card connection made no difference, even though some localized mashing down in that area could affect the ability to boot.

So, all of this internal investigation, and I remain in the same place. So it's now kind of an extra computer, has a way of being useful, but this laptop bought for its great portability only is useful by smacking it around to get it to boot, then must be treated ever-so-gingerly to not upset the delicate connections you have resurrected for a time.

OMG! What am I doing in the meantime? While I keep getting a steady stream of emails from Dell about "deals" on laptops or whatever, the deals seem to all be in $500-600 dollar land, at least, and most are more. Oh yes, I'd love to send you $600 for a laptop that I might need to replace in 18 months, conveniently after the warranty expires. What I found was a demo Lenovo laptop at Office Depot, for which I paid $360, having a dual-core processor and a 250MB hard drive, 4GB RAM. Its main issue was that some kid had shoved something across the keyboard so that the F10 key no longer would stay in place. (I can't recall any software that really needs or uses the F10 key, and besides the mechanism works, it's just that there is no key on top of it)

So, it's heavier to be sure. But now I have a faster computer. I can set up a virtual machine running Windows so I can interact with the hospital's software. Not such a bad trade. But it's still a laptop, subject to all the physical breakdown problems I've seen before.

2010-11-07T13:54:00.003-05:00

"You have a brain tumor"

You might think that for neurologists this is something we say "all the time", but it's surprisingly and thankfully infrequent. My guess is that even neurosurgeons don't even have to break the news very often, since they are seeing someone who has been referred because of the knowledge of a tumor.

A capsule of a recent event went something like this – I'm asked to see someone for some intermittent weird sensations in a hand and later also in his face. This comes and goes. Exam is quite normal in all respects, even for any signs that there is any loss of sensation in his hand. So, what is this? A stroke or TIA? I recently saw a woman with a similar story, also negative exam, and she had a thalamic stroke.

This time, a very obvious tumor. Keep in mind that, as far as medical terminology is concerned, "tumor" just means "some kind of mass". A blood clot in the brain is a tumor. A fatty deposit somewhere is a tumor. The tumor that most people think about medically would be called a "neoplasm".

At any rate, this man's MRI very strongly suggested a neoplasm. So now it comes down to breaking the news. I confess to some tossing and turning that night. I learned about the finding by phone in the evening, but there was no point in calling him on the phone, rushing into the hospital to spill the beans. How will he take it? Be upset? Be upset at me? Break down into inconsolable sobbing? You never know.

Like so many things that you cogitate about, worry about, feel your stomach churn about, it was something of a nonevent. Nonevent to me, but there can be no doubt it was an important event to him regardless.

My experience-based advice is this:

Do not shy away from this.

You must have control of your faculties when you break this news. You cannot be involved in your own internal conversation with yourself while you are divulging this kind of news.

Be attentive to body language and every other sign of severe distress. Many people simply clamp down emotionally when this sort of news comes, so the only sign of an intense problem may come from the involuntary things they do as you explain what you know.

Be in no rush to leave. Wait for a sense of how they are handling it. Wait for verbal reactions. Wait some more. Ask for some feedback, especially if you're not getting much.

Regardless of how complete you think your interaction was, you must plan to come back to ask if there are more questions. You have just hit this person with what amounts to a stun gun.

There is no reason to explain much of anything in detail. There is no value in sketching out the range of what this "might be". It is what it is, and what you need at this point is something definitive that will only come from the pathologist after a biopsy or resection.

Like so many of these things, it was not as bad as I had envisioned it could be in my ruminations, but nonetheless I needed those ruminations to prepare myself mentally.

2010-09-10T12:27:00.002-04:00

Deflation

My answer to the upcoming, Bible-thumping, OMG moment we have with the Koran-burning set for tomorrow. Even Obama weighs in on it now.

If I have this straight, all this amounts to is a pretty successful effort by someone wanting to get national and global newsplay about some insipid act of burning a Koran. Reminds me of the oft-carried-out US flag burning from years past. People stopped doing that when they realized that it became meaningless and the reporters failed to show up for it.

Here are some suggestions

1. Ignore these people. Let them burn one or more Korans.
2. Point out that burning the physical representation of one or more Korans does nothing to change or negate the message of the Koran, does nothing to negate the impact of Islam.
3. Establish 9/11 as a Koran Awareness Day, where passages from the Koran are read in public, read in churches, published in the press, online, on TV, to illustrate that this is a work that has withstood time, does not of itself provide the seeds of terrorism or intolerance.

In short, you provide antidotes to the reason why these people decided to do this. You draw attention away from them, you counteract religious intolerance, you proactively present positive images in the face of hatred.

2010-08-14T12:54:00.002-04:00

Reality

People ask me at times what I think of House or ER, or some other TV drama about medicine. When I say that these shows aren't very interesting to me, I suppose they think that it's because I think that I don't like them because they show some seemy dark side of medicine that we're trying to hide.

Aside from the fact that House is such a distorted portrayal of medical logic, the biggest problem I have is that these shows do not portray anything much resembling life as we know it, in-or-outside of medicine.

Perhaps the biggest complaint I have is similar to one of my reactions to the various Star Trek, where life in the 23rd or whatever century is portrayed as being honest, kind, fair, and in short, totally divorced from life as we know it.

Here is an example:

As I understand the technology of Star Trek, I cannot for the life of me fathom what happened to the human sense of making fun of other people. Let's imagine one of these meeting they show, with the table surrounded by the various officers, captain at the head. Surely, we might expect someone to transport a whoopee cushion to someone's chair as he/she sat down, with the whole table erupting in laughter as the person sits down to the sound of pffffffffffttttt!". This is human nature.

No, we can't have that. Everybody on Star Trek is serious. Frighteningly serious. The humor they do have makes news anchor humor seem like ROFL humor.

The real medical world contains all of the silly, stupid, offbase humor that goes on everywhere else. We know when to be serious, but we know how to have fun, too.

2010-07-31T13:05:00.005-04:00

Heat Stroke -- NOT!

I've seen 2 patients this summer misdiagnosed as "heat stroke" who actually had a "stroke stroke".

Heat Stroke

This is an unfortunate nomenclature which has nothing to do with strokes as an ischemic problem in the brain. What is happening in heat stroke is that you are exposed to heat for a prolonged period, and after a certain amount of time, your body's coping mechanisms break down, for one thing, your sweat glands peter out. Since sweating is one of the primary ways that your body copes with heat, this leads quickly to a rise in body temperature. The other issue with temperature control is that it has its limits as well.

Your brain has something like a thermostat that reacts to body temperature.

This graph to the right in all of its imprecision is meant to illustrate how the brain responds. The "set point" of your brain is this trough in the middle of this curve. So whether your body temperature is going up or going down, to a certain extent your body will respond. But the important thing to see is that beyond some limit, that response actually diminishes, so when body temperature gets too high or too low, there is a decompensation and associated dropoff in whatever response your brain has to a temperature which is too high or too low. So above or below a certain point, temperature continues to rise or fall. As we get older, the graph gradually flattens, which explains why the elderly are at higher risk for both hypothermia and hyperthermia.

The key elements of diagnosing heat stroke are an excessively high temperature and the absence of sweating, along with other physiologic results of hyperthermia.

If you do not measure an abnormal temperature, then the brain should be functioning normally. If it isn't, then you need to look further. Needless to say, if an MRI had been done in either of these patients, a stroke (as in stroke stroke) would have been diagnosed immediately.

2010-07-27T12:47:00.004-04:00

Dreams

About a year ago, after some 20+ years in practice, I was working harder than I ever have, and this includes my residency and yes, even internship.

Internship is marked by uncertainty more than absolute work, since at that stage, you never know what's coming.

The scenario of this late in career period of time was that I was the lone member of my group covering a particular hospital. Over the years the number of neurologists, neurology groups seeing inpatients had shrunk, so that the bulk of the work was being done by some self-proclaimed neurologist hospitalists, in other words, they were not under contract with the hospital, but having announced themselves as such, had adsobed much of the inpatient work.

A series of events ensued, one of which was that my group became employees of said hospital corporation. The other shoe dropping was that this hospitalist group of 2 broke up from internal issues, and the remaining member, "disenchanted", decided to abandon ship, i.e., leave this hospital for coverage.

Suddenly, a 400+ bed hospital had for all intents one neurology group for neurology consultations, and de facto I was the sole recipient of these daily consultations. As if a switch were flipped, my days were driven by the steady yet erratic influx of double-figure consultation requests. So my days began earlier and ran later, starting at 6am, running to 9pm, 10pm, 11pm, and even later as I tried to keep up with the influx. I might technically be done at 9pm, but then get a request at that moment, and yes, I could put it off until tomorrow, but overnight there might be 3, 4, 5 more, so better to just see that 9pm consult tonight so I go to bed with a clean slate.

At the time and even in retrospect, the most disturbing thing to me as this materialized was the content of my dreams was replaced by dreams of being in the hospital seeing patients. Entirely. I found this disquieting, since this became a 24/7 experience for me. I have to say, I would not have believed that daytime behavior could so radically affect dreams. One begins to fear for sanity.

I don't know what signs became apparent, but finally the other members of the group stepped in to pick up some of the pressure, and once again dreams were transformed, to something more recognizable as normal, but of course what is a normal dream?

2010-07-17T13:18:00.006-04:00

Dirge

I can feel the rhythm now.
Sometimes I can hear the distant
drumbeats or organ-pedal tones
playing out their sequence of ominous low notes.

We've already heard the other shoe drop
long ago, and so many others have dropped
that each time we think the closet is empty
another falling shoe shows up.

So now we have this constant yet variable
queasiness in our solitude,
and we sometimes wonder if it's Sartre's nausea we feel,
even though he has long ceased those corporal feelings.
Did he pass it on?

Restless slumber, disquieting moments during the day
watching some interaction play itself out
to an incomplete resolution.
Another uncomfortable state of existence.

2010-07-15T20:25:00.002-04:00

Memory

One of the things neurologists do, of course, is assess memory, yet it's also something that all of us deal with on a daily basis unrelated to concern about some pathological disorder of memory.

There are many "memory experts" who have written about the ways they have little tricks to remember things, but there are so many potential things to remember that this only goes so far.

Recently, I saw a doctor that I hadn't seen in years, called out to him, and was hoping to use his name in the conversation, since it's always a good thing socially to not only remember that you know someone, but also show that you remember who they are.

The best I could do was Leonard. I knew that was right, he just looked like Leonard, but the last name? Yipes. The only thing that kept surfacing was Leonard Cohen, and if there was anything I knew, it was that I didn't personally know anyone named Leonard Cohen. But the harder I tried, the more times I tried, I could get past it. Bummer.

I ended up using his first name, which may have pleasantly surprised him enough that things were Ok -- after all, he never used my name, so he may have been having the same experience.

Later, I did what I often do in this situation, an alphabetical search. I start at the beginning of the alphabet, with Leonard A, Leonard B, Leonard C, and so on. And within no time I had it, and I'll say, it is not a common last name either.

So what is this, some mnemonic device? I would consider a technique, but it's certainly not like the usual sorts of methods that might more logically be called by that term. I would consider it a way of blocking intrusive and wrong memories. The problem I was having was my mind kept getting locked up in the kneejerk Leonard >> Cohen connection, so what this alphabetic search does is attempt to break that connection and force some other last name first letter in there. And it worked, really within less than a minute. It's always impressive when something works that well and that fast.

2010-07-11T08:58:00.003-04:00

Howard Schultz on Health Insurance

The first obvious question for many will be "Who is Howard Schultz?" He is the founder and CEO of Starbucks. The July-August issue Harvard Business Review has published an interview, most of which is about his return as CEO a couple of years ago in a successful effort to turn the company around.

I'm not a big consumer of Starbucks coffee, but his answer to one question in particular caught my eye:

What's an example of a decision you've made that Wall Street didn't like?

Health care.Our health care costs over the past 12 months were approximately $300 million. [Starbucks offers health care benefits to any eligible employee who works at least 20 hours per week.] The thought that we could cut that benefit -- I couldn't do it. Within the past year I got a call from one of our institutional shareholders. He said, "You've never had more cover to cut health care than you do now. No one will criticize you." And I just said, "I could cut $300 million out of a lot of things, but do you want me to kill the company, and kill the trust in what this company stands for? There is no way I will do it, and if that is what you want us to do, you should sell your stock."

If there were more CEO Howard Schultzes out their, we might still need health care reform, but it might not be such a difficult problem.

2010-06-03T19:35:00.003-04:00

Information Transmission in Organizations

This sounds like the title of some research project that might be published in a business journal, but what I want to talk about is simply some observations that have emerged in stark detail as I have practiced medicine for the last 30 years.

Neurology is a specialty that is obviously an area that most doctors and nurses struggled with in their training. This is not meant to be a derogatory statement, since I can easily recall that when I first tried to learn neuroanatomy I was rather convinced that there was too much to learn, and that it was all quite beyond my capabilities.

As you complete training in a field quite foreign to other health care workers, you become a kind of source of information that seems mysterious, and you become a font that people come to for enlightenment about various neurologic illnesses. If that weren't enough, I also did a fellowship in neuromuscular diseases, which can be a bit of black box for many neurologists, let alone those without some degree of comfort about neurologic diseases.

So now we finally get to the point suggested by the title. An individual person, let's say a nurse on a particular unit on a particular shift, wants to know some details about some condition. I can certainly expound on some subject, for example the various features of, expectations of, treatments for, a condition like Guillain-Barré syndrome, but this is a cul-de-sac conversation. It's not marked down somewhere, not entered in any notes, not passed on to other nurses, maybe not even well-assimilated by the nurse I'm talking to. And so it's like dumping my time into a hole, where it disappears.

Tomorrow, another nurse wants the same information. Do I deliver my time into another hole? The only practical thing for me is to find some spot in between, which I'm afraid probably comes across as being reticent to explain things, maybe withholding information, not being as explanatory as I can be. It might be easy enough to try the "Google is your friend" approach in some palatable way, but I know quite well that this will be the source of a lot of misinformation and noninformation for esoteric topics.

It's a major dilemma, and I don't think that most hospital organizations either understand it or have any investment in doing something about it.

2010-05-22T10:22:00.002-04:00

End of Life Decisions

These decisions are thankfully not an everyday experience, but still common for a neurologist to be involved in. Whereas there is a lot of intellectual angst about the topic, when you're at the bedside, it's mostly on a very personal level.

In many cases, you have a situation where someone was "perfectly Ok" one moment, then some disaster strikes -- a major stroke, cardiac arrest, or pulmonary embolus. Maybe the person came in the hospital for some routine procedure when disaster struck, either rapidly or in some sequential fashion, as one complication after another set in.

There is, of course, the rather straightforward concept of brain death, implying a total loss of all brain activity, in which case it doesn't matter how strenuously you try, you will not keep this person alive in any sense, since it tends to lead to circulatory collapse. When the blood vessels have no tone in the muscles of their walls, you simply cannot sustain a blood pressure even with medications or even stimulating the heart.

Mostly we are dealing with something far less than that, just a brain severely damaged in some patchy sort of way. So we try to assess, prognosticate what's ahead. A recent patient, a woman in her 40s, suddenly collapsed at home, EMS came, shocked the heart into a viable rhythm, she went to emergency cardiac catheterization where stents were placed, then to the hypothermia protocol, where patients are cooled for 24 hours, something shown to help protect the brain.

In her case, it wasn't enough. Twenty-four hours pass, then 48, 72 and beyond, and still only a very, very few signs of reactivity. Her EEG wasn't flat, but her overall condition indicated that there was severe, widespread damage, and especially involving deep brain structures. As I often explain to families, the brain is arranged something like a funnel, where everything coming in and going out passes through the neck of that funnel.

If the damage is only in this funnel neck, it might cause locked-in syndrome, in which a person might be quite conscious, yet simply unable to interact with anyone. There is a French film, The Butterfly and the Sarcophagus which is a true story about such a patient.

This woman's EEG did not suggest this, but lots of damage in various locations. So now it comes to the family to decide what we do. I do not, or try not to advocate any course of action, but mainly describe what I see, and make sure that they understand options. The easiest option for the short-term is to punt, just continuing to wait. But after many days pass, with no further improvement, we have to make decisions.

We can continue to maintain everything, ventilator support as needed, start tube feedings, and begin looking toward long-term care. The term persistent vegetative state comes into the conversation. It implies that the person is unlikely to become consciously aware of their surroundings, and I think it's important to keep a general commonsense notion of 'consciously aware', not some absolute suggestion that there is no reactivity to sounds, to voices, to stimuli. Generally, vegetative patients do not stay in a coma. Eventually they develop some kind of states that look like waking and others that look like sleeping, along with some minimal reactivity.

There are those who either on some religious grounds, or perhaps their own fears and anxieties, cling to any signs of life, interpret every movement, twitch, reflex, eye motion as signs that the person is conscious. But what kind of consciousness is this?

I think we can't help but introduce some personal perspectives at this point. Would I want to exist like this? Would I want this for anyone in my family? Long-term care has expenses, but this isn't about the expense, it's about my own sense of life worth living. Why would I want to cling to every last heart beat, every last breath inside a body chained to a bed with feedings, and no ability to interact with anyone? Not for me. But I also add that this time it's not my decision, and whatever you decide, you need to make sure you are comfortable with the decision, since it's one of the most important decisions you will ever make. Oddly enough, we mostly don't make this decision for ourself, living wills notwithstanding. It's going to be make by our family.

I also take care of ALS patients (Lou Gehrig's disease), and there reaches a time when, even though the brain is still Ok, you become a prisoner in your own body, unable to eat, unable to do the least thing for yourself. You never know what you will do until faced with the choice, but I don't think I could follow Stephen Hawking's example.

And so, when the decision came from this young woman's family, it was that they didn't see the future giving them back the woman, the sister that they knew, and knowing her felt comfortable that this is how she would see it too. So care was withdrawn, she was made comfortable, and we let her go.

2010-05-13T22:50:00.002-04:00

Hiccups
A bug in human software

This is my conclusion. Some years ago there was on ongoing mail discussion in one of the major medical journals (doesn't matter which one, since in the end it came to no great conclusions).

We all know about various circumstances that can trigger them, or at least it seems that way. We certainly see them arise in certain neurologic situations of posterior fossa or brainstem problems that by some mechanism get them going, and there are cases reported of hiccups lasting many years in an individual.

To me it can only make sense that they're a "bug" in the nervous system when you realize that they cannot have any possible physiologic purpose. Nothing good comes from them whatsoever. Mostly we can just be thankful that eventually there is something that resets itself to stop them.

2010-04-22T16:49:00.002-04:00

Pedophilia and the Catholic Church

I'd like to take a different approach that many or most seem to take, which seems to mostly be Pope-bashing, Priest-bashing, and sooner or later various legal actions which will be invariably labelled as "trying to send a message" but seem more like trying to make some money out of this.

From a medical-psychological point-of-view, there needs to be a realization that while this may not be epidemic in the clergy, but certainly at some level it seems to be an endemic problem. We might react by saying that pedophilia is a widespread societal problem, which I suppose is true enough, but we are dealing here with a segment of the population espousing the highest moral standards.

Maybe there is some cathartic effect of repentance, bashing pedophilic priests, paying out sums of money, but I see a number of questions that arise.

1. Do we understand how it is that some men choosing to enter the priesthood might have these kinds of issues? What is it about their backgrounds that may lead to this?

2. What is the culture of the seminary which, depending on ones perspective, either is unaware of these things, or perhaps fosters them in some way? We certainly have heard tales of sexual behaviors in seminaries -- is this widespread?

3. How can the modern Church reconcile these problems with the steadfast maintenance of the idea that priests must be unmarried and celibate? Is celibacy or the pretense of celibacy a root cause of the problem?

To me these are the far more important questions we should be asking the Vatican to answer.

2010-03-24T12:25:00.004-04:00

Let me see if I've got this straight...

I recently bought a Dell computer, which came with Windows 7 pre-installed. I promptly replaced that with Linux, and then set up a virtual machine and installed Win7 from the disk I got. I'm not sure how, but my Win 7 has detected some anomaly, and now is telling me that I have a Win 7 that is "not genuine". Every time I start it up it wants me to connect to Microsoft to purchase a license for this pirated copy.

I also read recently that Dell is refusing to reimburse anyone for computers which came with Win7 pre-installed, since this came at "no charge".

Ok. I can accept this. I'd like to purchase 10 copies of Win7 at no charge, please.

2010-03-23T12:47:00.002-04:00

A Call for Change

This might be construed as a nonmedical commentary, but it is and isn't at the same time. It's a call for a change in the fractured mindset we can so easily see in America right now. A call for a lowering, an elimination of the hate-filled language we continue to see and hear, espoused and encouraged by the various hate-mongerers out there.

We try to portray ourselves as a Christian nation which supposedly wishes to create a situation which follows the teachings of Jesus of Nazareth, who promoted the "turn the other cheek" mentality.

I do not see the Christian ideal evidenced by all the hate we see in the news on a daily basis. I don't see it in the opposition to some kind of universal health care --" yes, you may need health care, yes, you may not have insurance, but I will not help you get it, I will watch you die first."

This is not a healthy environment in which to raise our children. We cannot advocate hate, and acting on hate as a sensible way for us to live our lives. If we say that hate is Ok, then we say that it's Ok to spew hate at your doctor, your boss, your spouse, your neighbor -- where does it end?

We must begin to speak out, and speak out in unison, that all this hate-mongering, all this hate-tolerance is unhealthy, it's bad for our country, and no good will come of it.

2010-03-12T21:32:00.003-05:00

Scribus in the Hospital - 3
over the top

It may have seemed that what I've already shown was as much as one could do, but you'd be wrong with that assumption.

Once we have access to something like Scribus, with all of its layout capabilities, you don't have to stop at lines, labels, barcodes, and text. Add images.

There are ways of doing all sorts of things. Behind the scenes, I have added a free program called Hoversnap to the mix, and now I can make screen captures of scan images, so I can add these to the chart.

I would quickly add that in the long run, these have no relevance. These chart pages get scanned into the EMR system, and as you can imagine are totally useless at that point, since they come out as they would running them through a fax machine. So why do them at all?

Education. In two directions. One is for the non-neurologists, who do not necessarily know what they're seeing on scans, and therefore don't generally bother to look at them, and admittedly the important pictures are typically a handful of hundreds. So I trim it down to the essence.

The other is for the nurses (and other non-physician staff). My note talks about what I see in the images, and the pictures show what I'm talking about. So everybody gets some education about brain scans and what they show. And people appreciate this – you know they do, because they go out of their way to tell you. Furthermore, this is round-the-clock teaching – even the overnight nurses get in on it.

As I said at the beginning, I am not advocating this, I am not suggesting this is what all doctors should do, it's just something I am doing, and I enjoy it and feel it's worth my time.

2010-03-09T20:40:00.011-05:00

Scribus in the Hospital - 2

Here is what these notes look like. This, of course, is a bogus name and a more or less made-up history, although certainly neurologists hear this kind of story all the time.

The last post showed you the generic form used as a starting point, but here I have created a patient label. This was done in Scribus with a "script", a term used for a short program written in the Python programming language, which is able to interact with Scribus to carry out some operations, and do things like creating this rectangular-shaped label on top of the one you saw in my last post that said "Attach Sticker Here".

Rather than delete that other frame, I just create this one with an opaque white background.
The script prompts me for the bits that go in there, then makes the frame. I should add that the script automatically capitalizes the patient's name, and makes the font bold for the name on the label – if you can do it, why not?

After that, then I make the barcode for this patient's hospital number – Scribus has a plug-in to do this – then I just place and resize (it's 195 pts x 20 pts).

Something my actual template has that you didn't see in the last post is a frame all set up with "NEUROLOGY CONSULTATION" at the top, again, a frame with a white background. In this case, I want to hide the lines so we don't get visual interference and legibility problems. In Scribus, I'm using something called Story Editor, which is a simple text editor, simple as far as the text entry goes, but allows for assignment of various typographic features to the text. I know I talked about my narrative style in the last post, but as you can see, this is a bit truncated, with a lot of phrases instead of the complete sentences I would use in an office note, which is the only note there will be and therefore reads more like a letter.

So I've finished my note, now what? It just so happens that the various computers the doctors use are hooked up to network printers on the nursing station, so I just print right to them, and as luck would have it, most of the time they use paper with pre-punched holes at the top since they're used largely for printing out lab results, so I print my note, sign it, and it's in the chart.

Oh, what about orders? I've done a few which also include orders in the left column made with Scribus, but mostly I like to write these out by hand, it seems to save time – also, I've noticed that you may think you know everything you want to order, then as you're putting the sheet in the chart, you realize that you need to add something else, and then something else... Usually what I will also do is to write in the time on the order so I can compare the two columns. Almost invariably it takes no more than 10-15 minutes from when I start the progress note to when I write the order on the printed out page. I don't think that compares so unfavorably with how long it takes to handwrite a similar note, and certainly speaking for myself, is a major legibility improvement.

One thing that happened, and you won't be surprised I'm sure, is that nurses were rather quickly coming up all smiles and complimenting these notes. It never is a bad idea to bring a smile to a nurse's face.

I should mention at the end of this post that while I try to do this as much as I can, there are days when I just don't have the time for this. I'm not compelled to put this much into these notes, since I also dictate a note anyway, and for example, last Friday when I eventually had a total of 8 new consultations to see, plus all the followup visits and other tasks of the day, I did maybe 3 or 4 this way. Generally speaking, though, I'd say it's about 80-90% done with Scribus.

2010-03-07T21:16:00.006-05:00

Scribus in the Hospital

This is something I'm experimenting with lately. The idea was to be able to make my notes for the chart by typing them in. This raises a number of questions, like how much time does that take? Does this really work? Can you do it on some kind of regular/daily basis?

I'm certainly not trying to be an advocate of the concept or of how I do it. For many years in the office, I generally take few if any handwritten notes. I sit there with the patient, take their history, and type out my notes, then save them in the chart. I used to print them out and physically put them in the chart, but since we've had an EMR, they just get saved on the server. It's doable if, like me, you're a touch typist, and certainly leads to something anyone can read.

When I started it I wondered about how I would manage with the fact that word processor text entry is a linear process -- you keep appending what you've done, whereas if you're handwriting a note, you can skip around the page and go back and stick something up where it seems to fit better. But that wasn't such a big deal once I figured out a standard outline of sorts to use, and it isn't so hard to use arrow keys or whatever to skip up and down a bit. You can always reorganize later, if you want, but these are just working notes anyway.

The next step was doing all my own typing in the office. All of it. The official notes that go to referring docs, letters for this or that. It started out when we were having a bit of a backlog in typing, and it might take a couple of weeks for my transcriptions to come back. Meanwhile the patient calls, and I'm trying to remember what I said in my dictation, which I don't know until my typing gets done. Now that I do it myself, I finish all of it the day I see the patient, so it's in the mail and in the chart that same day. Let me add that my "style" if you will is a narrative style. I am not fond (putting it mildly) of these highly structured tabular/spreadsheet-like reports that are all too common from doctors' offices these days, where most things are in words and a few short phrases, and lots of medical lingo.

So when you do all this typing, you become pretty proficient at it. It may have been out of boredom, but I decided to experiment with hospital chart notes. While we have a LOT of the patients' information computerized, we still cling to paper charts, especially for the doctors handwritten notes. I dictate my consultations just like everyone else, but I've always written a fairly long note before dictating -- it helps me collect my thoughts for dictating as well as have something in the chart before the transcription gets done (actually usually within an hour or two of dictating most days).

For the heck of it I decided to create a progress note sheet, and did so with Scribus, so everything you see in that picture at the beginning of this post was created in Scribus, even the bar code, which by the way just denotes the type of page it is -- I gather that when these pages get scanned into the system the scanner uses the bar code to make sure each page gets to the right section in the chart.

In my next post, I'll take the next step, turning this generic page into the most legible doctor's note you'll ever see.

2010-02-05T12:57:00.002-05:00

Warning! Warning!

An increasing source of irritation are the messages from some health insurance plan, or some mass pharmacy letting me know about their concerns about the fact that my patient, Mr./Mrs. X is on a medication that has been shown to have problems in the setting of some other medication, related to their age or some other issue.

Let's imagine a general intrusiveness in people's lives. You're outside mowing your lawn, and a car stops, a man comes out and wants to make sure that you are aware of all the risks that might entail mowing close to the road, running over stones or rocks, and especially the risks of refueling your lawn mower. And so you go about your day, with warnings by some concerned person about how you refuel your car, how you shop for poultry, whether you're wearing the right running shoe for the obvious pronation you show as you run.

Most of these I just look at, try to sift out the purpose of the message, then discard. The other day I felt that I needed to step up and defend my patient, who at the age of 61 was accused of being elderly, and therefore subject to risks that she would not have if she were "unelderly". Maybe it was generated by someone in their 30s.

I wrote, "This patient is not elderly" and faxed it back to them.

2010-01-30T11:02:00.016-05:00

New Computer

After slowly watching my home-built, home-updated desktop getting slower and slower at various things (I think at least one of the hard drives is sick, and its age is denoted by the fact that its motherboard has USB 1.1 ports), I decided to just get a new one. I did look into getting the parts, motherboard, CPU, case, etc., etc., but after looking at prices of pre-built vs. doing that, it made no economic sense. This is, of course, a matter of being on the lookout for good buys.

I know that for many, HP is a popular choice, but I have been wanting to support Dell for their support of Linux (Ubuntu), not that I feel restricted to getting a Dell with Ubuntu already installed.

So a couple of weeks ago I got an email about one of their Vostro desktops, checked it out, looked at the deal ($312 off), compared that to a custom build, and bought it, with a few mods - upgrade to and E8400 Intel Core Duo, 3GB RAM, 320GB hard drive. It came with one of various versions of Windows 7 -- all 32-bit, interestingly enough, but this didn't matter so much to me (details below), so I just got the one that didn't cost me extra.

My aging desktop is a dual-boot Linux-WindowsXP machine. Dual boot machines give you some flexibility but actually are a pain in the butt. This rebooting into the other OS for something or other is aggravating. Also, because of Windows only being able to see vfat formatted drives, I would always have some vfat formatted partitions for sharing data without needing to reboot.

Now comes virtual machines, and more specifically VirtualBox, originally made by a German software company that was bought by Sun, and it's available for free. So now I could run Linux on a Windows machine or vice versa, and it's the vice versa I'm more interested in -- why? Because if I want to browse or check my email, Linux is by far safer. Everything else considered, this is the decision-maker. Also, Linux users are familiar with and expect multiple desktops, so I can leave my virtual machine up and running full size in one desktop, and flip over to another one in Linux any time.

So I received my Dell (Vostro 220s) yesterday, set it up, booted into Win7 once to make sure it worked, then shut it down and blew Win7 away to install 64-bit Fedora 12. In the past I wouldn't have had the courage to do this, but after doing some research, worst-case scenario #1 was that I would need to reinstall Win7, and it did come with a reinstall disk. Worst case #2 was that I would send it back to Dell for a "restocking fee."

So now this morning, I've installed VirtualBox, set up my Win7 virtual machine, installed Win7*, and I'm good. Well, almost there. The screenshot shows what I have now. My monitor is capable of a 1600x900 display, but Win7 could only offer 4:3 ratios, so what you see there is the biggest I could go and keep it all on the screen when I flip to full-screen mode in VB. My guess is the answer is on the drivers disk from Dell.

Update: no the answer is not on the Driver disks from Dell
Further update: The answer came from a command in VirtualBox. Since the VMs can only see what VB allows, I needed to create display parameters that the VM could see. You do this with VBoxManage:

VBoxManage setextradata WinXP_1 "CustomVideoMode1" "1600x900x32"

after which WinXP can find this display resolution. I made another one for Win7.

BTW, Fedora recognized my 1600x900 monitor and selected that all by itself. It also found my printer as soon as I hooked it up, and set it up -- no searching for a driver, no getting a driver disk. Fedora probably took longer to install, mainly because I typically install a lot of software (all free, of course), including both Gnome and KDE window managers (if you can, why not?)

So the final chapter will come when my Windows XP Pro 64-bit disk arrives in the mail. Why that "dinosaur"? One of the whole points of this purchase is that I need to be able to connect to the hospital and to my office from home (you probably thought this post had nothing to do with medicine). My hospital requires Windows XP and IE6 (yes the dreaded IE6) for connectivity. So that will be the other virtual machine I make on this computer, the one I'll probably use more often.

Soon I'll post about how I've begun using Scribus, my favorite desktop publishing software, in the hospital.

* Incidentally, I did nothing illegal. I looked at the license that came with my disk, and it says that I can install this on the hardware that I purchased with it, and furthermore, there is a specific clause that allows me to install using virtualization on the hardware I purchased.

2010-01-24T12:45:00.003-05:00

Dementia News

The January, 2010 issue of Archives of Neurology has some articles I find of interest.

MCI and Exercise

There were 2 articles on MCI (Mild Cognitive Impairment) and the effects of exercise. The first, from the Puget Sound VA, was a controlled trial of 33 men and women, testing aerobic exercise vs only stretching. Women were more likely to see benefit from this, especially with tests of executive function (more or less products of the frontal lobes).

The second article was a population-based study, in other words, taking a group of people with or without cognitive impairment, then seeing how they may differ, in this case in regard to exercise. Like some other studies, this one too showed that those with better cognition were more likely to carry out some form of moderate exercise on a regular basis. These kinds of studies always have questions about what is the cause of what -- are you more likely to avoid dementia by exercising, or more likely to exercise if you do not have dementia? One has to suspect a bit of both is true.

Does donepezil slow Alzheimer's progression?

Donepezil is the generic name for Aricept, widely used these days, not only in diagnosed Alzheimer's disease, but also by some for MCI, with the idea that it might forestall the development of Alzheimer's. This study used processed MRI images to follow the volume of the hippocampi (structures in the brain that have to do with memory formation) at a 2-year interval. No apparent effect of donepezil was seen, however.

2010-01-20T11:51:00.003-05:00

This is an empty blog except for this notice. I decided to delete all content, and since I didn't save any of it, it is simply gone, unless Google has secretly kept some memory of it somewhere.