On Suicide…..assisted or otherwise

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originalRecall that in England, back in the day, it was technically illegal to commit suicide. Actually the English cared nothing about whether they offed themselves, it just gave them a chance to confiscate their property. This from the guys that shipped the Irish to America because it was cheaper than feeding them during the potato famine and shipped social undesirables to Australia simply to get rid of them.

Taking one’s life in America is not technically illegal, but very, very unfashionable. Any unsuccessful attempt landed the individual in a position of “substituted judgement” where they can land in an emergency department or a psychiatric facility with no civil rights until they “get their mind right”.

https://www.youtube.com/watch?v=8CBqjZX6FjE

Suicidal ideation has been a marker for “incompetence” to understand that “life”is always better than death” (italics mine), and choosing death for whatever reasons is a marker for “involuntary treatment” to get the afflicted person to understand that reality. After treatment, the afflicted person has their mind right and voluntarily chooses life because they have come to understand it’s always preferable.

However, as I mentioned in my previous missives about aging musicians and others choosing death, those rationales are different than endogenous depression. They feel they lived what they wanted to and after the blaze of their streak across the sky extinguishes, they no longer have any desire to live in the new world. That’s a different thing, and we’ll see much more of it as there are a LOT of persons out there (much of it because of the baby boom) that are out of the loop and life in the new loop doesn’t work. That said, many are prosperous in their 70s (Paul McCartney, Neil Young et al). But there are a LOT of their ilk out there that no one hears from till their obit appears.

29906170001_3726240352001_video-still-for-video-3726115417001Now, in the new millennium, a whole different agenda for suicide is appearing, that of terminally ill persons that aren’t quite bad off enough for traditional hospice but definitely suffering with no respite. The classic example that has been brought up is that of Robin Williams, deciding to cope “his way” with progressive Lewy Body Dementia, a particularly cruel, progressive disease that doesn’t spare the victim any misery

https://en.wikipedia.org/wiki/Dementia_with_Lewy_bodies

Again, traditionally, the best course for many is hospice where suffering can be alleviated by a titrated treatment plan. But Hospice is usually thought of as an end stage remedy, when it’s “time to die”. Because of our ability to “prolong life” by a high intensity clinical care program, we’re lengthening the distance between ambulatory, functional suffering and the “death spiral”. As this distance increases, suffering persons want the legal and moral ability to decide when they’ve had enough, and that time may come before the “death spiral”.

More people are now deciding it should be their call as to when to end their suffering, but the nuts & bolts on how to accomplish that goal remain murky. The way out for some of these afflicted is sometimes painful and uncomfortable. Death by hanging or shooting. Robin should not have had to hang himself when he decided his time was up. He should have received “humane” treatment by someone that cared enough about him to respect his wishes and that he was competent to express those wishes.

This will inevitably become a legal issue, the reciprocal of the issue of a woman controlling what goes on within her own body, a firestorm that’s on the way. There are a few States that allow physicians to assist in a suicide and as far as I can see, those plans work well and are not misused. I think it’s time for us as physicians to start looking at this issue through the lens of the new millennium. It’s isn’t our father’s world anymore.

A great many of us are aging reasonably well but the specter of “not so well” is always shadowing us. At age 73 I’m still doing pretty much everything I want to do, albeit a bit more clumsily but I still feel the same passions I felt in my 20s. I’m working pretty hard to maintain my physical strength to match my expectations for as long as I can. But the day will come when I will not function as I desire due to progressive age and God knows what other disease that could grasp me.

When that day comes and I’ve hopefully reached the bottom of my bucket list, I could deal with lying around in a personal care home for a while, photos of glory days on the wall, with a cable TV and a laptop to keep up with what’s happening in the world. If the day came where I was a burden to anyone, was uncomfortable and unable to get around, I have a hidden stash of sixty tabs of 10 mg Propranolol and ninety 10 mg Ambien tabs. I might very well decide when it’s right to exit stage left, and you know me, I’m neurotically maintaining notebooks of virtually everything I’ve ever done in my life so those that come after me will get a chance to know me.

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

                  Dylan Thomas (1952)

David Crippen, MD, FCCM
Professor Emeritus
University of Pittsburgh (Ret)

A political/medical care observation for the New Year

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donald-trumpIt is after all Sunday and this is a bit more of a time for a “Village Green” observation by your FL, for what it might be worth. What I’m about to say involves an obligatory observation on National politics because it impacts what’s happening in medicine today and in the near future. My observations are NOT so much for public debate here as they are simply pointing out facts, as they are readily apparent. Please just reflect on this, not start arguments. Med-Events does that very nicely. If you want to argue about politics, join Events.

A paper came across my desk (enclosed) suggesting that the potential for health care providers’ autonomy is under assault and eventually will all but disappear. I think there are clear reasons for this. The demand for medical care continues to increase but the supply remains relatively static. All kinds of schemes have been developed though the years do decrease the demand (cutting the price). Denying service for pre-existing conditions, “managed care”, “rationing by inconvenience” and yet the cost of health care continues to increase yearly.

The “Affordable Care Act of 2008” (Obamacare) hoped to put a dent in that by spreading the cost out over a very large population, some sick, some well, and of course, “opt-outs” wouldn’t be allowed, as they would eventually turn up in emergency rooms demanding care even though they hadn’t paid the premium. Part of this plan would have been the “public option” to take care of outliers.

There isn’t really much argument that this plan would have worked pretty well, allowing for adjustments, had it been implemented as formulated. Not perfect but a very good start to get people covered for their health care affordably. What happened was a bit unexpected. We didn’t realize at the time that opponents of the President became the “party of no” vociferously obstructing, delaying and destroying everything and anything that came out of that White House. The ACA then became a political issue and was widely advertised by the Party of No as something it wasn’t. Then the Public Option was killed, removing much of the efficiency of the entire program, followed by allowing healthy people to opt out of the program leaving a large population of sick ones.

Of course, as a natural consequence of supply and demand, the price per individual rose, as it would have (and did) for any kind of health care indemnification. Blamed on the program, of course. I had lunch with a very intelligent, perceptive friend (not the only one I have that supports repeal of the ACA) who solemnly advised me that she couldn’t wait to see the ACA repealed because middle class people couldn’t afford it and it was literally bringing the economy down. Never mind that any- and every health care indemnification program in the country was similarly raising their rates, including mine.

Enter the stimulus for all this, the current President-Elect of the USA, Mr. Trump, and his new best friends, ultra-conservative Republicans now in control of congress and soon to be also in control of the Judiciary. Mr. Trump, a very talented and experienced huckster knows nothing about any of it, but his new friends do and they’re now after many years of trying, in place to do damage to health care and a great many other things in our lives.

As is widely observed, the election of Mr. Trump caught virtually every observer by surprise, but not me. They that Pennsylvania is a state with two cities on either end (Pittsburgh & Philadelphia) with Alabama between, and that turned out to be true last Nov 8). I saw it coming as I rode bikes around the rural center of Pennsylvania, spotting Trump signs on virtually every home or business in small towns and country areas. I knew all these people would vote and they intended to “shake up” the establishment that no longer worked for them (not suspecting they had the potential to destroy it).

So now, before the new President-Elect actually takes power, we’re already getting a view of how it’s going to be.

  1. The institution of a Presidential Cabinet full of officers dedicated to untried and unlikely theoretical political ideals, not necessarily the benefit of the population.
  1. The dissolution of a health care system that currently serves about (said to be) twenty million should to one degree of another with the promise of something to replace it someday.
  1. A President-Elect that has publically disputed the opinion of every single individual in every single intelligence and law enforcement office regarding the illegal and intrusive activities of Russia in our political-social system. “The difference between skepticism and disparagement”
  1. As of Friday, the funding of a wall separating the USA from Mexico asked to be funded by congress with a bill to be sent to the other side with no mechanism to collect it. Estimated cost ~ 25 billion $ and estimated by most experts to be worthless.
  1. Active plans to decrease any and all funding for the poor and disadvantaged, active plans to decrease taxes for the well-off, active plans to get more guns on the street and eliminate “Planned Parenthood”, a service that benefits many women.

All this even before January 20.

Now, again, I ask not for argument. The above remarks are above argument, they simply exist and can be substantiated anywhere. It’s just my humble personal observation and it all matters in our health care future, which is why I bring them up.

Our current health care situation is quickly falling apart for at least two reasons (I’ll omit my scathing remarks on what’s going on in medical education).

1. I honestly believe that there is about a 50-50% chance that Mr. Trump’s coalition will collapse completely within 30 days of Jan 20. He has no clue about the delicate realities of global politics and his Cabinet members have no real experience in any other than “business” and that isn’t the way any of it works. Any number of other countries in the world could hurt us more than we could hurt them if they took a mind. Mr. Trump’s coalition fully intends to create a society built on unlikely or untried theoretical political conditions as a practical matter. It is absolutely not out of the question that the fabric of our society could be ripped apart into chaos and very quickly.

It’s already started. An increasing number of Republicans, his own party, have figured out he has no firm foundation for any of his Tweeted opinions, all capricious ramblings of what he happens to think at the moment. They’re making it known they’re re-thinking their support for him. This brings up another potential reality, that Mr. Trump et al will become very quickly bogged down in a system of government meant for- and created for bipartisan cooperation to get things done. If Mr. Trump’s coalition descends into the same kind of stubborn non-participation that has marked the past eight years, then nothing (again) will go forward and our system of government will descend into vicious and bitter fighting, wasting time and money in a very dangerous world. So much for “fixing” broken government. I do NOT see Mr. Trump actually achieving many if any of the advertised platform (such as it was) that elected him.

2. If any of that hat happens, our currently fragile health care provision system will collapse, if for no other reason than our current strategy to cope with administrative rationing will fail with it. Insurance and government strategy is to make reimbursement increasingly complicated so that those unwilling or unable to comply don’t get paid. What we’re doing now is allowing “middle management” and “financial specialists” to deal with the increasing complexities of reimbursement.  There are now an entire hall full of administrators and financial people where a lot of doctors used to be (including me). These guys peck at computers all day long all getting excellent salaries and benefits.

Now, at this point, everyone on this List should download and read every word of the following Time Magazine site (let me know if it doesn’t open for some reason).

http://content.time.com/time/subscriber/article/0,33009,2136864-1,00.html

Pay particular attention to the justifications given for incredibly outrageous charges by an automated service “Chargemaster” for patient caught in the middle- too young for Medicare and too many resources for Medicaid. Both Medicare and Medicaid pay providers only a small fraction of “Chargemaster” bills and they’re accepted. Also pay attention to the salaries for middle managers, CEOs, COOs and the like. You’ll note somewhere in the middle that the CEO of the University of Pittsburgh Medical Center’s salary (before bonuses) was close to 6 million $ per year. The same guy that mandates draconian budget cuts for the clinical departments, including mine every year.

W
e as providers are losing the battle of self-determination. We are losing that battle because we’re handing middle managers and financial officers the authority to order health care in an administrative system that considers us irrelevant. It considers us providers that create demand and they want to limit demand. They formulate policy and let us know how we fit into it, which is why the majority of us are not “hospital employees”. We can be controlled.

This is the state-of-the-art now for providing medical care for our population and I can assure you that if the administration, such as it is, of Mr. Trump collapses, this will all collapse with it. If Mr. Trump’s administration becomes embroiled in an endless fight with everyone creating chaos and stasis, this system will follow suit. If Mr. Trump is successful in killing the ACA, there will be a lot of people left wondering what and when their promises will be kept, even if it could be financed which is unlikely if he spends 25 billion on a useless wall. It took Obama two years to formulate the ACA and it wasn’t perfect. We’ll see what Republicans dedicated to “conservative principles” can come up with and when they can come up with it.

To end this diatribe as I sit here “retired” with a cup of coffee and my trusty iMac, I am very, very fearful for the future of the country, the health care system or the world for that matter and I’m not by nature a terribly pessimistic person. I am now an observer. We’ll all observe in time.

 

 

The Orient Express: Paris to Istanbul. (8/24 – 9/1/2016)

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1.Orient ExpressWife Linda and I took the trip from August 24 – Sept 1, 2016. Some observations for whatever interest anyone on this list of friends might have.
The original “Orient Express” connected the English Channel with the Black Sea in the 1920’s, an era where trains were “the” modes of travel. With its connecting trains, it passed over the railway systems of thirteen different countries of the continent of Europe. Even then, it was expensive travel and those doing so insured that it was a class act. Black tie and female finery for dinner and each car the lap of luxury. The genre was immortalized by Agatha Christie’s “Murder on the Orient Express” (1934) and the film of the same name in 1974.
Automobiles and super highways made it pretty obsolete and the original trains fell into disrepair in numerous train graveyards across Europe, to be resurrected in the 1980’s to their former glory by entrepreneurs. There are several routes now, the centerpiece being the Paris to Istanbul route, 5 days and five nights. The cars are truly opulent now (see photos) and the former glory has been maintained.
First, some observations on some of the characters we met.
Seven middle-aged women that lived on the same block for 33 years somewhere in Connecticut. They got married there, had their kids there and now they’re in their late 50s. They could have been the models for “Desperate Housewives” (2004-2012). There were originally eight of them and they all had vowed to make this trip together at some time in their old age. Then one died unexpectedly and left the money to make the trip to the remaining seven in her will. So the seven went together as a group, did all the activities together. I watched them and saw a veil of sadness within them, an occasional tear.
There was a gaggle of very Arabic women, complete with headdresses. Must have been about ten of them, maybe more and they were pretty much together on some of the end cars. One of them stood out from the rest. Some of the guys called her the Queen Bee. She had a different kind of hair-containing appliance, exposing her neck and face. She was tall, had the cheekbones and complexion of a drop-dead beauty (see photo).
So when we got into a hotel and some WiFi we “think” we found her. Best evidence is she’s “Her Highness Sheikha Mozah bint Nasser Al Missned” the second wife of the former ruling Emir of Qatar. He has three wives. My guess is that none of them assemble in the same room at the same time but they manage some contact as the Emir as 24 children, six by this woman. He appears to be retired since 2013.
She’s incredibly well educated and has had her fingers in many world social, political and cultural pies. Said to be one of the best-dressed women in the world. She’s been seen hanging out with numerous world leaders. They all stayed to themselves and I suspect some of them were bodyguards. My wife ended up tangling with one of them after wandering around getting told that one of the bathrooms was “private”. Wrong thing to tell a woman that (she opined loudly) has been thrown out of worse places by better people. Snake eyes all around.
This lady apparently got the train in trouble when we tried to pass into Turkey. The Turks are famously neurotic about who gets into their country and demanded to eyeball each and every passenger and their travel documents including mandatory visas. A weak variation on the theme of “Midnight Express” (1978). According to our porter, the train was held up for a while as the Turks decided how much they liked the former Emir’s politics, but since he was no longer in power, they relented and we ultimately went on our way.
So, what was the experience like?
First of all, it was expensive, very expensive and the adventure we had anticipated wasn’t quite what we got. This was billed as a nostalgic trip back in time to experience what it was like to make this trip the way it was in 1920. To a certain extent, it was that, but with some caveats.
The temperature on arrival in Paris was 95 degrees F and it stayed that way for most of the trip but the train was beautiful. The modules are tiny, barely room to sit and the heat was oppressive, including in the evening. Luggage must fit on an overhead rack like on aircraft. A cabinet opens for a washbasin and mirror. There are no shower or bath facilities. No WiFi. There is no air conditioning except in the bar car and the dining cars. Open window suffices. Every other day we were all shuttled to five star hotels in various Eastern European cities for showers and to get away from the tiny train accommodation.
Dinner was black tie and females gussied up to the max, including lots of bling. Food was world class excellent, with a named chef in residence on the train, the kitchen running 24/7 to feed a hundred passengers. He came out every night and accepted lots of praise. French, of course.
Two adults getting dressed for dinner in such a tiny space is fraught with unintended humor and physically exhausting, each literally reaching around the other. During the day there was not much to do but gawk out the window at the rarely changing landscape. At night, after dinner, the porter converted out tiny module for sleeping, two fold out trays about 6 feet long and maybe 2.5 feet wide. It was so hot that the window had to be open and it was VERY noisy thought the night, bright lights and trains proceeding the opposite direction 6 feet away at over 100 mph about every half hour. It sounded like a full-on Guns ‘n Roses concert all night long.
The highlights of the trip were dinner and the every-other-night hotel to get a shower and sleep in a real bed quietly. Yes, it was an adventure but one I’m pretty happy not to repeat. It’s a been-there-done-that trip with lots of photos to remember it by. Happy to have had the opportunity to do it, but much more of the world to see.
If you’re interested in this trip look deeply into it and talk to me before deciding. Maybe I’ll comment on our wondering around Paris and especially one of my top five favorite cities in the world, Istanbul. A city no one should die before visiting. Maybe next Sunday. I have a ton of photos.
I give the trip 3 of 5 clickity-clacks for the overall noise and discomfort experience, definitely 4 of 5 for the adventure quotient.

Orient Express Paris to Istanbul

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Orient Express 1Wife and I have not taken a real “vacation” since we were in Nepal in 1983. I figured time to celebrate her burgeoning career as chief nurse anesthetist at one of the UPMC hospitals, basically the boss, running the operating rooms. A big, tough job. Then sort of making note of my semi-retirement, cut back to teaching only. More time on my hands.

We’re taking the reconstituted Orient Express train from Paris to Istanbul. 36 sleeper, restaurant and Pullman cars, the styles originating from the 1920s. The original Orient Express ran from 1983 through 1977. At it’s peak, it was the lap of luxury and really the only way to get anywhere quickly in Europe in the late 1800s. It’s a six-day trip, Travel through seven countries with day/overnight stays in Budapest and Bucharest.

The Orient Express name became synonymous with old-world luxury train travel – as well as with international glamour and intrigue, culminating in the film “Murder on the Orient Express”, that’s a classic.

http://www.imdb.com/title/tt0071877/

This is a much bigger deal than I realized when I signed up. There IS a strict dress code, something I have eschewed in the past. No jeans, t-shirts, tennis shoes. All clothing must be “smart business attire”. That means “slacks” and shirts with collars. I own nothing like that. Dinner at the hotel stops, gentlemen will wear jacket & tie. Dinner aboard the train will be “black tie” for gentlemen and appropriate female attire (long dresses), sending me out to rent a Tux and my wife out to purchase female finery, including “heels”, none of which she owns.

Why this trip?

Some of you might remember a film a while back, “Somewhere in Time” (1980)

http://www.imdb.com/title/tt0081534/

Christopher Reeves becomes obsessed with a portrait on the wall of a woman from the early 1900s and desires to go back there for her so desperately that he is able to accomplish that goal by dressing in impeccable 1900s garb and self hypnotizing himself physically into that era. They fall in love and plan a life. But (no spoilers) this is not his time and there are ripples in that time that unpredictably and suddenly return him to his correct time. He sinks into a deep depression, sits in place at his original departure place and dies of starvations, whereupon his young woman greets him and they are re-united. It’s a really, really interesting film.

I have no plans to follow Christopher. I do, however, have an interest in returning to sites where I existed much earlier in my life to feel any faint vibrations of that time. I returned to Vietnam over 40 years on to feel those vibrations and I wrote a book about it. Much of it was disappointing. I return to various homes and places where I have lived and sit for a while just looking at them, feeling what I can of the past. I got off my bike and sat in the middle of a Route 66 leg in New Mexico for a while feeling the faint vibrations of my childhood and my father riding on that road in the 50s.

I do feel the vibrations of my past in some of these places and I savor that. They were “better” times for me. I would go back if it were possible to accomplish it Chris Reeves-style. I would build another full life there, then I would hide paintings and photos of me living my life again and dying there for any of you to find behind some boards in the attic as my house is eventually torn down to make way for progress.

I think the train is a throwback to the past that a lot of those on it want to return to. The trip is done exactly as it did in the late 1800s, no WiFi, no TV or other modern amenities. I guess it’s the kind of throwback I like to think about.

 

Film review: “Everest” (2015)

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1280x720--njFascinating film loosely based on the disaster occurring on Everest in 1996 in which 8 climbers died in a freak storm. Several books were written about it. Jon Krakauer’s version is considered to be a masterpiece on life and death at high altitude and is mandatory general education reading.

http://www.amazon.com/Into-Thin-Air-Death-Everest/dp/B00005B1WA

The plot involves the trek of two coincident expeditions, costing each climber US$65,000 to attempt the feat with no guarantee of success. However, because of pressure to succeed, both trek leaders Rob Hall (New Zealand) and Scott Fischer (USA) bend their own safety rules to accept more risk in hopes of making the summit. Both sets of climbers actually reach the summit but there is a delay in descending, allowing a sudden vicious storm to move in, wiping out 8 climbers including Fischer and Hall, both of whose bodies have never been recovered from the mountain. There are said to be over 150 bodies scattered around the mountain today.

The real saga, however, consists of the story of Dr. Beck Weathers from Dallas, Texas who, left for dead on several different occasions, manages to find the strength to descend the mountain in perilous condition. He describes in detail how it felt to be dead and for what reason he felt the desultory need to move on anyway. When he finally stumbled into a lower camp, they set him in a corner of a tent to finish the dying process. But he’s alive today and his book is fascinating for his descriptions of very existential concepts involving death and survival:

http://www.amazon.com/Left-Dead-Journey-Home-Everest/dp/0440237084

The cinematography is stunning and greatly enhanced by the new 3-D process that gives splendid depth to the visual effects. Of course, the effects are a little too good, suggesting the liberal use of Computer Graphics Interface (CGI). Most of the mountain scenes were filmed on the Tyrol in the Italian Alps for safety and cost-effective ergonomics. Some scenes were filmed on Everest but in the lower altitudes. Many panoramic shots of the mountain were superimposed with actors via computer effects, especially the high altitude scenes.

“Everest” is a very tense experience, but in the end the tension dissolves into sadness amid tearful goodbyes, violent storms and frozen corpses.

I give it five of five icy eyebrows. Highly recommended by me. Warning: the ending is a four-hankie weeper.

Addendum: I can offer some perspective on this film because I was on Everest in the spring of 1983.

I came upon a private group that wanted to go to Nepal to do some serious peak ice and snow climbing with all the accouterments. So after some discussion, they agreed to take my wife and I even though we didn’t have much practical experience. They said we could learn on the job and they would look after us. I studied up on high altitude issues and brought a supply of Diamox and IV solumedrol, antibiotics, decongestants and other things.

After some acclimatization time doing lesser peaks, we crossed the Khumbu Glacier uneventfully complete with all the scary cracking of the ice. We reached Everest Base Camp at around 18,000 feet and decided to go ahead and climb up the col to South Face Base Camp I at about 20,000 feet just to see it. It was pretty arduous.

There was no point in climbing up to Base Camp II at 21,3000 feet. The route to the summit begins there. It was really more of the same and we would have to spend more time coming back. These camps are nestled between steep ridges on both sides to the only way out is the way you came in.

The Base Camp and Base Camp 1 are famously filthy dumps, with abandoned oxygen bottles and other detritus laying everywhere. It looks like a junkyard with hundreds of climbers in season milling around waiting to go their way in whatever trail. At times in the past there has actually been a “traffic jam” of climbers trying to get to the various bases. Many of the would-be summiteers were famously inexperienced as were their guides, setting situations up for disasters in the “Death Zone” (over 26,000 feet) where many of the physical laws of God and man are suspended.

We swung around to the Southeast back over the Khumbu to the other peaks in the Nuptse vicinity. It was all ice climbing with crampons and ice axes, attached to each other via ropes through pulleys.

As we climbed, I progressively felt the effects of altitude. Over 21,000 feet or so, every step was a superhuman effort and required stopping to catch your breath such as it was.  Much of this for me meant no sleep. Every time I’d doze off I started hyperventilating and work up with a start. I also developed a very irritating persistent dry cough said to be common at high altitude. Acetazolamide helped somewhat until we got over 20,000 feet. I was pretty much sleepless the rest of the time.

Some of the things I saw were so spectacular I can close my eyes and see them now and I took a lot of photos but to be truthful, I have no interest in ever doing it again. It was a good thing to do at my then age, but it was definitely a one-time thing. For the life of me, I cannot remember the formal names of any of the peaks we climbed, if they even had one.

* A YouTube montage of other photos I took in the area. This montage is high-def and so you can open it up to full screen. (60’s-era Nikon FTn).

https://youtu.be/9ujmSnanEfI

 

The Blue Ridge Parkway

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blueridgeparkway07One of the most easily assessed and spectacular field trips in the country isn’t too far from here. The Blue Ridge Parkway, America’s longest National Park, meanders from Virginia to North Carolina, a distance of almost 500 miles. The pre-start of the ride begins in Front Royal, Virginia and is named the “Skyline Drive” down as far as the Waynesboro area, 109 miles where it turns into the BRP from then on. The Skyline Drive isn’t all that great but it’s the most direct lead-in to the BRP so it’s just as well you start there.

The “real” BRP connects Shenandoah National Park with Great Smoky Mountains National Park. It begins at Rockfish Gap near Waynesboro. You can easily do the entire length of the BRP and get home in about a week. It usually takes three days to traverse the entire length because you can’t go very fast. There are several lodges actually on the BRP road and they are about equidistant from each other and you can easily get off and back on for food and lodging along the entire route.

http://www.nps.gov/blri/planyourvisit/upload/BLRImap1-1.pdf

By history, the construction of the BRP began as part of Franklin D. Roosevelt’s “New Deal”. Work began in 1935. The Works Progress Administration, the Emergency Relief Administration and Civilian Conservation Corps camps performed most of the work. During World War II, conscientious objectors were pressed into this construction. The parkway took over 52 years to complete, the last portion opening in 1987. 2015 marks the 150th year anniversary of the last Civil War shot fired east of the Mississippi near present-day Waynesville, NC.

The BRP is considered by many to be the gold standard of American touring trips. Many bikers and sports car clubs congregate to run all or part of the BRP. Most of the road consists of what bikers like to call “twisties”, tight corners and switchbacks in heavily forested areas with very little if any traffic. The elevation also varies dramatically from lower areas to over 6000 feet, changing the weather patterns from warm to downright chilly. The BRP is amenable for family sedans and SUVs, but of course not nearly as enjoyable as in a small open-air vehicle.

The traditional pinnacle of bikers’ rides, further west where Tennessee meets North Carolina is the “Tail of the Dragon”, an 11-mile stretch of US 129, an incredibly twisty road sporting 318 tight hairpin corners. However, the Tail has become overcrowded, especially with novices riding it much too fast and getting hurt pretty regularly.

If you follow the BRP on the map down to it’s near end where it makes a right turn toward Cherokee land, you’ll see a little town called Waynesville, NC. In that area, the crème de la crème of spectacular and sometimes challenging tours occur. Rides in this area are named and mostly bikers come from all over the world to access them. The “Moonshiner 28”, “Devils Triangle”, “Diamondback 226”, “Six Gap North Georgia”, “The Rattler” and the “Copperhead” to name a few. These roads were built long before Interstates and surveyors were forced to build them around the mountainous conditions with many twists and turns around obstacles. There is virtually no traffic on any of them anymore except sports car clubs and bikers.

http://www.motorcycleroads.com/75/1335/North-Carolina/The-Copperhead-Loop.html

I’ve been riding these areas for over ten years and I know all of it by heart. Last week was a time slot with nothing much to do and the weather was good so I decided to do it all again. I also decided to just ride down there on my venerable BMW R1150GS, the Rock of Gibraltar on two wheels, because having to deal with a trailer on several motel overnights would be a time wasting problem.

From my house to Waynesville, NC is about 560 miles. This is the area of all the fabulous rides so I decided to forego doing the entire BRP again as I’ve done it stem to stern in the past and didn’t have the time this trip. So I rode the Interstates to the area of interest and did it all in four days. I did do parts of the BRP in North Carolina this trip. On the return trip, I was weary of motels and so decided to ride it straight, 560 miles in about 11 hours. I wasn’t sure I could do it and so had the option of stopping along the Interstate anytime, but I did OK.

I’m now wondering if maybe I might try the “Saddle

sore 1000” put on by the Iron Butt Society (1000 miles in 24 hours). Would be cool to have the “World’s Toughest Motorcycle Riders” badge on the back of my Beemer. If you recall, former Chief CCM Fellow Erik Diringer did this ride successfully a few years ago but I was engaged elsewhere at the time and I couldn’t try it with him. At any rate, here are the photos of the trip, giving you some idea of the beauty of the area. Even along the Interstate. You’ll notice one photo with a red arrow. This is one I didn’t quite get showing two huge Confederate Flags on the porch of a home. Enjoy if you have an interest:

Bike trip to Tune town

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Dells 1Somewhere on my bucket list was a trip back to Wisconsin Dells (Wisconsin), a shameless tourist trap drawing thousands of visitors to a town normally (in winter) housing only 2800 souls). Water slides, roller coasters, various carnival-type attractions over literally square miles now.

The original Dells tourist area was created for boat trips to see the limestone rock formations along the Wisconsin River. Then Tommy Bartlett created a big water ski show. An entrepreneur acquired an army surplus DUKW (an amphibious truck commonly called a “duck”) and opened a scenic duck ride to see the accumulating sights and the theme park followed.

My pal Gil Ross hit the description of rounding the bend into the Dells area perfectly. It’s like entering “Tune Town” (Who Framed Roger Rabbit, 1988)

Summer of 1964, my family had moved to Georgia and I was more or less on my way down there by car from our previous home in Menomonie, Wisconsin. As I passed through the Dells area, I ran into a friend from Menomonie who was working as a waiter somewhere and he talked me into staying. I found a room to stay cheaply and looked for work. Everything I owned was packed into my MG Midget.

First job was stuffing windshield wipers with Tommy Bartlett Waterski Show ads. 12 hours a day, seven days a week for 80 cents an hour. They supplied the old beat up junk car and I was expected to be in constant motion all day long. Every once in a while I noticed someone from the Bartlett show driving around checking on me. That lasted one day.

I then found a much better job at Paul Bunyan’s Logging Camp Restaurant as a table bus boy, clearing dinner tables. 90 cents an hour 14 hour days but one day off and all the food I could eat. This was a great deal.

http://www.paulbunyans.com

College kids from all over the State descended on The Dells to work the various attractions, all for thinly veiled child labor conditions, but in the immortal words of ZZ Top, “they gotta lot of nice girls there…..”, and they did. The social life was pretty much full time. No one slept much. I met and went out with a lot of girls, taking one to nearby Madison to see a Beach Boys live concert (their white pants, striped shirts era) with Brian Wilson singing and playing bass. The show opened by the Kingsmen (“Louie…Louie”).

Took another one down to see the opening of the Beatles “A Hard Day’s Night” from which I emerged with a hearing deficit. Young girls screamed at the top of their lungs the entire show, could not hear one word of spoken dialog. Took another to the Museum of Science and Industry in Chicago to see the “Visible Woman” exhibit. A woman sliced vertically from tip of scalp to thigh and encased in glass both sides. All organs in position and visible. As far as I know it’s still there.

It was a good time and I look back on it as a very good part of my young life at age 21, before the next shoe dropped and I found out about responsibility. Going back there has always been on my bucket list but it’s at least 700 miles from me and I never got around to it till now.

Because of another trip postponement, I found myself with a full week with nothing at all to do other than hang around the house, so I figured this would be a good time to make a long distance bike ride of it. I’d much rather be on the road on a bike than a car so it seemed like a good trip. Part of that was to see how I would do considering I still have some residual weakness here and there from a flare-up of Guillain-Barre. I would make an attempt with the option of stopping or turning back if I got into trouble. I might get ten miles, 100 miles or make the whole trip. Unknown quantity.

As it turned out, I made the trip with minimal difficulty. I did note some weakness difficulties in my back, shoulders and upper arms but none enough to be a significant problem. My left hip continues to be a bit weak but quite stable on the bike seat so it never gave me a significant problem.

On arrival in the Dells, I found it to be much, much bigger and noisier than it was when I was there. In my day there was one thoroughfare, now there are several four-lane highways traversing the area. LOTS of water slides, roller coasters and theme parks now. Lots of shops and traffic.

Paul Bunyan is still there with the big statue of him and Babe the blue ox. The place is now about three times bigger than it was when I was there. Now ensconced in a maze of other attractions. In my day, it was pretty much stand-alone by itself at one end of town. Entering, one walks thorough a huge curio and tourist memento area before getting into the actual dining area.

My waitress dressed in logging attire asked if I had been to Paul Bunyan before so I sang the saga of the busboy experience in the summer of 1964 in five-part harmony. She and I talked for a while. The waitresses make $3.00 an hour plus tips and they still have to share part of their tips with the bus-boys, without whom they would not have table turn-around. When I was there, some of them tried to stiff the bus boys, who soon figured it out and cut back turning their tables. She was a sophomore at the University of Wisconsin and, yes, the social life there was still to die for.

The cuisine, such as it was, is still about the same, all you can eat of such staples as chicken and beef. The food was barely edible, but for tourist trap food it was fairly cheap to feed a family. I sat around and soaked up the memories for a while, rode around the area briefly, and then headed out for home.

The entire trip from stem to stern ran four days, 1500 miles averaging nearly 400 miles a day, three overnights along the way. So I marked off #379 on my bucket list. #378 coming up.

 

Dells 3

 

 

 

 

 

Dells 4

40th anniversary of Vietnam reunification.

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Stuff you never heard of and had little interest in 😉

saigon-tankThis date (April 30, 1975) marks the 40th anniversary of the day North Vietnamese tanks rumbled through the streets of Saigon and broke through the fence at the Presidential Palace to formally re-unify North and South Vietnam. Today, this action is called Reunification Day (Ngày Thống nhất) and is a public holiday in Vietnam.

https://www.dailyherald.com/article/20150429/news/150428483/

This action signaled the bitter end of the “Vietnam War” (technically more of a “conflict”), known in Vietnamese as Kháng chiến chống Mỹ (“Resistance War Against America”). It was the start of the transition period beginning July 2, 1976, when the Provisional Revolutionary Government of the Republic of South Vietnam and North Vietnam merged to form the modern-day Socialist Republic of Vietnam.

I bring this date up for two reasons. First, because I would like you to think just a little about Vietnam. It was one of the most important events in modern history, in many ways shaping the new millennium. But the Vietnam Conflict is quickly headed for obscurity if for no other reason than the exigency of our current nonsense conflict in Afghanistan. A war that can never be won by anyone, as the Russians previously proved in the 80s.

Secondly, I want to passionately recommend to everyone in earshot to find and view a new documentary by Rory Kennedy (Robert F’s daughter): “Last Days in Vietnam”. This documentary can be viewed on the PBS channel intermittently and also free on some of the PBS websites. It can be watched free on several sites:

http://www.pbs.org/wgbh/americanexperience/films/lastdays/player/

It can be easily downloaded off iTunes as well.

This is a very objective and important documentary because it vividly portrays the human aftermath of extremely bad political decisions. It is painful to watch but necessary to give a perspective to the human suffering that occurs following imperious political policy. The bad decisions of the French resulted in 1,726 killed in action and 1694 missing in action in about 6 months at Dien Bein Phu. The Russians were unceremoniously thrown out of Afghanistan after 13,310 soldiers had been killed, 35,478 wounded. Those lessons should have been heeded.

I went back to Vietnam in 2011 after 43 years and I have some profound reflections on things pertaining to it. Vietnam has changed so radically and yet has so stayed the same. In 1968, the entire country was a big American military base. Many troopers never saw any of the cities or the rest of the country. Ankhe City didn’t exist. Camp Radcliff dwarfed the entire region. Same for Camp Holloway In Pleiku, Camp Eagle in Phu Bai and endless others.

In 2011, I saw the real country for the first time without the Army green and camouflage that had obliterated every landscape. Therefore, that trip was much more of a simple tourist effort than a trip back in time. Many in my present reality were not alive in 1968. Coming back to that place was a much emptier experience than I had previously anticipated.

Most or all of the areas where I Iived my life are no longer recognizable. I felt no particular clarification or verification of any of my life as a result of going back to the past. Whatever I might have been seeking has eluded me. Thomas Wolff was right on more accounts than one; you can’t go home again and you can’t go back in time to re-live either. Trust me, I have tried.

Perhaps I yearn for a “Somewhere in time” where Chris Reeves desires to go back so intensely and approximates himself into a time warp so accurately it actually happens and he is given another chance at another path to take. But alas, in the end it might be possible to have it transiently, but the coin always lurks that brings it all tumbling down.

And so we come back to the clearing at the end of our road and make what we can of it.

“Goodbye to all my friends at home
Goodbye to people I’ve trusted
I’ve got to go out and make my way
I might get rich you know I might get busted
But my heart keeps calling me backwards
As I get on the 707
Ridin’ high I got tears in my eyes
You know you got to go through hell
Before you get to heaven”

Steve Miller Band (1977)

Some acerbic notes on the new generation of physicians

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“My impression is that the older ones found work-life integration while the younger ones are focused on work-life balance. There’s not a lot of balance when up at 3 am with a sick patient or 5. And the a common refrain is “I don’t want to work weekends “

Crippen: When I was a medical student on clinical rotations in the early 70s, I was expected to be the first to arrive and the last to leave. I “took” patients and was responsible to the resident for reporting on morning rounds everything going on. I did procedures under guidance and I got chewed out or my ass kicked when I didn’t perform up to expectations. I was expected to have no other obligations during that rotation and it NEVER crossed my mind to complain that I was overworked. Had I done so, that revelation would have been greeted with dropped jaw astonishment and an admonition to get with the program or take my mangy ass elsewhere.

When I was a resident at Bellevue, there were about 100 patients on the general surgery service and ten in the surgical ICU. There were two first year residents on the service and every-other-night call. Do the math. Similarly, there was no excuse for not getting the work load done. One learned to prioritize to get the important stuff done and suck up the hassles on the rest. Complaints of overwork were nonexistent. Not conceived of.

And yes, I did walk to work 20 miles one way on crutches in waist deep snow fighting off alligators and snakes along the entire course.

Then in the new millennium, Libby Zion came along and the path of least resistance led to the proposition that residents were overworked and too sleepy to function so they had to be given a break. That evolved to a situation where medical students and residents became entitled. No more of this “service” stuff, it has to be all book learning education. Complaints of “I’m overworked” are forwarded to the RRC (Residency something Committee) a body that immediately investigates all such complaints and the burden is on the teaching program that they’re not overburdening the poor babies with a work load that they can’t handle. As a result, that work load gets smaller every year.

This is an honest to God true anecdote told to me by the Chair of one of our clinical departments here. He was teaching a session for medical students on some subject he felt was important and after a while one of the students raised her hand. She told him maybe he had spent enough time on this subject and maybe he should move on. Astonished, he told her he wasn’t finished yet, whereupon she picked up her books and walked out.

Medical Emergency Teams (MET) appear in at least some, not all, data to be doing a good job in interdicting acute deterioration episodes for hospital inpatients. As they evolve, however, the propensity for nurses to call for the MET instead of the responsible resident evolves with it, for a number of complex reasons. Then the responsible resident stands at the back of a crowd of people watching as their patient is taken care of by someone else. The issue as far as the hospital is concerned is that patient safety trumps medical education, and that may be. But in the immortal words of Bill Gates:

“We always overestimate the change that will occur in the next two years and underestimate the change that will occur in the next ten”

And that’s exactly what’s happening with medical education. We’ve entered a realm where the “education” portion has exceeded the “experience” portion. We’re teaching them all the contents of the Textbook of Medicine and then sending them out into a world where the translation of education into experience is required to survive, and it isn’t there. They were standing in the back of the crowd that day, and every day they survive the mix is a day that their minuscule experience base fails them. To be exceeded only by the next wave of graduates.

Similarly, critical care fellows have complained about night and weekends now for the 28 years I have been involved with the UPMC system and they are following the lead of the rest of them. When I was a fellow in 1986, I was on call every third night and every other night when someone one went on vacation or got sick. Now the fellows are on call one night a week and the night calls are progressively being taken over by Certified Nurse Practitioners and Physicians Assistants. The fellows want to think of themselves as executives now, in a teaching and mentoring mode for the night and weekend crews. How they are getting that knowledge base now is with books and simulators.

I hasten to add that there is nothing intrinsically wrong with the CRNP and PA mode of direct patient call after hours. I have some in the NICU and they are REALLY great in every respect. They do EXCELLENT patient care and they know when to call for the executive modulators, which consist of the Resource Intensivists covering the house at night.

The problem with this model is that since every critical care fellow has the same training as most other residents in their specialty, they are at risk for the same dumbing-down (not always). As the syndrome as Med Student/resident Entitlement continues, will the fellows not bear fruit from the poisoned tree? Unclear at this point. We shall see.

There has been a lot of hand wringing about the poor overworked physician trainees that I am not particularly impressed with. I went through all that and not only did I survive, it made me a provider that is never surprised at ANY clinical situation because I’ve seen them all, and there aren’t many physicians that have had a fuller personal life than me (trust me on this).

Hand wringers lament that overwork and overstress creates drop outs, landing in psychiatrists office, going through ten divorces or killing themselves from what amounts to PTSD related disorders. Sorry, I can’t fix those that sink into PTSD. I wish there was a better way to sort those with a tendency for PTSD out before they get into medical school (unlikely as long as grades move all). I went through all that in Vietnam and I just worked it out and went on. I know Viet vets that thrived on it and wish they could go back and do more of it. PTSD is just luck of the draw.

I don’t know what the fix is for PTSD. I think arbitrarily decreasing work loads may solve some of it but invokes the Great Principle of Unintended Consequences (GPUC), we’re seeing it now and we will continue to see it in the future. Well rested physicians aren’t necessarily the ones you want to look up and see during a disaster in the middle of the night. But then at the rate things are going, no one may ever see one after 5 pm anyway.

I am the last of my kind.

Some comments on the Veterans Hospital situation in May, 2014

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I have a book somewhere in my library written in the late 70s that details how Vietnam vets got the same treatment as those complaining now at a New York Va. The problem was identical. That facility, however, had a huge number of injured and sick vets referred them from all over the area. They simply rationed so that no population of vets got more than others. They all got the same and there wasn’t enough for anyone.

I prefer not to think that these people are intentionally stiffing vets, although the woman head of the Phoenix VA is now showing signs that she did all this to “look efficient” to her bosses so she could climb the career ladder faster. I think they figured out ways to ration care and hide it from the media (for a while).

I “think” the problem is an overwhelming mass of returning vets with a ton of medical problems and a limited amount of resource to deal with them. There are more doctors than Carters has Liver Pills all over Iraq and certainly Afghanistan. None of these doctors can do much definitive care there but they can “patch up” and send them back to the USA alive but with disastrous issues they would have ordinarily died from. Then they require a ton of expensive care that isn’t available in the system.

This is especially true for neurosurgical injury. If a soldier got a serious neurosurgical injury in Vietnam they died. In fact, if s soldier got an injury that a paramedic couldn’t fix at the scene he still had a pretty good chance of dying. Now they get patched up by doctors at up-front field facilities and sent back to the USA for a lifetime of expensive care and many remain non-functional, requiring some form of welfare support. All this is incredibly expensive and the funds were never available.

Most of the Vietnam vets were sent back with relatively inexpensive health care issues and there was enough resources in the VA system to cover them. When I was a resident in both Indianapolis and New York City, I trained at the VA hospitals in both those cities and I was never impressed that their resources were stretched. I thought patients there got pretty good care and very good training of doctors. Now they’re coming back requiring a LOT of chronic care for injuries that should have killed them and the system is dramatically overloaded.  So what do you do when you have resources for 100 soldiers a week and you have 1000 pushing at the gate to get in?

The answer in a perfect world is you prioritize in some way so those requiring the more acute care get it first and the rest stand in line till their number comes up. But watch the “Wounded Warrior” commercials on TV. They’re all acute and they all need more expensive technical care, ICUs, neuro care, extensive rehab for blown off limbs.

In this country, allowing one group to cut in line on the basis of anything will get vociferous complaints of favoritism and discrimination. So I have little doubt that the VA simply found ways to thin out the demand for services by backing them all up into a barrel and turning the spigot open to allow a defined number of them into the system that could deal as effectively as possible. The rest just backed up waiting their turn. There are lots of ways to do that. What they did in Phoenix is one. Then the media got hold of it and the resulting feeding frenzy didn’t point out the fundamental problem of too many injured soldiers trying to get too few resources. It pointed out incompetence and stupidity which is much better copy.

So how to fix the fundamental problem.

As long as we’re resuscitating otherwise mortal injury in Afghanistan, we will continue to deal with them inadequately in the overheated VA system. Now that the toothpaste is out of the tube in the media, it won’t go away. We have several choices.

1.  Pour a ton of money into the VA system creating a “separate but equal” care system for acute injury and rehab.

2.  Close the VA system for acute injury and spread these patients out through the nearly overheated public health care system and pay for that care via a separate reimbursement provision that the military has in place anyway for veterans who for some reason cannot access a veterans facility.

I “think” that #2 is the logical way to deal with these patients most effectively. The VA system clearly cannot deal with them at all, much less effectively. It would cost a lot more to bring the VA system up to speed than to adjust the “private” system. At any rate, we better do something soon because there are a lot of soldiers out there who deserve better.