Monday, August 29, 2016
BEING MORTAL by Atul Gawande Metropolitan Books
Dr. Atul Gawande is a surgeon and professor at Harvard Medical school. Both his parents were doctors and immigrants from India. He has written extensively on improving American medical practice, and this latest of his books, published in 2014, addresses the need for more intelligent care of the very old.
For most of human history, people who reached old age were cared for by their children or grandchildren. For those who had no family, there was, in the 1800's, the “Poorhouse”, which provided bare existence.
Two new developments came in the early twentieth century: (1) The Great Depression, that in USA prompted the creation of the Social Security Act in 1935, and allowed workers to accumulate funds for retirement. (2) The on-going progress in medical education gave doctors and hospitals the tools to prolong life – antibiotics, surgical procedures, better nursing care, etc.
We doctors were taught that death is the enemy, and longer life the victory. How to live that longer life was not part of medical school curriculum. With the illness or injury successfully dealt with, the patient gets discharged from the hospital with a brief list of instructions.
More and more, however, the healed one lives long enough to encounter lasting disabilities that the family is not equipped to handle: arthritis perhaps, or a “weak heart”, or failing memory. Not something that required returning to the hospital, but more than could be treated at home.
Thus came extended care in a “nursing home”, giving the patient time to convalesce, or perhaps get physiotherapy exercises. Those not able to recover (in the doctor's judgment) stayed on and on as permanent residents. Avoiding bedsores and maintaining the resident's weight and safety are worthy goals but the daily routine is usually run like an institution, not like the home the resident had left behind. Independence, privacy, and personal goals are mostly ignored.
“This simple but profound service,” writes Gawande, “--to grasp a fading person's need for everyday comforts, for companionship, for help achieving modest aims—is the thing that is still so devastatingly lacking almost a century later.” Around 1990, a company called Assisted Living Concepts went public and proved so popular that by the year 2000 its number of employees had grown from less than 100 to 3000, operating 184 residences in eighteen states. So popular that developers called almost anything “assisted living”, watered down versions with fewer services. Assisted Living has come to now mean a step between independent living and full nursing home care, with staff efficiency the key theme.
Bill Thomas, an upstate New York family doctor summarized the atmosphere of his town's nursing home as “boredom, loneliness, and helplessness.” He set about to bring in some life.” Green plants in every room. Bring in some animals – two dogs. “New York state code allows only one” his Board said. “And two cats on each floor,” he went on. (“The code won't allow both dogs and cats” said the administrator.)
“Let's just write them down. For discussion. Now about birds. Start with a hundred—at least one per room. Birdsong is the sound of life!”
“ARE YOU OUT OF YOUR MIND!” But the administrator didn't actually say no. With paperwork in hand, Dr. Thomas drove to Albany to lobby the State Board personally. He came away with a permit, waivers, and a small financial grant for this experiment.
A truck delivered 100 parakeets. No cages had arrived, so the delivery man put them in the nursing home's hair salon. 100 cages arrived that afternoon, but needed assembling. The staff spent hours chasing the parakeets through a cloud of feathers. Many residents took amused interest in watching through the windows as the staff struggled. “They laughed their butts off,” Dr. Thomas recalls. But having living creatures to care for brought new life to many of the oldsters. So did an after-school program welcoming children of staff to hang out and spend time getting acquainted with individual residents. Things were becoming more like home. And in the long run, the patients required fewer medicines, and fewer surgical operations
That's the main theme of Dr. Gawande's book. What does the eighty or ninety-year-old want to achieve in his/her limited remaining years? In taking the time to discuss this with his patients, he found that even those with Alzheimer's dementia still have goals. Not all the same goals, but each has his own. “I want to live as long as I can still eat chocolate ice cream and watch football on TV,” said one.
A piano teacher had fought cancer for months, only to have complications of her surgery and chemo bring her closer to her end days. Some at that point might have accepted “death with dignity”. She chose hospice care instead. In her remaining six weeks, she taught the piano students she loved for four weeks. And her old time students from around the country returned to play a concert for their beloved teacher.
In summary, Dr. Gawande does not require huge new government programs. Rather he advises doctors, nurses, administrators—and old folks' children--to pay attention, listen, and allow each person to write the end of their own personal story.
Saturday, August 13, 2016
In real life, author Dick Francis had a long career as a jockey on the race tracks of Britain, and wrote more than thirty-five mystery novels about horse-racing. This one, “The Edge”, is my favorite:
Brigadier Val Catto is chief of security at the Jockey Club, charged with keeping British horse racing honest. His staff had built up a tight case against a crooked operator, one Julius Filmer, only to have the case dismissed when one witness was murdered and the other four were terrorized into “forgetting” their testimony. One of Catto's agents, Tor Kelsey, has been tailing Filmer's suspected “enforcer” only to see the man drop dead of apparently natural causes.
Now Catto has received a phone call from his Canadian counterpart, about the upcoming “Transcontinental Mystery Race Train” to publicize Canada's race tracks. The train will take Canadian race horse owners and fans on a 10-day excursion from Toronto to Winnipeg to Vancouver. Filmer has just registered as a participant. He is widely known for his temper, his violence and unpredictable ways, and the Canadian Racing Commissioner wants help in preventing any criminal activity that Filmer may be planning.
Catto assigns Tor Kelsey to go to Canada to shadow Filmer on the excursion train, see who he contacts and what he is up to. Kelsey is expert in changing his appearance to blend into any racetrack crowd, an anonymous observer. When he checks in with the excursion supervisor who will be on the train, he learns the “mystery” will be presented by a group of actors, masquerading as passengers to conduct an ongoing murder mystery as part of the excursion's entertainment, acting out scenes in the elite dining car. To keep his anonymity while watching Filmer, he changes his own role from a rich young racing fan to a waiter in the dining car. Only Nell, the supervisor, and George, the train conductor know Tor's true job.
The widely publicized events get off to a magnificent start at Toronto's Woodbine Racetrack, where the featured race is won by a horse named Laurentide Ice, owned by a rich widow on the train, Daffodil Quentin. Tor discovers that Julius Filmer has become half owner of Laurentide Ice. He also discovers that Filmer is befriending Mercer Lorrimore, one of the richest men in Canada, also a racehorse owner, whose family has their own railroad car attached to the train. Filmer can be very charming when it suits his purposes.
The race train leaves Toronto at noon next day with everything going according to plan. The catered food is excellent. Tor's co-workers in the dining car assume he is one of the actor group, but appreciate his help with their own jobs. The drama group begins with an actor discovering another actor's murdered body. The train reaches Sudbury, Ontario on schedule, and makes a brief stop at the town of Cartier during dinner. Lorrimore's teen-age daughter gets up to go back to their private car at the rear of the train and she returns screaming. The car is not there. “I could have been killed,” she sobs, terrified.
The regularly scheduled passenger train is only 35 minutes behind them. In the pandemonium of the dining car, Tor leaps into action, locates the conductor, who stops the race train and radios an emergency message to stop the following passenger train at Cartier and a following freight train behind it at Sudbury. The race train reverses and finds the detached car about twelve kilometers back, no damage to the coupling; All evidence shows it had been deliberately uncoupled from the train in a manner to leave it standing undetected on level track, waiting for the following train to crash into it.
The Race Train makes a longer than scheduled stop in Thunder Bay, to allow a team of railroad inspectors to examine the Lorrimore's car and question the passengers, but they only
conclude that the car was unhitched by persons unknown, probably someone in the town of Cartier.
In Winnipeg, the train pauses for two days to participate in another racetrack event, won by another couple on the train. But the celebration begins to unravel when Daffodil declares in tears that she is leaving the train at Calgary. Her horse's new co-owner, Julius Filmer has nothing to say to her. Her horse's groom has been terrorized by threats from some unidentified man among the racing fans on the train.
The situation goes from bad to worse as the train approaches its final destination in Vancouver, with two more attempts to sabotage the train, followed by a suicide. The surprising outcome leaves the reader on edge until the last chapter. Most of the train's passengers continue to celebrate, unaware of the plot that Tor Kelsey and the Canadian Racing Commission are trying to foil.
There is action on almost every page, yet author Dick Francis delves deeply into many of the characters' fears and behavior, without slowing the story's pace A good read!
Wednesday, August 10, 2016
Denver Moore was a slave on a cotton plantation in Red River Parish, Louisiana, in the mid 1950s. He never wore chains, but “The Man” owned the land, the store, and the account book. Denver's job was to plant, tend and harvest 300 acres of cotton, and bring it to The Man, who weighed it but was the only one who read the scale or wrote in the book. Denver had a two-room shack with an outhouse, two pair of overalls bought on credit, a coal-oil lamp and every year at Christmas a hog. He never saw a paycheck, never knew there were schools for black people. Sometime around age 25 or 30, he hopped a freight train whose next stop was Fort Worth, Texas. He couldn't read or write, knew no job but cotton; lived on the streets, learning the code by which street people survive.
Deborah grew up in a small west Texas town “on land so flat you could stand on a cow chip and see New Mexico.” She first met Ron Hall at Texas Christian U; they had an on-and-off romance at first, while Ron did his two years duty in the Vietnam war. They married in 1969; she taught elementary school while Ron got his MBA and entered investment banking. He developed a sideline selling high-priced art to high-living clients. He was soon making far more money selling art than his bank job paid.
Deborah had strong views, and strong emotions. When Ron had a brief affair with a younger woman, Debbie exploded. “Nineteen years! What were you thinking! How could you do this!” Shoes, vases, figurines flew through the air, some were direct hits on Ron. After a sleepless night, they drove to their pastor's office where they spent most of the next day. Neither really wanted to end their marriage. They agreed to try to work things out. That night Debbie told Ron, “I want to talk with her. Will you give me her phone number?” Hesitantly, he gave it.
She spoke calmly into the phone when the woman answered. “This is Deborah Hall, Ron's wife. . . . I want you to know that I forgive you. . . I hope you find someone who will not only truly love you but honor you. . . . I intend to work on being the best wife Ron could ever want, and if I do my job right, you will not be hearing from my husband again.”
She quietly hung up and locked her eyes on Ron's. “You and I are now going to rewrite the future of our marriage. And if you go with me to counseling,” she said, “I'll forgive you. And I promise I will never bring this up, ever again.”
Denver Moore, meanwhile had been living on the streets of Fort Worth. After attempting armed robbery of a bus, he was arrested and sentenced to twenty years in prison. He got out after doing ten, and returned to Fort Worth with a reputation that most street people feared and respected. He slept in doorways, learned to scam a few dollars by faking dumpster diving, or visiting the Union Gospel Mission food line.
In 1998 Ron and Debbie worked in that mission as volunteers, Debbie seeking to renew the mission area with flowers and clean-up, Ron agreeing to help. Debbie confided that she had seen in a dream what it would look like in the future and that she had seen the man who would accomplish it. “I saw his face.” she said.
“In your dream?” Ron said.
Unlike most well-to-do volunteers who served for two or three days and then quit, the Halls appeared every Tuesday night to help serve the food, and to actively converse with those in the line. Those in the line were suspicious of them. On the third Tuesday, a near riot erupted. A large man hurled a chair across the room and yelled, “I'm gon kill whoever stole my shoes!” adding a string of curses.
Debbie whispered excitedly in Ron's ear, “That's him! The man I saw in my dream—the one who changes the city. That's him!” After several of the mission staff had calmed the man and led him away, she said again, her eyes sparkling, “That's him; I think you should try and make friends with him.”
“Sorry,” said Ron, “but I wasn't at that meeting when you heard from God.”
The man they had just encountered was Denver Moore, from whom everyone stayed at a distance. Ron did take the initiative, even though reluctant. It would be weeks before Denver and Ron would understand each other or even believe each other. Deborah had no trouble with either. She had it all worked out ahead of time, including the beautification of the neighborhood and the healing of the people. After persuading the Mission's cook to provide enough meat that the latecomers in the line would get some too, her next project was Beauty Shop Night, doing facials, makeovers, passing out little makeup kits to homeless women. Next, Movie Night, that packed the dining hall on Wednesdays.
Denver observed all this, but rejected all offers of Ron's friendship, until the night the Halls took two carloads of homeless to a live concert. At the close, he approached Ron and said,“I want to apologize to you. You and your wife been tryin to be nice to me for some time now, and I have purposely avoided you. I'm sorry. Next time you is at the mission, let's have a cup a' coffee and chat a l'il bit.”
A slow start gradually grew into firm trust; Denver guided Ron in the 'hood; Ron guided Denver in the business world . And when Debbie had cancer and lay dying, Denver guided both of them in what they had yet to do for the street people of Texas.
Monday, August 1, 2016
Book review # 6: THE BLIND SIDE by Michael LewisThe writer of this review usually doesn't pay much attention to pro football. Years in medical practice have led me to see the National Football League (NFL) as a brain-concussion farm. My first impression of this book was 'Way too much back-story. Who really cares about 300-pound football players, let alone their statistics? I was wrong.
This is a true story of one young man's determination to rise out of poverty and prejudice and achieve national recognition as a football star. He did so by becoming uniquely able to give his team's quarterback an extra second or two to pass the football forward and advance his team to the opposing team's goal line, scoring touchdowns and winning the game.
Michael Oher (pronounced Orr) began life as one of thirteen children of a mother addicted to cocaine, in a slum section of Memphis, Tennessee. He could hardly have been much lower in prospects--quiet, illiterate, measured IQ of 80. Teachers gave him D grades just to move him out of their classes. But he was huge; six feet five inches tall, a muscular 350 pounds, and fast on his feet. For a while he had been a bodyguard to the leader of the toughest street gang in the Memphis slum.
Things start to change when he stayed for several months with a friend, Steven. Steven's grandmother has just died, and her dying wish was that her grandson get a Christian education. Memphis had the largest private school system in the nation. So Steven's father puts him in his ancient car, figures that “Big Mike” may as well go too, and they head for Briarcrest, a large evangelical Christian school on Memphis's east side, where the Dad knows the basketball coach. But it is the football coach who is truly awed at the sight of Big Mike. His shoulders fill the doorway, and he's only sixteen! His grade-point average is only 0.6 in the Memphis public schools—yet the boy clearly wants to be here. And the football coach very definitely wants him.
After several weeks when his classroom test scores are all zeros, one of the more experienced teachers sits him down, one on one, to go over a test. An hour later, she comes out and tells the science teacher, “Michael knows the material, he just doesn't know science vocabulary!”
Once the school realizes his mind really can absorb knowledge, they see Michael as a kid who has nowhere to go but up. Sean Tuohy, an unofficial assistant coach, had started out himself as a poor kid in a private school, without even lunch money. He and his wife, Leigh Anne, now well-to-do owners of a fast food chain, take special interest in Michael. Their daughter, a classmate of Michael's and who is herself an athlete, knows many of the black student athletes. Their son, Sean Junior, age 9, sees Michael as the older brother he never had, and when the Tuohys discover that Michael has no place to stay, nowhere to even be warm at night, they take him into their home.
Michael became a powerful football player, once he learned the rules. One high school rival team had a boy who repeatedly trash-taunted Michael, who finally lost his temper, something he rarely did. This time he surged across the line of scrimmage, lifted his opponent and ran at speed down the field for fifteen yards, took a hard left into the opposing team's players on the sidelines, scattering them as he ran on to pin the boy against the football field's fence.
The referee ran to the Briarcrest bench yelling, “Coach Tuohy! He can't do that!”
“Did the whistle blow?” asked Tuohy.
“No, but he's got to let go of him when he reaches the sidelines!” The ref walked off a 15-yard penalty for 'excessive blocking'. Michael had moved the 220-pound defensive end at least 60 yards. In seconds.
“Michael,” Tuohy asked later , “Where were you taking him, anyway?”
“I was going to put him on the bus. I got tired of him talking. It was time for him to go home.”
“What did he say while you were taking him to the bus?”
“Nothin! He was just hangin' on for dear life.”
Everyone at school knew who he was after that, not only on Briarcrest campus, but on every football team in the state. But he still had many obstacles to overcome before being eligible to enter the University of Mississippi , and, later, first pick in the NFL draft, for his uncanny ability to protect the quarterback's blind side.
Author Michael Lewis has assembled the results of his massive research to give an understanding of the evolution of football in the 21st century. For those of us more interested in Michael Oher's human story, I recommend the movie version of The Blind Side, starring Quinton Aaron as Oher and Sandra Bullock as Leigh Anne Tuohy, his adoptive mother. But for the serious fan, the book has a lot of good background about college and pro football.