Old Doc's Blog

In The Week Before Christmas

2011-12-20T09:30:00.000-08:00

I questioned my patient's plan to move from northern Idaho to Colorado in the middle of winter, and near the ninth month of her first pregnancy.

"Joe found work down there, and we need to stay together," she explained. She seemed satisfied with her answer.

"What will happen if you go into labor in the middle of a Wyoming blizzard?" I asked gently. "Cars do break down sometimes, you know. If you must go, at least take the bus."

"Can't afford it until we get a paycheck. Anyway," she smiled at the rusty clunker parked outside my office window, "Joe just finished rebuilding the engine. And we'll carry a blanket. God'll get us there!"

The odds were strong against Jesus being born safely that night long ago, after a two-day journey from Nazareth. Mary must have had misgivings about the whole thing. Would a midwife be available? Or would the only one around be her husband? He was a good carpenter, but he didn't have much experience in assisting childbirth.

I think that perhaps we never have the right to demand miracles of God. But when there are no alternatives to taking risks, the knowledge that God is with us can sustain us in our endeavor. And God-directed endeavors can change the world.

(First written for "The Workplaces of Christmas" 1994, American Baptist National Ministries

Almost-a-doctor

2011-10-24T15:59:00.000-07:00

I walked through the autumn leaves in the fall of 1950, toward my first day as a real medical student with a feeling of exultant expectation. Up till then, I had found that being a “pre-med” didn’t make as much impression as I would have liked. With girls, especially, the attitude seemed to be “Forget this one; he’ll be buried in the books for four more years.” But now my embryo medical career was finally on track. I had at least made it in through the door.
     Classes for first year medical students were all held in one building, across campus from my home. I joined seventy would-be doctors in the lecture auditorium that first day, all of us waiting with apprehension for the professor of anatomy to appear, who would rule our lives for the next five months. First semester in medical school covered only two subjects: Human Anatomy and Histology, which is anatomy viewed through a microscope.
     Dr. Phillip Armstrong was a deceptively bland man in his fifties, who made no effort to put us at ease. His aphorisms were memorable:
     “We will address you here as ‘Doctor’. For some of you, this will be the only time you will ever hear it applied to you.”
“Up until now, you have worked to achieve a well-rounded education. Here, we intend to flatten you out.”
     We spent that first day getting organized into working groups of four, and learning detailed instructions for the care and study of our cadavers. We took notes on everything; one nervous student even jotted down the professor’s “Good morning.” We entered the dissecting room that first afternoon, wondering what our reaction would be to studying the dead. We four, Onas Morgan, Tony Rivera, Tony Slivinski, and I, grouped ourselves around our dissecting table, and surveyed the motionless shape swathed in pungent, formaldehyde-soaked layers of sheeting beneath the yellow oil-cloth.
     Following the instructor’s directions, working one pair on each side, we laid bare the groin area and made a first incision along the inguinal ligament, surprised at the toughness of human skin, careful to go slowly and meticulously, exposing and identifying each nerve branch and blood vessel. We would spend most of the first week on the abdominal wall, laying open each muscle layer under the critical eyes of the instructors and Dr. Armstrong himself.
     Dissecting a dead person brought a feeling of awe, different from working with dead animals in my pre-med courses. All of us had a healthy fear of making a mistake in the work and earning Dr. Armstrong’s displeasure. Perhaps he kept us off-balance on purpose during these first uneasy encounters with death.
     “The name of the muscle is not pronounced ‘ili-op-soas’ as it is spelled,” he said. “Say ‘ilio-soas.’ The ‘p’ is silent. As in swimming.”
     Three students dropped out that first week. One fainted dead away. Another threw down his scalpel, cursing, and stalked out. We never saw him again. Rumor had it that the third decided to take his girl-friend’s advice to study pharmacy instead.
We compensated for our insecurity with a certain amount of dark humor. Medical students learn a large number of limericks and memory devices, ranging from the fate of nymphomaniacal Alice or the efficient young man from Bel-Air, to the names of the eight bones in the wrist or the sequence of the twelve cranial nerves.
     We four lab partners learned that our cadaver’s name had been Peter B_____, who had died in a state hospital of “old age.” Weeks later, deep in the abdomen, we found that undiagnosed urinary obstruction had destroyed his kidneys.
     A month after entering medical school, I had acute appendicitis. The operation went well, but spinal headaches from the anesthetic kept me on my back for a week. I still recall trying to study, holding the six-pound Gray’s Anatomy textbook on my sore abdomen. I also remember, when I was exhausted by the four-hour work sessions in the anatomy lab the following week, that even Dr. Armstrong had a compassionate streak. He stopped at my table to ask quietly how was I, and to tell me it was all right to take a rest break occasionally.
     We four, and most of the rest, survived that five months and the examination at the end. One of my tense friends panicked when the examiner thrust a skull at him, jabbed a finger at the large opening at the base and barked, “What goes through there!”
“Food!” the student blurted, then winced as he realized the answer should have been spinal cord. Our universal wish, we all agreed, was that we could repeat the whole course, now that we knew what we were supposed to be learning.
     We celebrated the end of anatomy the last weekend in January, a double milestone for me. That night I first met the girl I would marry.

Nottingham High

2011-10-22T14:54:00.000-07:00

from "Bridge Ahead, A Medical Memoir" copyright 2008 Keith Dahlberg

High school is a time of many changes for any teenager. Still more so, if the teenager is a dissident. And I was a pacifist, in the middle of World War II.
I felt strongly about this. I took my cues from my Dad, whose sermons from the pulpit were pro-people, but against all war. To him, peace did not mean merely absence of war. He believed war went against the word of God and solved very few issues. It did not mean that a Christian should be a weakling or a doormat. On the contrary, Christians are expected to be strong in order to help the oppressed, enslaved, or lost to find a personal relationship with God, and so far as possible help them find a way out of suffering and injustice.
As a young man at the time of the first World War, Dad at first had refused even to register for the draft. He finally registered as a conscientious objector, although the draft board would have allowed him a clergy exemption. He continued to preach against war during World War II, even while he ministered to the needs of two hundred service men and women among his congregation in Syracuse. The FBI had him on their list for a while; they listened to him preach, and questioned the church members, but never found anything to even suggest that he was seditious or unpatriotic. (Years later, I read their conclusion in the FBI's dossier on Dad, released under the Freedom of Information Act.) His congregation, in fact, highly respected him, even though many members had questions about his message.
During World War II, a pacifist teenager was hard for most of my classmates and teachers to figure out. Following Pearl Harbor, the whole nation had mobilized to the war effort. Buy war bonds. If you can't afford a bond, buy war stamps each week until you have enough for a bond. Turn in your aluminum cooking pots to build airplanes. Plant victory gardens. Save gas. Knit sweaters. Write the boys overseas. The time I spent at Boy Scout farm camp, in 1942, weeding cabbage fields and picking beans, was to help the national effort to raise more food, and I had no problem with that.
But I had a decision to make on my own in wood-shop class in junior high school. The whole class was assigned the project of making scale-model wooden airplanes, about five inches long, used for training aircraft spotters and gunners in instant recognition. To me, that was supporting war and I told the shop teacher, Mr. Pepper, that I couldn't do it. "I understand,was his gruff reply, but I don't think he ever really did.
It got worse in high school, during home-room period each day. Students were expected to buy at least one war savings stamp (twenty-five cents) each Friday. If even one student in the whole school did not do so, the school could not display the 100% banner on the flag pole that week. Nottingham High never got to fly the banner when I was a student. Some of my classmates resented this, although most adopted a neutral attitude. Things improved after about a year when the school held a Red Cross fund drive one day. I figured up what I had not invested in war stamps over the past months, and gave it to the Red Cross, possibly more than the rest of my home room combined. A hostile classmate accosted me one morning, "How come you can give to the Red Cross but not to the war effort?"
I told him the Red Cross healed people. I added that I wouldn’t get any savings
investment returned after the war, like he would from his war bonds. He didn't like that at all; I thought he might hit me, but I stood my ground. The class president and his girlfriend were standing nearby; both took my side and told the guy to back off. After their endorsement, things got better.
During 1945, the Baptist Youth Fellowship at church became active in drama. I had a bit-part in Elmer and the Love-Bug, found that I liked acting, and when a drama club at school presented Why I Am a Bachelor, I got the lead role, playing a misanthropic lecturer. It was a corny play, but the student body liked it. In looking back, perhaps part of its popularity was their opinion that the role fit me exactly.
In my senior year, I happened to have Miss Frederica Smith as my English teacher. "Sister Smith was a middle-aged, self-possessed soul in horn-rimmed glasses who believed in getting the whole class involved. After we had studied poetry and verse-making for two weeks, Miss Smith announced that, tomorrow being Valentine’s Day, each student would choose some character from literature and write an appropriate valentine to him or her. After making sure that the Bible was considered literature, I submitted my valentine, from Samson to Delilah, with a straight face:
All the while I’ve been making your people feel blue,
Though I’m fighting with thousands, yet think I of you.
I’ve torn city gates from their place in the wall,
But your icy cold heart I cannot move at all.
In times of distress I’ve relied on my brawn,
But that’s no help at all when to you I am drawn.
Of all the Philistines I think you’re most fair
But Baby, I can’t keep you out of my hair.

The class, Miss Smith included, burst into laughter. To my surprise, I was later elected senior-class poet based on this offering, and was invited to join the staff of the school newspaper, but I never wrote any more poems worth remembering.
The year went by quickly after that, and on June 24, 1946 graduation night came for 256 of us. Our principal, Harold Coon, was graduating too, moving up to a post in the school district headquarters downtown. There was the usual procession to Pomp and Circumstance, speeches, awards etc. My mind was chiefly on summer vacation; I would go directly from school to the railroad station and catch the night train west for my second summer of work at Green Lake, Wisconsin, along with one of my classmates.
I was startled out of my reverie by hearing my name called at the tail end of the athletic and citizenship award presentations. Mr. Coon announced that the class had voted me the one they would most like to represent them in life. I hadn’t known there was such an award, but it’s the one I would most like to have.

Front Halves of Horses Sent to Washington DC for Assembly

2011-10-12T19:34:00.000-07:00

That was one of the guesses about what was being manufactured at the super-secret city of Oak Ridge, Tennessee back in the 1940s. The closely guarded production turned out to be purified Uranium-235 for the first atomic bombs, but in a back-handed way the earlier guess has been quoted as a paradigm for thought processes in the nation's capital.
This was reinforced in my hometown of Kellogg, Idaho back around 1984, when the Cold War and atomic bomb threats were often in the news. Someone in the national bureaucracy, pondering how to save citizens' lives in case of atomic attack thought "Mine tunnels!" The Silver Valley in northern Idaho has more than 200 miles of tunnels underground, thought to be enough to accommodate most of the population of the city of Spokane (seventy miles away, it's true, but they had a super-highway.) Accordingly, 200 cots and a few initial supplies of food and medicine arrived for storage in our local hospital against the day of holocaust.
The bureaucrat's thinking was not entirely off the wall. An atomic bomb hitting Fairchild Air Force Base (ten miles the other side of Spokane) might conceivably give citizens an hour or two to take shelter from the radioactive dust that would be borne on our usual westerly winds. And after three weeks underground, people might (we were told) be able to survive in the diminishing radioactivity. When Mount St. Helens had blown up, four years earlier, the volcanic dust did indeed reach Kellogg and beyond. The local miners noticed that it only penetrated the mine tunnels about 300 feet before adhering to the moist tunnel walls, and it was reasonable to suppose that radioactive dust from a bomb might behave in the same way. Anyway, some of us had enough interest in the topic to spend some of our days off evaluating the suitability of mines as fall-out shelters.
After getting permission from the mine companies, four of us - a fireman, a public health worker, an instructor from the mine rescue training school, and myself (a doctor) - formed the core of a crew to map the mines, We pre-supposed that in any atomic attack electric power would be gone, and the mine hoists and ventilation fans would not be operating. So only entry level, horizontal tunnels would be accessible. (Try climbing twenty flights of stairs, the distance between one mine level and the next, and see how your legs feel.) There would be no light or food except for what could be brought in or stored ahead of time.
There is natural air circulation in many mines, and a warm enough temperature. Our public health man tested various underground water sources and found some of them drinkable. Some had drainage ditches that would provide sanitation. The tunnel floors are rocky and wet, and many of the mines had nothing but a vertical shaft access. We checked out ten or fifteen mines. It wasn't until we saw our mine rescue expert casting worried glances at some of the rotting mine timbers in a long-abandoned tunnel that we decided we had explored enough.
The mines of Shoshone County, Idaho, those with horizontal access, drinkable water and breathable air, had enough room to accommodate perhaps 1,200 people, if food, medicines, and electric batteries were stored ahead of time and people did not mind the dark, damp, sometimes dangerous surroundings.
But as is often the case, bureaucrats in the nation's far-away capital city had no clue about conditions in mines. Nor did they realize how much preplanning, and checking the facts of the local situation, was needed to provide genuine safety for the people on site. Our bureaucrats took no further action.
When I told some of my patients about our study, showing room in the mine tunnels for only about one-tenth the local population, let let alone 250,000 Spokanites, they were philosophic. One told me:
"Well, that's okay, Doc. If the bomb ever drops and we can't dynamite the river bridge in time to keep the city folks out, I'll just sit on my front steps with a six-pack of beer, and watch the fireworks."

Watchdogs versus "Government Interference"

2011-07-28T15:46:00.000-07:00

Think about this a minute. You maybe have a burglar alarm at your business site, or a watchdog at your home. Military installations routinely post sentries. And most of us are familiar with airport security inspections. None of these guardians are violating Constitutional rights. You may not like the inconvenience, but few would dispute the need. That's because there are occasional people out there, whether citizens or aliens is irrelevant, who do not respect your property or your life.

So why is a watchdog agency such as the Federal Aviation Authority, or the Federal Drug Administration, or the Securities and Exchange Commission, or any of dozens of other government groups considered "interfering" when they blow a whistle on the shenanigans of Wall Street, or lax safety inspection, or executive greed?

Someone does need to blow a whistle when a smelter lets clouds of unfiltered lead dust billow out of the smokestack. Or when a drunk takes the wheel of a car. Or when a bank or insurance company risks its customers' investments by loaning billions of dollars to high risk enterprises.

When an industry persuades Congress that deregulation of pharmaceuticals, or neglecting building codes, or cutting taxes are in the public interest, there is often a thin line between good business practice and corruption.

When a physician, called about a patient, doesn't see the patient but orders some medicine over the phone, and then charges the patient's insurance a fee for doing an exam, "because he is taking the responsibility," he's getting pretty close to fraud. That's a nasty word, but sometimes it has to be said, and it is another large factor in the rising cost of medical care.

There are trade-offs. If the government is to repair highways, it must find funds to pay for the workers, the material, and the equipment. If there is obvious waste in a program, it doesn't make sense to let the money continue to bleed away while the work stands idle. Nor does it make sense to continue to borrow endlessly and let hundreds of billions of dollars go to pay interest on the debt. And it doesn't make sense for a First World nation to leave 15% of its citizens medically uninsured. This makes the taxpayer or those with insurance pay the cost for the visits of the uninsured.

What Government Could Do Better: One of the tasks of Congress is to create laws for public benefit. To leave no doubt of what the law means, Congress adds regulatory clauses, often to the extent of a thousand pages or more. That length creates a lot of doubts of its own. For one thing, I doubt that many lawmakers or their aides have read the whole thousand pages carefully enough to grasp their full meaning.

How about a two or three-page summary stating concisely the purpose and actions required by the act, to which the other 997 pages must conform? And if any don't conform, they must be revised until they do.

The public wants action to produce a medical care act that reduces waste, increases efficiency, and addresses the problems of 45 million uninsured citizens. Instead, both houses of Congress, and many agencies besides, jockey for a political agenda rather than addressing the merits and flaws of the act they are trying to put together. Such delays cost money. Endless catch phrases and frank misstatements of meaning, on TV ads and talk shows, don't get the job done.

Congress can't expect to mandate new standards of care without funding them. It is hypocrisy to say "no new taxes," while cutting federal funding, leaving the states to finance new federal laws through state taxes. And cutting funding for watchdog agencies would be reckless negligence.

This blog post is adapted from my book, "Access to Medical Care, Common Sense for Doctors, Patients, and the Public," © 2009 by Keith Dahlberg, MD; iUniverse, publisher.

Road Block Deadlock

2011-07-26T13:15:00.000-07:00

All right, it's time to stop fixating on each party blocking the other party and work together to move the nation off the railroad tracks before the train comes along.

Okay, there have to be budget cuts, and yes, they must include parts of the major entitlement programs; I say that as a Democrat and beneficiary of Social Security and Medicare myself. Those who have no other income should not bear the burden, but those of us who do have other resources should not expect full benefits to go on increasing forever. Incremental reductions over several years need not be a disaster.

Republican spokespeople are fond of saying that new taxes destroy jobs. What do they think budget cuts do? I am told (today's Spokane Spokesman-Review editorial) that failure to renew the operating authority of the Federal Aviation Administration last week laid off 4,000 clerical workers, and that in turn halted construction work on the nation's airports and runways, suspending the jobs of the construction workers.

Hospital emergency rooms have been the last resort of the uninsured ill and injured. Now there is a movement afoot, already enacted into law in some states, to limit Medicaid patients to only three paid ER visits per year, with shared computer data bases to detect hospital-hopping. With unpaid ER visits increasing each year, hospitals have no other choice when their funding is cut, but what is the child with chronic severe asthma or any number of other maladies to do?

Yes, small businesses need reassurance that they can plan ahead on tax rates, etc., but the mega-corporations' profits are doing quite well, thank you, and they may have to struggle along, even without the tax loopholes and exclusions and subsidies to which they have been accustomed.

One big difference between President Obama's four trillion dollar debt reduction and the one trillion proposed by Mr. Boehner is the saving in annual interest costs. At six per cent, that extra three trillion cut saves l80 billion dollars per year. So, enough with the smokescreens already. Even the Congressional rookies will have to learn to sacrifice. It comes with the job.

National Debt Reduction

2011-07-15T16:43:00.000-07:00

"No new taxes" and "No cuts in entitlements" have both become paralyzing cliches in the past week, arresting any tangible Congressional work output, and stifling productive thought.

Let's take perception a step further. If you don't pay off your personal credit card debt, you eventually lose your credit. Credit card payments require cash. So does the government credit card.

And a large portion of any cut funds were used to pay people's paychecks, (or indirectly to pay those who produce materials.) And if, on the average, people make $ 50,000 per year, every billion you cut from the budget means twenty thousand more jobs lost, plus the income tax revenue those people could have paid.

But there is no doubt that we must cut spending. My previous blog (scroll down) addresses relatively painless ways to reduce Medicare and Social Security costs. Lest any one accuse me of lacking details, allow me to advertise a small book I published two years ago, "Access to Medical Care: Common Sense for Doctors, Patients and the Public" It's fifty-six pages long, can be read in a single evening, and is available on Amazon for $ 8.95, (soon to also be a six dollar e-book.) I just read the whole book again this morning, and believe it to still be as relevant today as in 2008. Except the last chapter, "Working Together". Congress is still undecided on that.

Solving the Nation's Fourteen Trillion Dollar Debt

2011-07-10T20:44:00.000-07:00

I'm glad to see that the President and Congressional leaders appear to be getting closer to reality about lowering the national debt. At least, all sides now acknowledge that defaulting on the debt or endless raises in the debt limit are dead ends. I hope they will also see that cuts in spending and increases in revenue must both begin now, not two years or ten years down the line, if we are to retain our creditors' trust. Some suggestions where to start:

Social Security is one of America's biggest expense programs; I and tens of millions of other senior citizens depend on it for a major part of our old age income. My wife and I contributed to the fund for decades, and now our combined SS benefits are a little over 2,000 a month. We have about an equal amount of other, non-government income, and with our house and our children's college paid for, a modest reduction would not be a hardship for us, as it would be for some who depend on a 500 dollar benefit as their only income. Leave theirs intact, but many of us who are better off could make both Democrats and Republicans happy by accepting a few per cent reduction in our benefit, and a less generous tax break at income tax time. (Because of my low tax bracket, I am only taxed on about 30% of SS income.) You could call that last one either a spending cut or a tax increase, depending on your political view, but there is no doubt that applying it to upper-middle and upper class families translates into billions of dollars off the deficit annually.

Medicare is another big budget expense. My open-heart surgery at age 77 has given me five more years of active life so far, and I am grateful to both the program and to my surgeon, who may have accepted a reduced fee at Medicare rates. But I have a neighbor who also could have benefited from such expensive surgery; he had a heart attack, had to quit his physically active mining engineer job, lost his employer-funded insurance, and ran out of unemployment benefits. There are few new jobs for a fifty-five year old. Emergency rooms have to accept him even if he can't pay, but the ER has to charge over $1,000 per visit to the rest of us to make up for the 45,000,000 Americans like my neighbor whom no insurance company will accept.

Medicare is an even bigger problem than Social Security, because SS beneficiaries eventually die (and that's okay—I sure don't want to be kept alive on machines for months). Patients eventually die too, of course, but medical science keeps on growing, and growing more costly every year. New tests, new machines, new and vastly more expensive medicines come on market, and more training and knowledge is expected of doctors, nurses, technicians and therapists. No matter how rich the nation, there will come a point where there won't be enough funds to pay for all the medical inovations each year.

Some nations' medical systems deal with this problem by having waiting lines. Others have hospitals whose pharmacy shelves are empty before the end of the fiscal year. Still others simply let their people starve or die untreated. Call these methods rationing if you like, but eventually every nation must prioritize. America is to be congratulated on having a good public health system in general, with emphasis on prevention, immunization, and maternal and child health care as priorities

Doctors could share in the burden, too. During my fifty years of medical practice, many doctors would accept some patients that couldn't pay much, or could pay nothing at all. The doctors kept track of how much medicines cost, and prescribed generics when possible. And they listened to the patient first, before firing off orders for routine tests. Today many doctors prescribe with no idea of the cost.

Government could help. Everybody talks about simplifying tax forms, but it hasn't happened yet. I have always been a big fan of charitable gift deductions, but I bet most of us who support charities would continue our support even if only 50% of each gift were deductible instead of the more generous deduction of 50% of adjusted gross income. Hey, are you giving to help the needy or to help yourself?

As to complicated tax forms, consider Singapore, arguably the nation with the largest budget surplus (and one of the smallest populations) in the world. My son has lived there for years, making a well-paid living. He says it takes him only a half hour to fill out his Singapore income tax return, but takes days to do his US form. 'Nuf said.

Military costs are a big budget item too. Sometimes it's necessary to defend our nation, or to stop genocide as part of an international effort. I would like to think failed nations like Somalia and a few others have taught us we cannot police the whole world alone.

National debt interest payments of half a Trillion dollars are one of the biggest expenses we should learn to do without. Every trillion we reduce the debt this year means 60 billion dollars less interest we must pay next year (@ 6%.)

Millionaires and corporations, are you part of this nation or not? You need to contribute to debt reduction too.

Prospecting for Gold

2011-06-28T08:43:00.000-07:00

Back in the 1930s, when gold was $36 an ounce, many people found it worthwhile to head for mountain streams with a shovel and a pan. It was harder physical work than some of the amateurs expected, and the icy water from melting snow was hard on those with arthritis, but if you were lucky, you could eke out a living. Nowadays, silver is worth $36, and as I write this, gold is getting $1,548 per ounce. What makes gold so valuable?
Well, inflation accounts for some of the price rise of course, but basically, people want it, and are willing to pay that high price. Can you eat it? No. Will it keep you warm? Nope; won't burn; and a blanket of it would be way too hard and heavy. But it has several other features that are unequalled by almost any other substance.
First, it is beautiful, not only as a symbol of wealth, but in itself. About half of new gold production is used in jewelry, especially in Asia. Second, gold is dependable. Even when inflation lowers the value of paper money, gold is usually accepted in exchange for goods. About one sixth of gold production is stored in government vaults like Fort Knox ,or the Federal Reserve in Manhattan, which also holds funds in trust for other nations. Another sixth of the annual gold production is held by private investors. Thirdly, gold has industrial uses. Silver and copper are better electric conductors than gold, but they tarnish..Gold never tarnishes or corrodes. Plating switch contacts in computers and other electronic devices with a very thin layer of gold prolongs the life of the device.
For all these reasons, gold continues to be in demand. Most gold nowadays is produced, not by lonely prospectors with gold pan and pick, but by international corporations employing thousands of men and women. As recently as five years ago South Africa was the world leader in gold production, but its gold mostly lies two to four kilometers below the surface, and is therefore expensive to mine. Recently China took first place with 320,000 kilograms mined in 2009. Australia, South Africa, United States, and Russia were all nearly tied for second place with a little over 200,000 kg apiece. Most of USA's gold nowadays comes not from California or Colorado, but from Nevada, with Alaska next.
Papua New Guinea is rising through the ranks of gold producers, being number12 in 2009, but may soon be number 6 if some of its new projects are successful. A Canadian company working in PNG is pioneering the first deep water gold mine, Solwara 1. There, a mile below the ocean surface, the top of an undersea mountain is covered by a hundred-feet-thick layer of copper and gold-bearing silt deposited from a natural hot water vent spewing a black plume of mineral matter. (think of it as a baby volcano.) Nautilus Minerals Corporation believes it can pump this sediment up through a pipe, dry it aboard ship and haul it by the barge-load to the town of Rabaul, 70 kilometers away for further refining. And a former Nautilus executive is now leading a similar project deep in the Red Sea off Saudi Arabia.
Pumping sediment or gravel off the ocean floor appears to be much less polluting than on-shore mining. Any initial residue can be laid down on the ocean floor again No blasting is involved, no sludging of rivers and flooding of rice fields. Presumably little or no toxic waste deposited at the site (though it will ultimately have to go somewhere.)
But there must be precautions taken. There are hundreds of such sea vents in the dark deeps, home to strange life forms which don't depend on sunlight or chlorophyll, but live on the sulfides and other minerals from the vent. No one has thoroughly studied these plants and creatures yet; no one knows what medicines or other products they might produce. We must not carelessly damage their environment, even if it can be shown that they can migrate on deep ocean currents to other hot, nourishing sea vents hundreds of miles away.
Nor should we endanger fish and other dwellers nearer the surface by polluting rivers with sludge, cyanide, mercury, acids and other toxic products used to refine gold and other minerals we extract. A great many people's jobs and income depend on wildlife, forests, and tourist industries. Jobs and income from mines and and oil wells are also important, but must be balanced against those from co-existing industries.
As an example, a huge deposit of copper and gold in Alaska lies at the root of the Aleutian Peninsula, near the shores of Iliamna Lake and the rivers that drain into the Pacific Ocean's Bristol Bay, the center of Alaska's salmon fishing industry. Two mining corporations, Rio Tinto and Anglo-American, are proposing a 2 mile-wide, 2000 feet deep open pit mine, with 80-foot high dams to contain waste products. They have not reassured anyone about plans to use cyanide or other toxins in the refining process; they reportedly only say they are "considering" the matter.
When genuine and legitimate conflict arises among two industries like mining and fishing, the average wage earner can't compete with the resources behind the big company executives and lawyers. The only ones with clout enough to assure that proper precautions are taken are government watchdogs. I will have to amit I don't really like the arrogance (and sometimes incompetence) of some bureaucrats, but neither do I like the arrogance and greed of some big businesses.
I practiced medicine for thirty-five years in Idaho's "Silver Valley" mining towns. Some mine accidents are inevitable, but others are preventable. In 1972, ninety-one miners died of monoxide poisoning in an underground mine fire for which management was unprepared. No one thought it could happen. A few years later, the filter system in the lead smelter was accidentally destroyed. It could have been repaired by shutting down the smelter for a few days, but management decided (deliberately, the jury found) to ignore the danger to the surrounding towns and run operations without filtering the lead from the smokestack. The lawsuits over the next few decades have cost management over one billion dollars. Corporate CEOs sometimes make huge errors, that cannot later be corrected. That is why public authorities must sometimes step in and say. "Thoroughly study the effect on the environment and local economy first." There are other values besides gold.

Book Signing

2011-02-14T11:39:00.000-08:00

BOOK SIGNING

I was down in Richland, WA, house sitting and cat sitting for my daughter while she was away,and using the time to sell a few books to the local libraries and bookstores. I hadn't made major plans in advance, but usually carry a dozen-or-so assorted copies of my books in the car when traveling.

Talking with the book department supervisor in a local franchise of a regional chain, I showed her my latest novel, The Samana Incident, and its companion novel, Flame Tree, and asked if she'd like to carry a few of each in stock.

"Glad to," she replied; "we can arrange a book signing too, if you like." This took me by surprise. Store managers aren't usually that receptive to authors wandering in off the street, even if they can reasonably be featured as a local or regional author. Maybe her budget is better at the beginning of a new year.

"When's your busiest customer load?" I asked.

"Probably Friday, four to seven. People are getting off work then, and it's payday for a lot of them."

"I'll be here. I have a few copies of my other books with me, too. Can I sell them?"

"Sure. But I'll have to make a separate inventory contract for each one. Fill out these forms, and then leave the books here. You get 60%, we get 40."

My publisher takes 50%, but even the remaining 10% of the 60 nets me about a dollar-fifty per copy, and there is always the possibility of more business later on in other branches of the bookstore chain.

Friday, at ten to four, my wife and I checked in. The manager had set up a table facing the entry doors, with all my books arranged. But wait a minute; where were the copies of Flame Tree?

"I'm sorry. Our major wholesaler already has that one available in their list. We would have to order through them." She handed my six copies of Flame Tree back to me..

"Can I give these six to my wife and have her sell them out of my car in the parking lot?" I asked.

"You can do whatever you like as long as it's not inside the store" I didn't know what her boss might think of that idea, but I took her at her word, and stationed my wife in the car and myself at the book table.

Bookstores provide authors with a chair, but I've found it better to spend most of the time standing and making eye contact with approaching people. (Guys, if a man and woman enter together, eye the man. His wife/girlfriend will likely express interest too, if he stops., and you avoid the risk of irritating the man by eying his girl. My greeting is not "Would you like to buy one my books," but "Do you like a good story?"

The potential customer may pick up a book and/or say "About what?" Some, of course, will just pass by, perhaps with a smile of brief greeting, or with eyes averted. That's okay; Some do stop. I try to answer with no more than a sentence or two for each one they seem interested in. I think it helps to have all five displayed - if an author has that many titles to offer, most people assume he can write.

The first to approach me that night was a boy who couldn't have been more than eleven or twelve. After looking over my table, he asked "Did you write these?"

"Yes I did."

"I've written a book too," he said.

"Have you? What's its name?"

"Pulling Weeds to Picking Stocks." he said. Seeing me take out a notepad, he offered "Here, I'll write down my website." Talking about this experience to the store manager later, she told me, "Oh yes, I know him; he did a book signing for us not long ago."

I have learned that I can't tell much about book readers from their appearance. Three grungily dressed teenagers eyed my table from a distance for a short while and then came up and looked at the books. "You a doctor? That's cool." They muttered among themselves for a while, and it turned out that hadn't enough money among them to buy a book. But they reappeared after a few minutes and chose the least expensive Access to Medical Care, for $8.95.

I thanked them, and offered to autograph it. "How shall I sign it"

"We're a musical group. You can sign it to Pigeon Fist."

"What?"

They spelled it out. So I signed the book "To Pigeon Fist" and my name. Who knows? maybe one or more of them are headed for medical school.

One thirty-something man with a dirty T-shirt over a large abdomen, was apparently just off work. I asked him what kind of story interested him. "Oh, music." What kind? Rock. I didn't have anything to fit that, but he bought a book anyway.

A young couple took a copy of Samana, and after I told them it was a sequel to Flame Tree, wanted that too. I think they were more intrigued by buying a copy out of a car in the parking lot, but my wife said later that yes, they came out and bought one.

Others bought out of interest in the stories or because they worked at the nearby hospital, or just seemed to be looking for something, I - and maybe they - didn't know what.

With a final purchase of two books by a lady at one minute to seven, table was bare, every copy of every book sold (except Flame Tree out in the car.)

The manager wanted five more copies of each, but shipping them would shave away my narrow 10% profit. Never mind, she said, I could send them with my daughter next time she comes home.

Why Set a Novel in a Country Like Papua New Guinea?

2010-11-26T19:29:00.000-08:00

Aside from a few old geezers who fought the Japanese in Papua New Guinea sixty five years ago, and the occasional missionary or tourist who has been there, who cares what happens in a mountainous jungle island, far beyond the exotic lagoons and hula dancers of Hawaii? Why complicate a plot with strange people, odd customs, and geography?

One reason is, there's a market for such books . Some people like to read about the Navaho Tribal Police, or the Ladies' Number 1 Detective Agency of Botswana, or Chief Inspector Chen of the Shanghai Police, all of which have become popular series.

A second reason is, an unfamiliar country gives many opportunities for unexpected twists in the plot. In Papua New Guinea, the setting of my latest crime story, the majority of the population are very poor, without much schooling. They are vulnerable to exploitation by timber merchants or mining companies who destroy the forests on which the people's lives depend. They are willing to listen to anyone with a get-rich-quick scheme, only to find out that someone else gets rich at their own expense.

In such a country, an honest cop or government official can stand out, especially if the writer can make his character believable as well as unexpected. As the story develops, and the real problems of the country evolve, whole new opportunities for extending the story to a series arise. When I started this story ten years ago, PNG had little to offer the world except scenery and some gold and copper to mine. But now in the past year, PNG suddenly turns out to possess some of the largest fields of natural gas in the world. International gas and oil companies are investing 15 billion dollars over the next several years to produce 6.6 million tons of liquified natural gas per year to export to Asian markets. How will corrupt and inexperienced government officials handle this windfall?

There's the foundation for yet another story about Police Lt. - now Captain - Jason Kerro.

The Samana Incident

2010-11-11T14:21:00.000-08:00

Lieutenant Jason Kerro, Royal Papua New Guinea Police, thought the early morning report of an armed attack on the foreign translators' base at Samana was an ordinary robbery attempt by the "rascal gangs" that roamed the country's Highlands. No one in town had recognized these intruders, or knew where they had come from or had gone. Except that one spoke English with a foreign accent, and had cut the power to the radio station and town switchboard before being driven off by security guards.

Jason suspects a connection with the assault rifles and drugs that have been turning up for sale in nearby Mount Hagen. The word on the streets is that some of the police are taking payoffs from smugglers moving in from Asia, but no one is talking about it; those who did are no longer alive. Jason doesn't know which of his police colleagues he can trust.

The sponsors of the translators' base, concerned with the safety of the families there, send in a pair of investigators with past experience with Asian drug dealers. George and Vienna Daniels are, to all appearances, short term medical volunteers at Samana's clinic. Jason soon discovers their usefulness as under cover allies in areas beyond his own jurisdiction. The intruders have hidden their trail well, but George and Vienna supply Jason with the edge that opens the case.

Look for it at your local bookstore,or ask them to order it: "The Samana Incident" by Keith Dahlberg. iUmiverse Press, ISBN 978-1-4502-6311-5. Also available on amazon.com, or from the iUniverse on-line bookstore, In soft cover ($14.95) or e-book format ($9.99)

Billion-Dollar Boondoggle

2010-08-03T19:40:00.000-07:00

The federal government charges its Environmental Protection Agency (EPA) with protecting human health and the environment. Over the last thirty years it has worked effectively in the North Idaho "Silver Valley" mining area (lead, zinc and silver) to decrease health hazards through covering the site of the lead smelter and zinc refinery, and removal of polluted soil from yards, parks and playgrounds. Blood lead levels rarely exceed the national safety level of 10 micrograms per deciliter nowadays, and free blood tests are still available to those who request them.

Although EPA tells us that human health is no longer at risk from lead, zinc, arsenic and other minerals in the environment, it wants to extend its work to the whole watershed of the Coeur d'Alene River's South Fork, to protect fish and other wildlife, because some species are sensitive to zinc levels that are harmless to humans. The cost of the project, they estimate, will be 1.3 billion dollars, and the duration will be 30 to 90 more years or longer.

Their premise has some logic. Shoshone County, Idaho, has been a major mining area for 125 years, with over 300 mine sites, most of them small and no longer operating. Some of the mine tailings and ground water sources still have significant mineral content. EPA wants to funnel all those sources (a volume estimated at 30,000 gallons per minute, or about 5% of the river's volume) into the EPA's Central Treatment Plant at Kellogg, which currently handles about 1/10th that volume. There, the metals are precipitated out by raising the water's pH and trapping the metals in a flocculent sludge with alum. The purified water, no longer acidic, is put back into the river. EPA pumps the sludge to a 2-acre pit on top of the nearby Central Impoundment Area (CIA).

The CIA is a 200+ acre collection of tailings from the Bunker Hill Mine (lead, zinc and silver) which the EPA covered over with plastic sheeting and then laid down clean soil and grass on top of that, to prevent recontamination of the surrounding cleaned-up areas. All of the CI Area is sealed off except for the sludge pit destined to take water pollutants from the whole South Fork drainage basin. The pit has no plastic lining or anything else to prevent fluid from the sludge from draining downward into the original alluvial plain and aquifer that feeds into the adjacent South Fork River.

When I asked EPA how fast seepage of the sludge liquid occurred, EPA estimated 9 gallons per minute; the Idaho Department of Environmental Quality (DEQ) estimated 35 gpm. A couple of 5 gallon bucketsful seeping downward into the soil doesn't sound too alarming until you multiply 10 gpm x 60 minutes x 24 hrs x 365 days and get a figure of over 5 million gallons each of the last 10 years plus five to seven more years before EPA intends to make a new, plastic-sealed sludge pit. When I asked the metal content of this seepage, both DEQ and EPA said they didn't know. Probably most of the pollutants remain in the sludge, but before I risked re-contaminating the lakes and river downstream, I'd try and find out. Five million gallons a year wouldn't have to carry much.

One of EPA's dilemmas is finding places to deposit the lead/zinc-polluted soil they have dug up from house lawns all over the valley. There are quite a few uninhabited gulches available, several of which they have already used, but the present repository they are placing in the middle of the river's flood plain, next to a large marsh inhabited by the very birds and fish they are trying to protect. The Coeur d'Alene River floods every few years; a flood in a tributary in 1974 took out the eastbound lanes of Interstate 90, not to mention houses. A flood sweeping away the contaminated soil could undo the EPA's last 20 years of cleanup. EPA appears unconcerned

And then there is the cost—1.3 billion dollars. The so-called Asarco Trust Fund, from fines and settlement with the mining companies contains about 0.45 billion, and EPA is quick to point out that it can generate twenty million in interest (but only if they don't spend the principal.) Other than that, and some of EPA's own budget, the only source of funds would from Idaho citizens' taxes. Raising $ 900 million from about 2 million people is allegedly legal, but I question its morality, spending that much on the health of a few thousand fish and birds when the state is cutting back on funding for schools, medical care, roads, and other human needs

There wil be a public meeting August 4th where EPA will once again present its case, and another on August 9 when Idaho legislators and business people will present theirs. I hope common sense will prevail. Not always the case in politics.

Learning from Disaster Response

2010-01-17T21:40:00.000-08:00

DAY 5 OF THE HAITI QUAKE: CNN and other news media are doing a good job of reporting both good and bad events in Port au Prince. All disaster responses seem desperately slow,at first, given the critical 2 or 3 day time window for saving lives. But response to this mega-disaster is actually proceeding about as fast as can be expected, given the number of victims and the limited harbor, road and airport facilities.

Several issues, however, seem to have got less attention than needed:

Security: Rumors are inevitable, but common sense suggests that a medical team should not abandon its patients for unidentified "security" issues. CNN's Dr. Sanji Gupta should be congratulated for taking the initiative of staying all night with one hospital's patients until the medical team returned. (When this issue arose in the Cambodian refugee crisis of 1979, Thai military had a dusk to dawn curfew for our medical teams in our camp of 25,000 people. But they let one medical team stay each night in the thousand-bed hospital; fears about our safety proved groundless.)

The response now, at the end of day 5, shows that distribution is improving, but slowly. Water tanker trucks, replenished from decontaminated sources outside the city might be more efficient than passing out 100,000 bottles of water (which represents less than a single drink for each of two million people.

Cranes, bulldozers and helicopters are first priority needs after an earthquake. Flying these in on the first day would seem a higher priority than transporting swarms of officials who want to "see for themselves." Haiti has a second harbor and airport at Cap Haitien, well out of the quake zone. Helicopters could shuttle supplies from there to improvised landing pads almost anywhere in Port au Prince, until the harbor is working. But such plans must be set in motion quickly. Spending the first two days merely considering options means thousands die unnecessarily.

Large rescue plans tend to focus operations in the main population center and work outward from there later. That's where the most people are, of course. But people outside the epicenter starve or die of trauma just as quickly, and in some disasters people beyond the city receive no help until weeks later. (The 2005 quake in Kashmir with 75,000 deaths comes to mind.) Even with bad roads, teams could be sent by helicopter or truck out to secondary population centers.

God bless the local citizens who began rescue operations, with their bare hands in many cases, and who translated from Creole to English or French for newly arriving rescue teams. And bless all the competent and caring people who dropped what they were doing back home and showed up in Haiti to help. Many of you will look back on this as the high point of your career.

Death Panels and all that

2009-09-21T13:42:00.000-07:00

Like Mike Doonesbury this morning, I had thought all the Death Panel furor was behind us. But if Gary Trudeau thinks it's still a current topic, and Newsweek gives it featured coverage (The Case for Killing Granny, Rethinking end-of-life care, Sept. 21, pages 36-40 and page 8), it may be useful to review it one more time for those gullible enough to believe that we old-timers are about to be shut out of the system and left to die. That's deliberate nonsense. The facts are:
Living wills (or advance medical directives) have been around for years. My own was first notarized in June 1997, and I update it as "still valid" and sign it every year or two to show that my mind hasn't changed. I make sure my own doctor and any hospital I go to has a copy.
The reason doctors and hospitals advise people to do this is so that the your personal desires are on record even if you are later found unconscious, or are unable to communicate, or have relatives telling the medical attendants to do this or do that regardless of your own stated wishes.
You may state that you want everything done to keep you alive, or want Hospice care, or want to let nature takes course, or any degree of treatment in between. It's up to you. But unless your desires are recorded while you are still conscious and of sound mind, the doctor or hospital will have nothing to go on.
My own advance directive says, in part, "If I am disabled by [for example] stroke, dementia, or cancer, I do not wish my life prolonged artificially. If there is no reasonable chance of recovery or fully conscious existence, then let my dying process take its natural course without tube or IV feeding, radical surgery, extended use of a respirator or other resuscitation measures. Relief of pain and/or routine nursing care are OK. I do not want my medical care to threaten bankruptcy of my family and heirs.
"In particular, I do not want attorneys, judges, doctors, or ethics committees quibbling about my intent or wish. What I want is to go to my Maker when my time comes, with what measure of human dignity is possible."

The difference between a "Death Panel" and a Living Will is who makes the decision - a nameless bureaucrat, or you yourself?

As a doctor, I have seen people kept alive for a few extra days while they are dying of incurable, painful cancer or other disease, and their medical costs keep building up to loss of home and all the family's funds, only to prolong the pain or keep the heart beating, but with no useful outcome. But without instructions to the contrary, doctors do what they can to keep a person alive.
President Obama's Health Plan encourages doctors to counsel patients on how to make their wishes known. It's still a matter between only you and your doctor.

The President's Medical Plan Speech

2009-09-09T20:26:00.000-07:00

I listened carefully to the President's address this evening, both as a retired doctor and as a senior citizen now living on a moderate fixed income. In general, it was well received; even the Republicans stood and applauded at several points.
He laid out the main actions and the reasons. Skeptics on both sides will say "not enough detail", but he emphasized the results he was seeking: against the law for insurance companies to refuse coverage of pre-existing conditions, against the law to drop insurance or raise the premium when a client's treatment is too expensive; everyone can keep their present policy if they like it, and their present doctor too. There will always be details to work out, and I expect modifications will be necessary after the plan has been in operation a few months or years.
Most people's first reaction will probably be "How can the nation pay for all the extra care when the 45 million uninsured get coverage?" But the fact is, these 45 million are already here, already getting care, in the Emergency Room—the only place required to take care of them—but an ER visit is ten times the cost of a doctor's office visit.
You don't believe that cost ratio? Google the comparative prices. What I found was $170 for the average first office call, and from $1,000 to $2,000 for an average ER visit, tests, and treatment included in both. Sometimes the severity of the case demands ER care, but moving the headaches, colds, and minor injuries into the doctor's office can save billions per year.
Opponents like to quote the figure one trillion dollars over the next ten years as the increased cost of the President's plan, but that's 100 billion per year. Savings from over-testing, over treating, and over use of the ER could easily cover that.
My first reaction to Congressman Boustainy's rebuttal was that I thought the President covered all those points, but then I realized Mr. Boustainy would have had to write his speech before he heard the President, who had finished only about five minutes earlier. The only differences I can see are the Republican wish to make insurance purchasable across state lines (which I like) and their desire to "Press the reset button and start over" which would send us back to square one.
The biggest savings in present medical care I see are (1) tort reform with resultant easing of over-testing and over-treatment, and (2) lifting the ban on competitive bidding on pharmaceutical contracts. Downsizing the "donut hole" is useless if drug prices get upsized the next day.
Overall an excellent speech, and substantive. More later.

The Reston, VA, Town Meeting

2009-08-25T19:23:00.000-07:00

I have just watched the town meeting at Reston, VA, held by Congressman Jim Moran, with Gov. Howard Dean, MD (Vermont) fielding audience questions. All things considered, it went rather well, although there was a lot of orchestrated shouting in the beginning, until one of the political activists in the crowd was invited to submit his question and speak to it for five minutes only, or leave. He left, rather than speak under the rules of courtesy.
The subject was, of course, House Bill 3200, Health Reform. Mr. Moran spent most of the first hour explaining the bill's provisions and dispelling ten of the most widespread misconceptions making the rounds ("Grandma's going die", "The government will assign you a doctor", etc.), and then Dr. Dean, himself a physician as well as an ex-governor, explained the major points as well as what was left out of the bill and why.
I am pleased that the bill preserves personal choice of each person's choice of insurance carrier and choice of doctor, and is designed to have everyone medically insured. I would be more optimistic about the plan for handling the cost if the bill had not left out two of the biggest ways of lowering health care costs.
Tort reform will not be in this bill. Dr. Dean explained that including it would mean submitting it to the House Judiciary Committee which is strongly opposed to tort reform, and would not have allowed it to come out of committee for a vote on the floor. But by capping the non-medical, non-economic costs some lawyers seek, tort reform would reduce those tests and treatments of little benefit to the patient, done only to prevent a trial lawyer from accusing the doctor of negligence. Dean did predict that continuing progress toward nationally recognized standards of medical care will eventually solve the problem. (Adhering to standard of care is a strong defense against claim of negligence.)
Bidding down the price of medicine for Medicare and Medicaid will not be allowed, in exchange for a 50% reduction in the "donut hole" where seniors pay the full price of medicine out of pocket. This was an agreement between the President and the pharmaceutical companies. I think the President would have found bidding a much bigger way of cutting costs of medical care (Dr. Dean said the VA bidding system cuts the cost of their medicines to between one-fourth and one=half of what the other programs pay.)
But politics is recognizing what will pass Congress and what will not, and doing the possible. The final bill must pass the Senate, too. Mr. Obama may yet give all citizens a way of paying their medical bills without going bankrupt. I hope so.

Dealing With Our Fear of the Future

2009-08-12T17:01:00.001-07:00

"How can we possibly pay for medical care for forty-five million more people who have no insurance?" The answer is, you are already paying for it, and at more than three times the amount it should cost.
These uninsured are not millions of newcomers to America. They are already here in the system, our fellow citizens with low-paying jobs or no jobs at all. Doctors who are willing to accept some non-paying patients already see them every day of the week.
Every time any of those forty-five million gets sick or injured but can't get in to see a doctor, they go to the hospital emergency room, the only place that by law must accept and examine them, and give them emergency care. Usually the ER doctor on duty has not seen that person before and must do a reasonably complete exam and lab tests to know what's going on. The charge for an emergency room visit, as many readers know all too well, averages over $1,000, compared with an average for an office visit or urgent care center of $150.*
Every time an uninsured patient, who can't pay for his care out of pocket, gets medical care at an Emergency Room, you, and all of us, are paying the cost of his care out of our present taxes or the increased rate a hospital must charge to make up for what they can't collect from the non-payer. These 45,000,000 are already in the system, and we are already paying their costs. It makes sense to get their colds and minor injuries out of the ER and into the doctor's office, at less than one-fifth the cost we are paying now. That alone would save about half the alleged trillion dollars of new insurance premiums.
In addition, instead of getting medical care after his condition has reached crisis proportions, the newly insured can get preventive care or early care, reducing chances of his needing hospitalization later on (where the cost of care is even higher than the ER.)
It's true that when the presently uninsured get insurance, they will use doctors more often, but the increased need for doctors will not be like all the newly insured are just getting off the boat and entering the country. They are already here. When doctors know that insurance will pay something for every patient, you will see more men and women entering medicine as a career.

*The reader can find many sources for cost information by Googling Consumer Health Ratings, Emergency Room, typical average cost.
I surveyed reports from Florida, Minnesota, and Vermont, plus an additional survey by G.M.P. Employers Retiree Trust.

Getting there is half the fun

2009-07-31T15:13:00.000-07:00

Yeah, right. Your six-year-old wakes up this morning with a really sore throat, a cough and a fever. Or maybe she has an earache. Or perhaps you've found a lump in your breast. Your family doctor's telephone receptionist gives you the run-around, "Our next open appointment is in six weeks. If you're really concerned, go to the hospital emergency room . . .would you like their number?"

No, thanks, you already have their number. A doctor who has never seen you before, and likely will not be on call the next time either, will put an automatic thermometer in your kid's ear, glance down her throat, and give you a prescription for a cough syrup you've already tried at home. See your doctor in three days if there's no improvement. Your doctor's already-full schedule is not the ER doc's problem. You'll get a bill for several days worth of your wages, and are no better off than before you came in. The ER doc is reasonably sure your child will be better soon, but he fails to convince you.

This really doesn't need to happen. You shouldn't have to use the expensive ER for an urgent, but non-emergency problem just because no doctor's office has any time open.

Doctors who allow the front desk to fill their appointment schedule chock-full ahead of time are not thinking things through. Common sense will tell any primary care doctor that many people's sickness appears without warning and they need help today, not next week or next month. And people merely needing a follow-up visit usually don't care if their next appointment is seven days or seventeen days from now, as long as they know they have one..

During my partnership days, my partners' habits drove me crazy. They all booked all their time in advance; one doc overbooked two extra people for each hour "because someone might not show up." Our large waiting room was usually full of irate patients, some of them waiting two hours after their appointment time. My partners were good doctors, but were clueless about office management, as long as the office looked busy. "The patients can always get in; they just have to wait a while if we're busy."

I decided I could run an office better by leaving the partnership and going solo, and I did.

Here is what works: The doctor sits down with his staff and they decide how much the average routine visit takes of the doctor's time. Not how long he'd like it to take, but how long it really does take, according to the people who work with him. Say, for example, that on average he can handle four visits per hour. More complex problems—a new patient, or a new pregnancy— might take 30 minutes or an hour, and so would have one or more extra time slots assigned. In my own practice, I could usually handle repeat office visits in 15 minutes. Saving some time for hospital rounds, record-keeping, minor surgery, etc. each day, I usually had around six hours per day for patients' office visits.

I told my receptionist she could fill two 15-minute slots for each of those hours ahead of the day. A third one each hour could be filled from the phone calls from people who wanted to get in that day for something they thought urgent. The fourth slot each hour was saved for walk-ins. People rarely had to wait more than 10 minutes beyond their appointment time, unless I had emergency surgery or a baby delivery in progress.

Was it a problem to have an occcasional empty appointment slot? Not for me it wasn't. I used the time to return phone calls,sign or dictate letters, catch up on my medical journals, order supplies, or enjoy a cup of coffee at my desk. My patients were more relaxed, and so was I, not having to keep pace with an always over-full schedule. I found that it's not always necessary to bring someone in every month just for a blood pressure check or a blood sugar, once their condition stabilized.

Not every patient who only had a question required an appointment; sometimes the question could be handled by phone. My receptionist always brought the patient's record to my desk along with the call-back number, She only called me out of a patient's exam room if she judged the call truly urgent, or if another doctor was calling about a patient, but I tried to answer the less urgent calls as soon as possible.

This system of scheduling even gave me time to see occasional people who hadn't been able to get an appointment with their own doctor. Many had a problem that could be dealt with in a single visit, after which they could go back to the other doctor again.

So - Doctors, rethink your appointment scheduling. Packing your schedule full ahead of time causes tension, always trying to keep up, and it makes your waiting patients fidgety, even miserable if they are feeling pain or are otherwise ill. You'll also be more at ease if you get in the habit of starting on time, and limiting the length of your coffee break. (Read the newspaper at home.)

Receptionist, If the doctor is unavoidably behind schedule (and hey, it can happen) let the patients know. If the doc is way behind, offer to reschedule them. If he's avoidably behind very often, let him know.

Improving Medical Office Efficiency

2009-03-07T09:23:00.000-08:00

I recently talked with two acquaintances, about a week apart, who had complaints about their doctor's office. Neither of these families had ever been patients of mine, but people tend to bring up medical subjects when they learn that I write about medicine. Both had complaints about their doctor's office help.

"It was embarrassing," one told me. "The doctor told his office girl to make me an appointment with the urologist (kidney specialist), and she made one with a doctor who turned out to be a neurologist (brain specialist). The neurologist sent me to a urologist not far away, and didn't charge for his own office visit, but why wouldn't she have known the difference?"

The other patient had had at least six back surgeries over the years (laminectomy) and no surgeon would now touch his scarred back. His local doctor was trying to manage the pain on various pills and patches, some of which eased his chronic pain, but not the "lightning spasms" that struck when he moved wrong. Additionally, over the years, he had developed reactions to some of the medicines, and the doctor was trying a new one. Medical insurance refused to pay for it. The doctor's office clerk said she would try and straighten the matter out, and would call him back.

She never did, not even to let him know the problem. He finally called his pharmacist to see if he could afford to pay for it himself, and found to his horror that a month's supply was priced at $525.00, half his entire monthly income, Presumably, the clerk could have found that out, but if she did, she never let him know. Presumably, also, the doctor should have known the price of the new medicine, but salesmen rarely mention that. Most doctors subscribe to a service that publishes latest drug prices, however.

Such things happen when new help is hired and isn't taught what the job involves, beyond how to fill the doctor's appointment book and send out the bills. Often there is frequent turnover of staff, either because of low pay, poorly qualified help, or poor instruction.

I learned, early on, to pay my staff a little more than the going pay rate, and to make an office instruction book covering phone etiquette, appointments, unhappy patients, inability to pay, emergencies, unavoidable delays, prescription refills, salespeople, etc. and updated it as needed. Knowing the price of my patients' medicines was my responsibility, and I tried to keep up to date and practical. I learned to try the more familiar, less expensive medicines first before going on to the "latest new drug" unless there was some specific reason to go directly to the latter.

The way our patients perceive us depends a lot on the people we employ. If you don't enjoy training new help every few months, Doctor, pay attention to them - the nurse, the technician, the clerk, the janitor, everybody, so they will stay with you. Competence and caring count, both yours and theirs.

Your office staff is one of your biggest assets. Treat them right. Don't leave it all to an office manager.

Mr. President, Medical Computer Systems Aren't that Simple

2009-02-09T10:07:00.000-08:00

"When everybody has computers, communication will be efficient, and medical costs will come down." This is what medical experts say.

Yah. Just about everybody in medicine already has a computer. It just can't communicate with all the other computer systems. Remember the 9/11 Commission report about New York's twin towers? Firemen's radios weren't on the same wavelength as the police, and City Hall had still a different system. Communication was chaos.

Recently a friend told me that because the U of Washington medical center in Seattle designed it's own computer system, our local Kootenai Medical Center can't communicate with it directly, but had to send his MRI report by a disc delivered by the postal service. His treatment was delayed by three weeks.

Doctor groups, insurance carriers, and government offices are in the same situation. Each listened to a different salesman, whose product was always "the best", and they spent hundreds of thousands of dollars buying, installing, training in the use of, and maintaining, their system, only to find out that the hospital or the next office down the road had a different system. They aren't about to pay out that amount of money all over again. "Let the other guy match up with me" is the common attitude.

Never mind that there are hackers out there in cyberspace that can break into any system. Only last month the news was full of someone who had accessed the social security numbers of millions.

Never mind that there are now double the number of clerks in every doctor's office, to transcribe the dictation for the records, and each clerk has to be paid. Never mind that the average patient's medical record has ballooned to ten times the number of pages it used to be before the computer age - computers can print it all out in a few seconds, but how long does it take to read through all those pages to find the information you are looking for?

Never mind that computers can crash, or records disappear into cyberspace, if there is no hard copy backup.

And never mind that doctors and nurses still make medication errors even with everything computerized. The data is only as reliable as the typist and the reader.

Computers are a necessary advance in medical information transfer, but so far they are not money savers. And mis-information can still spread—even more easily spread—by computer.

"Now, Dear, we don't really know that yet."

2009-01-30T20:13:00.000-08:00

My friend, herself a retired RN, has two stories to tell. The first happened when she was in her third pregnancy, with a past history of rapid labors, and she arrived at the hospital's emergency entrance "with a continuous contraction."

"I need to go to the delivery room," she told the nurse.

"Well, first we need to get your name, address, and name of your insurance." The nurse was proceeding by rote.

"I need to be in the delivery room!" gasped her patient.

"Everyone is in a meeting just now," soothed the nurse. "Now, your name?"

"HERE COMES THE BABY!" That finally focused the nurse's attention.

Fast forward fifty years: My nurse-friend has been referred to a gastroenterologist by her family doctor. A nurse practitioner is taking her history.

"I have upper abdominal pain. My GP found GI bleeding and a low hemoglobin."

The nurse smiled patiently. "Now, dear, we don't know that."

My friend had her family doctor's lab reports, but as often happens, the specialist only accepted reports from his own lab, "to eliminate error."

Before he would treat her, he required a gastroscopy (passing a scope down the throat and into the stomach to take a direct look.) "We're pretty busy," the patient was told, we can schedule you for six weeks from now." No medicine was supplied for the interim.

My friend returned to her family doc who gave a prescription for Prevacid. Taking that for six weeks healed her pain, and the gastroscope showed a stomach that by that time was almost normal.

Were she my patient, I would have just given her the prescription at her first visit and called in the specialist only if she wasn't improving after a week. Tests for blood in the stool, anemia and for Helicobacter (a common cause of duodenal ulcer and bleeding) can be done in the office. A scope should be done to rule out cancer, but the cancer will still be there when the specialist gets around to doing it.

My question to the specialist and his nurse would be, "Why don't you know that? Why didn't you confirm or disprove the family doctor's data at first visit, at least look at his lab reports, and save your patient time, worry, and money?" Sometimes it seems like no one listens to anyone else.

Nurses versus Surgeons

2008-07-23T11:05:00.000-07:00

Seven a.m. in the surgical hallway of Fort Anonymous U.S. Army Hospital on a dark December morning. Nurses in clean surgical scrub attire hurry between Central Supply and operating rooms with bundles of instruments and sterile drapes. Others wheel patients on stretchers, each to an assigned operating room. Anesthetists check their gas machines and syringes as the surgical teams gather at the scrub sinks, cleaning hands and forearms the required five minutes with antiseptic soap.

“I can’t find my scrubs!” a surgeon complains to the chief operating room nurse as she walks by, her eyes checking her nurse lieutenants as they go about their assigned tasks.

The chief nurse stops to look at the surgeon, then at the nearly empty rack where surgical scrub suits for the operating rooms are stored. “Why do you suppose that is?” she asks him.

“It’s not my job to know why that is,” he fumes. “My job is to be in the Operating Room fifteen minutes from now, ready to operate. Where are my scrubs!”

“Well, let’s think a minute,” she says. “How many scrub suits are hidden behind your desk in your office? How many stayed on the floor in the intern’s lounge when you changed back into street clothes last week? If you don’t put them in the laundry hamper, Major, they don’t get picked up. I can’t give you what I don’t have.”

“I don’t care about that,” the major snaps, “what we need in this OR is one of those scrub-dispensing machines!” He stamps off down to the laundry department to harass the workers who unload the laundry delivery truck each day. But they really couldn’t do anything about scrub suits the truck hasn’t picked up, and therefore can't deliver again.

“Dispensing machines don’t solve the problem,” the chief nurse remarks to her assistant. “The hospital in San Antonio had them when I worked there as an instructor. You have a card to insert, you punch in your size, and out comes a scrub suit. But the surgeons can’t be bothered to dump them back into the machine’s bin at the end of the day and get their card credited. If they don’t return them two days in a row, the machine voids their card and they come screaming to the nurses again.”

She turns her attention to another surgeon who is demanding a certain surgical instrument NOW. ”Dr. B is using it in Room 3,” she said. “We can have it resterillized in about 20 minutes.”

“My patient is on the table now. I need it now."

“It’s already in use. You didn’t think of that when you changed your scheduled time for this case, did you,” she says patiently.

“Look, I’m a surgeon. Surgeons operate. Nurses get instruments ready. If that one’s in use, get me another one from the supply house.”

“The supply house that sells that instrument is in Omaha,” she says sweetly. “I can ask them to send it urgent express, and we can have it for you on Wednesday. Otherwise we have to wait till Dr. B’s case is finished in a few minutes and we resterillize the one we’ve got.”

“I’m going to bring this up in staff meeting.” He strides angrily off down the hall.

“Do that,” she calls after him. “I’ll give you the serial number and cost figures. It’s expensive.”

Five hundred people attend the all-hospital Christmas dinner a few days later. Part of the entertainment after the meal is Christmas carols. Each group of tables is assigned one verse of “Twelve Days of Christmas.” The operating room crew’s tables are assigned to sing “seven swans a-swimming” with each successive verse.

“Colonel, Ma’am?” A nurse lieutenant leans across the table. “Seven swans a-swimming sounds kind of dull,” she says. “How about ‘Seven surgeons screaming’?”

“No,” says another nurse, “They don’t actually scream. What else could we say?”

The chief OR nurse lets them work it out. They finally agree on “Seven surgeons whining.” The chief nods. This isn’t her idea, but it expresses the thought.

“The Colonel says it’s okay,” is whispered from nurse to nurse down the row of tables.When the sixth verse of the song finishes, their verse is next.

“On the seventh day of Christmas my true-love gave to me-" The surgical nurses rise as one and sing out, “seven surgeons whining–"

There's a pause in the large hall. “I don’t think those are the right words,” the song leader says from the head table. “Let’s try again. On the seventh day of Christmas my true-love gave to me–"

The surgical techs rise again, “Seven surgeons whining-"

In the following silence, two or three voices from the surgeons’ tables are heard, “Hey, now, what is this?”

“See?” a nurse exclaims triumphantly, “there you go again!”

Later, as the party breaks up and people are saying their goodbyes, the chief surgeon and the hospital commander come over to the chief surgical nurse. “Colonel, what are you doing to those nurses?”

“Wasn’t my idea,” she says. “But, ya know, sometimes they need a little morale-building. See y’all Monday morning!”

2008-07-22T15:45:00.000-07:00

Heart on the Cutting Edge

October 31, 2000: The conference room was jammed with people, some picking up a sandwich and a bottled drink, others already seated at the long T-shaped table or around the edges of the room. A secretary brought in more chairs. At the far end of the room a couple of technician types hover over a foot-long object resting on two wheels at one end and a leg at the other. It looks like a toy farm tractor.

I choose a sandwich, look around for a seat, find none, and balance my paper plate with one hand while standing to see over the heads of those seated closer to the demonstration.

“Because a few molecules of air gradually seep through the plastic,” one tech was saying, “the pump occasionally must be vented by pressing this button, to restore full air volume in the pumping chamber. The heart will stop for six seconds during this and then the pump will automatically start again at sixty beats per minute and gradually come up to its original speed.” He demonstrated. The tractor-like toy on the table went Thug. Thug… thug…thug, thug, thug, and a heart monitor began to beep.

A stack of printed brochures is being passed around. I hold my plate with one hand, put my sandwich between my teeth, take a brochure and hold it under my armpit for the moment. The second tech uses an overhead projector to shine a diagram up on a screen. I glance around the room, see that the audience is mostly nurses, ambulance EMTs and a few doctors.

The speaker continues, “You’ve all been invited to this orientation because, up till now, patients with heart-assist pumps have been confined to large hospital centers while they await their heart transplant. But as you know, there are now around three thousand candidates for a heart transplant each year, and far fewer heart donors than that. This model you see on the table is an entirely new concept, allowing the patient whose heart no longer has the strength to maintain life to live in your community and function almost normally for years.”

He flashes another diagram on the screen. “Sacred Heart Medical Center’s Heart Transplant program now has successfully implanted the Pneumatic HeartMate Assist device in more than a dozen patients. At present, we in Spokane are the only center in America licensed by the FDA to do this experimental procedure. All of our subjects are still alive; some have gone on to receive a new heart transplant, others have been discharged to live in their home communities, including one here in your area. We want you to be familiar with the device and with what to do, and what not to do, if the patient should ever need medical assistance.”

I look at the gadget with renewed interest. The brochure shows a man carrying it on a strap over his shoulder, with a large plastic tube going into his mid-section somewhere. Another picture shows an elderly man with a backpack, fishing by a stream; in another, a blonde young woman is playing with her child. None of them seem concerned with the tube in their abdomen. I turn my attention back to the screen.

“As you can see, the internal pump is a simple design, attaching the bottom of the heart’s left ventricle to the aorta, with two valves to ensure one-way flow. The pumping chamber is implanted inside the abdomen. A flexible diaphragm separates the blood circuit from the external pneumatic pumping circuit which is powered by the control panel you see here on the table. Each time the blood-circuit chamber is 90% filled with blood from the heart, the control panel causes air to press against the chamber diaphragm, emptying the chamber into the aorta and onward to the arteries of the body. The air-pump locks on to the tube emerging from the patient’s abdomen. Each patient is sent home with two complete pumps, plus a hand operated pump for extra back-up, and several sets of rechargeable batteries, each set capable of six hours operation before recharging It can also run from an a.c.wall outlet, with the batteries taking over in case of power failure”

He went on to explain the meaning of each of several alarms; one directing the attendant to vent the pump, another to indicate the battery is getting low. “And this one,” he pressed something causing the control panel to flash a red light and emit shrieks, “tells you to change to the back-up pump immediately.”

He passed around a second brochure. “This one is for you doctors. There’s not really much that’s new. When the yellow light goes on, vent the pump. And remember, the patient can be in any kind of heart rhythm and the pump will still move the blood. The ventricle may even be fibrillating but the patient can still remain conscious. If he drops below a flow of two liters a minute, give large amounts of IV fluid and correct the heart rhythm. If the pump fails, switch to the backup pump and call us, to get him back to Spokane. You ambulance people, remember to vent the pump once for every 1,000 feet change in altitude, but you shouldn’t need to, going over the pass to Spokane. This pump system does not require blood thinners; one aspirin a day is usually enough. Most medicines are given in the same manner you would give them to anyone else. Any questions?”

I had one. “I got here a little late; maybe you already explained why this one set of instructions you handed out is written in Japanese.”

“Oops.” He looked flustered, reached into a box under the table, handed out English copies. “We invite patients from all over the world. I don’t know how that got in there. Other questions?”

“How long do these pumps keep working?” someone asked.

“The longest laboratory test is still running after eight years. Four of our patients so far have each logged over 200 days and counting. Obviously, pumps eventually wear out. We haven’t yet found out when. That’s one reason the project is still classed experimental. But the device is no longer just a bridge to keep the patient going until heart transplant. With the shortage of donor hearts, we anticipate many people will live with this device for years.”

“Does the HeartMate eliminate the need for CPR if a patient’s heart stops?”

“Play it the same way as you do with any other patient. If there is no pulse, that means no significant flow, and you need to give chest compressions. We’d just as soon that didn’t happen in the first three months after surgery; the connections inside the patient are sturdy titanium, but could be dislodged before scar tissue seals them in. Ordinarily all patients are kept in Spokane those first three months. After that, we want to see them every six months, but we are available 24/7 to answer your problems, and our phone numbers are in the handout."

“Cost?”

“We require either proof the insurance carrier will cover costs (which most don’t as long as a procedure is experimental) or three hundred thousand dollars on deposit, to cover all costs and on-going follow-up. We have no grant for this, but we do refund any unused amount. It’s not cheap, but compared with heart-transplant costs and on-going treatment, we think it will prove cost-effective and will eventually be accepted by insurance carriers.”

I consider another sandwich; then decide I had better not increase the program’s costs any more than necessary.

But as I carried my (English language) instruction book home I thought, it’s going to be scary, the first time the ambulance arrives with one of these people, but we’ve got the directions and the equipment, and the back-up folks in Spokane. Kind of awesome—Kellogg, Idaho on the cutting edge of a new technology, one of the first towns world-wide to participate.