Baseball (or as it should be called base ball) teams playing under 19th century rules have become somewhat popular of late. They seem to divide up into teams playing under 1880's rules and those going way Retro and playing the 1860's version. While passing through Stillwater Minnesota recently we took in a couple of innings of Civil War era base ball.
I love the uniforms, although they look hot and itchy. At one point the Umpire made a general announcement that, in consultation with the Ladies present, it had been decided that Gentlemen may roll up their sleeves.
Even today Umpires wear a somewhat old fashioned uniform. But not this Old! I am sure he researched the gestures used to make rulings. This means, then as now, "safe".
Wooden bats of course. If you showed up with an Aluminum specimen you would probably have been fined two dozen cigars and thrown out of the league. Note also the galvanized pail of water with a dipper in it. A nice touch on a hot thirsty day.
In 1860's rules the players do not wear gloves. On the other hand if they catch a ball on one hop it records an out, so there is that. The anachronistic sunglasses seem to have been allowed. It is a stretch, but in the 19th century green tinted glasses were in use...but to protect eyes from overuse not from the sun.
Although nobody seemed very concerned about the outcome of the game, for the record the above team, The Rochester Roosters, lost to the Arlington squad by a final score of five aces to three. Or perhaps four, nobody could recall.
With the casual nature of the competition, combined with the physiques and facial hair on display above, I could totally see myself catching on with a team next season.
Wandering unsupervised in various real and imaginary places. Detritus reflects my interests in robotics, travel, history and the odder aspects of the world around me.
Wednesday, July 31, 2013
Monday, July 29, 2013
Charles Babbage Sent Me
Computer Nerd: “Good
Afternoon Gentlemen. What can I help you
find today?”
Your Humble
Correspondent: “A laptop for my boy here.
Needs it for school.”
CN: “Right! Well, we have a nice selection right over
here. I suggest…”
YHC: “Ahem.
You were recommended to us as a place that might have some, er, special
items…”
CN: “We certainly serve a wide range of
customers, Sir. From those with rather
common place needs on up to those with, shall we say, discriminating tastes?”
YHC: “My first computer had a hard drive
capacity of 20 megabytes. That was
before you were born.”
CN: “I see.
Now, if you will just step over here.
Yes, behind that display. And
your voices, perhaps a bit of discretion would be in order..”
YHC: “So.
Do you have any?”
CN: “What you are looking for is very
difficult to find these days. Very
difficult indeed. But if you promise to
keep quiet about it I think we can make a satisfactory arrangement for you.”
YHC: “So you do have it then?”
CN: “Yes indeed. Here before you, in a world filled with gaudy
trash is a fine example of functional beauty.
A computer that will serve you without complaint or flaw. A reminder of an earlier, a simpler, yes I
will say it, a better time. Please give
it a good home, respect it and cherish it.”
And so it was that we bought one of the last Windows 7
computers on the – more or less – open market.
Friday, July 26, 2013
The Dog Days King of Iceland
The hot, lazy days of late July and early August have been known since ancient times as "the dog days". Although you can easily imagine a languid dog sleeping in the heat the name actually comes from the Romans. The hottest time of the year was also a time of sickness, which they felt to be under the influence of the star Sirius, largest in the constellation Canis Major (the large dog).
When double checking a few facts on the matter of "dog days" I encountered a remarkable biography, one I could not resist investigating further. Here then is the bizarre tale of the "Dog Days King of Iceland".
Jorgen Jorgenson did not have a happy childhood. Although quite bright he did poorly in school and was expelled at age 14. Although he was Danish it was arranged that he would go to sea on an English merchant ship. After the fashion of such times he was caught up by a press gang that delightful method of staffing the British Royal Navy by simply grabbing trained sailors from seaside taverns or directly off of their ships.
He spent a number of years in the South Seas, visiting Australia and New Zealand, before returning to his homeland just in time to witness first hand the Battle of Copenhagen in which Admiral Horatio Nelson attacked the anchored Danish-Norse fleet. As there was no formal declaration of war involved, the phrase "to Copenhagen" was a term for a surprise attack long before Pearl Harbor came along historically.
Jorgenson was soon given command of a small naval vessel that sailed for France, but was captured by a British ship. He was put "on parole", which mostly consisted of hanging around in England with nothing much to do.
News came to him that Iceland was short of food. He talked a merchant into funding a single ship expedition to trade with Iceland. His first attempt failed. Despite flying false colors as an American ship, his vessel was determined to be British. Probably noticing the current state of hostilities the Danish governor of Iceland refused to let any trading occur.
Returning to England the irrepressible Jorgenson launched another trade mission to Iceland, this time with two ships. The Flora and the Margaret and Anne reached Iceland in June of 1809.
At this point the goings on start to sound like a cheaply written comic opera.
The governor of the island, Count Trampe, would still not permit trading. So on Sunday when most of the population was in church, Jorgenson and his sailors surrounded the governor's house and arrested him. Jorgenson proclaimed himself "His Excellency, the Protector of Iceland, Commander in Chief by Land and Sea". Taxes were remitted. Danish property given away. The salaries of clergy were increased. There were promises of peace and cheap food.
It all was going so very well until a British ship turned up in August and deposed Jorgenson. As his brief reign corresponded to the Dog Days of Summer he is remembered in Iceland as The Dog Days King. It should also be noted that late summer in the newspaper business was once called The Silly Season, and this sort of tale would fit right in.
I recommend those interested in the later adventures of Jorgen Jorgenson to peruse this remarkable biographical sketch. For those short of time I will simply say that his later career was no less eccentric. At various times he was imprisoned for breaking parole, for bad debts and for pawning his land lady's furniture. He found intermittent employ as a spy, an author, a surveyor, an editor, a drunkard and in one remarkable instance a rather successful ship's surgeon. (While being shipped as a convict to Australia he was assistant to the ship's doctor. When said individual died Jorgen just took over the job).
Once established in Tasmania, then called Van Diemen's Land, he served in the police force with some gallantry against the "Bushrangers", convicts who had gone into the wild as bandits. Probably he was less gallant in action during The Black War, a genocidal campaign against the aboriginal inhabitants.
Oh, and he also married an ex-convict woman named Deborah Carbon in 1831, and managed to write two volumes of his autobiography before his death in 1841.
Two volumes was probably not enough.
More on The Dog Days King here.
When double checking a few facts on the matter of "dog days" I encountered a remarkable biography, one I could not resist investigating further. Here then is the bizarre tale of the "Dog Days King of Iceland".
Jorgen Jorgenson did not have a happy childhood. Although quite bright he did poorly in school and was expelled at age 14. Although he was Danish it was arranged that he would go to sea on an English merchant ship. After the fashion of such times he was caught up by a press gang that delightful method of staffing the British Royal Navy by simply grabbing trained sailors from seaside taverns or directly off of their ships.
He spent a number of years in the South Seas, visiting Australia and New Zealand, before returning to his homeland just in time to witness first hand the Battle of Copenhagen in which Admiral Horatio Nelson attacked the anchored Danish-Norse fleet. As there was no formal declaration of war involved, the phrase "to Copenhagen" was a term for a surprise attack long before Pearl Harbor came along historically.
Jorgenson was soon given command of a small naval vessel that sailed for France, but was captured by a British ship. He was put "on parole", which mostly consisted of hanging around in England with nothing much to do.
News came to him that Iceland was short of food. He talked a merchant into funding a single ship expedition to trade with Iceland. His first attempt failed. Despite flying false colors as an American ship, his vessel was determined to be British. Probably noticing the current state of hostilities the Danish governor of Iceland refused to let any trading occur.
Returning to England the irrepressible Jorgenson launched another trade mission to Iceland, this time with two ships. The Flora and the Margaret and Anne reached Iceland in June of 1809.
At this point the goings on start to sound like a cheaply written comic opera.
The governor of the island, Count Trampe, would still not permit trading. So on Sunday when most of the population was in church, Jorgenson and his sailors surrounded the governor's house and arrested him. Jorgenson proclaimed himself "His Excellency, the Protector of Iceland, Commander in Chief by Land and Sea". Taxes were remitted. Danish property given away. The salaries of clergy were increased. There were promises of peace and cheap food.
It all was going so very well until a British ship turned up in August and deposed Jorgenson. As his brief reign corresponded to the Dog Days of Summer he is remembered in Iceland as The Dog Days King. It should also be noted that late summer in the newspaper business was once called The Silly Season, and this sort of tale would fit right in.
I recommend those interested in the later adventures of Jorgen Jorgenson to peruse this remarkable biographical sketch. For those short of time I will simply say that his later career was no less eccentric. At various times he was imprisoned for breaking parole, for bad debts and for pawning his land lady's furniture. He found intermittent employ as a spy, an author, a surveyor, an editor, a drunkard and in one remarkable instance a rather successful ship's surgeon. (While being shipped as a convict to Australia he was assistant to the ship's doctor. When said individual died Jorgen just took over the job).
Once established in Tasmania, then called Van Diemen's Land, he served in the police force with some gallantry against the "Bushrangers", convicts who had gone into the wild as bandits. Probably he was less gallant in action during The Black War, a genocidal campaign against the aboriginal inhabitants.
Oh, and he also married an ex-convict woman named Deborah Carbon in 1831, and managed to write two volumes of his autobiography before his death in 1841.
Two volumes was probably not enough.
More on The Dog Days King here.
Wednesday, July 24, 2013
Memorable ER Quotes-Seven
Middle of the night. An older fellow is brought in, retired Professor. He might have had a minor fall, and there is concern that he is unsteady.
Nothing major turns up. His blood pressure is a little low. Ditto his heart rate, but that seems to be an ongoing issue. And he is sober as a judge. Well, as sober as some judges I know, with a blood alcohol level roughly two and a half times legal intoxication.
He is a widower it seems, and is lonely in the Assisted Living apartments. He likes his gin.
And he likes his ladies. I had a nurse get him up on his feet for the final, most practical test of stability.
His flushed face beamed with happiness as he strode down the hall way, fairly steady and with a young lady at his elbow.
He raised his free arm up high as if brandishing a triumphant sword, exclaiming:
"EXCELSIOR!, EXCELSIOR!"
I sent him back to the apartments.
Nothing major turns up. His blood pressure is a little low. Ditto his heart rate, but that seems to be an ongoing issue. And he is sober as a judge. Well, as sober as some judges I know, with a blood alcohol level roughly two and a half times legal intoxication.
He is a widower it seems, and is lonely in the Assisted Living apartments. He likes his gin.
And he likes his ladies. I had a nurse get him up on his feet for the final, most practical test of stability.
His flushed face beamed with happiness as he strode down the hall way, fairly steady and with a young lady at his elbow.
He raised his free arm up high as if brandishing a triumphant sword, exclaiming:
"EXCELSIOR!, EXCELSIOR!"
I sent him back to the apartments.
Monday, July 22, 2013
Memorable ER Quotes Six
"I am a Professional Poker Player"
This was from a pleasant young man in his early 20's who seemed to be strategically cultivating the look of someone in their mid teens.
"I am Maha Maya, the Mother of all Buddas!"
This from a rather vocal individual who was demanding five glasses of ice water and to be medivaced out immediately.
This was from a pleasant young man in his early 20's who seemed to be strategically cultivating the look of someone in their mid teens.
------------------------
This from a rather vocal individual who was demanding five glasses of ice water and to be medivaced out immediately.
---------------------------
A patient being admitted for another problem entirely pointed out some odd scratches on his abdomen.
"I bet you can't guess how I got those."
I admitted I could not.
"I was attacked by a chickadee."
Friday, July 19, 2013
Economic Report - Summer of 2013
The economy in summer resort areas has some quirks. A larger than usual percentage of it is directed towards indulging various minor vices. Here is a local emporium;
Fudge, Liquor and Fireworks. Yep, that just about covers it.
Fudge, Liquor and Fireworks. Yep, that just about covers it.
Thursday, July 18, 2013
Tree Shaped Tombstones - On the Bench, Part Two
Benches in the fashion of Tree Shaped Tombstones are rather pretty things. Functional too.
So, why didn't they catch on? Well, as I walked around Forest Lawn Cemetery in St. Paul it soon became obvious that these memorials had some issues with design. Now, the above specimen is on a nice solid foundation of cement. Some were not, and displayed variable levels of sinking and tilting...
Even the specimens that are mostly upright had problems. It is just plain sad to see things like this...
And worse..
These things are heavy, and unlike conventional tombstones they have long, weight bearing segments across the back and seat of the bench. It is not always easy to tell, but in numerous instances it looked as if these components had been replaced after breakage, going from the original limestone to either cement or some other sort of stone. For instance:
Clearly both units have been replaced. In my previous post I noted numbers carved into the benches. This seems very unlikely to have been allowed in the original production of the memorials....what family would accept delivery with crude numbers scratched on them? But as markers on replacement parts years later, I could buy that.
It is a little disturbing to see something designed to last forever fall into disrepair.
But I guess there is only so much you can do with a flawed design, or at a minimum, one not well suited to the extremes of northern climates.
In times past, and even today, there were often monument companies located near cemeteries. Perhaps there was one close to hand that specialized in this interesting style of tombstone. They certainly seemed to turn up at Forest Lawn in abundance, but have to be regarded as rare birds overall.
So, why didn't they catch on? Well, as I walked around Forest Lawn Cemetery in St. Paul it soon became obvious that these memorials had some issues with design. Now, the above specimen is on a nice solid foundation of cement. Some were not, and displayed variable levels of sinking and tilting...
Even the specimens that are mostly upright had problems. It is just plain sad to see things like this...
And worse..
These things are heavy, and unlike conventional tombstones they have long, weight bearing segments across the back and seat of the bench. It is not always easy to tell, but in numerous instances it looked as if these components had been replaced after breakage, going from the original limestone to either cement or some other sort of stone. For instance:
Clearly both units have been replaced. In my previous post I noted numbers carved into the benches. This seems very unlikely to have been allowed in the original production of the memorials....what family would accept delivery with crude numbers scratched on them? But as markers on replacement parts years later, I could buy that.
It is a little disturbing to see something designed to last forever fall into disrepair.
But I guess there is only so much you can do with a flawed design, or at a minimum, one not well suited to the extremes of northern climates.
In times past, and even today, there were often monument companies located near cemeteries. Perhaps there was one close to hand that specialized in this interesting style of tombstone. They certainly seemed to turn up at Forest Lawn in abundance, but have to be regarded as rare birds overall.
Wednesday, July 17, 2013
Tree Shaped Tombstones - On The Bench, Part One
I had seen one or two pictures of benches in the style of "tree shaped tombstones", so one day when I was playing around with Google Maps I was not particularly surprised to spot, from orbit, an example in the Forest Lawn Cemetery in St. Paul Minnesota. Actually, it looked like there were several of them.
It took a while for me to be in the area with time to spare for a side trip, but one sunny afternoon I drove on over.
As it happens, this cemetery is another of those odd places where tree shaped tombstones are common....and it has a remarkable number of tree-benches.
Here is one typical specimen:
And here in one view are three, with a tree shaped planter to boot.
Forest Lawn Cemetery is full of these things. Without visiting every nook and cranny I am just estimating, but there are probably forty or fifty of them on the grounds.
They are all similar, although there is enough variation in the pattern of the stumps and limbs to show that the sides of these were hand carved. And after a while you start to notice smaller differences. Here are a couple of examples with small odd flourishes....left by the stone carvers for no reason I can fathom...
Here is one with a more elaborate back piece, giving names and dates of the departed. I assume the death date of the first to go is the approximate age of these memorials.
Here is another bit of ornamentation, a Masonic emblem on the back piece.
All in all rather nice memorials. I can easily imagine putting one of these up on the family plot, then sitting there in a contemplative mood imagining that a beloved one who had passed on was sitting next to me in spirit. So why are these so rare? I will spin a few theories in my next posting, but the first clue was this:
I had thought that this number, carved into the seat of one of these tree shaped benches, was just a bit of petty vandalism. But then I found two other examples...a #2 and a #17. Too specific for vandals, especially when this well kept establishment had no other evidence of such misbehaviour.
So, what does it mean? Why so many benches there? Why so few elsewhere? And....numbers on the benches? I will be back tomorrow with more pictures and thoughts on Tree Shaped Bench memorials.
It took a while for me to be in the area with time to spare for a side trip, but one sunny afternoon I drove on over.
As it happens, this cemetery is another of those odd places where tree shaped tombstones are common....and it has a remarkable number of tree-benches.
Here is one typical specimen:
And here in one view are three, with a tree shaped planter to boot.
Forest Lawn Cemetery is full of these things. Without visiting every nook and cranny I am just estimating, but there are probably forty or fifty of them on the grounds.
They are all similar, although there is enough variation in the pattern of the stumps and limbs to show that the sides of these were hand carved. And after a while you start to notice smaller differences. Here are a couple of examples with small odd flourishes....left by the stone carvers for no reason I can fathom...
Here is one with a more elaborate back piece, giving names and dates of the departed. I assume the death date of the first to go is the approximate age of these memorials.
Here is another bit of ornamentation, a Masonic emblem on the back piece.
All in all rather nice memorials. I can easily imagine putting one of these up on the family plot, then sitting there in a contemplative mood imagining that a beloved one who had passed on was sitting next to me in spirit. So why are these so rare? I will spin a few theories in my next posting, but the first clue was this:
I had thought that this number, carved into the seat of one of these tree shaped benches, was just a bit of petty vandalism. But then I found two other examples...a #2 and a #17. Too specific for vandals, especially when this well kept establishment had no other evidence of such misbehaviour.
So, what does it mean? Why so many benches there? Why so few elsewhere? And....numbers on the benches? I will be back tomorrow with more pictures and thoughts on Tree Shaped Bench memorials.
Monday, July 15, 2013
Tree Shaped Tombstones - Genuine Woodmen Versions
Despite what you may read here and there on the internet, most "tree shaped tombstones" had nothing to do with the Woodmen of the World organization. You see lots of "trees" with no Woodman designation. And you also see a wide array of standard tombstones featuring the Woodman logo. But when the two occur together it is probably not entirely coincidental, the Woodmen did have a burial benefit that would permit buying a fancier marker. And I have noted a slight tendency for Tree Shaped Tombstones to be associated with fraternal lodges generally.
Here are a few specimens of "genuine" Woodmen trees:
Here are a few specimens of "genuine" Woodmen trees:
This one is from the Pioneers Cemetery on south Lake Street in Minneapolis. Here is a close up of the Woodmen logo, which does not seem to be aging well. Is urban air quality next to a busy street hard on these?
And another specimen from Western Wisconsin. Note that both of these are a sort of composite tree, combining a stack of logs with a mid sized stump.
Different logo too...
In addition to the similar, but not identical style I suppose you could note that both of these tombstones were for fellows with very Scandinavian names. But that probably just reflects demographic reality of the upper midwest. The next example is an interesting one...
It qualifies as a "tree shaped tombstone", albeit a modest single log version. But note that the M.W. of A. was a different organization from the W.O.W, even though they were founded by the same individual. The story of how the Modern Woodmen of America parted company with the Woodmen of the World is found here.
And here is another Modern Woodmen tree. This is a seriously over the top specimen I found in a cemetery in St. Paul, Minnesota. Axe, hammer (or gavel?) splitting wedge, ropes, a bird, just an awful lot going on here. I found some other remarkable specimens in this location, more on this as the week goes on.
Friday, July 12, 2013
The Primrose Path
I had heard the phrase "Primrose Path" many times but had not realized it comes straight from The Bard....Hamlet no less.
The phrase implies a tendency to take the easy, pleasant path when there are more rigorous, stone strewn alternatives. It is likely related to the concept of being led "down the garden path", although that one has some additional implications of willful deception.
I see the medical system go down the wrong path from time to time. Physicians today are smart. They have at their keyboards the accumulated wisdom of practitioners from time immemorial. They have diagnostic technology that is Star Trek level stuff compared to my training back in the early 1980s.
And I still see clinicians, good ones, get fooled.
There are many contributing factors, but one of the biggest ones is the lure of "the primrose path". We, both the physician and the patient, want the diagnosis to be neat, clean, something we can fix. We want easy.
This tendency may be more pronounced in an Emergency Room setting. We have significant time pressures - time spent unraveling a complex story in room 4 is accompanied by a steady drip of blood in room 9. We have patients and families who are in fact im-patient and who quite often arrive with a fixed notion of what is wrong. And despite the vaunted wonders of Electronic Medical Records we usually do not have the ability to review in detail previous clinical data. So often the patient is from out of town. Or is from a health system that guards their data jealously. The other day my passwords for our major outpatient health system just quit working. Naturally there had been another system "upgrade".
And of course some patients have no coordinated health care, they just wander from ER to ER. For these nomads the ambulance is more of a taxi service.
The end result of incomplete information often is a diagnosis of some kind of bacterial infection and the prescribing of an antibiotic.
"The doctor said I had just a touch of pneumonia."
"It was early Lyme disease, that makes the fourth time I have had it."
"I had another kidney infection." This last one is usually based on a mildly abnormal urine sample....the culture often comes back negative in a few days time.
If antibiotics were innocuous we would put them into the water supply. They are not. But worse than allergic reactions and more immediate than the issue of increasing antibiotic resistance, is the problem of missed diagnoses. My list of things that do not turn out to be a simple UTI, or an enigmatic tick borne illness, or "a touch of pneumonia" grows ever longer.
Heart attacks. Endocarditis with sepsis. Allergic reactions. Cancers of the lung, kidney or bladder. Leukemia. If we start lumping in the folks who were felt to just be "a little dehydrated" from a stomach bug and just in need of a bag of IV fluid I could add several more serious diagnoses.
Patients want that simple answer and that antibiotic prescription. Not infrequently they demand it. They are rightly worried about how much ER care costs and want to be out the door with as few tests as possible. And they are fairly often correct in their self diagnoses....it does not pay to become a medical Luddite and assume that nothing will be treatable with antibiotics, although some days it does feel that way.
Come closer for a moment, and I shall whisper something interesting in your ear...
Almost everyone who walks out of the ER with an antibiotic prescription feels better.
Of course they do, the placebo effect is still alive and well. And it gets a big help from the fact that several of the commonly used antibiotics have moderate anti-inflammatory properties. Sure, a person with a mild asthma flare due to a cold really ought to be on a short course of the anti-inflammatory steroid, prednisone. But that azithromycin or doxycycline for "almost pneumonia" is like being on Prednisone Junior and may well get you by. Heck, I am old enough to remember that we once used tetracyclines to treat the joint inflammation of rheumatoid arthritis!
Remember that most people do get over most illnesses.
Of course a trivial antibiotic prescription does not do much for that lung cancer, or that viral myocarditis, or the septic embolus that is causing that pale, visibly shaking patient to have a painful, white as the sheet leg.
So what can we do?
Not much I fear. I am seeing a trend in recent years. As primary care clinics are getting reimbursement bonuses for chronic disease management we are seeing them devote more and more of their resources to, no surprise, chronic disease management. For diagnosing something new the two pathways appear to be specialist referral or off the the ER. And the former route is so much paperwork and bother.
If I only handled emergencies, or to stretch it a bit include as well the urgent things that should be seen when the clinics can't, I would have a lot more resources to deploy. That abdominal pain that has been going on for months and has baffled several previous doctors is probably not going to be figured out in the ER tonight. Another batch of antibiotics for a soft diagnosis of diverticulitis may not be the answer.
But no matter what the demands of the shift turn out to be, physicians need to still think. Sometimes think really hard, considering and reconsidering a wide range of diagnoses. Pull up that clinic file if you can. Call that specialist to pick their brains a bit. There are some superb clinical data bases such as UptoDate, they are your friends.
And you have to sell the patients on this approach. You need to explain why you are repeating some tests and not others. I always try and look wise and full of gravitas while telling them that my job in the ER is to never miss a serious problem and that takes some effort.
Most ER stuff is actually very straightforward. Put in those stitches. Remove that fish hook. Stabilize a patient and call the helicopter. But some of it is very difficult indeed.
Doctors, don't take the easy path for convenience.
Patients, same advice.
Whiles, like a puff'd and reckless libertine,
Himself the primrose path of dalliance treads,
The phrase implies a tendency to take the easy, pleasant path when there are more rigorous, stone strewn alternatives. It is likely related to the concept of being led "down the garden path", although that one has some additional implications of willful deception.
I see the medical system go down the wrong path from time to time. Physicians today are smart. They have at their keyboards the accumulated wisdom of practitioners from time immemorial. They have diagnostic technology that is Star Trek level stuff compared to my training back in the early 1980s.
And I still see clinicians, good ones, get fooled.
There are many contributing factors, but one of the biggest ones is the lure of "the primrose path". We, both the physician and the patient, want the diagnosis to be neat, clean, something we can fix. We want easy.
This tendency may be more pronounced in an Emergency Room setting. We have significant time pressures - time spent unraveling a complex story in room 4 is accompanied by a steady drip of blood in room 9. We have patients and families who are in fact im-patient and who quite often arrive with a fixed notion of what is wrong. And despite the vaunted wonders of Electronic Medical Records we usually do not have the ability to review in detail previous clinical data. So often the patient is from out of town. Or is from a health system that guards their data jealously. The other day my passwords for our major outpatient health system just quit working. Naturally there had been another system "upgrade".
And of course some patients have no coordinated health care, they just wander from ER to ER. For these nomads the ambulance is more of a taxi service.
The end result of incomplete information often is a diagnosis of some kind of bacterial infection and the prescribing of an antibiotic.
"The doctor said I had just a touch of pneumonia."
"It was early Lyme disease, that makes the fourth time I have had it."
"I had another kidney infection." This last one is usually based on a mildly abnormal urine sample....the culture often comes back negative in a few days time.
If antibiotics were innocuous we would put them into the water supply. They are not. But worse than allergic reactions and more immediate than the issue of increasing antibiotic resistance, is the problem of missed diagnoses. My list of things that do not turn out to be a simple UTI, or an enigmatic tick borne illness, or "a touch of pneumonia" grows ever longer.
Heart attacks. Endocarditis with sepsis. Allergic reactions. Cancers of the lung, kidney or bladder. Leukemia. If we start lumping in the folks who were felt to just be "a little dehydrated" from a stomach bug and just in need of a bag of IV fluid I could add several more serious diagnoses.
Patients want that simple answer and that antibiotic prescription. Not infrequently they demand it. They are rightly worried about how much ER care costs and want to be out the door with as few tests as possible. And they are fairly often correct in their self diagnoses....it does not pay to become a medical Luddite and assume that nothing will be treatable with antibiotics, although some days it does feel that way.
Come closer for a moment, and I shall whisper something interesting in your ear...
Almost everyone who walks out of the ER with an antibiotic prescription feels better.
Of course they do, the placebo effect is still alive and well. And it gets a big help from the fact that several of the commonly used antibiotics have moderate anti-inflammatory properties. Sure, a person with a mild asthma flare due to a cold really ought to be on a short course of the anti-inflammatory steroid, prednisone. But that azithromycin or doxycycline for "almost pneumonia" is like being on Prednisone Junior and may well get you by. Heck, I am old enough to remember that we once used tetracyclines to treat the joint inflammation of rheumatoid arthritis!
Remember that most people do get over most illnesses.
Of course a trivial antibiotic prescription does not do much for that lung cancer, or that viral myocarditis, or the septic embolus that is causing that pale, visibly shaking patient to have a painful, white as the sheet leg.
So what can we do?
Not much I fear. I am seeing a trend in recent years. As primary care clinics are getting reimbursement bonuses for chronic disease management we are seeing them devote more and more of their resources to, no surprise, chronic disease management. For diagnosing something new the two pathways appear to be specialist referral or off the the ER. And the former route is so much paperwork and bother.
If I only handled emergencies, or to stretch it a bit include as well the urgent things that should be seen when the clinics can't, I would have a lot more resources to deploy. That abdominal pain that has been going on for months and has baffled several previous doctors is probably not going to be figured out in the ER tonight. Another batch of antibiotics for a soft diagnosis of diverticulitis may not be the answer.
But no matter what the demands of the shift turn out to be, physicians need to still think. Sometimes think really hard, considering and reconsidering a wide range of diagnoses. Pull up that clinic file if you can. Call that specialist to pick their brains a bit. There are some superb clinical data bases such as UptoDate, they are your friends.
And you have to sell the patients on this approach. You need to explain why you are repeating some tests and not others. I always try and look wise and full of gravitas while telling them that my job in the ER is to never miss a serious problem and that takes some effort.
Most ER stuff is actually very straightforward. Put in those stitches. Remove that fish hook. Stabilize a patient and call the helicopter. But some of it is very difficult indeed.
Doctors, don't take the easy path for convenience.
Patients, same advice.
Wednesday, July 10, 2013
Mind Games and Foil
In medicine you have to keep on learning things.
In the Emergency Room one of the cool new things is bedside use of ultrasound. While we will never be quite as nimble as the ultrasound techs, it is possible to train physicians to make very quick calls on important things like internal bleeding.
I have done some medical education on the topic and have been using a loaner device to widen my experience.
Now we are planning on buying our very own ER ultrasound machine.
I do have a slight worry though, one of the contenders is this:
Honest to God, this is the Mindray M7.
Of course Mindray is a fine company, maker of good equipment. But in my line of work we see a fairly high number of patients with mental health issues. And you just know that some day I will have to examine a paranoid individual with abdominal pain. I can see it already (in my "mind's eye).
"Ahhh! Ahhh! Get those Mind Rays away from me!"
I guess we could cover up the name plate on the machine.
With tin foil, just to be sure.
------------
Addendum: We did indeed purchase the Mindray model. I had to ask....and was told that it is a Chinese company. Mindray appears to be a kludgy translation from the Mandarin. In original form it means something along the lines of "A Higher Way of Understanding". Who knew? 26 Nov. 2013
In the Emergency Room one of the cool new things is bedside use of ultrasound. While we will never be quite as nimble as the ultrasound techs, it is possible to train physicians to make very quick calls on important things like internal bleeding.
I have done some medical education on the topic and have been using a loaner device to widen my experience.
Now we are planning on buying our very own ER ultrasound machine.
I do have a slight worry though, one of the contenders is this:
Honest to God, this is the Mindray M7.
Of course Mindray is a fine company, maker of good equipment. But in my line of work we see a fairly high number of patients with mental health issues. And you just know that some day I will have to examine a paranoid individual with abdominal pain. I can see it already (in my "mind's eye).
"Ahhh! Ahhh! Get those Mind Rays away from me!"
I guess we could cover up the name plate on the machine.
With tin foil, just to be sure.
------------
Addendum: We did indeed purchase the Mindray model. I had to ask....and was told that it is a Chinese company. Mindray appears to be a kludgy translation from the Mandarin. In original form it means something along the lines of "A Higher Way of Understanding". Who knew? 26 Nov. 2013
Monday, July 8, 2013
Ants of the Internet
This summer has been the season of much work, so I have been up north a great deal. I stay at our cabin which is actually a rather pleasant arrangement.
From time to time I see ants walking around inside. This is a clear violation of our understanding, our primate-insect accord....stay outside and I will be a gentle, Gandhi-like soul, leaving you unharmed. Sometimes I even remove small creatures from dangerous places. Come inside and you shall die.
So I put out various ant poisons. These guys want kindness, they should march their little six legged selves back outside.
Here at Detritus of Empire we get occasional and much enjoyed comments from thoughtful sapient beings. And also a few from what I assume are china based computer-spam bots. Most of the latter read like this:
"spot on with this write-up, i like the way you discuss the things. i'm impressed, i must say. i'll probably be back again to read more. thanks for sharing this with us. Lee Shin"
I deleted the attached website. Really, who needs that nonsense. It has an interesting grammatical structure to it. You would think anyone who knew the phrase "spot on" would have sufficient grounding in English to realize that you should capitalize "I'm" both as a first person reference and when it starts a sentence. Who wrote the initial spam? What were his or her linguistic qualifications?
Because they march over in little flurries, I figure there must be something that attracts these internet "ants". So I decided a little experiment was in order.
I am going to specifically try and attract the spambots. When they turn up I will delete the web addresses and just leave their kind, if hardly heartfelt, words. I will probably also edit any that are making indecent proposals.
So, operating under the theory that certain phrases attract them, here goes....
Jennifer Anniston
Acacia Berries
Weird Weight loss tips that Doctors do not want you to know.
Save money on auto insurance.
And for good measure:
i'm really impressed. i would like to learn more about chinese spam bots. i'll probably be back again to buy counterfeit designer handbags.
Note: I have never to date deleted a post, it seems like cheating. But if this attracts electronic attention beyond the entertainment level I may decide to "nuke it from orbit" after a while.
The bait has been set....
Addendum. Interesting....five days later, no spam on this target. And perhaps an overall reduction in spam generally. Hmmmmm.
From time to time I see ants walking around inside. This is a clear violation of our understanding, our primate-insect accord....stay outside and I will be a gentle, Gandhi-like soul, leaving you unharmed. Sometimes I even remove small creatures from dangerous places. Come inside and you shall die.
So I put out various ant poisons. These guys want kindness, they should march their little six legged selves back outside.
Here at Detritus of Empire we get occasional and much enjoyed comments from thoughtful sapient beings. And also a few from what I assume are china based computer-spam bots. Most of the latter read like this:
"spot on with this write-up, i like the way you discuss the things. i'm impressed, i must say. i'll probably be back again to read more. thanks for sharing this with us. Lee Shin"
I deleted the attached website. Really, who needs that nonsense. It has an interesting grammatical structure to it. You would think anyone who knew the phrase "spot on" would have sufficient grounding in English to realize that you should capitalize "I'm" both as a first person reference and when it starts a sentence. Who wrote the initial spam? What were his or her linguistic qualifications?
Because they march over in little flurries, I figure there must be something that attracts these internet "ants". So I decided a little experiment was in order.
I am going to specifically try and attract the spambots. When they turn up I will delete the web addresses and just leave their kind, if hardly heartfelt, words. I will probably also edit any that are making indecent proposals.
So, operating under the theory that certain phrases attract them, here goes....
Jennifer Anniston
Acacia Berries
Weird Weight loss tips that Doctors do not want you to know.
Save money on auto insurance.
And for good measure:
i'm really impressed. i would like to learn more about chinese spam bots. i'll probably be back again to buy counterfeit designer handbags.
Note: I have never to date deleted a post, it seems like cheating. But if this attracts electronic attention beyond the entertainment level I may decide to "nuke it from orbit" after a while.
The bait has been set....
Addendum. Interesting....five days later, no spam on this target. And perhaps an overall reduction in spam generally. Hmmmmm.
Friday, July 5, 2013
Bat Defense System - Version 5.0 (approximately)
I have posted before on the annoying problem of bats at my cabin. With an entire forest to chose from they feel the need to use the rafters over my door as a latrine. They don't sleep there, which is probably wise on their part. You are not supposed to take a tennis racket to them even when they enter your house. But a home owner can only be expected to tolerate so much....
Hey, it is fine that they flutter around at night. Kudos and my appreciation for eating all those mosquitoes even if they missed a few billion. But there is no need for them to hang over my front door and excrete stuff that is indubitably obnoxious and at least in theory laced with rabies virus.
My prior attempts at Bat Deterrence have run the gamut.
I first just tried to cover the rafters in their entirety. But that looked awful and made me wonder what other life forms might decide to take up residence in that cozy little vermin loft.
Next up was hanging little bags of moth balls. It may have reduced the numbers of moths, but that was not the issue.
In frustration I sprayed liberally with wasp killer. It is a potent insecticide and I figured if the bugs were gone the bats might go elsewhere too. No go. They are using my porch more in the manner of an unsanitary rest stop for truckers, not as a restaurant.
In desperation I tried to hang up ribbons of aluminum foil. I was hoping to confuse their sonar navigation. If they bumped their fuzzy little noggins together like hyperactive Three Stooges I would not have been disappointed.
It did nothing. Or at least nothing I could perceive. If the NSA is really eavesdropping on all of us I apologize to whomever was trying to pick up my WiFi signal. You did not miss anything btw.
So eventually I just did this:
This is just thin, slippery plastic sheeting. I used little tacks to put it up, a staple gun would be better and faster. The bats need something they can sink their little claws into, and this ain't it.
A detail view.
Note that I have only run it out part way. I am a reasonable man and will give the bats a little space so long as they do not excrete directly onto my Welcome mat. And in exchange I expect ongoing work on those mosquitoes.
Hey, it is fine that they flutter around at night. Kudos and my appreciation for eating all those mosquitoes even if they missed a few billion. But there is no need for them to hang over my front door and excrete stuff that is indubitably obnoxious and at least in theory laced with rabies virus.
My prior attempts at Bat Deterrence have run the gamut.
I first just tried to cover the rafters in their entirety. But that looked awful and made me wonder what other life forms might decide to take up residence in that cozy little vermin loft.
Next up was hanging little bags of moth balls. It may have reduced the numbers of moths, but that was not the issue.
In frustration I sprayed liberally with wasp killer. It is a potent insecticide and I figured if the bugs were gone the bats might go elsewhere too. No go. They are using my porch more in the manner of an unsanitary rest stop for truckers, not as a restaurant.
In desperation I tried to hang up ribbons of aluminum foil. I was hoping to confuse their sonar navigation. If they bumped their fuzzy little noggins together like hyperactive Three Stooges I would not have been disappointed.
It did nothing. Or at least nothing I could perceive. If the NSA is really eavesdropping on all of us I apologize to whomever was trying to pick up my WiFi signal. You did not miss anything btw.
So eventually I just did this:
This is just thin, slippery plastic sheeting. I used little tacks to put it up, a staple gun would be better and faster. The bats need something they can sink their little claws into, and this ain't it.
A detail view.
Note that I have only run it out part way. I am a reasonable man and will give the bats a little space so long as they do not excrete directly onto my Welcome mat. And in exchange I expect ongoing work on those mosquitoes.
Wednesday, July 3, 2013
Tense Times at The Last Place on Earth
I went to a conference in Duluth recently. Driving through downtown I saw a sign that simply demanded my return for further investigation...
URINE CLEANER
So, on a brief lunch break I hiked over and saw:
This is the Last Place on Earth, a notorious establishment that makes the newspapers with regularity. The owner, a Mr. Carlson, is an "in your face" individual who sells bongs, "adult toys", and most notably, "synthetics".
Synthetic is a general description of a variety of substances that mimic the active ingredients in marijuana and other drugs such as Ecstacy. The Last Place on Earth is one of the few places to openly - oh I think we can safely say, blatantly - sell the stuff in my part of the world.
Not surprisingly this has attracted a great deal of attention from the Authorities. By noon hour there was one police cruiser and two officers on scene. When I was done with the conference I swung by again and saw:
There were five or six squad cars and at least eight officers on hand. There was also a crowd of about forty people who appeared to be waiting to get into the establishment. They might have all been investment bankers and Lutheran pastors, but I think not. To describe the world as it really is, rather than how political correctness would have things, they were a motley bunch, and looked twitchy and irritable. So, what is really going on here?
I found a lot of information in THIS news article.
This explained a lot. As I walked through this crowd I experienced something I had only encountered one or two times before in my life. This looked like a protest, albeit one with no organizing ability. But it felt like a restless mob, one capable of riot with little additional provocation.
I asked an officer on one end of the sidewalk, "What's this about?"
"Synthetics".
I asked an officer at the other end, "Why are they all here?".
"The guy just got back from court".
So. The Star Tribune article mentions that every morning at the 10am opening time there would be dozens of motivated customers out front, ready to acquire the wares within. Imagine how these folks felt by 4pm.
Let's not mince words. The owner of The Last Place on Earth is making money, and substantial amounts at that, helping people get high and to avoid some of the consequences of doing so. When he refers to his beach front estate in Mexico as "The house that Urine Cleaner built" he is not even attempting to be coy about it. (Urine Cleaner for you innocents, is a system to try and keep your urine drug screen from telling the truth about your illegal habits).
I see people messed up on Synthetics in the ER all the time. They act crazy. I had one handcuffed individual haul off and kick me last year. The officers on hand did offer to arrest him for assault. But I was so pleased to have effectively parried an assault from a punk half my age that I declined their kind offer.
Yes, Mr. Carlson is a strong believer in the right of citizens to do damnably stupid things. In another news article he was boasting that he would pay the tattoo bills, up to $150, for anyone willing to have the name of his establishment inked onto visible areas as a permanent advertisement.
But this is not as open and shut a case as one might prefer. There are people of varying political orientation who defend legalization of drugs. On the one end of the political spectrum are pure Libertarians. In addition to various laudable goals such as smaller, less intrusive government they think people should be allowed to do, well, lots of stuff. On the other end of things...
Yesterday I discussed the implausible survival of Occupy Duluth. Click on their website, it chronicles in great detail their involvement with the very neighborhood where this business is located. They can clearly see the societal damage being done, both by the chemicals and by the things people resort to in pursuit of them. But they can't quite find it in their hearts to condemn it.
(I wish I had learned of their neighborhood meetings in advance. I would have very much enjoyed talking with them. They have been worked up of late regarding Genetically Modified Organisms. One wonders how they would feel when hearing that the real marijuana of today has been radically modified from what their parental units toked at Woodstock, and that the synthetics are made of chemicals so weird and hostile that I am quite sure even their arch foe Monsanto would have nothing to do with them!)
Under the restless and crowded circumstances it was difficult for me to get close up pictures. But in the window of the shop was a poster promoting the candidacy of Mr. Carlson for President. Yes, the head shop owner ran for Leader of the Free World. He only got 3,149 votes, which according to Wikipedia rounds out to 0.00% of the electorate. Chalk one up for people who feel our voting system is still secure, I figure that many people just liked the nice Scandinavian name.
In his unsuccessful candidacy Mr. Carlson was the standard bearer of "The Grassroots Party". I ran this past my rather Libertarian son. He opined that perhaps legalizing dope was too narrow platform on which to propose running a country. But heck, maybe they have loftier ambitions.
Their party logo suggests, ah, maybe not.
Well, it is the Fourth of July. A time of frivolity in the form of picnics and pyrotechnics. But I find myself in a serious mood today. What exactly are our obligations as citizens? How do we balance the greatest amount of personal freedom with a societal imperative not to get jazzed up on mysterious orc-chemicals and try to kick old men?
As you sip a beverage today, ponder this point. And remember that across the spectrum of our fellow Americans there is a surprisingly even distribution of wisdom and folly, of compassion and contempt, of heroism and knavery. That Occupier may be a naive, impractical fool....but may also genuinely care about the lives ruined by drugs. A Conservative of the Religious variety may think those who sell and use drugs are likely going to hell, but will pray for them and hope to be wrong.
Be tolerant. Take citizenship seriously.
I found a lot of information in THIS news article.
This explained a lot. As I walked through this crowd I experienced something I had only encountered one or two times before in my life. This looked like a protest, albeit one with no organizing ability. But it felt like a restless mob, one capable of riot with little additional provocation.
I asked an officer on one end of the sidewalk, "What's this about?"
"Synthetics".
I asked an officer at the other end, "Why are they all here?".
"The guy just got back from court".
So. The Star Tribune article mentions that every morning at the 10am opening time there would be dozens of motivated customers out front, ready to acquire the wares within. Imagine how these folks felt by 4pm.
Let's not mince words. The owner of The Last Place on Earth is making money, and substantial amounts at that, helping people get high and to avoid some of the consequences of doing so. When he refers to his beach front estate in Mexico as "The house that Urine Cleaner built" he is not even attempting to be coy about it. (Urine Cleaner for you innocents, is a system to try and keep your urine drug screen from telling the truth about your illegal habits).
I see people messed up on Synthetics in the ER all the time. They act crazy. I had one handcuffed individual haul off and kick me last year. The officers on hand did offer to arrest him for assault. But I was so pleased to have effectively parried an assault from a punk half my age that I declined their kind offer.
Yes, Mr. Carlson is a strong believer in the right of citizens to do damnably stupid things. In another news article he was boasting that he would pay the tattoo bills, up to $150, for anyone willing to have the name of his establishment inked onto visible areas as a permanent advertisement.
But this is not as open and shut a case as one might prefer. There are people of varying political orientation who defend legalization of drugs. On the one end of the political spectrum are pure Libertarians. In addition to various laudable goals such as smaller, less intrusive government they think people should be allowed to do, well, lots of stuff. On the other end of things...
Yesterday I discussed the implausible survival of Occupy Duluth. Click on their website, it chronicles in great detail their involvement with the very neighborhood where this business is located. They can clearly see the societal damage being done, both by the chemicals and by the things people resort to in pursuit of them. But they can't quite find it in their hearts to condemn it.
(I wish I had learned of their neighborhood meetings in advance. I would have very much enjoyed talking with them. They have been worked up of late regarding Genetically Modified Organisms. One wonders how they would feel when hearing that the real marijuana of today has been radically modified from what their parental units toked at Woodstock, and that the synthetics are made of chemicals so weird and hostile that I am quite sure even their arch foe Monsanto would have nothing to do with them!)
Under the restless and crowded circumstances it was difficult for me to get close up pictures. But in the window of the shop was a poster promoting the candidacy of Mr. Carlson for President. Yes, the head shop owner ran for Leader of the Free World. He only got 3,149 votes, which according to Wikipedia rounds out to 0.00% of the electorate. Chalk one up for people who feel our voting system is still secure, I figure that many people just liked the nice Scandinavian name.
In his unsuccessful candidacy Mr. Carlson was the standard bearer of "The Grassroots Party". I ran this past my rather Libertarian son. He opined that perhaps legalizing dope was too narrow platform on which to propose running a country. But heck, maybe they have loftier ambitions.
Their party logo suggests, ah, maybe not.
Well, it is the Fourth of July. A time of frivolity in the form of picnics and pyrotechnics. But I find myself in a serious mood today. What exactly are our obligations as citizens? How do we balance the greatest amount of personal freedom with a societal imperative not to get jazzed up on mysterious orc-chemicals and try to kick old men?
As you sip a beverage today, ponder this point. And remember that across the spectrum of our fellow Americans there is a surprisingly even distribution of wisdom and folly, of compassion and contempt, of heroism and knavery. That Occupier may be a naive, impractical fool....but may also genuinely care about the lives ruined by drugs. A Conservative of the Religious variety may think those who sell and use drugs are likely going to hell, but will pray for them and hope to be wrong.
Be tolerant. Take citizenship seriously.
Monday, July 1, 2013
Progressive Politics - Apples Wanted
Duluth Minnesota is an interesting place politically. It is considerably more liberal than similarly sized communities around the Midwest. Probably this reflects the strong union heritage in the iron mining industry that was once key to the local economy.
They still take their politics seriously. Here is an old building that is using surplus political signs for window repair.
Most of these signs appear to be from the last campaign of Jim Oberstar. Oberstar was an 18 term member of the US House, who shockingly lost his 2010 election bid to a political neophyte. A kid who I once coached in baseball was an Oberstar aide. He was stunned.
Down the street a ways we find this interesting complex.
Paul Robeson last turned up on the pages of this blog as a member of the remarkable " Stratfords" baseball team. I had thought that his status as a progressive political figure had been all but forgotten in these modern times.
But there it was. I have not been able to fully trace the history of the place, but this area of Duluth is home to a notable black community. More recently the Ballroom was the winter quarters of Occupy Duluth for a while. Later a fire damaged the adjacent property and the entire complex was condemned. The Occupiers built an encampment out back until they were evicted in the fall of 2012. Some of the signage on the front of these buildings is interesting...
It looks as if near the end there was some kind of retro-antiques market held here. Was it connected with the Occupy folks?
On the right we have a 1%/99% poster. Front and center we have an appeal for apples. The fruit? The computers? Drop off here, or we will.....
Not quite sure what they were going to do if you did not give them an Apple.
I suppose I am guilty of poking a little fun at the idealistic Occupy folks. But lets give credit where it is due, they are still around and still socially active. In trying to learn more about the Robeson Ballroom I ran across the Occupy Duluth Duluth website.
I admire perseverance.
They still take their politics seriously. Here is an old building that is using surplus political signs for window repair.
Most of these signs appear to be from the last campaign of Jim Oberstar. Oberstar was an 18 term member of the US House, who shockingly lost his 2010 election bid to a political neophyte. A kid who I once coached in baseball was an Oberstar aide. He was stunned.
Down the street a ways we find this interesting complex.
Paul Robeson last turned up on the pages of this blog as a member of the remarkable " Stratfords" baseball team. I had thought that his status as a progressive political figure had been all but forgotten in these modern times.
But there it was. I have not been able to fully trace the history of the place, but this area of Duluth is home to a notable black community. More recently the Ballroom was the winter quarters of Occupy Duluth for a while. Later a fire damaged the adjacent property and the entire complex was condemned. The Occupiers built an encampment out back until they were evicted in the fall of 2012. Some of the signage on the front of these buildings is interesting...
It looks as if near the end there was some kind of retro-antiques market held here. Was it connected with the Occupy folks?
On the right we have a 1%/99% poster. Front and center we have an appeal for apples. The fruit? The computers? Drop off here, or we will.....
Not quite sure what they were going to do if you did not give them an Apple.
I suppose I am guilty of poking a little fun at the idealistic Occupy folks. But lets give credit where it is due, they are still around and still socially active. In trying to learn more about the Robeson Ballroom I ran across the Occupy Duluth Duluth website.
I admire perseverance.
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