Catching On

Every now and then you realize you’re way too deep in what you do for a living…

Have you ever played Catch Phrase? It’s a great game. The electronic version is a fat disc that shows unusual word or phrases on a screen, and teams of two or more players try to guess the word or phrase. When one team gets it right, the disc is passed to the next team. There’s a timer in the device that beeps with ever-increasing urgency, and the team holding the device when the buzzer goes off loses the round. You can guess that this leads to the disc being flung about like a hot potato as time grows short. It’s kind of like Password on steroids.

Anyway, I’m over at a friend’s house the other night, and a bunch of us ED folks are playing Catch Phrase. It’s my turn to guess the answer, and my partner Kristin is looking at the screen. She turns to me and says “People do this all the time in the ER,” and she starts to gag and make a gesture with her hand like things are coming out of her mouth.

I knew exactly what she was doing. It is something people do all the time. It’s one of my least favorite bodily functions that expels one of my least favorite bodily fluids. (Blood, urine, lung stuff I can handle. GI secretions? I’m outta there.) But I know too many words for it, including:

Vomiting
Vomicking
Nauselated and Vomicking
Barfing
Upchucking
Regurgitating
Worshipping the Porcelain God
Producing the Technicolor Rainbow
Aspirating
Aspiration Pneumonia
Aspiration Pneumonia in a Nursing Home Patient
What you do when Administration Comes by

After about a minute and a half of this, with the beeping growing more intense and frantic, she grabs me by the collar. “WHAT AM I DOING?” she shouts?

“You’re throwing up, right?”

“RIGHT! IT’S THROW UP. THROW UP! LIKE NORMAL PEOPLE SAY! THEY THROW UP!”

And the disc was passed.

True Creepy Story

This is absolutely true. I’m driving down the street taking my son for an overnight visit with his grandparents. As I pass by one of the homes on their street, I noticed there are huge black birds circling over the house. I slowed down to find that they were also perched along the eaves, standing on the concrete facing of the garden wall, and even pacing up and down the driveway, driving their hooked beaks into the pavement with a mixture of determination and boredom. It was like something out of a Hitchcock film, but all the more scary because you knew…beyond a shadow of a doubt…that there was neighbor inside who hadn’t been seen in quite a while.

Don’t look for a punchline here, because there isn’t one.

A Soccer Suit

…I am the armchair fan who desperately wants to love this game, and, like untold thousands (millions?), had no choice but to curse it out, turned off by incompetent refereeing, a situation exacerbated by a governing body so intransigent and arrogant it makes British Petroleum look like a warm and cuddly quilting circle. "I am very, very satisfied," Jose-Maria Garcia-Aranda, the head of FIFA's referees, said of the quality of officiating in the World Cup matches…

…Even the most tradition-bound purists must agree that a goal should be a goal. So when referee Mauricio Espinosa mistakenly disallowed Frank Lampard's goal on Sunday, a score that would've enabled England to tie Germany 2-2, it was a very big deal. And when FIFA general secretary Jerome Valcke all but ruled out the use of video replay that would correct such situations, it exposed a sport crying out not just for visionary leadership but for leadership with some grasp of reality. Not counting a goal for fear of dehumanizing a sport with replay is not in the tradition of anything besides the tradition of ignorance.

Jack McCallum, sportsillustrated.cnn.com, June 28, 2010

The Fédération Internationale de Football Association (FIFA) officiating problem is really pretty easy to solve. Take a lesson from American medicine and make both the referees and the governing body legally liable for bad decisions. After all, it’s not like the actions of the referee go without consequence. A decision to allow, or disallow, a goal has a major impact upon the ratings of individual players and their ability to make a living at their chosen sport. Similarly, football clubs depend on proper officiating to ensure that both game results and overall standings are true and correct. With low-scoring games, a single inappropriate goal can cause a large change in the standings, which in turn affects a club’s ability to attract players, fans, and advertising. In addition, many football leagues feature end-of-season “relegation,” in which the lower performing teams and sent down to a lesser level league, and the best of the minors is promoted to the big time…and big money. The revenue impact of relegation on a team, let alone the psychological hot on a community, is staggering. If doctors can be sued for errors in decisions that affect the livelihood of others, even in those cases when these decisions can’t be made on any objective evidence at all, why shouldn’t FIFA?

The threat of liability, of course, will drive a headlong rush to embrace as much technology as possible to put error out of the realm of possibility. That is the current unreasonable standard in medicine…that there is perfection in an inherently unstable art…and one of the main reasons why doctors do so much testing and imaging and so little talking and educating. But if referees knew that they could be held personally liable for a missed goal or allowing an illegal play, I don’t know any that would participate at the sport’s highest level. They might if they were indemnified by FIFA itself, but would the organization want to take on the question of liability? I don’t think so. Like medicine, they will rush to a technologic solution and install goal cameras, mandatory instant replay of all scoring plays, and maybe even a coach’s challenge to eliminate their own risk. Because World Cup soccer is not about fair play or making sure that the better team wins at the end of the day, but all about FIFA.

FIFA president Sepp Blatter has apologized to England and Mexico for the refereeing errors that helped eliminate them from the World Cup…

The English said 'thank you.' The Mexicans, they just go with the head,'' Blatter said, indicating that they nodded. "I understand that they are not happy. It was not a five-star game for refereeing.''

England was denied a clear goal that would have leveled its match against Germany at 2-2, while Argentina took the lead against Mexico with a goal that was clearly offside.

Associated Press, June 28, 2010

If you still had any doubt about the arrogance of FIFA, this should resolve that quandary. I would think that the Swiss Mr. Bladder (intentional error, because the lines he spouts sound a lot like the organ’s contents) would be grateful that he got a “Thank you” from the English. It would have been a lot easier, and probably more appropriate, for the Red and White to say something like “Still got those hidden Nazi bucks bankrolling your election?” (Blatter’s 2002 election to the Presidency in FIFA was surrounded by charges of bribery and corruption.) And as for the Mexicans, I think a head nod was the most gracious gesture possible to someone who clearly feels he lives on a plane far above these mere dark-skinned colonials. I can think of a few other motions that might have gotten the message across more clearly. I’d probably even be willing to help.

In the early 1970s, Blatter was elected president of the World Society of Friends of Suspenders, an organization which tried to stop women replacing suspender belts with pantyhose.

“Sepp Blatter,” Wikipedia, June 28. 2010

Ah, well, that explains it all. If you can’t talk a woman out of her pantyhose, you’ve got to find something else to screw.

Newtonian Sex

There were plenty of starry nights, but a NASA commander says there was absolutely no sex in space during a mission that brought three female astronauts to the International Space Station.

Space Shuttle Discovery commander Alan Poindexter spoke definitively today on the outer space romance ban during a trip to Tokyo, where he and his team discussed their two-week resupply mission in April.

"We are a group of professionals," Poindexter told a reporter when asked about consequences for space sex. "We treat each other with respect and we have a great working relationship. Personal relationships are not ... an issue. We don't have them and we won't."

Michelle Ruiz, AOL News, June 28, 2010

At one point in my life, I played Professor at Embry-Riddle Aeronautical University here in Daytona Beach. I taught a couple of courses, most notably a three-hour extravaganza called “Human Factors in Space.” The course was designed to explore the physiologic and behavioral aspects of space flight for budding engineers and, like most university courses, I was able to take twenty minutes of material and turn it into twenty weeks of work, plus papers and a two-hour final exam.

(As you can guess, the ERAU curriculum is aviation-focused, with most students getting degrees in aeronautical science…pilots…aerospace engineering, aviation management, meteorology, that sort of thing. It’s a very good school, and if The Child chooses any of those career fields I’d be happy to have him go there, despite the added burden of doing his laundry for yet another four years. But knowing the students well does create some problems when they graduate. About eight years ago I was on a commuter flight from Daytona to Atlanta when I heard a voice in the cockpit say, “Hey, doc!” It turned out that the First Officer was one of my students, one who had gotten a C minus only out of my good graces because I figured he was such as slouch that he’d never wind up in a position of responsibility and he was so good spirited about the whole thing that I felt bad giving him a D. To his credit, the flight was about as tranquil as it could have been. It was also the most unnerving fifty-two minutes I’ve ever had in an aircraft.)

Being that the class is full of hormone-addled collegians, it was obvious that they were going to ask about sex in space. That’s why I made sure the lecture was noted on the syllabus, so I could avoid having to keep answering the question until the appointed time. But Isaac Newton could have predicted all you have to know about having sex in space.

Think about sex. Now wipe the smile off your face (assuming you are smiling…I do extend my best hopes for you) and think about the mechanics of sex. Not only do two people have to come together in an intimate way, but they have to be able to stay together and they have to be able to move against one another. On earth, that’s not a problem. If one partner is on top of the other, in whatever configuration might be, gravity keeps them in place; and even if the partners are on the same level, if you will, gravity keep them pinned to whatever surface they happen to be on, whether it’s a bed, a floor, or the backseat of a 2003 Saab 9-3.

In space, gravity is not a factor. (Technically, it actually is a factor, but not to the extent where it’s noticeable on most routine activities. If gravity weren’t in play at all, spacecraft wouldn’t orbit a planet, but would just shoot straight out into space. The more appropriate term is microgravity, not “zero-G.”) So if two people come together, they will not do so on a surface because there is no gravity to keep them there. Instead, they will tend to “float” within whatever enclosed space they inhabit at the time. Floating sex sounds like a lot of fun, and I suspect that it would be. However, if you’re floating abut, and one partner thrusts forward, Newton’s Third Law (the “equal and opposite reaction” one) suggests that there will be a corresponding movement in which the other partner will be pushed backwards, not only seperating themselves from their desired but also slamming against whatever wall, container, or overhang happens to be nearest in the direction of flight. They way to avoid this, and biomechanically the only way to have efficient sex in space (this was a human factors engineering course, after all) is to indulge in a bit of goal-oriented bondage play, restraining one partner to a solid surface with straps or tapes while the other secures his or her position through the use of brackets, handholds, or some other way to hold the body in place.

So what’s the real answer to the question, “Has anyone ever had sex in space?” We know the official answer, as well noted by Commander Poindexter. The real answer, of course, is “Not that we know of.” Let’s be frank…there have to have been times when there was some definite attraction between members of mixed-gender flight crews. (I’m excluding pathological attraction involving cross-country drives and the use of astronaut diapers to stalk your beloved.) So if I’m really attracted to the girl working the robot arm (and you can take that any way you wish), do I want to give it a shot, especially with the radio to Houston off and the good graces of my crew members? You bet I do. And if I was not one of the involved parties, would I be willing to go down to the middeck, close the hatch, and put on some earplugs so my colleagues could have a half hour to themselves? Absolutely. (Although the ear plugs might prevent me from hearing some really good lines, like “I felt the earth move,” because it is, and “I feel like I’m floating on air,” which you are. Which are better lines than “I hope this duct tape peels off,” and, “Gee, when we’re locked up here together for two weeks without a shower, you do pretty much smell like a gym locker.”

I think we should explore these issues with the same intensity we devote to learning the hidden story of Jake and Vienna (whom I do not know personally, but have seen on three magazine covers this morning at the local bookstore and found myself intrigued that a girl should be named after a sausage). Personally, I want to know these things not because I am a voyeur, but a scientist. When our sun goes supernova in a few billion years, the continued existence of the human race may depend on our interstellar procreative prowess. And how else to you learn stuff besides experiment and observation? I hereby volunteer to go up and try it. I’ll take notes. You can even make a video. But that astronautess had better be smiling.

Basic Instinct

A 2-year-old octopus oracle — born in England, but raised in Germany — has predicted a German win over England in Sunday's World Cup game.

The mollusk named Paul chose a mussel out of a water glass marked with the German flag over a mussel in a glass with the English St. George's Cross, said Tanja Munzig, a spokeswoman for the Sea Life Aquarium in the western city of Oberhausen, on Friday.

Paul has proven to be a reliable oracle in the past — he predicted Germany's win over Australia and Ghana and its loss to Serbia. During the 2008 European Championship, he predicted 80 percent of all German games right, Munzig said.

Associated Press, June 26, 2010

Being of a medical mind, this animal prognosticator made me think of Oscar the Cat. As you may know, Oscar has been written about in the New England Journal of Medicine:

Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families.

David Dosa, MD MPH, NEJM, July 26, 2007

Oscar is even the subject of a book which not only tells his story, but also offers lessons in caring, compassion, and end-of life care. That being said, I think the best end-of-life lesson I can learn from a cat is not to smell like tuna, and I will shortly be adding to my medical power-of-attorney form a codicil specifying that should I be placed in a nursing home, an attendant will be paid to place an open can of Little Friskies at the other end of the hallway three times each day (once per shift).

Oh, wait, back to the AP article:

Other animal oracles in German zoos cannot claim such a strong track record.

Nineteen-year-old hippo Petty falsely predicted a German win over Serbia last week. She had to choose between two piles of hay with red apples on top at the Chemnitz zoo in eastern Germany and nibbled from the wrong pile.

Tamarin Anton, a monkey at the same zoo, chose the wrong raisin a few days ago, incorrectly claiming that Ghana would beat Germany, kicking it out of the World Cup.

Not to mention the schnauzers that predicted the outcomes of the last two World Wars. As memory serves, Germany didn’t fare too well in those matches, either.

Rule Britannia!

A Lego Note

Yesterday in the car The Child was telling me he had read that if you have 16 Lego bricks, each of them a little square with four studs on the top, there are enough combinations to keep you busy for a lifetime. So I’m not surprised by the infinite variety of things he comes up with given his three full drawers of pieces and parts collected over the past decade. In fact, this weekend he built a Lego museum, complete with exhibits on zoology, the wild west, life on Mars, an armory, a pirate ship, and a gift shop.

Yesterday he was puttering around with his toys…actually, he was stalling because I had asked him to clean up his room before going on a mission to seek pizza…and he brought out a small pink and yellow helicopter to show me. “What do you think, Dad?” he asked. “I call it the Chopper of Doom.”

I looked at the model, which was indeed a very convincing helicopter. He had, however, constructed it from pink and yellow bricks that I think came to us as some kind of Happy Meal toy. The sloped brick that represented the front window of the cockpit had an imprinted picture of a female being with blond pigtails, yellow flesh, and a bill.

“Son, you can’t call it a Chopper of Death. It’s pink and has a girl duck for a pilot.”

“What can I call it, then?” he asked, whipping it up and down in a flight path designed to poke out an eye.

I thought for a moment. This is a formative stage in his life, and I don’t want to say anything negative about the female end of our species. I want him to inculcate a sense of respect towards women, as well as a secure sense of his own gender identity. So I settled on something that I thought was pretty clever.

“You can call it the Chopper of Feminine Quack.”

He liked this a lot, and soon we came up with a theme song for the inevitable television show that will result when news of his creation spreads to the coast:

It’s the Chopper of Feminine Quack!
It’s the Chopper of Feminine Quack!
It’s pink and it’s yellow and it’s flown by a duck.
It’s the Chopper of Feminine Quack!

Because this is Lego, however, the chopper soon became boring. Which is why, within minutes, there was also the Killer Robot of Feminine Quack, the Airplane of Feminine Quack, the Speedboat of Feminine Quack, the Other Slightly Different Helicopter of Feminine Quack, The Seaplane of Feminine Quack, and the Guided Missile of Feminine Quack.

Thank the Lord there were only 9 pieces in his model, or this could go on forever.

Bored by the Board

Libertarian ideology rejects most of the modern regulatory systems that protect consumers, because everyone should be responsible for determining whether the hamburger contains E. coli on his own. But does that do-it-yourself dogma apply to the regulation of medicine, too? If you're Dr. Rand Paul, practicing ophthalmologist, the answer is emphatically yes.

According to an amusing story in today's Louisville Courier-Journal, the Kentucky Republican Senate candidate bills himself as a "board-certified" physician even though he is not actually certified by the American Board of Ophthalmology -- the only recognized body that certifies doctors in his specialty.

Paul's only certification was provided instead by something called the National Board of Ophthalmology, which is very convenient because he operates that organization himself.

Joe Conason, Salon.com, June 14, 2010

Most doctors in this country are board certified in something. In a nutshell, board certification means you have met certain training requirements and passed some kind of exam that qualifies you as a specialist in the field. In my case, becoming certified by the American Board of Emergency Medicine (ABEM) means I completed a three-year specialty training program and passed both a multiple-guess written exam and an oral exam consisting of a wide variety of patient scenarios. (Needless to say, the issue of being board certified and being certifiably boring are two separate discussions.)

ABEM was one of the first boards to require recertification. It was easy for them to do, as it was a relatively new specialty with no one who had been certified very long when the decision was made. As a result, nobody felt too inconvenienced. It was different for organizations like the American Board of Internal Medicine (ABIM), where there were already thousands of physicians out there who were certified once under a “one-and-done-for-life” agreement. If they suddenly required 20,000 physicians who had been functioning just fine for the last 40 years to spend their time and money on a new exam, they would have had a wholesale rebellion on their hands. So according to one of my ED colleagues who started life as an internist (he’s much better now), the ABIM sent everyone who was already certified a postcard that had two boxes on it. If you checked one box, you could take the exam again every decade or so, paying a hefty fee for the privilege. If you checked the other, you never had to see the inside of a test booklet for the rest of your natural life. Guess which one most people chose.

The next step is to add a component of continuous learning to the certification process. Most states already have Continuing Medical Education requirements, where you need to be able to document participation in so many hours of CME each year. But these requirements are written for physicians in general and do not relate to the individual specialty. Organizations such as ABEM are looking to fill this gap. For example, I am now required to read a selected panel of articles each year (for no CME credit, by the way), and then pay a fee ($95.00) to take an on-line test. If I do this successfully eight out of the ten years of my certification, I get to pay another fee to take a longer 205 question on-line comprehensive exam, which may or may not have anything to do with the articles I’ve read, for the low, low price of $1,715. If I miss one of the yearly exams, I can take an even longer written 305 question exam for the bargain price of $920. If I miss two or more, then I get to take the longer written exam and an oral recertification at a total cost of $2060. (But wait! There’s more! If you act now, we’ll throw in an amazing spiral slicer!) Interesting to note that it’s cheaper not to do the continuing process…there’s not exactly an incentive to participate.

The recertification process can be a pain, but I really don’t have a problem with it, at least in theory. (That being said, I’ll be perfectly happy to trash the system in the few months before I take the higher-priced exams with my money going to who-knows-where to do-who-knows-what except to make my life more miserable than it has to be, and Lord help me if I don’t use a number two pencil or blacken the oval completely.) But the next step in the evolution of board certification in emergency medicine is clear argument against intelligent design. It’s called Assessment of Practice Performance, or APP, and on the surface it’s not too bad. It’s supposed to assess competence in patient care, communications, professionalism, and practice-based learning through participation in quality improvement programs. Clearly, these are good things to know.

The part that bothers me is that these APP requirements apply only to “clinically active” diplomats of the board. What this means in practice is that if you’ve you’ve managed to get yourself out of the ED and into a comfy executive chair on the administrative floor, there’s no need to ever prove your clinical competence again. I have a real issue with this, as I have always been of the belief that no matter how high you rise in an organization, at some level you should still be able to do the job you were originally trained to do. So if you started out as a copier repairman and are now Chairman of IBM, you should still be able to fix a copier. I wouldn’t expect you to become a corporate accountant or a software engineer, even though your position in the food chain may be over those departments. But you ought to be able to fix the copier, and should go out of your way to do so every now and then. It “keeps it real,” as it were, and it’s incredibly difficult to lead with credibility when you are no longer able to work under the same conditions as those you‘re trying to direct. (That’s one of the main reasons I continued to do ED shifts while working full-time positions in public health.) If you’re unable to continually demonstrate competency in your original position, why should anyone assume you are competent in a higher post? And it certainly seems disrespectful, if not arrogant, on the part of non-practicing physicians to hold those doctors who actually see patients to a higher level of qualification despite the fact that they all present the same credential to the outside world.

And that’s the problem with the new scheme. Allowing those physicians who no longer see patients to hold themselves out as clinically competent ED docs (as the board certification would suggest they are) is contradictory at best and, in my mind, frankly disingenuous. But even if ABEM does the right thing and makes all diplomats meet the same standards, there’s always hope for those NPC (No Patient Care) docs. We can just ask Rand Paul to come up with another board or two…

Absence Update

Writing With Scissors has been under the weather due to a viral syndrome. Fortunately, with rest, a lack of fluids, and a good scrubbing, it is on the road back to health. Now I just need to argue with the Sprint people that their system has a "redirect" virus implanted into their network, because I only seem to get pointed to search engines that offer me the opportunities to purchase photos of "girls near you" in various relationship states when I'm on the network and not when I use the wireless service in a coffee shop or so. Not to mention, of course, that the enitre sytem is now slower than Congresisonal action on immigration reform. They will, of course, tell me that I'm wrong, and refuse to do anything to help. A royal battle will ensue. You know how if you have a bad week to start with, you actually look forward to yelling at someone? That's us.

A Note for Father's Day

Every family has traditions, and chasing the ice cream truck is one of ours. My father taught me to do so when I was a kid, and now The Child and I have perfected the art of stalking the frozen treat. So it was no surprise that we spring into action today when we were on the beach at Daytona. The Child heard the truck first, and I spied it coming up the beach lanes towards our Base Camp. I jumped out in front of the van to bring it to a stop, while he went for the backpack to get the money we’d need. And forty-three seconds later, his pace slowed by an arthritic right knee but his enthusiasm undimmed by age, my father came lumbering up the beach.

You know how you have those moments where you wonder how you could ever be related to those people who claim to be your parents? This was not one of those times. There is no question that these three generations of men were united with one goal in mind: To pay the highest price possible for an ice cream on the beach. And because we are men…Rodenberg Men…we did just that.

Happy Father’s Day to one and all.

Let's Twist Again

The other night at work a nurse brought me a prepackaged table that had been found lying unguarded on a counter near the new drug storage cabinet. “What’s this?” she asked, holding out a blister pack containing an oval, pale yellow tablet.

A bit of skillful detective work (we flipped the package over and read the label) found the tablet to be benztropine, otherwise known as Cogentin. The nurse can’t be blamed for not knowing what it was. It takes a wily and experienced (translated as “old”) clinician like me to fully tell its’ tale.

The story of Cogentin actually starts with the older antipsychotic medications like chlorpromazine (Thorazine) and thioridazine (Mellaril). The science suggests that schizophrenia and other psychotic states are caused, at least in pa art, by excess activity of a chemical called dopamine within the brain. Thorazine, Mellaril, and other older, “typical” antipsychotics work by blocking the action of dopamine within the frontal cortex and limbic system, portions of the brain involved in thought and feeling. But dopamine is a two-edged sword. Excess dopamine activity may lead to schizophrenia, but one of the hallmarks of Parkinson’s Disease, which is primarily a motion disorder, is a lack of dopamine within the deeper structures of the brain that control movement. As a result, even appropriate doses of antipsychotics can result in problems, which fall under a broad heading of “neuroleptic-induced movement disorders.” Cogentin is one of the medications used to control these side effects.

I learned about these problems for the first time on my med school psych rotation. At Western Missouri Mental Health Center (“Listening to the Voices in Your Head Since 1899”), the locked 4th floor was the hotbed of schizophrenic activity in Western Missouri. At the time, the preferred treatment for schizophrenia...or at least the only one I heard about…was to give as much Mellaril as you could find, followed by Cogentin for the inevitable side effects. This was the sole treatment plan authorized by our attending physician, who had an encyclopedic knowledge of Mellaril and a fully anencyclopedic knowledge of any other psychotherapeutic drug on the market. This is during an era when the number of effective drugs you had to know about was probably seven, and while it was known that brain chemistry probably had something to do with mental illness, most likely what really made you nuts was that your id had gotten into a fender bender with your superego and was contacting the Oedipal Law Firm to sue your mother or something like that. But once I had figured out the predominant treatment plan, it suddenly made sense why Father Marshall, who I thought was merely the Catholic Chaplain at the hospital, had a tongue that constantly darted in and out from between his lips like a garter snake and seemed to be talking to no one in particular at any given time.

(It was also one of the peculiarities of the time…and it still may be, I don’t know…that all the attending physicians and residents in psychiatry were foreign medical graduates. It always puzzled me why, in a specialty where communication and cultural sensitivity is probably more important than any other, the majority of doctors couldn’t speak the King’s English, let alone mine. But on occasion we were able to use this to our advantage. We’d tell patients who were destined to spend some time at Western Missouri…WoMo…that, “there are doctors there from all over the world that are here to take care of you.” That would hold ‘em long enough to get across the street.)

Most of time in the ED, these side effects are simply interesting things to note. On occasion, however, they present as a real live acute condition. People who have never been exposed to high-potency antipsychotics before may suffer from what’s known as a dystonic reaction. Dystonia results in contractions, twisting, and contortion of the facial muscles and the extremities, the same look you might find in Tea Partiers who inadvertently strolled into a showing of the Hustler Classic “Who’s Nailin’ Palin.”

The Golden Age of Emergent Dystonia in the 1990’s was a result of a marketing error. Haloperiodol (Haldol) is a potent antipsychotic that works by in a manner similar to Thorazine. Diazepam (Valium) is an anxiolytic and muscle relaxant that causes drowsiness. Both of them were small blue tablets. So when you were having trouble getting to sleep, your friend with the “thinking problems” gave you one of their small blue tablets that were “just like Valium.”

The folks who made Valium were understandably concerned that their tablets were getting mixed up with Haldol. So they decided that they would distinguish their product by cutting as small “V” into the tablet. At the same time, the makers of Haldol wanted to be sure that their tablets were not being mixed up with Valium, so they cut a small “H” into their tablets. Given that both tablets were the same color and about a third of an inch wide, this precaution had no effect at all.

Dystonia is actually really fun to treat. It’s one of those rare “instant cures’ in the ED that make you look like a total ace. The patient comes in all twisted and looking like The Elephant Man without the lumpiness. They are scared to death because they can’t control what their body does. But an intravenous injection of diphenhydramine (Benadryl) literally fixes then within about two minutes. One fun thing to do is to give the medication, wait fifteen seconds and then ask the patient to slowly recite the alphabet. You can actually see their bodies relax and hear their speech clear up as they go, and by the time they hit M they’re all better. When this occurs, they cannot be effusive enough in their praise of you. (These are the patients who go to Steak n’ Shake in the middle of the night and are so happy not to be deceased that they bring you a Double Steakburger and an Orange Freeze without you even asking.)

There are better medications out there now, antipsychotics that work through several different mechanisms at once and pose much less risk of harm to the patient. Still, it’s sometimes sad to see our quick fixes go by. There are so few opportunities for heroism in the ED, or at least heroism that the patient is aware of. It’s a truism of the ED that when you actually save a life, chances are the patient is too far out of it to have any memory of you. The doctor who gets the credit is the first one they see when they wake up. Especially if his tongue flicks in and out like a snake.

Job 51

Griping about work seems to be a universal human trait, and even those who have followed the oft-given advice to “follow your dream, and the job will appear” I’m sure have days when they feel like their drowsy fantasy has become a living nightmare. I’m guilty of these kinds of thought as well. Consciously, I know that working in the ED is a good job. Fine pay, no call, mild respect, occasional stress, and an excellent sense of “work family” found nowhere else except maybe law enforcement and the military. Yet there are more days than I care to admit where I don’t want to go in and face the next patient who’s been sick forever (presumably since the Korean War…and if it was service-connected, they'd be at the VA) and give the patented two minute spiel entitled “I can’t fix you in the ED today.”

That being said, I’m often amused by small gift books such as “50 Job Worse Than Yours,” which includes such occupations as Chick Sexer and Maggot Wrangler. But I think I’ve run into Job 51. It is:

Arena Marshall at Q-Zar Laser Tag in Tampa, Florida

I learned this about a year ago at a birthday party attended by my enthusiastic “Look-Dad-I-won-enough-Skee-Ball-tickets-for-a-plastic-snake-I’ve-named- Constantine” son. (I think he plays Age of Empires II waaaaaay too often). One of the perks for parents in the new trend towards activity-focused birthday parties is that the old folks usually get to play, too. So at the insistence of The Child, I joined his party group (“D-man’s Team.” Apparently even small suburbanite children get rapper names) for a round of light amplification by stimulated emission of radiation mayhem.

The concept of laser tag is relatively simple. You get a laser gun and a plastic vest. The vest has a flashing square on the front and the back. If another player’s laser hits you on the square, you are “hit” and your gun goes inactive for a few seconds. If you run out of lives (which I did four times in the space of a fifteen minute game, and that includes a good eleven minutes of cowering in a corner…see below), you have to run to a recharge station and get another life by waving your gun in front of a piece of plexiglass. No, I have no idea how it works.

You start by getting a briefing on the rules. The briefing room has five tiers, divided into a green side and a red side, each holding about twenty combatants. Once the players have filed in, the Marshall arrives. Her job is to deliver a briefing about the rules. She has to do so to twenty screaming ten year old boys per side, pre-fueled on ice cream, hot fudge, soda, cake, and the general hubris that comes with an absence of parental supervision, the acquisition of firearms by preadolescent males, and the winning of plastic snakes named for Roman Emperors. She has to explain to this seething mass of testosterone and sugar that there will be no yelling, no running, and no physical c0ntact. She does it saying she will throw the person out. She has to do it at least sixteen times each day.

The job doesn’t end with the briefing, however. During the game, she has even more duties. They include explaining to befuddled parents how the trigger works, why your vest is on backwards, and walking about holding a child’s sleeve with her right hand and that of an angry parent with her left, stopping every adult to ask, “Is this one yours?” (Fortunately, for once the answer was no.) And the look on the poor girl’s face would have blunted the sharpest edge; the desperate gaze of someone who knows this job is not a resume builder, not a step towards middle management, and not even a way to meet cute guys at the mall; the look that says she knows all a job at Q-Zar will do for her is give her a severe case of night blindness and a desire to, no matter how much she may love any future offspring, absent herself completely from any parenting activity from ages 8 to 37.

I was repeatedly tormented by a very large prepubescent girl who took great delight in firing about forty billion laser beams at me just after I recharged my gun. What’s more embarrassing is that, despite the clear evidence of her cardiac and diabetic risks, I still couldn’t manage to hit her “broad side,” or any side. I was also stalked by a thirty-something parent with extremely large teeth that glowed green in the black light of the arena who would pop out from behind obstacles and barriers and cry, “Hahahaha! Gotcha!” as if this was the singular thing that gave him pleasure in this world. (For the record, I use the “singular pleasure” theory a lot to justify the behavior of others. For example, I used to get a lot of parking tickets form campus police when I was teaching at the University of Florida. For no good reason other than sheer obstinacy I would not pay them…I mean, they already used my taxes to build the parking lot…and so once every six month or so a campus “kiddie cop” would come swaggering by and demand payment. Rather than get mad, I just figured that if calling a doctor out on his tickets was as good as they got in life, why deprive them of the moment? So I would hang my head, and apologize profusely, and even generate a sniffle of true remorse. They would give me thirty days to pay up, but which time a new cycle of ticketing would have started all over again.)

It turns out that the only way to avoid getting hit all the time is to curl up on the ground with your back against a wall, cross your arms over your chest, and hope nobody sees you. If course, you can’t shoot at anything, either, but I found some comfort in adopting a Ghandian non-violent approach to death by tag rather than raging, raging, raging against the tagging of the light.

In the end, it turned out that our team had won despite my efforts to the contrary. But that should not deprive you of the right to brag about all the wonderful heroics to which you were never a part. At Q-Zar, however, you can’t even maintain that illusion. Your score is electronically recorded, and at the end of the match they give a printout you’re your statistics on it. Everyone compares cards, and failure to do so invites suspicion. So in fairly short order The Child learned that the Great and Powerful Father was far and away the worst player on the Green Side, with a whopping hit percentage of 14.9%. I think this is slightly worse than Mr. Ed, and we know how hard it is to shoot with hooves. I comfort myself with the knowledge that the guy who graduates last in his med school class is still called doctor, and that people like Jim Sorgi still get a Super Bowl ring.

Thank you, Q-Zar. I’m more grateful for the job that I do…and for the one that I don’t.

Cubby and Me

A little-known fact about Daytona Beach is that it is the home base of the Class A Florida State League. Our local entry into the minors are the Daytona Cubs, and an evening out at a Cubs game is truly one of the real pleasures of summer here on the Fun Coast.

I love going to watch the Cubs games, and usually get to five or six games each year. Certainly some of it is the baseball, and for the same reason that college basketball can be so compelling where the NBA is not. The players are mostly young kids. A few are high draft picks, and are merely collecting experience (and signing bonuses) before their inevitable promotions. Some of them are trying to prove themselves, striving to climb the ladder to the major leagues. Sometimes they will play spectacularly, and sometimes they will act like boneheads as they try to master their trade and impress scouts from the next level of play. But most of the players know that this is as far as they go, so they play to play with a totally different, and incredibly refreshing, attitude than those who have already “made it” and for whom playing ball is not a dream, but a career.

I also have a soft spot for our ballpark. Jackie Robinson Stadium (known as “The Jack”) is a very minor league place, and it shows. It’s old and charmingly on the shabby side. But that’s the fun of it all. The stands along the first base line dwell under a tin roof, complete with netting across the front and the required obstructed views from the green support beams. Those who live dangerously will opt for seats in the bleachers behind the home dugout, and work without a net. The bleachers back up onto a channel of the Halifax River, and if you listen closely you can hear foul balls sailing over the heads of the fans hit the concrete in front of the concessions and plunk into the water. Fouls tips on the right bang off the tin roof en route to hitting someone’s boat at the marina on the opposite side of the street. If you sit up high enough, you can look out over the palm trees just behind the outfield fence and see the high bridge over the gleaming waters of the Halifax River offer safe passage down to the beach. On a really good day, you can even catch the smell of the ocean and a soft maritime breeze coming in from right field. It’s an idyllic spot to watch a ball game on a warm summer night; and compared with other new, cookie-cutter minor league parks built in the middle of urban renewal or surrounded by suburban parking lots, it’s a very pleasant world away.

(By the way, we’ve been discussing the General Admission seats. They cost $7.00…$6.00 for students and seniors, although if your child has an “A” on his or her report card he gets in free. The twenty-four box seats are $12.00 each, and feature both a designated waitress and a freestanding folding metal chair that you can turn to any angle you please. Maybe if you’re lucky you’ll meet Front Row Joe, who has recently broken the 1,020 mark for consecutive games attended at The Jack.)

The other thing that’s so great about a Daytona Cubs game is that there is no pretense whatsoever that this is a major league operation. I do understand that minor league ball is a growth industry, and that there is often little difference (but for price) in the experience between attending a game at a major league stadium or a new minor league park such as Steinbrenner Field in Tampa or Victory Field in Indianapolis. But I’ve always thought minor league ball belongs in minor league places, and cities like Daytona fit the bill. (I think our logo of the team…a polar bear wearing sunglasses…is also just way too cool, and fits our team in a way you can only do in the minor leagues. Like anyone ever took seriously an NHL team called the Mighty Ducks of Anaheim? Please.)

This lack of pretense carries over into promotions and between-inning activities. (It goes without saying that at the Class A level, the singing of the National Anthem is an adventure every night.) At major league parks, promotions are sponsored by telecoms and major banks. Last Wednesday at The Jack, it was Radiology Associates Dollar Ice Cream Night. Radiology Associates are the x-ray physicians I work with in the ED, and since I have given them so much business over the years I was delighted to take their ice cream at half price. I figure this is worth an acknowledgement, so when the PA Announcer notes that “Dollar Ice Cream Night is brought to you by Radiology Associates, I get up and shout my thanks. “Hooray! CT scans! Hooray! MRI! Hooray! Transvaginal ultrasound!” It was a sparse midweek crowd so, for better or worse, there were few people about to share my enthusiasm.

(Ice cream also goes surprisingly well with Woodchuck Cider, which is sold from a tap stuck into the side of a refrigerated trailer next to the Italian sausage grillers just under the third base stands. Woodchuck and other adult beverages are especially cheap on Thirsty Thursdays, when a 32 oz cup is only $4.75. I’m just sayin’.)

In between innings, there are all kinds of things to entertain the crowd, but again these are done in an intimate, informal, let’s all just hang out together sort of way. There is no Jumbotron, no scantily clad salsa dancers, no KissCam, no random shots of the crowd so people can wave frantically at themselves. Instead, as befits the home of the Daytona 500, we do a lot of racing. There are games such as the burrito speed-eating contest, the “Little 500” involving small bikes and traffic cones, the “who-can-put-on-a-frozen-t-shirt-first” race, and the “Who Let the Dogs Out” run, where kids take off from behind first base, run across right field to touch a “Metro PCS” sign on the wall at deep left center, and then leave the field along the warning track. (There’s always one for two little kids who don’t make it across the grass before the first pitch of the new inning gets flung.) And then there’s the nightly humiliation of our mascot Cubby as he races a small child from first to third. (Cubby’s record over the past six years: 0-137.)

My favorite game is called “Crabs In Your Pants.” There are two teams, and on each team one player has to stand with his back to his partner and toss stuffed crabs over his head into the oversized pants worn by the other. As a medical person, one can’t help but wonder if after catching the crabs, you shouldn’t throw a bottle of Ridd in there as well. (Public health never rests.) And of course there’s the singing of “Take Me Out to the Ball Game” during the Seventh Inning Stretch, led by a random fan from the stands and which, like the national anthem, is both a nightly tradition and an adventure.

The game was actually pretty well played, with the Cubs behind by a single run going into the top of the ninth. Then the Port Charlotte Stonecrabs got three more runs, and it didn’t look good for the Cubbies. I don’t think of myself as a “fair-weather fan,” but I also hate being witness to the agony of defeat. So I started to head out towards the parking lot (which during the daytime serves the courthouse and the public library), looking over my shoulder the whole way because I had this idea in my head that Cubby would spot me walking out and accost me for my disloyalty. I felt like I was less in danger when I saw smoke coming from behind the left field fence. It may just have been the cigarette from the guy who puts up numbers on the scoreboard, but I thought that perhaps Cubby was trying to organize a rally with the Radiology Associates Aztec Ritual Sacrificial Fan of the Night. (“Hey, Cubs fans!” Turn to page 6 in your program! If you see a picture of Huitzilopochtli, say your farewells and report to Guest Services behind home plate!”)

Some people will just do anything to win.

Health Care Reform: After The Fact

Well, it finally happened. After all the Tea Parties, the Coffee Clubs, the Lemonade Lounges, and the Beer Bunches, Congress went ahead and passed health care reform. It’s now the law of the land. I’ve been avoiding trying to think too much about it. Frankly, one reason is because that in my brief career in public service I’ve enjoyed working with people from all parts of the political spectrum, and taking any hard and fast position is bound to annoy someone I like and respect. It’s probably selfish on my part to put personal relationships over politics, but its reality. I’ve always held in my mind a lesson learned from friends in South America. I couldn’t figure out why they never wanted to talk about the subject at hand when I hit the door, but were perfectly content to wait days, even weeks, before really getting down to work. “Friends first, then business,” was the reply. Since then, it’s always seemed like a better way to run my life.

A second is probably some guilt over not really having a position, or at least one that I’ve publicized. Sure, I’ve nibbled around the edges, but that’s about all. I’ve learned that one of the privileges of having your own blog is the ability to take shots at everyone without actually having to put your own opinion on the line. The third, and probably most important reason I tried to avoid comment is that I’m honestly not sure what I think, and I’m honestly not sure why I’m not.

But after some weeks of reflection, I feel like I ought to say something. It is the largest piece of social legislation since Lyndon Johnson’s Great Society, and (more to the point) it affects me both personally and professionally.

So here’s the bottom line. All citizens of the United States should have access to a basic level of health care. Nobody should be denied access because they are unfortunate enough to have a chronic illness or condition. The new law is a major step forward. This is an idea I absolutely agree with. Period. Full stop. End of sentence.

I think what bothers me is that I’m not sure the new law will do what it’s supposed to. There’s an employer mandate to force businesses of a certain size to support health care coverage for employees. But if the fines for non-compliance with the mandate are less than coverage costs, why should an employer buy in? Similarly, if an individual finds that the extra bill for not buying coverage is less than the coverage itself, will they still choose to buy? And if someone doesn’t report their lack of insurance to the IRS or doesn’t pay the fine, will the government enforce the law, putting people in prison because they don’t want to buy health insurance? (By the way, medical care is free in prison.)

In a previous blog, I’ve noted that the majority of physicians in this country don’t want to see Medicaid patients in their practice, so it’s hard to see (barring the growth of a new health care sector of high-volume, low-cost Medicaid clinics) how the new influx of Medicaid patients will actually get to see a physician. The administration’s effort to raise primary care Medicaid payment rates to match those of Medicare is a start, assuming that Medicare cuts (a backbone of funding for the new law) don’t dampen the enthusiasm of physicians to accept these patients as well. But unanswered are the questions of access to specialty care under the new legislation, reimbursement for preventive care and counseling, and diminution of medicolegal risk.

And I’m still at a loss to figure out how the law will lower health care costs. If insurance companies are (rightly) compelled to insure those persons with pre-existing conditions, premium rates will assuredly rise across the board. Taxes on medical devices simply drive up the cost of the device. If individuals are purchasing private sector insurance policies with government subsidies, federal expenditures necessarily rise. If employer support for coverage flags, how much more will it require in government subsidies to keep people insured? If new Medicaid recipients are allowed unfettered access to services, costs will spiral out of control. And even assuming that the new law is “cost-neutral” (which is, I think, a suspect prospect), what the estimates do is note that the rate of medical inflation over the next decade will be lower, not that costs will decrease in any way from the present value.

There’s a few philosophical issues as well. I’m not bothered by the issues of increasing federal debt. (I should be, but since it’s clear that neither party in power since 2000 has cared about it, I’m not sure it’s worth my fiscal angst.) The mandates bother me in the sense that I’m not sure I like the idea of being required by the government to buy a private sector product. (I’ll happily leave the constitutionality of that to the lawyers.) I still haven’t gotten over the public bailout of the financial firms that got us into the latest recession, and can’t figure out why once again we’re going to channel more federal dollars to those same insurance companies many blame for being the root of the problem.

But do these objections outweigh the moral correctness of insuring that everyone in this nation has access to health care? Absolutely not. And I wholeheartedly reject the argument that everyone already has access to health care because they can always go to the ED. Having lived my clinical life there, what you get is a screening for emergency conditions and sent on your way. You do not get primary care, preventive care, or anything even vaguely resembling comprehensive care. False statements such as these are used to “cover” for a system that is irrevocably broken. There are any number of fair objections to the way health care reform has evolved. But they do not overtake the basic need for access to care.

I’m also bothered by the failure of nearly everyone…and this is truly bipartisan...to recognize the inherent contradictions in play. Insurance companies are part of the problem, but we’re going to give people public funds to buy their products. Health care access is the goal, but there’s nothing to encourage doctors to see more patients. Cost control is critical, but there are no brakes placed on the runaway train. Improving the health of the nation is the goal, but those measures which can have the most impact on health are ignored. Opponents of the bill were simply that, and offered nothing concrete as an alternative for debate.

But I think the heart of my discomfort lies in the recognition that the new law really isn’t about health. Health is defined by the World Health Organization as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” By way of contrast, health care refers to system of delivery of medical treatments (doctors and hospitals), while health coverage refers one view of how such services are mediated between patients, physicians, and external payors (public and private insurance plans). This distinction is critical to understanding the true impact of the current bill.

Let’s be clear about what has happened. We have started to address the problem of health care coverage. We have not yet begun to address issues of health care quality, health care costs, health care financing, or health care access. The final bill holds provision for panels to study a host of issues, but no definitive statements or policies designed to remedy these problems. For all its volume, the bill is actually quite limited in scope. And any evidence of its effect on health itself is considerably muted.

Supporters of the bill would say that coverage enhances health by insuring access to care. But history has shown us that the biggest factors in improving health, at least in the physical sense that we think of in the United States, is not the existence of an advanced and aggressive health care system. Health is most improved by those measures that fundamentally change the landscape and facilitate healthy behaviors. Updated and enhanced immunizations laws, clear indoor air statutes, the provision of physical education in schools, environmental regulation, mandatory seat belt and motorcycle helmet laws, and cultural change will do far more to promote health than any manipulation of insurance plans.

One of the tasks of the health care community is to help policy makers understand the difference between health, health care, and coverage. Monitoring health outcomes such as life expectancy and infant mortality rates are measures just as key to evaluating our efforts as are persons covered and costs for care.

So in the end, the new law is a significant step forward. (I’m purposefully avoiding the term “Great Leap” because I don’t want to be enmeshed with Maoism or the whole “Obamacare as Socialism” argument which, for the record, it’s not.) I’ve still got some questions. Nonetheless, I support the legislation because it’s the right thing to do. And I look forward to the day our nation recognizes that in the end, health is what really matters. Unfortunately, we’re not there yet.

Hopefully, we can all keep in mind that health care reform is a work in progress. I don’t know about you, but I’m looking forward to the next round.

Behavior Modification

Kurt Killgore was riding his bicycle across a busy street at three in the morning. He swerved to avoid a truck, fell of the bike, and landed on his right side. The paramedic crew thought he might have a broken collarbone, and rightly put him in a sling. His pain was severe. It was so severe, in fact, that the only way to kill the pain was with sleep. Which he did all the way here during his ambulance ride.

The EMS crew woke him up to move him onto the bed. He opened his eyes and looked straight at me, standing at the foot of the bed. “Hey, man I need something for pain. The damn paramedic wouldn’t give me anything.”

I shrugged. ”Seems to me you were sleeping pretty good.”

“Oh yeah? Well, f…k you. I love you too, man.”

According to the paramedics, he was one of those guys who was full of love for his fellow man. Apparently this duality…carnal lust and romantic affection…was his usual response to anything that was asked of him. Nice to see someone with true joy in his heart. Gives me faith in the human condition. Also good to find that once again my gender identity has been reinforced.

I shook my head and stepped out of the room while the staff got him over to the exam bed, the effort accompanied by much moaning and groaning and use of creative language. The nurses did their part, trying to get some kind of story from him, and trying to start an IV just in case we needed it to do things like, well, treat pain. However, he decided it was much more important to swear at the nurses an occasionally reach out and grab at them instead of allowing us to care for his stated complaint. Finally, it was my turn.

“I’m Dr. Rodenberg. What happened to you?”

“I’m in pain, man. Pain. I need something for pain. And why are these f…..g nurses sticking me for an IV? I need something for my f…..g pain.”

“Can’t give you anything for pain ‘till I figure out what’s going on.”

“What’s your f…..g problem? I’m in pain. I don’t want those b…..s touching me. You better give me something now, man, if you know what’s good for you.”

I took a deep breath, about to begin one of those well-rehearsed speeches I’ve built up over twenty years in the ED. There’s a whole catalog of these speeches. There’s the reassuring, “I don’t know what’s going on but it doesn’t look like anything serious so you can go home,” talk. There’s the hopeful, “Do you think maybe talking to one of our psychiatric staff might help?” conversation. There’s the very sad, “Your loved one is in very critical condition, and while we always hope for the best we plan for the worst” discussion. But the, “You’re being a jerk and I’m not going to put up with this anymore” lecture is one of my favorites.

“Okay, here’s how this works. You know where you are and what’s going on, so you’re in full control of your senses. So you can choose to stop this behavior. If you don’t, and you continue to be abusive to my staff (I get very possessive in these moments; I don’t know why), I’m going to assume that you’re refusing care and I’ll have security escort you out the door. And if you grab at someone again that’s called assault, and the cops will be here to drag you to jail quicker than spit. Are we clear?”

“Man, you don’t…”

“Are we clear on this?

He grunted in a non-threatening way. Care proceeded as it should; x-rays of everything on the taxpayer’s dime, some pain medication to put him out of our misery, and nice dressings over abrasions on his elbow and knee that will soon resemble his socks, adhering to him for the next several years until the breakdown of nuclear forces between the gauze atoms causes them to disintegrate. He was discharged back into the real world with a sling on his right arm for his broken collarbone and admonitions to (chose one or all) get a bike helmet, put ice on your shoulder, use Tylenol for pain, call the local detox center or Alcoholics Anonymous for help with your drinking problem, follow-up with an orthopedic surgeon in 4-5 days for recheck, and go in peace, all of which will remain unheeded.

I don’t know why, but this kind of interaction gives me great satisfaction. While it can’t really contribute to the care of the patient, I can at least make my work family feel protected and supported. Not sure it’s in my job description. Just think of it as a value-added service.

"Forty Kilometers in a Leaky Ol' Boat..."

A few final notes from Santa Catalina:

The weekend of our visit was not just our anniversary, but also the annual Catalina Island Flying Fish Festival. Apparently the warm summer water breeds lots of kelp, and the flying fish come into the kelp beds to hide from predators and deposit their eggs. The local version of the species is the California Flying Fish, the largest of the class that can top out at 19 inches long.

We took our role as celebrants of this annual extravaganza of piscine aeronautics very seriously. The first night on the island we took the Flying Fish Boat Tour, an hour-long nighttime passage along the southeast coast using searchlights to stir up and sight the fish. In the end, we saw lots of things jump, but nothing chose to fly. But it was still a good tour, and I liked getting out from the town to see some of the hidden infrastructure of the island (power stations, cargo docks) as well as Seal Rock, which is, strangely enough, a rock that seals sit on. The well-practiced guide got off a couple of prime one-liners as well during the safety talk. “See this life jacket? Take a good look at it It’s the only one we’ve got,” and, “You’ll need to stay in your seat because it’s a fire hazard. If you don’t, I’ll get fired.”

Because the fish suffered a failure to launch, I wasn’t able to get up close and personal with a flying fish until two days later at the Flying Fish Festival Parade. It was a little parade as befits a little town, mostly a fire truck with lights on leading a small collection of decorated golf carts and Mini Coopers down the waterfront. The Lions Club Segway Drill Team was there, as were a bunch of preschooler in costume and a poodle dyed pink with cardboard fins stuck on it’s back. Gill the Flying Fish, the festival mascot, made an appearance, and the parade was topped off by the seven members of the Avalon High School Drama Club singing “The Jet Song” from West Side Story.

There was a street fair going on as well, and I really felt it was incumbent upon me to show my support for the fish. So I bought a nylon flag to wave during the parade, and a young girl who was helping her mother in the booth asked if I wanted to see a real flying fish. I did, so she opened up a cooler that had two flying fish in a bed of ice. It turns out you pick them up by their wings, so I did. It also turns out that if you move it’s wings (actually elongated pectoral fins, if you’re keeping score) back and forth, you can make it’s mouth open and close and it looks like it can talk. It was at this point...making a dead fish talk…that The Bride rightfully shook her head at me and moved further off down the block.

********************

There have been bison on Santa Catalina since a silent film crew brought them over to film a western and never took them off. As a Kansan, bison are nothing new. But I forget that not everyone has seen a bison, let alone a herd of them. So it was amazing to me that when a bison was spotted, the bus tours stop and people spend hours taking pictures of something I’ll quite happily eat.

********************

There’s a building on the island called the Tuna Club. Founded in 1898, the Tuna Club is the oldest fishing club in the United States. The club’s main goals are "to elevate the sport of fishing to its highest possible standard, and for the protection of the game fish of Southern California.
Located on the edge of Avalon Bay, the Tuna Club is a California Historical Landmark and is on the National Registry of Historical Places. Many notable dignitaries and personalities have been members of the Tuna Club, including Theodore Roosevelt, Winston Churchill, Cecil B. DeMille, Charlie Chaplin, and Bing Crosby (http://www.catalina.com/art_historic.html)."

The Tuna Club originally caught my attention because of some outdoor displays of sea life organized by a research branch of the University of Southern California. This is how I got to hold a sea cucumber, and was reassured that the black sand it pooped out into my hand was actually cleaner coming out than it was going in. (They were scientists, so it must be true. I also hear that USC had a financial relationship with a highly recruited octopus and will not be able to participate in the Goldfish Bowl for the next two years.)

Speaking of the Tuna Club, I never got to go inside. So I wonder what actually goes on in there. Is it the kind of place where tuna go after a hard day at the office, a place to kick back, put up your fins, and snack on a mullet? And what do they talk about? “Man, you wouldn’t believe this guy today. Tried to get me with a plastic worm. Plastic! Can you believe it?” Or maybe, “Sorry guys, gotta go. She wants me swim through the kelp and fertilize the eggs again. All 5000 of them. I’m getting too old for this, you know?” And are all tuna welcome, or do the bluefins blackball the yellowfins? Is Charlie a member?

Yep, sometimes I really do think too much.

********************

There’s an advertisement for a restaurant on the island called The Avalon Grille that summarized every stereotype I ever had about Southern California. It features an older man with dyed blond highlights and an open shirt and jacket dining with a much younger slender and well-siliconized woman in a red strapless dress. One can just imagine that he’s thinking “I hope the Viagara works this time,” while she wonders just how creepy it is to sleep with someone older than your Dad.

This reminded me an incident about a year ago, when The Bride (who is significantly younger than me) and I were shopping at the Mall of Millennia in Orlando. She was getting a few odds and ends, and I was whipping out the credit card from time to time to pay for them. As we walked by a series of full-length mirrors, it occurred to me that if one were to look at us, this young well-assembled woman in four-inch heels followed a step or two behind by a slightly stooped older guy, one might take us for the folks in the advert for the Avalon Grille. I pointed this out to her, and asked “Do you think anyone ever thinks you’re just a trophy wife?”

Smiling, she said, “If I was a trophy wife, you’d have a hell of a lot more money.”

********************

On Monday morning we had a very nice walk up to the Wrigley Memorial, a granite and marble structure that overlooks acres of botanical gardens about a mile inland from the Town of Avalon. It was mostly an uphill walk, and so we were both pretty tired when we finally reached the stone staircase at the right side of the edifice. Encouraging each other, we climbed to steps to the top and took in the view. It was only after we turned to make our way back down that we found there were no steps over on the left, only a gentle, undulating slope.

“There’s no steps,” noted The Bride.”

“No,” I said.

“You made me walk up steps.”

(You know how sometimes you can see a problem coming, while also knowing there’s not a silly thing you can do about it? Yeah, this was one of those times.)

“I didn’t know.”

“YOU MADE ME WALK UPHILL FOR A MILE AND THEN YOU MADE ME WALK UP STEPS.”

“Yes.”

“I HAVE BLISTERS.”

“I’m sorry.”

“WHAT ARE YOU GOING TO DO ABOUT THIS?”

I’m still working my way out of this one. Might take another trip to fix it. Stay tuned.

Zip-a-Dee-Do-Dah

(In the interest of saving time, I’d like to offer you some options as you consider the following entry into The Blog. You can choose to read the short version or the long one. Here’s the short version:

“Brack-brack-brack-braaaack! Bock bock bock bock bock. Braaaack!”

For the longer choice, see below.)

There are a lot of reasons The Bride and I think we’d do well on The Amazing Race. We have lots of complementary skills. I’m good at word games, while she’s good at math. I’ll eat just about anything, touch icky stuff, navigate, and dive. She’ll jump off high places, ride scary things, and drive fast.

These attributes become most apparent when we’re on vacation. Last summer we spent a week in the Florida Keys. We rented a jet ski for an hour, and she really wanted to drive. Which she did…fast…laughing the whole time, while I hung on to her waist like a Harley bitch and screamed my freakin’ head off. She would be heading out into the open sea, and I would be constantly looking backwards to find the marker buoy that indicated the way back. When she would turn about to make another run, I would say something like, “Why don’t we get off and have a swim? (The water was warm, and a quick paddle would delay the next screaming episode for just a few more minutes.) So I would jump off the back of the jet ski and splash about, while she would continually be on the lookout for sharks and rays and barracudas and pirhanas and other things that might skeletonize your feet if you so much as dipped a toe into the briny gulf.

Which leads us back to Santa Catalina, and to one of the many activities that were planned for our stay. Specifically, we are at the base camp for the Zip Line Eco Tour. For those who aren’t familiar with a zip line, it is essentially a set of wires strung between platforms along a mountain. You ride in a harness which is clipped to a pulley, while gravity and momentum take you down the hillside, one platform at a time.

(Before we go on, it’s important to the story that you understand there are things I won’t do. Sitting calmly and adjusting the straps over my nose and mouth when the oxygen masks fall from the ceiling of an aircraft is one of them. Another is a roller coaster. I cannot stand the feeling of falling, and even the thought of a fall causes me problems. And except for seven million years of hominid evolution, there is no good reason why I think a fall from a height is a bad idea. Flying doesn’t faze me, and I’ve got a private pilot’s license of my own. I’ve flown in ultralight aircraft, I want to go parasailing, and to fly a hang glider with a fan-like engine strapped to my back. Skydiving’s also on the list. On the other hand, jumping off the ten-foot board at the local pool drives me nuts. Maybe it’s the feeling of being out of control that gets to me about a fall.

Nonetheless, it’s often all I can do to ride kiddie coasters with my son. Here’s an actual dialogue we had at Legoland, just before riding the Coastersaurus, designed for the youngest visitors to the park. He was six, almost seven, at the time.

Child: “Are you scared?”

Me: “No.”

Child: “Then why are you telling me it’s okay to scream on a roller coaster?”

Me: “Because it shows you’re having fun.”

Child: “So if you scream like a girl, you’re not scared, but you’re having fun.”

Me: “Exactly.”

Child (after ride): “Gee, Daddy, you had a lot more fun on that ride than I did.”

Me: “Yes. I don’t think I can ever have that much fun again in my life.”

Fortunately, it appears that he has inherited my abject fear of coasters, so I don’t have to worry about being around the next time he is forced to ride a coaster, which will most certainly be at the request of a girl. Which is also the last time I rode one. That girl is now The Bride.)

All the above being said, if there’s one thing I’ve learned over the years, it’s how to put up a brave face. (At least until the moment of truth, when the sniveling coward inside emerges from his shell like Botticelli’s Venus arising from the waves.) So I sat there with the rest of the group, chatting amiably about my aversion to roller coaster aversions. Apparently I did quite a job, because The Bride leaned over and said, “Okay, how much of this talk is actual fear and how much of it is you being charming?”

“About 80/20, with fear in the lead,” I replied. This was also an attempt to be charming. The truth is that it was more like 95% charming. I wasn’t really scared at the time, because I thought I had it all figured out.

In retrospect, I thought that zip lining would be kind of like skiing. First there’s a bunny hill where you can’t go very fast or fall very far, and you to use a rope pull to get to the top of the sloe. Then there’s a series of slightly higher inclines and more complex lifts to master until you finally get to the top of the mountain on the longest chair.

So I kind of thought the zip line course would follow the same model. You know, there would be a small line, maybe 100 yards long, where you might be ten feet off the ground. Once you were convinced you probably weren’t going to die (at least not yet), there would be another one just a bit higher and slightly longer. At some point, you might go over a crevasse, but this would be very quick, without any real time to think about what lives in the abyss and how fast it will eat you when you hit the ground.

Needless to say, that’s not how zip lines work. It’s a function of physics, really…since there’s no way to go back up, it starts up high where the ground is steeper and the spaces between platforms are deep and wide. So the first line goes several hundred feet with trees fifty feet below, while the second is a little over 1000 feet long and soars 300 feet above a canyon floor.

It’s a five line series, but all I saw were the first two. This is because the minute I came over the top of the mountain and saw the first station, the edge of the platform and the wire over space, I felt the Angel of Death smiling over my shoulder and froze. Deferred. Made a risk-benefit decision. Or, perhaps more accurately, chickened out.

I’m standing there at the top of the platform, looking out into space. I am not crying. Guys do not cry. We tremble, perhaps, and may on rare occasion weep, but we do not cry. The Bride, however, is in tears, but only for the most wonderful of reasons.

“I can’t go.”

“Oh, if you don’t go, I won’t go either. I don’t want us to be apart on our anniverserry.”

“No, you have to go. You’ll love this.”

(The bus driver who took us to the top of the mountain said the whole thing was very romantic. I’m trying not to cry because I’m terrified. She’s crying because she doesn’t want us to be apart. I’m insisting that she leave me in the throes of a panic attack because I want her to have fun. Could be a Hallmark card.

“To My Wife:

I love you so much, there’s no error.
You go on, I’ll flee in terror."

I’ll take royalties, please.)

While this is going on, any number of passer-bys in golf carts (the preferred way to get about the island) are pausing to watch this romantic interlude. Meanwhile, every time I screw up some courage and take a step towards the platform, I become aware of an impending autonomic parasympathetic discharge. I believe lay people call it a need to barf.

Eventually we got it worked out. I would take a video of her between the first two platforms, and then when she was out of sight I would head on down the mountain and meet her back at the base. It was a great walk with some beautiful views, and I had a great time. Plus, there was no sweating, salivating, or barfing, and all of my bodily fluids stayed within the cavities where the Good Lord intended them to be.

I actually got to the base camp before the group was done with the zip line tour. This was actually the most awkward part of the whole thing. The staff know you were the one who chickened out. You know they know. They know that you know that they know. And so you purchase a large number of zip line tour baseball caps and sweatshirts as an act of atonement.

Please do not let my experience dissuade you from doing a zip line. The folks at Catalina Zip Line Eco Tours were nothing but professional, and I have no doubt that the operation is as safe as it comes. The Bride had an absolute blast. But if they would like some unsolicited advice, how about a bunny line?

PC Police Blotter

Hallmark has pulled one of its graduation cards off the shelves after the National Association for the Advancement of Colored People complained that it used racial stereotypes and contained an abusive slur aimed at black women.

The card's micro speaker has two Hallmark characters, Hoops and Yoyo, bantering about how the graduate is going to dominate the universe. They tell the planets to "watch your back" and issue a stern warning to "ominous" black holes.

(The NAACP) say that the audio sounds more like "black whores," and that card is implying that black women are not as capable or as powerful as their white counterparts.

Hugh Collins, AOL News, June 12, 2010


Groucho: "Now down here are the levees."
Chico: "That's-a the Jewish neighborhood."

The Marx Brothers, Cocoanuts, 1929

I haven't heard the entire message of the Hallmark card, so I can't comment on what it does or doesn't say. However, I do find it interesting to note that the Anti-Defamation Leauge of B'nai Brith did not issue any charges of anti-semitism when the disaster in New Orleans was blamed on the failure of the levees. Nor do I recall a large outcry from the gay community when there were clearly problems with the dikes.

Echolalia

Here’s a linguistic memory of Santa Catalina that will stay with me forever.

You know how certain phrases become keynotes for a relationship or an event? For example, The Bride and I have developed our own language of metaphors that reflect certain moments in our lives. For example, one of them is “Learn, learn, learn. You can learn at the fair!” This came about during our first trip to the Kansas State Fair in Hutchinson, where we got a firsthand look at cattle restraints. (You don’t think they just stand there for branding, do you?) Another is the phrase, “Gee, maybe someone could made a two-dimensional graphic representation of that,” based on the time I got us lost in downtown St. Louis looking for the Bowling Hall of Fame because I refused to look at a map.

This happens outside of the marital bond as well. I was in Israel on a public health preparedness study tour about three years ago. What we found was that every speaker began their presentation by noting that “Israel is a small country, about the size of New Jersey.” It got to the point that even before a speaker would start, one of us would raise our hands and ask, “Is it true that Israel is a small country, about the size of New Jersey?”

(It was a great time, and I did indeed “learn, learn, learn” that for us, preparedness is a hobby. For Israelis, it’s a way of life.)

In Santa Catalina, one of the mad-made landmarks is the Casino, a strange hybrid of Renaissance and Art Deco that somehow manages to outshine both its parents. (However, just like a mule, I suppose it is unlikely to reproduce.) It sits on a rocky point just to the edge of town, and it’s one of those things that are always in view. This means that every bus driver, boat guide, kayak instructor, and street vendor reminds you that “Casino is an Italian word meaning gathering place.” I think there is probably something in the law of the island that says if you do not repeat this fact once every three hours, you will be deported to the mainland and given a choice of jobs as Lindsey Lohan’s probation officer or Head of Risk Management for BP.

While the phrases by themselves are amusing, the problem is that when you build up a repertoire they end to run together. So by the end of the trip, I would look out over the harbor of Avalon at this wonderful Mediterranean structure, and note that “Casino is an Italian word meaning ‘about the size of New Jersey.’ Learn, learn, learn. We can learn in New Jersey!”

If only there was a two-dimensional graphical representation of how to find it…now, wouldn’t that be something!

A Guessing Game

Yesterday I mentioned that I often feel like I was born at the wrong time. It turns out this isn’t all bad, and sometimes it has its’ benefits. For example, living out of time was how I was able to figure out where The Bride was taking me on the fifth anniversary of our life sentence. (The charge was first degree affection. I refused to plea bargain.)

I had planned the honeymoon in secret, and now it was her turn. She had arranged everything quite cleverly, even deciding to fly to Daytona to start our trip rather than meeting me in a more central airport for fear I would check in on my own and learn my destination.

I watch a lot of those PBS specials where they reunite old pop groups (at least the surviving members, which is in itself kind of sad). After the show, I go on-line and spend a foolish amount of money on CD’s to find 1) How many of the guys on the show were really in the group; 2) that the songs they did on television were not just their only hits, but that the rest of their songs really aren’t that good; and 3) that I was doing just fine when I supported my local PBS station and bought the DVD of the program. (That being said, I am grateful for knowledge of The Four Coins, whose rendition of “Shangri-La” is simply the best two-minute single of the entire decade.)

One of these programs was called “Magic Moments: The Best of 50’s Pop.” Apparently the number four was a big deal in that era…the Four Aces, The Four Lads, The Four Coins, and The Four Preps. (There were also four Ames brothers, and four Hi-Los, two His and two Los.) By the time they filmed the show, there were only two original Preps left (not to be confused with perps, although if a Prep became a perp that would easily explain their absence from the band). One replacement was the Jim Yeaster, the guy with the really high voice from The Association…you know, the one who hits the note, “…and gaze into your” – change key- “EYYYYYYYYYYYYYYYYYYYYESSSS,” at the end of the bridge in “Cherish.” The other was Dave Sommerville, lead singer for the Diamonds (“Little Darlin’…bop, bop, badadadada.")

(By the way, the song “Little Darlin’” has the best spoken bass line in human history. As chanted by Bill Reed:

“My darlin', I NEED you
to call my own and NEVER do wrong.
To hold in mine
Your little hand.
I'll know too soon that ALL is so grand.
Please, hold my hand.”

Check it out on YouTube.com. Brilliant.)

So we’re on this plane to John Wayne Orange County Airport (“Check your baggage, pilgrim”) and I still have no idea where we’re going. All I know is that it’s somewhere around LA, and that the most obnoxious callers on the Jim Rome show, to which I am sometimes forced to listen in the vapid wasteland of midday radio, seem to live there and call it “The OC.” I have no idea why we would be going to a suburb of L.A. Going to Disneyland makes no sense, as just an hour down the road we have Disney World, and Disney Hollywood Studios, and EPCOT, and Universal Studios, and Sea World.

So we’re two hours in the air with another two to go, and I’m still clueless. This makes me happy. I’ve always been comfortable in my ignorance, and this is no exception. Besides, I really like surprises.

The Bride, however, HATES surprises, and so she’s been after me for a week for me to ask her for clues so I can guess. She would want to know, so why don’t I? So she asks again, “Do you want to know where we’re going?”

I smile at her. “No, not really. This is fun.”

“Can I give you a clue?”

I can hear see the tension rising in her voice, and while there’s little to fear, I know that if I continue to frustrate her she’ll finish off the airline peanuts before I even get a chance.

“Sure, I’d love a clue.”

I think this is a good solution. She can give a clue, and while she’s thinking of it I can reach over and snatch the peanuts. Besides, her clues are usually so obscure they mean nothing. For example, her last clue was “Where we’re going, Ricardo is doing the wine pairing for our anniversary dinner.” All that means to me is that it’s probably not going to be wine, roses, candlelight, and a night with The Colonel. So it was a perfect clue. She felt like she was giving away the surprise, I stayed in total ignorance of reality, and all’s well in the world.

“Okay, here’s the clue. The Four Preps.”

The Four Preps. I know them. What did they sing? There's one song with a mystery title, but the lyrics are "I was a big man yesterday, but boy you outta see me now." That doesn't make sense. But they did two songs on the PBS special, and the other one was...oh, that's right...

“Twenty-six miles across the sea.
Santa Catalina is a-watin’ for me.
Santa Catalina,
The island of romance, romance, romance, romance.”

And that’s where we wound up, a taxi ride (with a stop at Jack-in-the-Box for tacos) and a ferry trip later….on the Island of Romance. Romance. Romance. Romance.

Wrong Era, Wrong Coffee

I’ve previously alluded to the fact that in many ways, I think I was born into wrong era. I would have done great in the late 1930’s and early 40’s, because then I would have had a legitimate shot at wooing Barbara Stanwyck, Paulette Goddard, or even Vera-Ellen. Being born in time for the sexual revolution and the hazy crazy lazy days of the Summer of Love might have been fun as well. (I have this personal “bucket list” of things I want to do once I’m totally done working, my family is financially secure, and I have the liberty to totally fry my brain. This list includes taking selected drugs to see what happens. I realize I’m going about this the opposite of most folks, but I had a rather undistinguished drug and alcohol profile during college, so I’ve got to make it up on the back side.)

By the time I had my “intimate interpersonal relationship” coming of age, it was the early days of the AIDS epidemic and nearly every avenue of fun was completely shut down. And even now, I don’t understand much popular music, and popular culture is so far distant from me that I get more from “hard news” magazines like The National Enquirer than I do from People Magazine. (It’s a stark realization to know that you’re already a dozen years past the entertainment community’s mean target demographic of 18-35 years of age.)

I’m also not good with technology. I don’t mind the cell phone or texting, but I like it on my own time. There’s something to be said for not being available and not needing an excuse to prove it. And while I like what computers can do, operationally I’m pretty much still working with my first new computer, a 40 MB hard drive monstrosity I bought in 1986 for the tidy sum of $900. It had a word processor and a spreadsheet, and that’s still mostly what I use. (Kind of miss the orange and black CRT screen and the dot matrix printer, but what can you do?) I also believe that, with the possible exception of Beatles Rock Band, the Atari 2600 is the most complex game system anyone could ever want.

(This reminds me of the time that there was an exhibition on the history of toys at the Children’s Museum of Indianapolis. I took The Child, and after endless displays full of things that caused me to point and say, “I had that! I had that!” there were two TV screens with Pong. Pong! I was in heaven. Nobody born after 1980 has an idea how cool that is, but at the time this was a major league deal. I still remember 1978, when my father went to Sears and spent $150.00…about four million in today’s money…to get a Pong game. He was the best Dad EVER. Actually, still is. (Happy Father’s Day in advance.)

Excitedly, I talked The Child into a game. After a shaky start…it had been thirty years or so since my wrist was in prime Pong condition…I’m having an absolute blast. I’ve remembered how to get the ball to come off the paddle at a crazy angle to give it spin, and how, if you are moving the paddle just right when you hit the ball, it’ll actually go faster accorss the screen. Of course, with his quicker reflexes and better vision…I was still too vain to wear my glasses back then, even for distance…he was kicking my posterior. But this was fun! And it was a bonding activity. Daddy and Boy quality time. So I’m standing up, then sitting down, leaning left, then careening right, twisting my body in all kinds of pain-inducing ways to put some English of the ball, when I hear this little voice off to my left asking, “Dad, what else does it do?”

I’m focused on the screen, so I don’t realize what I’m stumbling into.

“That’s it. You hit the ball back and forth until the other guy misses. Isn’t this GREAT?”

Another minute or two, and he scores three more points.

“You sure it doesn’t do anything else?”

“No. Now serve.” (I’m six points down and the “let him win to build his self-confidence” parent is losing ground to the Hypercompetitive Dad.)

Forty seconds, another point. There’s a sigh from below. “I’m done now. Can we look at dinosaurs?”

And so the video game torch is passed.)

My taste in movies is also somewhat out of date. I’m a big fan of old movies, and one of my favorite actors in the late Danny Kaye. Most people know him now from the children’s movie “Hans Christian Andersen” or the comic “The Court Jester.” (I also highly recommend “The Secret Life of Walter Mitty,’ especially the doctor scene. Pocketa-pocketa-pocketa.) Kaye was a master of convoluted language, which led to the most quoted outtake from his films. In brief, he’s trying to poison another knight, and he doesn’t know which cup is tainted. So he has to repeat to himself:

“The vessel with the pestle holds the pellet with the poison.
The chalice from the palace holds the brew that is true.”

This is later complicated by some additional business with a flagon. (The one with the picture of a dragon.)

This all comes together because last week in the Atlanta airport, The Bride asked me to stand in line at Starbuck’s while she went to check on the gate.

“Why do I have to get the coffee all the time?” I asked.

“Because it’s in the bible.”

This was a new one. “Where?”

She smiled. “You know, the Book of He-brews.”

This got me thinking about other comical chapter titles in scripture. Aside from guys with funny names (and who doesn’t smile when they think of Habakkuk?), I’ve always thought the chapters in the Christian New Testament whose titles start with “The Epistle of Paul the Apostle” just sounded funny. (It occurs to me that this may only be funny only in English translation. The Spanish “Epistolos de Pablo” sounds maybe more like a children’s television show, especially if you say, ”Ninos! Es el tiempo de Epistolos de Pablo!” using the deep voice and cadence of the guy on Univision who does the promos for Sabado Gigante. No theological insult intended, to be sure.)

So as these various strains of though wander about in my brain, I started to wonder how Danny Kaye would handle the issue of biblical alliteration and coffee:

“The Epistle of the Apostle has the pellet with the poison.
The Bible without libel holds the brew that is true.”

Some mornings I really need to get more sleep.
 

Writing With Scissors is on vacation from June 3rd to June 8th...we'll see you again soon!

What's in a Name?

One of my Facebook friends asked me the other day where I get the names for my patient stories on The Blog. This is a serious issue, as there are laws out there out for maintaining patient confidentiality. So I try to disguise the patients as best I can. I don’t write about patients the day I see them and I intentionally alter the clock, so the casual observer can’t figure out the timing of their ED visit even if they can get hold of my personal schedule. I also try to not to include racial or ethnic characteristics unless they’re vital to the story. Of course, the people who work directly with me often know exactly who I’m talking about, regardless of whatever name I use for the patient. After all, they were there the same as I was, and there’s not much I can do about that. But they’re bound by the same need to protect patient confidentiality as I am.

Names are important, as they make the patient in the story a tangible reality rather than a generic, made-up sample of the species. But coming up with a fictitious name for the patient, especially one that doesn’t sound anything like the actual name, doesn’t use the same initials, and doesn’t reflect ethnicity or culture is a lot harder than it sounds. I don’t know for use, but I think this is because there’s no way you can objectively select a new name for someone you know without the name reflecting something about them. Take five of your best friends and try to think of random names for them. I’ll bet you’ll find that in each case, the new name either reflects something about them (or at least you’ve excluded certain choices) because of what you know about the person’s race, religion, social background, or personality. That being said, you want to write the stories about Life in the ED, and you really can’t do so without having a patient at the center of it.

So avoiding name recognition is the biggest problem of patient privacy, and it’s really a much more difficult problem than you might think. That’s why I’m thankful for the internet-based Random Name Generator (http://www.kleimo.com/random/name.cfm). If I might quote from the introductory blurb:

“The random name generator uses data from the US Census to
randomly generate male and female names. Use it for screenplays,
fake id's, car rentals, pick-up lines, books, prank calls, movies.
Give a random name to that special someone you meet at the bar.”

(I’m not sure about giving random names to someone special from the bar. It makes it a lot more difficult to call them after you’ve got their number, and in my experience women seem to place a premium on you actually knowing their names. I am, however, comfortable with giving myself other names as the situation requires. For example, I always tell the folks at Starbuck’s that my name is Bob. While I try to imbue it with nobility, the fact is that in the waning years of the 20th century and the nascent years of the 21st, Howard is a dorky name. Bob is just easier. Then there was a night in Houston many years ago when a neurosurgeon from the University of Florida and I were on a NASA course and spent the evening drinking top shelf tequila shots at a Mexican café frequented by astronauts. I was the Chairman of the Department of Surgery and he was the Chair of Neurosurgery for the night because those were then names on the University credit cards in our pockets that night. There are also times when I’m discharging a patient and am asked my name. I’m Dr. Rodenberg if they say they liked the service; I could be any one of a number of different names if they don’t. Just kidding, risk management. Maybe.)

The Random Name Generator takes first and last names from Census data and ranks them in order of frequency. You put in the “obscurity factor” you desire…level 1 comprises the most common names, level 99 the least…and the computer matches them up, common first names with common last names at a setting of “1,” vice versa at the other extreme. (I usually use a setting of 20…a bit off the beaten track, but no too obscure as to be unbelievable.)

Here’s a sample of Level 1 names, both male and female:

1. Anthony Woody
2. Anita Silverman
3. Claire Palmieri
4. Frank Daly
5. Bruce Rhoden
6. Terri Braden
7. Hannah Hamner
8. Aaron Hadley
9. Theresa Sam
10. Grace Keeney

Here’s a list of Factor 99 monikers:

1. Ezequiel Bullert
2. Jenette Criton
3. Mure
4. Waylon Gheewala
5. Skye Hadson
6. Lenna Distance
7. Latoria Depietro
8. Letty Ladika
9. Benton Butel
10. Vincenzo Jingst

So that’s how it’s done. Random names keep patient identities private while still letting you tell the good stories. That being said, I am suddenly enamored with the name Vincenzo Jingst. Vincenzo Jingst Rodenberg. Now there’s a name for a kid. Or maybe a puppy. Vincenzo the Dog. My Dog Vinnie. Yeah, I like that.