Curmudgeon's Wastebasket

The Last Christmas

2011-12-14T13:43:00.000-08:00

“You’re always bah-humbuggy during the holidays, Curmudge. Why’s that?”

“Holidays are an awful lot of work, Julie. But they’ve always been more work for Mrs. Curmudgeon than for me. She worked harder than Santa Claus, but I was just a helpful elf.”

“How so, Rudolph? Did it have something to do with her profession as a church organist - choir director?”

“It had everything to do with it, Julie. Choir rehearsals began in October for the major Advent oratorio. But the efforts didn’t begin to get intense until December. Then we had to decorate the house for holiday entertaining. A tree inside and on the porch, figurines all over the place, and more greenery than a national forest. If all of the candles had been lighted, the house might have burned down.”

“Thank goodness it didn’t. So when did all the entertaining occur?”

“It began with a small dinner party for my long-ago professional colleagues and their spouses. We were a fairly subdued bunch, as you’d expect from chemists, but it took a while to straighten the house after they left.”

"I know the next event—the big oratorio with festival choir and orchestra. Remember last year’s awful snowstorm on Saturday? On Sunday there were more singers in the choir than people in the congregation.”

“Traditionally, we held the big choir Christmas party on the following Wednesday evening. That was the main reason for all the decorations in the house. The night before was spent making 80 or so ‘Aunt Lucy’s ham-and-cheese sandwiches’ to be served at the party. The usual beverage of choice was ‘Ethel’s punch’ that I concocted.”

“Of course, all of the parties included caroling around the grand piano. One year, even one of your friends with Alzheimer’s sang.”

"That’s right, Julie. With 40-50 people, the house was filled to overflowing. You can imagine the cleanup job after everyone left. At noon on the following day, Mrs. Curmudgeon’s colleagues from church came for lunch. Then a week later we did the full-house thing over again for another circle of friends.”

“Golly, Curmudge, with the parties and great music, I’ll bet that everyone had a wonderful time. It’s pretty evident that Mrs. Curmudgeon loved good friends as much as she loved good music. But I must admit that the whole effort sounds exhausting.”

“It certainly was. During one of our late-night cleanups, I commented to Mrs. Curmudgeon, ‘I hope we won’t be doing many more of these.’ It was not my intent to be prophetic. However, Mrs. Curmudgeon must have sensed more clearly than I that her interstitial lung disease was worsening and that these parties might be the last.”

“And finally Christmas arrived—along with pneumonia.”

"Mrs. Curmudgeon had to play three church services on Christmas Eve. It was quite a struggle for her to climb the 32 steps to the organ loft. Her breathing was labored…as if she were climbing to the top of Mount Everest. By the time the final service was over, it was Christmas Morning. She came down from the loft completely exhausted, and three weeks later, she died.”

“Curmudge, it sounds as if you helped everyone else to have a merry Christmas. Perhaps you and Mrs. Curmudgeon had a good time mostly because everyone else did.”

“Julie, she made great music and hosted holiday parties for about 40 years. In years past when people would ask when Mrs. Curmudgeon planned to retire, her answer was an emphatic, ‘Never.’ She would go on to explain that she hoped to flop dead on the organ console. She came close.”

Return to our Roots

2011-11-19T12:12:00.000-08:00

“Listen up, Julie. We may be returning to our roots.”

“If you think that’s going to make you any younger, Curmudge, you’ll be disappointed.”

“I mean our blogs, Kaizen Curmudgeon and Curmudgeon’s Wastebasket. Remember how Kaizen Curmudgeon began in May 2007. Our intent was to document the progress of our Lean transformation at Affinity. Although we couldn’t always focus on Affinity, we were able to limit ourselves to Lean and its required leadership. We maintained that through the middle of October 2008. Then our anticipated local contributions failed to materialize. While waiting, we expanded our scope further into health care and leadership topics that might be of interest to our readers. We are still waiting and writing about topics from the literature that our readers might not otherwise encounter.”

“In those early days, Curmudge, draft postings that were rejected by our reviewers were, literally, dumped into your wastebasket. Then in January 2010 we formalized your trash can into a new blog, Curmudgeon’s Wastebasket. During the last half of 2010 and the first part of 2011, Wastebasket was populated by e-mails describing emergency medicine as practiced on the battlefields of Afghanistan. Since then, that blog has been relatively dormant.”

“Dormant no longer, Julie. It has been suggested that we return Kaizen Curmudgeon to its roots and limit it to discussions of Lean at Affinity. Most future discussions of other topics formerly posted in Kaizen Curmudgeon will be posted here in Curmudgeon’s Wastebasket.”

“Wow, Curmudge. Think of all the topics our Kaizen Curmudgeon readers would have missed if this limitation had been in place for the past three years: Patient Safety, Mistakes, Checklists, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, Sepsis, Primary Care Medicine, and more.”

“One might call missing those postings unintended consequences. So geht es im Leben.”

“You meant to say, ‘such is life,’ Curmudge. Postings on Kaizen Curmudgeon will quite likely become less frequent. Our new path forward will require more effort, but we’ll make the best of it.”

"As usual, Jaded Julie, you’ve got that right.”

Afghanistan ER--Mack Is Back

2011-06-13T17:29:00.000-07:00

“Hey, Jaded Julie, Mack is back safe and sound.”

“Hooray! We’ve been waiting a whole year for that to happen. Does that mean that we won’t have any more postings with the Afghanistan ER title?”

“I don’t know. He was planning to accompany the troops on at least two more missions before the end of their deployment, and I haven’t heard anything about them. Perhaps he’ll have something to say when I see him in about a week.”

“Curmudge, I’m concerned about how the transition will be for one coming from the horrors of war back to the relatively peaceful U.S. No more patients with legs blown off and ghastly pelvic wounds. No more wearing a uniform soaked with (other people’s) blood. No more wondering if your next step will be your last.”

“It will certainly be a relief, but probably much more. We tend to think that to a physician it’s all in a day’s work, but they can’t avoid being affected by what they are seeing and doing day after day.”

“Do you suppose that it might be somewhat like grieving, where one’s sense of loss—and possibly in Mack’s case, outrage—will subside over time?”

“A big similarity will likely be that although images of persons and events will fade, a portion will be indelibly etched in some far corner of one’s mind. Apparently that has been the case with veterans of World War II. The rate-limiting step in healing is how long it takes for one’s mind to accept that what once was reality is no longer the case.”

“Interesting thoughts, Curmudge. They remind me of the Kaizen Curmudgeon blog where we often discuss topics about which you know little or nothing.”

Afghanistan ER--The Mountain

2011-05-04T08:22:00.000-07:00

“Listen up, Jaded Julie. Mack copied me on a note that he sent to some of his Army friends.

‘Hi, everyone,

I just heard about Bin Laden's untimely death. Thanks for all the well-wishes and kind words. Sunday and Monday I was on an air assault mission. Yesterday, I was sleeping in the strong point and guys started talking about it. I guess the news was put on the tactical radio net. I was half asleep, thought I had just imagined it, but later when I woke up, I found out it was true. I think he was mainly a symbol, a coward who has just been hiding for the last ten years, so I don't know how this will change our fight over here.

Last two days were pretty tough; mission was up in the mountains. Saturday, some of one of the platoons was up on this mountain, a piece of rock about four-1/2 stories above the rest of the area. Anti-personnel mine blew the right leg off one of the guys, right at mid thigh. The temperature was about 98 degrees. I had to run (or as close to that as I could manage) about 500 meters through uncleared terrain with a guy in front of me with a Vallin (mine detector) and one of the squad leaders, climbing over walls and cutting through compounds. Then one of my medics and I had to claw our way to the top of this thing to take care of him. A proverbial nightmare!

The whole time the helo was saying over the radio that they were almost out of fuel and were going to have to turn back if we didn't get him down to the bottom in minutes. The Fast-One failed to fire its needle; never had that happen before. Eddie was conscious, but I could barely feel a radial pulse. So I decided to go for the second IV and try to get the other unit of Hextend on board and also do some IV morphine because he was in so much pain. Never had a lousy IV start give me so much anxiety! The first responders had done an excellent job on the tourniquet, as high on the thigh as this was; but there was so much oozing we kept adding combat gauze and more pressure dressings. All in this little spot on top of this damn dirty rock.

We had to lower the guy over the side and practically skate him down on a Fox litter. IVs both pulled out by the time we reached bottom, but got what we needed in. I thought we were going to lose him; but they told me last night he's alive, has had a surgery or two, and I think he's on his way to Landstuhl.

The exertion of the whole thing was horrible. I had a weapon, full aid bag, and also was carrying 7 liters of water because of the heat. I felt like the climb was going to do me in, especially with me being twice the age as everyone else. Anyway, I got back to the FOB last night, am lying low today. Have about 3-4 days until next mission. (I can't believe with less than a month until we actually fly home that we are still at this horrendous op tempo!)

Forgive me for unloading this war story. I'm not including my civilian friends that won't understand anything anyway. Take care and please stay in touch.—Mack’ “

“Curmudge, just hearing the story makes me feel exhausted.”

“When we lived in Washington State, Mack and I would speed-hike up mountains in the Columbia River Gorge. But then we were 20 years younger.”

“And no one’s life depended on how soon you got to the top.”

Afghanistan ER

2011-04-25T09:47:00.000-07:00

“Hey Curmudge, I understand that Mack’s battalion is located in a new forward operating base.”

“It doesn’t sound much better than the old one, Jaded Julie. I just received this e-mail from him wishing a Happy Easter to friends and family:

‘Hi, everyone,

Happy Easter. I hope that everyone’s enjoying the day. I went on a raid today, actually flew out at about 0200 this morning. I think it was one of the most sinister places in this country I’ve been. A village with lots of little alleys and roads with walls on both sides. There were snipers taking shots at times during the day. One of the engineers got shot through both thighs; one of my medics and I took care of him. They may have hit the femoral vein, but I think he’ll be OK. Happened just as the sun was coming up. It was horrendously hard to carry him out of there to the helo, since the fields around the village were flooded in some places. Afghanistan is the #1 heroin-producing country in the world, and every square foot of ground in this part of the country is covered with poppy plants about to be harvested. We captured four guys who were making IEDs and explosives. Late in the afternoon, maybe an hour before we were getting ready to fly out of there, everyone was sitting up against a wall. Some of the guys were starting to clear the PZ for the flights out, when the enemy cut loose with five minutes of machine gun fire. Since we were behind the wall, no one got hit or anything. It was steaming hot all day, and everyone brought as much water as they could carry; but we were almost running out by the time we got out of there. Now I’m back in my hooch listening to “The Time Warp” from the Rocky Horror Picture Show and checking e-mail. About to get midnight chow. Please stay in touch because I’ve really enjoyed hearing from you while over here. Take care—Mack.’ “

“Curmudge, your grim countenance tells me that that wasn’t the kind of Easter you were expecting Mack to have.”

“You’ve got that right, Julie. I had Easter dinner with friends in a restaurant that was hosting a lot of noisy, seemingly carefree young people. I find the contrast between their Easter and Mack’s Easter disturbing.”

Debunking the Program-of-the-Month Myth

2011-04-14T07:35:00.000-07:00

“This is what you and I were talking about four years ago—before the Kaizen Curmudgeon blog even existed: ‘Jaded Julie announces to everyone within earshot, “I’ve seen them all—Total Quality Management, Quality Circles, Baldrige, ISO 9000. We tried them, spent a lot of money, management lost interest, and they went away. They were all just the program of the month, like this new Lean stuff. It will go away too.” '

“To which I responded, ‘No, Jaded Julie, you’re wrong (mostly). Lean is not the program of the month, and it has worked too well to simply ‘go away.’ Here are the facts:

· All of the programs that you listed came from a common origin, W. Edwards Deming’s principles of driving out fear, employee empowerment, studying and improving processes, and reducing waste.

· The programs had many elements in common, such as people working together in teams.

· Over time, the programs evolved, became more sophisticated, and were given new names.

· Programs came and went because they were mismanaged. On this point you were correct, Julie: Management often lost interest before the programs could pay off.’ “

“You’re right, Curmudge. I was too quick to criticize; I’ve learned a lot in the past four years. Lean has been working well for us, and it has become widely used in health care organizations. But what are some of the other current programs? When I encounter them in my reading, I want to know what the author is talking about. However, it’s my guess that success doesn’t depend so much on the program itself but on how vigorously it is implemented.”

“Let’s start with an old name, Gemba Kaizen . Although this is the predecessor of Lean, the name is a trademark and is not used very much. Among the principles of Gemba Kaizen are management’s role in upholding standardization, focusing on the process, analyzing process data, establishing and implementing countermeasures, following PDCA cycles, revising standards, and policy deployment.”

“That sounds a lot like Lean. Because it is Lean’s predecessor, that should be no surprise. Lean has also strengthened the emphasis on housekeeping (5S), process analysis using value stream mapping, and A3 problem solving.”

“Most of what we have discussed can also be found in Six Sigma, where their project elements include Define-Measure-Analyze-Improve-Control. In addition, there is emphasis on process control, statistical design and analysis of experiments, and training of project leadership (black belt and green belt).”

“I assume, Curmudge, that you are going to mention the Institute for Healthcare Improvement’s (IHI) Model for Improvement.”

“IHI is sort of like a supermarket; if you need something, they are likely to have it. In this case, IHI can provide a lot of guidance as well as tools for improving a process. Principal elements in their Model for Improvement include: Forming the Team, Setting the Aim, Establishing Measures, Selecting Changes, Testing Changes using plan-do-study-act cycles, Implementing Changes, and Spreading Changes. A newer IHI tool is their Improvement Map .”

“Although the Improvement Map is free of charge, Curmudge, I understand that its use requires installation of Microsoft Silverlight software.”

“Here’s an improvement program—also fairly new—that comes from The Dartmouth Institute for Health Policy and Clinical Practice. It’s called Clinical Microsystems. To me, it looks like a highly structured, Lean-like approach to process improvement with preprinted documentation. The microsystem is ‘your unit,’ and it is defined as ‘the place where patients, families, and care teams meet.’ For people in the unit, job #1 is to provide care, and job #2 is to improve care. Steps on their Improvement Ramp include: Assessment of the unit, Theme (identified in the assessment), Global and Specific Aims (specific numeric goals), Ideas for Change, and then Plan-Do-Study-Act cycles. The organization provides so-called Greenbooks for applying these steps to specific units within a hospital (Inpatient Units, Emergency Department, etc.).”

“As you suggested, Curmudge, these programs—the old as well as the new—have a lot of features in common. So tell me, how does the newcomer decide which of these she will propose to her organization?”

“Jaded Julie, although we favor Lean and call it the Affinity Performance Excellence System, one does not need to be a purist. Pick and choose what might work best in your organization or unit. And feel free to supplement from the works of Quint Studer (Hardwiring Excellence) and James C. Hunter (Servant Leadership).”

“When we wrote much of this four years ago, we were contemplating changing my name to Enthusiastic Emily. Whatever came of that?”

“Jaded Julie, it will never happen. Your name has become a household word, or at least a hospital-wide word. You will no longer be jaded when I am no longer a curmudgeon.”

Afghanistan ER--Firefight

2011-02-24T07:44:00.000-08:00

“Hey, Curmudge. We haven’t heard from Mack recently. Is the war in Afghanistan over?”

“Don’t I wish, Julie? Mack was in the States for a mid-deployment leave, but he’s back over there now. He copied me on this note to a friend:

‘Hi Rich,
It's been a decent week here. We had a ground assault mission three days ago; was nice because it was only one day. We left at 0400, got back at 19, in time for hot chow. The purpose was to hunt for bunkers and weapons/explosive caches. We found a lot of stuff and blew it all up. In the afternoon we got into a rather large firefight. The Taliban were actually hitting with more than their usual accuracy, meaning they were hitting the grape rows in front of us. We fired a ton of ammo, not really sure if we hit anyone, but certainly stopped their shooting. What the enemy usually does is fire on us for a short period of time, then simply break contact and disappear in the grape rows. They usually shoot from buildings like houses or grape huts but not for long. If they did we would get a bead on them and destroy them. They are usually not very accurate; their plan is to get us to pursue and lead us through fields where they have planted IEDs. We don't usually go for that anymore. The best part of this day was that no one stepped on an IED or got hurt. I'm all scuffed up from crawling over 5-foot high walls, etc. and destroyed a set of ACU pants. I'm certainly the oldest one out here, at age 49. Most everyone is in their 20s.
Mack’”

“It probably doesn’t make Mack feel any better to remember that he was an infantry platoon leader (prior to med school) before some of the younger soldiers were born.”

“Julie, if Mack slows up the troops any—and he probably doesn’t, I’ll bet they are still glad to have ‘The Doc’ come along with them.”

Afghanistan ER

2011-01-25T11:02:00.000-08:00

“Hi, Curmudge. I see that Mack copied you on a note to one of his medical colleagues.”

“Right, Jaded Julie. When you read the note, it will be evident that it could only be fully understood by another Army emergency medicine doc who had served in combat. When I asked Mack about some of the terms, he dictated a rather cursory glossary (below). Here’s the note:

‘Hi Ian,
Had a terrible air assault day before yesterday, very dangerous area. One person killed by IED. Also Local National blown up accidentally by our APOB while we were trying to breach through really dangerous IED seeded area. Even though they did the whole procedure to warn the locals and clear everyone out. It was after dark when we crossed after the explosion, the people up front found a guy on the road, huge facial wounds but alive and struggling. I put in a tibial IO, (I carry the mini-drill in my Aid Bag). Hit him with IV Ketamine (in spite of the head wound. I heard that increased ICP with Ketamine was not really borne out by literature. Also only thing I had to adequately sedate him for any extended time). Also used some Versed. Did a cric, balloon failed so exchanged it for new tube over a stylet. Ran 2 Hextends IO for the crappy radial pulse. The guys used their Tac lights on their M-4s for light. Set up hasty LZ and evacd him. Guy made it back to the Role III alive; they did labs, CT scan, everything. He had a brainstem bleed and a depressed skull fracture, so they withdrew care and he died. My two medics and I were covered with blood. Several of us fell into a creek trying to get back to the exfil LZ so had to wait for 3 hours in the freezing cold while wet. We were in PZ posture in the dark; the Chinook almost landed on us. Whole planeload had to dive off 6-foot embankment to keep from being dismembered by the bird, then crawl up the sides of the ditch and run for the helicopter. Still scratched and sore from that.
Anyway, that's my world for the last 3 days. Take care—Mack’”

“Gosh, Curmudge, every note from Mack further strengthens my belief that war is Hell.”

“I believe most everyone can get that impression without the glossary, but here it is anyway:

IED—improvised explosive device
APOB—chain of explosives fired several hundred yards ahead of advancing troops to explode IEDs
IO—intraosseous. An ‘IV’ into a bone instead of a vein.
Ketamine and Versed—anesthetics
ICP—intracranial pressure
Cric—cricothyroidotomy; an incision in the front of the neck to establish an airway
Hextend—colloidal plasma volume expander
Tac lights—very bright, focused, visible light source mounted on weapon
Role III—advanced medical care. A battalion aid station is Role I.
Exfil LZ—helicopter landing zone to extract troops at end of mission
PZ posture—troops lined up in Pickup Zone in order of entry into helicopter”

“The glossary improves my understanding, Curmudge, but it doesn’t assuage my feelings one bit.”

“As always, Julie, you’ve got that right.”

Afghanistan ER

2010-12-29T08:06:00.000-08:00

“Hi, Jaded Julie. Mack copied me on his exchange of Christmas notes with his friends, Ernie and Susan. You might find them interesting. Here’s the note that Ernie and Susan sent to him:

‘Christmas Day is just about done where you are, and the grandchildren here are already winding down - all the Santa gifts are opened and being played with. But we wanted to wish you a very merry Christmas and lift you up with a prayer that 2011 will be a year of much more peace - for you in particular and for all of us in general.’”

“It sounds like a classical, peaceful American Christmas, Curmudge.”

“This is Mack’s response:

‘Dear Ernie and Susan,
Christmas has been pretty nice. Today was a nice, quiet day. Just got a cold so spent a few hours napping at the house. The whole camp has had it; I'm like the last one to get it. Just got back from screening a detainee tonight. Christmas Eve was a little more exciting. I was eating lunch when one of my medics ran in the chow hall and told me we had traumas coming. Apparently one of the good Afghanis in a nearby village was the victim of a Taliban motorcycle drive-by. Shot in the chest, head and leg. His cousin brought him to right outside our FOB, with the guy in the back of a minivan. Stokes, one of my medics, and I took the little ambulance and had a hair-raising ride to the gate. Blood everywhere. The van was outside the gate on the highway since they couldn't come in. We drove through the gate onto the highway, usually a no-no since the Ford has no armor (and we were in T-shirts!!) The Ford does have a siren loud enough to peel paint, however.

I had the Afghanis in the van lay the guy by the side of the road and I did a "cric", which is a surgical airway where I cut a hole in his throat and put in a breathing tube, right there on the road. Fortunately no snipers. We put the guy in our ambulance and took him back to the aid station. Unfortunately he died; had a pulse of something like 29 when we got him on the table, but I think we got some I/O points with the local population for trying.

We had a beautiful candlelight Christmas Eve service in the chapel (tent) last night. I played the piano for it like I do for most of the church services.

Today Major General Terry (RC South Commander) flew in to visit everyone for Christmas. We enjoyed meeting him very much.

Anyway, I'm guessing you guys had a pretty nice Christmas Eve service at church. Feel free to read this letter at Sunday School if you want, so they know we had a good Christmas as well. Stay in touch and God bless. -----Mack.’”

“Curmudge, the FOB (Forward Operating Base) must be a fortified island of relative safety amid a sea of anarchy. So why am I shuddering? Maybe if I put on a warmer sweater…”

Afghanistan ER

2010-12-14T08:27:00.000-08:00

“Good morning, Jaded Julie. You may be interested in the news bulletin (below) that I saw on the Web yesterday:

‘Six American soldiers were killed and more than a dozen American and Afghan troops were wounded on Sunday morning when a van packed with explosives was detonated at a new jointly operated outpost in southern Afghanistan. The soldiers were inside a small mud-walled building near the village of Sangsar, north of the Arghandab River, when the bomber drove up to one of the walls and exploded his charge around 9 a.m. The explosion blasted a hole in the thick wall, causing the roof to collapse on the soldiers inside. Others quickly arrived and clawed and pulled at the waist-deep rubble to free the buried troops. The building had been occupied by the Americans and Afghans for only a few days, an American official said, and was beside a narrow road. It was not immediately clear how the van managed to get so close without being challenged or stopped.’”

“Doesn’t sound good, Curmudge. We’ve heard about mud-walled buildings before. Did you send a note to Mack asking about it?”

“I did, and here is his reply:

‘Yes, that suicide bomber was for us. It occurred on Sunday morning at a small outpost, happened to one of our platoons, one that I have been out with a number of times and been at the exact same type of outpost with. Good I wasn't killed in a blast, but frustrating that I wasn't close enough to do anything to help. I was sent out there quite quickly by the command, but when I got there, all the dead and worst injured had been already evacuated. They were just digging through the rubble; I took care of a couple of Afghan Army folks. I've been busy checking out the remaining folks here, also there is a huge emotional toll since 6 guys were killed like that. Been busy, up until 0200 last night just talking to distraught guys.
Jim Slone, my PA, has gone on leave, so I can't really leave the Aid Station on base to go on missions, since we have to have at least one care provider on hand.’”

“My feelings are a mixture of thankfulness and rage, Curmudge.”

“Mine also, Julie. Mack said that with winter coming on, the Taliban chiefs will sit at home by the fire in the security of Pakistan and send out the young jihadis to become martyrs. I guess he’s right.”

Afghanistan ER

2010-11-30T07:54:00.000-08:00

“Here’s Mack’s latest note, Julie. I’ll read it to you:

‘We did have a huge Thanksgiving dinner. I literally ate too much. Our mission that you mentioned was successful in that we accomplished what we set out to do. We went into one of the worst Taliban areas, found improvised explosive and burned and blew it up. We also found a Taliban Aid Station and burned it down. The real sad thing was that the other platoon was moving and an Afghani soldier moved off the cleared path and stepped on an IED, blew both his legs off, also injured an interpreter. Some of our guys were carrying him to the helicopter and the enemy apparently had a buried remote-controlled IED ready. When the stretcher bearers passed over it, they blew it up, killing two of our guys, injuring several more, and of course killing the Afghan guy on the stretcher. I was six hundred meters away with the other platoon and couldn't go help them since all the ground between us was not cleared and likely seeded with plenty more explosive devices. It was extraordinarily frustrating to not be able to help. Everyone was furious and despondent at the end of an otherwise tactically very successful mission. Memorial service was yesterday.

We are in our new Aid Station, which was just completed. It is beautiful and three times as large as our old one in the old stone Afghan building. The new place is by the helicopter landing zone; can be windy at times. Also too close to the trash burn pit, and I am lobbying hard to get the burn pit moved. Anyway, after I got back from the mission I pretty much just slept all day while the medics moved everything from the old building (none of them were out on the mission like I was). It was sometimes exhausting out in the field, climbing over the stone walls in the grape fields with full packs, weapons, etc.’”

“Golly, Curmudge, it must be awfully depressing for the troops and for the folks back home at Fort Campbell for the battalion to be losing at least two soldiers per week to IEDs.”

“Julie, I seem to recall reading about medieval times when battles were stopped to allow the wounded to be removed from the field. I guess now we are fighting an even more primitive civilization.”

“Civilization? Aren’t these the guys who condemn women to death by stoning?”

Afghanistan ER

2010-11-22T08:28:00.000-08:00

“Another note from Mack. It’s rather short:

‘Pretty busy over here; lost some guys to a suicide bomber in the field. These were guys I had just been on the same mission with for 6 days. Then I went back in to check up on things at the aid station. Next day, guys I was just walking with out there were blown to bits by a s_ _ _-a_ _ with an explosive vest. Also three injured. I can't stand the fact that I was with them; then the moment I leave to go back here to work, this thing happens. Memorial service tomorrow.’”

“Do you have any comments, Curmudge?”

“Nothing that isn’t profane, Julie.”

Afghanistan ER

2010-11-17T08:13:00.000-08:00

“Well, Curmudge, after spending the past couple of days thinking about Mack’s letter in our last posting, do you feel any better?”

“I don’t feel better, Jaded Julie, but I understand better. Mack is living out his belief that wounded soldiers should receive the best medical care available at the point of injury. And he has determined that he will be available. As long as he has a good PA back in the aid station, Mack will practice battlefield medicine literally in the field. He may be setting a new standard for infantry battalion surgeons.”

“I can just hear the platoon sergeant announcing, ‘Listen up, guys. I have some good news and some bad news. The good news is that the doc is going with us on this mission. The bad news is that that means our platoon has the toughest assignment and we are the most likely to sustain casualties.’”

“Let’s hope the good news outweighs the bad and that the bad news doesn’t actually occur.”

“But Curmudge, isn’t a physician too valuable to go out into the field like Mack does?”

“I’m sure, Julie, that every parent feels that way about their 20-year old rifleman son.”

“Mack said that he and the medics carry M-4’s and act like riflemen until someone is wounded. I thought that medical personnel were noncombatants and had red crosses on their helmets.”

“That was another war, Julie. To the Taliban, a red cross—especially a cross—would look just like a bull’s-eye.”

“Curmudge, wouldn’t a physician feel out of his element in the field carrying a rifle along with his aid bag?”

“That might be true for a lot of docs, but not Mack. When he first went on active duty in the mid-1980’s, he was an infantry platoon leader. That was before a lot of today’s young soldiers were born.”

“Finally Curmudge, do you still get that knot in the pit of your stomach when you read notes from Mack?”

“It’s there all the time, Julie, and it will remain there for the next several months.”

Afghanistan ER

2010-11-15T09:14:00.000-08:00

“Curmudge, a few weeks ago, on October 11, you shared a note from Mack describing injuries that he and the troops sustained from improvised explosive devices (IEDs).”

“Right, Julie. It brought the war in Afghanistan awfully close to home. He recently provided more details about the mission in a letter to an old friend from Appleton. Mack sent me a copy; I’ll read part of it:

‘Dear Joe,

The last 5 months have been quite an adventure. It would take quite a while to detail everything, and I can tell you stories on end if you are interested. I will tell you about the mission where the IED attack happened. To start with, I am a ‘battalion surgeon’ in an infantry battalion. The term ‘surgeon’ in this case, means the chief medical officer for a military unit as opposed to being a surgeon who takes out gall bladders, etc. As you know, my specialty is Emergency Medicine, i.e. working in an ER.

I have gone on all the major offensives/missions. What happens is I usually go with whichever platoon or company looks like they will encounter the most resistance and have the greatest potential for casualties. I carry an M-4 (it's a shortened M-16 with a collapsible stock like the riflemen carry) and function pretty much like a rifleman the way the medics do until something happens. There is a combat medic in each platoon and I "plus up" the given platoon in these situations.

This particular mission was a Clear and Hold, where we move through the countryside, clearing houses/ compounds to ensure no enemy there and identify/destroy any IEDs that are found. The second evening we were settling down to eat a meal and sleep when the radio call came in that one of the guys in the next platoon over had stepped on an IED and had lost a leg. I ran with the company commander who was with our platoon up to the area where they were, (a grape field). The guy was pretty messed up, one leg gone, open pelvic fracture, severe rectal and pelvic injuries. The medics and I got the guy stabilized and we called in a helicopter to fly him out. We were somewhat shaken up by what had happened to him. I went back to my platoon and we went to sleep. The next morning we were to move to a new compound (Afghani houses, or compounds are mud-walled courtyards with individual rooms built into the walls as opposed to the whole building having a roof like an American house), and we packed up and moved to the place. It had been searched to ensure no bombs were rigged or anything. We had just moved inside when the first bomb went off. It was about 15 feet from me, but it was inside the foyer and I was just around a corner so that protected me from shrapnel. In the explosion guys were thrown through the air, lots of smoke, etc. and lots of confusion. I was checking out the guy who landed right in front of me; then people started shouting that someone was badly injured. I yelled that everybody who could walk should go toward the walls and bring the badly injured to the middle.

We were working on this guy who had shrapnel to his face, legs, etc, left middle finger partly blown off, fragments in right elbow, etc. in the middle of the courtyard when the second bomb went off along the wall. My medic and I fell across the guy to keep the dirt chunks/ fragments, etc from falling on him, then got him wrapped up to fly out. Because of the concussion there was an increasing number of people vomiting, losing balance, etc. I sent out 5 on the first helo, then 12 on the next one. We sent out some more on a convoy that brought the battalion commander to the scene later. By this time the platoon was not really combat effective, so the rest of us flew out late that night on a Blackhawk. My medics at the base camp with my PA checked the remainder of the people out including me. I just had a headache and jaw ache the next day, then pretty much felt back to normal aided by my pounding max doses of Tylenol. My parents did get a call the next morning from Fort Campbell saying I had had a mild ‘TBI’, but fortunately I had e-mailed my dad late the night before so he know I was still coherent.

I hope that wasn't too laborious a read. This week has been somewhat difficult as we lost two guys who were killed outright by IEDs. My PA and my medics and I were in the Aid Station three nights ago when the locals brought in two girls (age 4 and 7) who had been badly burned in a gasoline explosion. Apparently the parents had bought what they thought was diesel fuel but turned out to be gasoline for their heater. When they filled it and lit it, Boom! Burns about 80-90% of bodies. We intubated the kids, dressed the burns, and flew them out. Apparently they both died the next day, judged by the hospital to be not survivable burns, changed to comfort care only.

I should be home next spring/summer and certainly plan to stop to see you the next time I'm in Wisconsin.

Take care---Mack’”

“What’s the lesson, Curmudge? It sounds as if the good guys took it on the chin.”

“Julie, when I read this, my only feeling is the knot growing in the pit of my stomach. Let’s think about Mack’s letter and talk more about it in a few days.”

Afghanistan ER

2010-10-18T08:49:00.000-07:00

“Hey, Curmudge, has Mack recovered from the concussion he received from the IED blasts?”

“His email notes seem pretty normal, Jaded Julie. A few headaches, but none of the more serious symptoms that one expects from traumatic brain injuries. He has been back ‘home’ at the forward operating base (FOB) for the past few days, but living there is not especially easy.”

“I understand that the Americans share the FOB with British and Afghan soldiers, and that the sanitary conditions are not the best.”

“Here’s what he says, Julie, in his latest note:

‘Do you really think I haven't been ‘encouraging’ these people to improve the Porta-Potties? We've been doing everything we can, including trying to restrict as many as we can for US and British use only. This was determined to be ‘discriminatory’ to the ANA, so they are back to dive-bombing the latrines. They actually stand up on the toilet seats and let it go, and if things don't quite fall into the hole, oh well. The struggle is ongoing.’”

“Do you recall, Curmudge, our writing about sanitation in Third World countries back on March 3? If 40% of the world’s population don’t have any toilet facilities, there are a lot of people out there who might not know how to use them if they had them.”

“And a couple of years ago on May 8, 2008 in Kaizen Curmudgeon we talked about how a leadership culture change sometimes involves learning things that seem unnatural, like potty training for young children. So there in Afghanistan the culture change is more than like potty training, it is potty training.”

Afghanistan ER

2010-10-11T08:36:00.000-07:00

“Another note from Mack, Jaded Julie. I am at a loss for words, so I’ll just read his:

‘Hi, everyone,

This weekend was quite eventful. I was in a double IED blast. We were in a compound and there were two houseborne IEDs that went off, first one about 15 feet away from me; then while we were taking care of the guy hurt worst in that one, a second bomb went off. I just got done being checked out in the Aid Station at Howz-E-Madad. Only a little sore, have a mandatory 24 hour rest period that we do for soldiers who have been in IED or bomb attacks as part of the mTBI (mild traumatic brain injury) policy for prevention of worsening, etc.

I had been on this patrol mission since Thursday. Last night a guy stepped on an IED, lost his leg but also had terrible pelvic injuries; we did all we could do for him, (treating him in a grape field). He had two surgeries today, I think, and is on a flight to Germany. I already had a pretty depleted Aid Bag today when the IEDs blew up; now it's completely trashed as are my clothes and everything. I still have someone's blood on me; it took forever to get everyone flown out and I finally got a helicopter ride back here about 10 PM or so. I am going to leave the bloody stuff in front of the house and go take a shower.

Take care and stay in touch----Mack’

After reading this, I sent him a note suggesting that this might be a good time to revisit the concept of a board-certified physician going on patrols.”

“You can already guess his reply, Curmudge. He will probably say that the horrible wounds suffered by the troops make it all the more essential that he be there. If it hadn’t been for Mack and his medics, the soldier who lost his leg would have died right there in the grape vineyard.”

Afghanistan ER

2010-10-04T08:01:00.000-07:00

“Hey, Curmudge, it looks as if you have another note from Mack.”

“It’s pretty short, Julie, and is mostly a thank-you note to his brother. Here, I’ll read it to you:

‘Thanks so much for the last package. I've been doing a lot of field time with this big thing you've probably seen in the news.... Would've been downright unhealthy without all the wet wipes, toilet paper, Gatorade, and of course, the cookies for morale and a break from just straight MRE's (field rations). Very interesting and slightly precarious last several days. Last night I was on the ground 400 meters from a kinetic strike (F-16 making two runs dropping a two-thousand pound bomb each time). Most terrifying explosion I've ever experienced and I think the rest of the group felt pretty much the same.’”

“Not anything about emergency medicine in this one, Curmudge. Let’s assume that’s good news.”

“As much as I appreciate getting these notes, they always leave me a bit shaken. At least this time it was the enemy on the receiving end. Nevertheless, I’m reminded of how much danger the troops—even the medical personnel—are in.”

Afghanistan ER

2010-09-24T08:39:00.000-07:00

“Hey, Julie, Mack has been ‘out of the office’ for several days and just sent this note:

‘I was just on a 10 day mission. Was projected to be pretty dangerous with lots of casualties, but didn't turn out too bad. I did have one scary patient where I put in a chest tube in a partially-built guard tower. Whole thing was pretty exhausting. I did wade across the Argandab River during our "push." You should look that one up, since this is apparently a pretty notable river here.

We have another mission coming up very soon, (sooner than I would have wanted for rest purposes). By the way, please send another roll of duct tape (not for medical use).’”

“I think I understand what an Afghanistan emergency room is, Curmudge. It’s any place where a wounded soldier needs the urgent care of a physician.”

“Perhaps Mack’s team should adopt the motto, ‘The best of care anywhere. Literally, anywhere.'”

Afghanistan ER

2010-09-15T09:14:00.000-07:00

“Hey, Curmudge, I see that Mack copied you on another email to his friends. It appears that he only writes to them when something exciting has happened.”

“Exciting isn’t the right word, Jaded Julie. This time it was tragic. I’ll read part of what he wrote:

‘Hi, everyone,

Hope your Labor Day holiday was good. Ours over here got pretty tumultuous. We were sitting down to a special Labor Day dinner they had in the mess tent when the word came that incoming (fire) was expected. I had to leave half my dinner behind as everyone had to go to bunkers, etc. A mortar hit a Hesco (barrier wall) and bounced into a bunker. It blew up at head height right in the middle of a group of American contractors that worked with us. It was the worst mass-casualty event I've ever been involved with. People lying all over the place with terrible head injuries gurgling blood etc. Two died within the hour, then one more died the next morning at the hospital where we had flown him. (I tried as much as I could to help him.) Several more still in bad condition. It's taken a couple of days to just clean the blood off ourselves and the equipment. Still getting more incoming, lots of time in body armor. Our morale is very good, including mine (so far). I have a tiny ‘cottage’ that one of my medics and I built so I don’t have to sleep in a tent all winter. I’ll try to send a picture of it. I can say that I own property in Afghanistan, albeit in an unsafe neighborhood. Anyway, we’ve got a burned baby coming in. Gotta go--Mack.’”

“Curmudge, it sounds as if on Labor Day the term ‘triage’ reverted back to its original meaning.”

“The training of the whole medical team undoubtedly kicked in; but after things settled down, all of them—Mack, his PA, and especially the young enlisted medics—must have realized what an emotional experience their first mass-casualty event had been.”

Afghanistan ER

2010-08-11T07:17:00.000-07:00

“Hey Curmudge. I see that you received a note from Mack.”

“Right Jaded Julie. He copied me on an email sent to several of his friends here in the States.”

“I understand that he is a battalion surgeon in Afghanistan.”

“That’s his title. Actually he is an emergency medicine physician. Would you like me to read part of his note? Here it is:

‘Just wanted to say hi. Pretty exciting last several days. My medics and I have taken care of a lot of people, 49 traumas in 2 months. Mostly Afghanis, (Military and civilians including kids). Took care of a 5 year-old boy with gunshot wound to head, very serious, flew him out stable. We've saved a lot of lives. Yesterday I was on a patrol and we got ambushed and had half-hour firefight. No one of us hurt. The Kiowas (helicopters) came in to shoot them up. I played guitar in the chapel service last Sunday…’“

“One question, Curmudge. What was a board-certified physician doing on a patrol?”

“It must have been a slow day back at the battalion aid station. He undoubtedly left his PA in charge.”

“Curmudge, is there a lesson in this story?”

“I hope so, Julie. There in the midst of a war and a dusty, almost Biblical setting, they are achieving the basic goal of medicine everywhere. As Mack said, ‘We’ve saved a lot of lives.’”

When Education Becomes Indoctrination

2010-04-14T07:52:00.000-07:00

“Curmudge, our topic for today looks rather ominous. Perhaps we should start with an example. Our last discussion ended with the males of the village acquiring enough education to build systems for providing clean water and basic sanitation. Then what?”

“In their madrasa the boys undoubtedly learn reading and writing. However, if their teacher is an Islamic radical, he may also be indoctrinating them with the belief that the United States is the ‘Great Satan’ that must be destroyed by people achieving ‘martyrdom.’”

“So Curmudge, in our eyes these so-called ‘martyrs’ become murderers and suicide bombers by blowing themselves and innocent people to bits. It doesn’t do much good for these people to grow up with clean water and sanitation if their ultimate desire is to be dead before they’re old enough to grow a beard.”

“It’s even worse, Jaded Julie, when a whole nation becomes indoctrinated. Sixty-five years ago (I was 11 years old) American civilians viewed Japanese kamikaze pilots as a small group of deranged zealots willing to crash their planes onto American ships off Okinawa. Only slightly later did we learn that the whole Japanese nation had been brain-washed into believing that Americans were a sub-human race to be resisted unto death. This was clearly demonstrated by Okinawan civilians jumping to their death off high cliffs before the advancing Americans.”

“I can understand the history, Curmudge, but their psychology blows my mind. I hope the Islamic terrorists possess the only remaining vestige of such a warped mindset.”

“Unfortunately it’s not true, Julie. The modern-day North Koreans have been propagandized in much the same way as the World War II Japanese. The North Korean educational system teaches a belief in the unique moral superiority of the Korean race (1); Americans are depicted as an inherently evil race and sketched as jackals with paws and snouts.”

“Golly Curmudge, that would seem unbelievable except that it has been pounded into the minds of North Korean children for the past forty years.”

“There’s more. ‘They are also told that the South Korean masses, for all their material comfort, are ashamed of being under the thumb of the Yankees and yearn to live under Kim Jong-Il.’ The propaganda apparatus continues to assure the North Korean people that their economic sacrifices (over a million starved to death in the 1990’s) are essential to support their ‘military first’ regime and protect them from the Yankees.”

“If we didn’t know authoritatively that all this is the truth, it would seem like some sort of diabolical fairy tale. How will this situation end?”

“For our purpose, Julie, we can conclude that education can be a force for good; but when it becomes propaganda, it can become unspeakably evil. History is full of additional examples. For North Korea, the end game is a total unknown. Watch out for further writings by B. R. Myers to keep up to date on the situation (2). However if you want to sleep well at night, read medieval novels by Ken Follett.”

(1) Myers, B.R. The Cleanest Race: How North Koreans See Themselves—and Why It Matters. Available from Amazon.com. See also review by William Alexander.
(2) Myers, B.R. North Korea on the Edge. http://online.wsj.com/article/SB10001424052748704100604575145672974954144.html?KEYWORDS=BR+Myers

Will education be the key to the Third World's health problems?

2010-04-07T08:37:00.000-07:00

“Curmudge, it’s hard for me to forget about the problems of that Third World country that was our imaginary destination a few weeks ago. Wouldn’t the people’s lives be better if they could somehow get an education?”

“Jaded Julie, it depends on their culture and ultimately, on their government. With their hanging latrine, the people we visited were already one rung up on the sanitation ladder. I’m sure you recall that 2.6 billion people don’t even have a basic latrine, and many of those folks might not even appreciate the value of one. So the first step in education would be to put sanitation in the mindset of the populace.”

“What about formal education like reading and writing?”

“The dominant belief in some cultures is that women should not be educated. So in those locations at least half of their intellectual capital is wasted. Fortunately those children who are able to attend school will eventually be able to interact with their government and nongovernmental organizations (NGOs) to learn about developing clean water systems and basic sanitary facilities.”

“So, Curmudge, how might they obtain clean water?”

“It depends on the locale. They might dig a well or collect rainwater. Even in the U.S., my mother and her sisters used water from the rain barrel to wash their hair; it was softer than the spring water that they drank. Surface water in the Third World would have to be purified to make it safe. That could be done inexpensively by filtration through a ceramic cone or treatment with Clorox or similar chemicals. A solar still should be adequate to produce drinking water for a small family.”

“What about sanitation? There must be something for undeveloped countries that is better than that hanging latrine that we saw.”

“There are several systems, Julie, including composting pit latrines and their commercial version, the Ecosan waterless toilet. We needn’t discuss operational details other than to say that they are simple and should be inexpensive. I’ve seen these, fitted with solar panels, in national parks in the U.S.”

“We’ve done it, Curmudge. We’ve solved the water and sanitation problems of the Third World, at least theoretically. So everyone should live happily ever after.”

“It’s not necessarily so, Jaded Julie. Governments or ethnic groups can come along and turn everything we’ve said on its head. We’ll talk about that next time. You won’t like the story.”

Governments and Health in the Third World

2010-03-31T07:48:00.000-07:00

“Curmudge, do you recall our imaginary visit a few weeks ago to that Third World village where the people had such poor health and sanitation? I suspect that those people’s sorry situation is duplicated in many locations throughout the Third World. What’s the root cause of their plight?”

“In my opinion, Jaded Julie, the root cause is poor government. I’ve heard it said that in the U.S. one gets rich and then goes into politics; in the Third World one goes into politics and then gets rich. In these countries, graft is rampant. When the developed world sends (lends?) money to Third World countries, it often ends up in the pockets of the leaders and their cronies. These folks don’t seem to believe that a government should exist for the benefit of its people.”

“Citizens of Third World countries often do quite well if they are able to emigrate to a developed country. What is their country of origin lacking that prevents their ‘pulling themselves up by their bootstraps’ back home?”

“For the most part, the countries of the world that are the most poverty ridden are those without democratic governments that foster free markets. This is documented by studies published by the World Bank. At the bottom of the ease-of-business scale are those little countries of Africa that would be difficult to find even on an up-to-date map. The vast majority of the populations of these same countries live in poverty.”

“That must mean, Curmudge, that the countries in which the citizens prosper are those in which it is easy to do business.”

“Exactly. At the top of the ease-of-doing-business scale are Singapore, New Zealand, Hong Kong, and the U.S. in that order. The World Bank’s criteria include: starting a business, dealing with licenses, hiring and firing workers, registering property, getting credit, protecting investors, paying taxes, trading across borders, enforcing contracts, and closing a business. We know intuitively that most of these conditions are favorable in the countries of the developed world.”

“I saw you reading an article by Steve Forbes in which he elaborated on some of these criteria.”

“According to Forbes, the rule of law that we enjoy in the U.S. is essential. Commercial contracts must be respected by everyone, including government bureaucrats, and government cannot seize your property or nationalize your business. ‘Low tax rates on income, profits and capital gains foster more risk-taking and higher growth, bringing about a richer economy with a higher standard of living—along with higher government revenues.’”

“Curmudge, some people don’t believe what Forbes said about lower tax rates bringing a higher standard of living and, at the same time, higher government revenues.”

“Forbes’ statement is undoubtedly based on the Laffer curve. Although it is somewhat controversial, the political philosophy of those who totally reject it appears to have blinded them to the realities of history. Speaking of history, the concept of the Laffer curve has been around since the 14th century.”

“So back to those impoverished folks in the Third World village we visited a few weeks ago. We could help that single village by sending our own resources, but what can be done to assist the whole poverty-ridden nation?”

“If the source of poverty is despotic leadership, Julie, one solution might be regime change. The feasibility of that depends on the relative strength and determination of the regime and of the people. Peaceful change came to the former Soviet–bloc countries in 1989-90 because virtually all of the citizens participated in peaceful demonstrations that the communist leaders were unwilling to suppress violently. Elsewhere, regime change has not occurred because despotic leaders were willing to put down unrest irrespective of the cost.”

“I have the feeling that today’s discussion might end on a discouraging word, Curmudge. If they don’t get a democratic, somewhat benevolent government, the folks we visited may have to put up with their polluted water and hanging toilet for a long time.”

“They are not the only people with concerns, Julie. Even people in developed countries have to work hard to keep their standard of living from being eroded by their government. To quote Thomas Paine, ‘The greatest tyrannies are always perpetrated in the name of the noblest causes.’"

Cultures--Bad and Good

2010-03-25T08:38:00.000-07:00

“Curmudge, I believe that you’ve felt that one of the best aspects of the Lean culture was its respect for people.”

“Right, Jaded Julie. Although I always enjoyed my work, I now realize that I often worked in a poor cultural environment. I guess I was just stoic and didn’t know any better. Fortunately, there were other places where the culture was extraordinary.”

“We can learn from experiences that were bad as well as from those that were good. Let’s start with the bad ones. Can you give some examples?”

“The company’s culture was great until the founders retired. The new CEO was from Chicago, so he moved corporate headquarters there (at great expense). As I recall, the building had five stories; the top floor was for the exclusive use of the top executives and their administrative assistants. Whenever I met with my boss, her assistant would escort me from the third floor; the elevator door wouldn’t open at the fifth floor for mere peasants. When one stepped out of the elevator, you faced a life-size stylized horse which likely cost much more than a real one. If the horse could have talked, it would have announced, ‘You are now in executive country.’ The art work on my boss’s office walls was exquisite. It had to be because it was inspected periodically by the ‘picture police.’”

“To say the least, the corporate culture doesn’t sound very egalitarian. You once told me that it wasn’t so much the executive floor that bothered you; it was the political stratification that seemed to be palpable throughout the whole building.”

“That’s for sure, Julie. Corporate royalty had an executive dining room on the top floor and a garage beneath the building for their company-owned cars. Fortunately, some of the perquisites trickled down to the lower floors. Managers had offices with a window, and directors had corner offices. Others, like me, had cubicles in the middle of a big room. I was grateful that because my regular location was here in the Fox Valley, I only visited corporate headquarters occasionally for meetings.”

“Although the whole situation sounds pretty dismal, were there other aspects of the culture that really got your goat?”

“There sure were. Another location of the company had layoffs that occurred in waves. During one of these periods, when the P.A. system summoned a person to report to Human Resources, it usually meant that his job had been eliminated. In addition, when I read the company’s annual report, I learned that they paid more for the executives’ golf club memberships than they paid me in salary. I remain perplexed at the top-level executives’ apparent disinterest in how the company’s venomous culture impacted the rest of their employees.”

“Wow, Curmudge! Your experience with medieval management must have been a real downer.”

“There are more examples, but perhaps not quite as egregious. Many years ago in a different organization, a new president was hired from a university in the South. Despite the organization’s extraordinary culture, he made no attempt to understand it or to build upon it. It was his way or the highway, and most staff members—including me—chose the highway.”

“I hope, Curmudge, that these truly bad experiences were matched by some that were truly good.”

“We’ll talk about those soon in Kaizen Curmudgeon, Julie.”

Return to the Third World

2010-03-11T07:33:00.000-08:00

“Jaded Julie, I’m certain that you recall the unpleasant details of our imaginary trip to the third world last week. Remember those local people who were staring at us as we were inspecting their hanging latrine? They sure didn’t look very happy.”

“All of the details were unpleasant, Curmudge. Maybe those folks thought that we were going to add to the overcrowding in their primitive toilet. No need to worry. I’d suffer extreme constipation before I’d use that grubby thing.”

“That assumes, of course, that you didn’t have diarrhea, which you would have gotten within a few hours after drinking the local water. But what I also noticed was that many of the locals appeared to be in poor health.”

“You’re right, Curmudge. Some of the children had distended bellies, and I saw a woman with a grotesquely enlarged leg. She looked as if she were part elephant.”

“That’s why they call her disease elephantiasis, Julie. You must have cut class the day they covered tropical diseases in nursing school. Actually, there may have been several of the locals who weren’t able to come down to peer at the visitors from far away. They were bed-ridden because they were too ill with malaria or AIDS.”

“I’m becoming convinced that life is extremely fragile in undeveloped countries.”

“Here are some data on the top five diseases that show just how fragile it is (1):
Lower respiratory infections (pneumonia, etc.): Over 4 million deaths per year.
HIV/AIDS: Over 3 million deaths from AIDS in 2004. 39.4 million infected with HIV.
Malaria: Between 1 and 5 million deaths per year. 300-500 million cases per year.
Diarrhea: 2.2 million deaths per year. 4 billion people infected per year.
Tuberculosis: 2 million deaths per year. 2 billion people are infected.”

“I’ve read the list. The next five are measles, whooping cough, tetanus, meningitis, and syphilis. Then there are the so-called 13 neglected tropical diseases (NTDs) that infect 1.4 billion people worldwide (2). The most common of these is roundworm; that’s what gave distended bellies to the kids we saw. Elephantiasis (I just looked it up), snail fever, and river blindness are on this list. So Curmudge, why aren’t people in the industrialized world more concerned about these people and their diseases?”

“My speculation, Julie, is that people are very insular by nature. We read about the problems of our own world every day, and those are the ones we are concerned about. If we perceive a personal threat from our immediate surroundings, we’ll cling to that belief as strongly as if it were a religion. Dogma usually trumps objective science.”

“If that’s the case, we’re apt to become preoccupied with the first threat that someone puts into our head.”

“That seems likely, Julie. Skeptics probably sleep better at night, and realists do everything in their power to solve real problems like those we’ve seen in the Third World.”

“Specifically Curmudge, what can we do?”

“As you said last week, everybody should revisit their priorities. Senior citizens can open their checkbooks, and as a nurse, Jaded Julie, you would be a great asset on the mission trip from Affinity to Peru next fall.”

(1) Top killer diseases in the developing world. http://www.alertnet.org/topkillerdiseases.htm
(2) Global Network for Neglected Tropical Diseases. http://globalnetwork.org/

A Trip to the Third World

2010-03-03T07:16:00.000-08:00

“Jaded Julie, please name the most serious environmental problem you can think of.”

“That’s easy, Curmudge. Global warming. At least that’s what everybody says.”

“Who is ‘everybody’?”

“The newspapers. The politicians. Well…everybody.”

“I’d like you to take an imaginary trip with me to a rural area of a third world country. Will you go?”

“As old as you are, I knew it was going to be imaginary. Okay, let’s go.”

“We’re here. That shack over there is where you’ll be staying.”

“Wow, it’s hot! What’s that horrible odor? It smells like a sewage treatment plant with a power failure. I hope those mosquitoes buzzing around my head aren’t carrying malaria. And if my ‘luxury villa’ (shack) has only one room, where’s the bathroom?”

“The ‘hanging latrine’ is right over there (1). It’s an outhouse with a rag door on 4-foot high stilts. There’s no seat, but there is a ditch underneath. It doesn’t flush, but in the monsoon season the rain carries everything farther down the ditch. One walks up a rickety sloping ladder to get to it; if you lose your balance on the way up, the result will be—to say the least—memorable. Oh, and by the way, you’ll be sharing this ‘facility’ with those 500 people who are staring at us, and you’ll share your one-room ‘villa’ with seven of them.”

“Where’s the toilet paper?”

“Don’t ask.”

“And where do I wash my hands?”

“In that stream over there; see where the ditch runs into it. It’s the same place you’ll get water for cooking and drinking. I hope you brought your own soap. Or if you want somewhat cleaner water, there’s a well five miles down the road.”

“Please, Curmudge, get me out of here! I’ve seen (and smelled) enough.”

“We’re back home, Julie. Appleton never looked or smelled better. After experiencing our imaginary trip, you may be interested in these statistics (2):
· 40 per cent of the world’s population do not have access to a basic latrine. That’s 2.6 billion people who don’t even have a bucket or box (3).
· Up to 80 per cent of illnesses and five million deaths per year in the developing world are related to sanitation and water.
· 4,500 children die every day from diarrheal illnesses.
· Every year more than 3.5 million children do not live to celebrate their fifth birthday because of diarrhea and pneumonia.”

“Curmudge, I couldn’t stand spending a day in the place we just visited, yet those people must spend their whole lifetime there. I’d better revisit my earlier thought about global warming. Let’s see…the world’s leaders—even those from developing nations—are talking about spending billions of dollars per year on an uncertain solution to an uncertain problem that might occur at an uncertain time in the future. Contrast that with spending orders of magnitude less money on known solutions to the known problems of dirty water and inadequate sanitation that will kill 4,500 children today. The everybodies that I mentioned earlier need to re-think their priorities. I have certainly changed mine.”

“Jaded Julie, you are indeed a gem.”

(1) WaterAid The State of the Worlds Toilets 2007.
http://www.wateraid.org/documents/the_state_of_the_worlds_toilets_2007_1.pdf

(2) Dickson, B. and Salmon, B. Looking Back at International Year of Sanitation.
http://www.theepochtimes.com/n2/index2.php?option=com_content&task=view&id=9791&pop=1&page=0&Itemid=1

(3) George, R. Nowhere to Go. The Rotarian—January 2010.
http://www.rotary.org/en/MediaAndNews/TheRotarian/Pages/toilets1001.aspx

600 Years into the Future

2010-02-24T06:57:00.000-08:00

(A continuation of our earlier posting, 600 Years Ago)

“It stretches my belief, Curmudge. You can foresee 600 years into the future?”

“No way, Jaded Julie. I can’t even see tomorrow on the calendar without my trifocals. We’re actually going to consider what’s going on today with an eye toward 600 years in the future. We’ll use the same assumptions as last time, with an average global temperature rise of 0.7 degrees C. per 100 years. Once again the wizard…”

“…the wizard? I thought he was put into a dungeon in 1410.”

“Same guy. His sentence was 600 years. Wizards have a long life expectancy, and they are very persistent. As I was saying, once again the wizard successfully peddled his global warming story to the world leaders; and their response was similar to what it had been in 1410. They held international meetings, (almost) reached agreements, and pledged (sort of) great sums of money to help developing nations.”

“The advent of the airplane certainly made it easier to attend those international meetings.”

“But it all went bust. The pseudo-agreements depended on countries acting contrary to their own economic interests. Money for developing nations, as with previous ‘foreign aid,’ would have gone into their leaders’ Swiss bank accounts. International scientific efforts were confounded by politics and vested interests, and the wizard was exposed as a pretender.”

“Curmudge, there must be a better way.”

“There is, Jaded Julie, and it is called capitalism. First let’s consider its opposite, socialism, which has been proven to be a total failure (the Soviet Union), or an opiate of the people (Western Europe). Characteristics of socialism include confiscatory taxation and centralized planning made by political appointees or bureaucrats with de facto tenure. The results of socialism are high unemployment, little opportunity for initiative and personal growth, and a passive citizenry totally dependent on the government for their welfare.”

“That doesn’t sound like a good way to solve a problem like global warming, assuming it is a problem. So how might this be approached in a capitalistic society?”

“Julie, I thought you’d never ask. To begin with, decisions made by millions of informed citizens, thinking critically for and about themselves, should be better than those made by a few powerful bureaucrats. If given respect and the opportunity to make things better, able citizens will gain an understanding of climate change and will devise ways to adapt to it or possibly avert it.”

“Hey, Curmudge, you just spoke of respect for people and making things better. That’s Lean; we finally got there!”

“Government should allow those with ability to succeed or fail depending on their own creativity and initiative. Equal opportunity doesn’t guarantee equal outcomes. If governments had always discouraged inventors and entrepreneurs, we’d still be living in 1410. In their normal mode of operation, governments only redistribute the pie; entrepreneurs make the pie bigger.”

“With that as an introduction, Curmudge, how are capitalism and Lean going to give us a better outcome from global warming?”

“Because they are betting their own money and are not depending on political favoritism, individuals should not be taken in by boondoggles. A smart entrepreneur will not develop a solution until he is certain there is a problem. As time passes and new information becomes available, he will be continuously refocusing his efforts. That is Lean-type continuous improvement on a long time scale.”

“If there really is global warming, and our best knowledge says we can’t control it, how will capitalism respond?”

“It’s pretty simple. Ariens will make more lawnmowers and fewer snow blowers. There may be more skin cancer, so more dermatologists will learn how to do Mohs surgery. We’ll adapt, and we might live longer.”

“Finally, Curmudge, why did we title this posting 600 Years into the Future? We talked mostly about the present.”

“Well, Jaded Julie, it seemed like a logical successor to our earlier posting, 600 Years Ago. Besides, a title is the author’s prerogative. I don’t recall there being a tornado in Gone with the Wind.”

600 Years Ago

2010-02-17T07:49:00.000-08:00

“Today, Jaded Julie, we’re going to do some thinking outside of the box.”

“That shouldn’t be hard, Curmudge. You are outside of the box.”

“We’ll begin by making some assumptions for which there has been some evidence in recent years (1). Let’s assume that the earth’s average temperature has been rising linearly at 0.7 degrees Celsius per 100 years and that a total increase of four degrees C. converts the earth into a jungle. At 0.7 degrees per century, that would require 570 years. For simplicity, let’s round it off to 600 years and begin our story in the year 1410, i.e., 600 years ago.”

“I’m with you, Curmudge. Beam me down, Scottie.”

“Life was not easy in 1410. While the kings lived like kings, the common people in the country eked out a living in agriculture and those in the cities built cathedrals. Along came an all-knowing (so he thought) wizard who convinced the Pope and all the world’s kings, czars, and caliphs that we were faced with the future tragedy of global warming. (He was wrong. In 1410 we were actually at the end of the Medieval Warm Period.) Further, the wizard proposed that global warming could be averted by stopping the growth of the burning of fossil fuels, at that time coal and peat. The world’s leaders agreed with the wizard and decreed that his proposal be implemented.”

“I think I see what’s coming, Curmudge. The growth of a civilization parallels its energy use. If additional coal could not be mined, the development of civilization would have been arrested at 1410. I shudder at the thought; it would have been ‘Groundhog Day’ forever.”

”Worse than that, Julie. Without coal for steam engines, the Industrial Revolution could not have occurred, and our life expectancy would still be around 40 years. Even the printing press might not have been invented. In fact, most of the inventions created after 1410 would not have happened.”

“Things like cars, airplanes, computers, modern sanitation and health care, nuclear power, space flight, and Krispy Kreme donuts.”

“One bright spot, Julie. When the would-be wizard’s forecast did not materialize, he was probably thrown into a dungeon.”

“Is there a lesson in this, Curmudge?”

“Sure. World leaders should be wary of purported wizards; and if they do believe the wizard, they should not be taken in by recommendations of global, draconian measures. And finally, if the wizard is proven wrong, burn him at the stake.”

“Wow! The hot seat would seem fitting for someone who built his reputation on ‘warming.’ By the way, we didn’t mention Lean once in this story, and that’s supposed to be the subject of this blog.”

“Of course we didn’t, Julie. In 1410 Lean hadn’t been invented yet. But hang in there; Lean will be in our next conversation.”

(1) Plass, G.N. Carbon dioxide and the climate. Reprint of author’s 1956 article in American Scientist 98 (1) 58-67 (January-February 2010)
http://www.americanscientist.org/issues/feature/2010/1/carbon-dioxide-and-the-climate/1

Peer-Reviewed Publications

2010-02-10T09:16:00.000-08:00

(This is the continuation of a series of postings introduced on January 22, 2010.)

“Curmudge, the term ‘peer-reviewed’ has been in the news a lot during the past few months. This might be one of those extremely rare blog topics about which you know something. Would you be so kind as to enlighten me, or is this a subject—like differential equations—that you have totally forgotten?”

“I would be delighted to share my recollections, Jaded Julie. Because I had manuscripts peer reviewed between 1961 and 2002 and did a bit of reviewing myself, much of it has become hardwired.”

“Please give it a try, Old Guy. Let’s start by looking at the process from the author’s standpoint and how he or she decides what is publishable.”

“The critical guideline in this whole process, Julie, is integrity. If data from an experiment or series of experiments provides the basis for a finding or story heretofore unknown to the world or to others in your discipline, it is a candidate for publication. But one can’t cherry-pick his data. If some of the data don’t fit your story, they can’t simply be ignored; they can only be rejected if they are statistical outliers.”

“I can appreciate the importance of integrity. Doesn’t everyone have some element of vested interest in his research?”

“Vested interest comes in many flavors, Julie. Late in one’s career, the author’s delight in contributing to knowledge would represent the low end of the vested interest scale. At the far end of the scale is current work in atmospheric science. It seems that in that discipline one’s findings impact multimillion-dollar technological ventures, politics, and the fate of the industrialized world. The higher one goes on the vested interest scale, the greater the temptation to compromise one’s integrity.”

“So back to the guy in the lab. The author writes his paper, including data to support his hypothesis (remember, no fudging or cherry-picking) and enough experimental detail to permit someone to duplicate the work, and sends it off to a journal for publication, right?”

“Exactly. Often he must wait many months—up to a year—for the peer review process to transpire.”

“Am I correct, Curmudge, that publication in a peer-reviewed journal has traditionally been the ‘gold standard’ for scientific knowledge?”

“You are essentially correct, Jaded Julie. Remember, however, that the ultimate tests are (1) one’s work must be independently reproducible by someone else, and (2) any forecasts must turn out to be true. Nevertheless, despite all of its warts and blemishes and potential for hanky-panky, the peer review process has worked pretty well. Because my area was not highly controversial and was populated by a limited number of scientists, peer review was not very onerous for either authors or reviewers.”

“Curmudge, what’s that ‘potential for hanky-panky’ that you mentioned earlier?”

“Here’s an example. Consider a topic about which there are two schools of thought and in which editors and reviewers have a vested interest. Remember that peer review is a single-blind process in which the reviewers know the author but not vice-versa.”

“I think I can see what’s coming, Curmudge. If the editor’s position on the topic is ’A’ and the author is advocating position ‘B’, the editor can reject the paper out of hand or send it to reviewers that share position ‘A’ who will recommend rejection. I feel sorry for the poor author. He’s been shot down, but he doesn’t know by whom. And potential reviewers who are interested in position ‘B’ may wonder why they never receive any manuscripts to review. ”

“That’s it, Julie. If the author can’t find another journal whose reviewers will at least consider evidence of position ‘B’, he and position ‘B’ are effectively suppressed. This would appear to be ‘political’ science, i.e., science for the purpose of politics or vested interests. My speculation is that this might represent the untimely and unjustified demise of traditional peer review.”

“So how do we summarize the lessons of these last four postings?”

“It’s pretty simple, Julie. Be wary of politicians talking about science, of people confusing effect with cause, of scientists with a vested interest using complex mathematical models that can’t be experimentally verified, and of researchers who suppress publication of findings that don’t agree with their own.”

Curmudge and Jaded Julie Talk about Models

2010-02-03T07:38:00.000-08:00

(This is the continuation of a series of postings introduced on January 22, 2010.)

“Models, Curmudge? You mean those super-slender gals who look as if they have an eating disorder?”

“No, Jaded Julie. We’re going to talk about mathematical models; these are mathematical depictions of processes. Models were described in our discussions of queuing theory last July. Authors that we cited in Kaizen Curmudgeon a few weeks ago used models to forecast physician income in a medical home. We use value stream maps all the time as visual models to depict processes in the hospital. The equations that I learned in physics classes long ago were models of physical processes; they included statics (e.g., forces on a stationary beam), and dynamics (a ball rolling down an inclined plane).”

“Wow! There must be a model for everything. I’ll bet that the advent of the computer has made it possible to model processes that are more and more complex.”

“That’s for sure. We’ll talk more about that later, but let’s start by considering a very simple example. Our daughter moved to a new house in Madison, so I consulted MapSeek* to learn how to get there. In addition to directions, MapSeek said that our daughter’s house is 104.61 miles from ours and that it would take us 1 hour and 54 minutes to get there. In computing our travel time, MapSeek must have used the model, time equals distance divided by an estimated average speed. Their average speed was 55 mph (104.61 miles ÷ 1.9 hours).”

“I’m with you, Curmudge. Because the MapSeek routing uses Highway 26, their average speed must have been adjusted for slowing down in Rosendale to avoid getting a speeding ticket and perhaps also for the possibility of getting stuck behind a farmer pulling a load of manure on 26, a two-lane highway. But is the best route now using Highway 26 through Rosendale? U.S.-151 is now four lanes all the way from Fond du Lac to Madison. Perhaps we should give this new information to MapSeek so they can adjust their model.”

“That would certainly seem to be the proper thing to do, Julie. But let’s consider this hypothetical case. Suppose the MapSeek people own a coffee shop in Rosendale. They wouldn’t want to change their recommended route and their model because it would hurt their coffee shop’s business. That’s called having a vested interest in their model and the data that go into it. MapSeek would prefer that we shut up about there being a better route; perhaps they might even try to suppress all discussions of alternate ways to go from Appleton to Madison.”

“Hey, that’s not fair! We all depend on MapSeek for the correct information.”
“It’s a sad story, Julie. We can see through what Mapseek might do because it’s hard to color the results from a simple, transparent model based on a classical equation. In addition, Mapseek’s work can be easily tested empirically. But when a bunch of suspect data are poured into a complex computer model that is arcane, abstruse, and tentative, anything can happen. That is especially true when someone has a vested interest in the outcome.”

“(Although Curmudge uses words that are known to only a few people and are hard for the rest of us to understand, I get the picture.) Hey, Curmudge, your story is a parable, isn’t it? May I explain its lesson?”

“Go ahead, but don’t get too specific.”

“Think critically. Be slow to accept the conclusions of investigators attempting to model a complex process when their work is supported—even indirectly—by people with a vested interest in their results.”

*Our apologies to MapQuest for using a name similar to theirs in this totally hypothetical example.

Curmudge and Jaded Julie Talk About Cause and Effect

2010-01-27T07:21:00.000-08:00

(This is the continuation of a series of postings introduced on January 22, 2010.)

“Jaded Julie, I’m concerned that many people don’t understand basic science.”

“If basic science means physical chemistry and thermodynamics, I would be concerned that you are concerned. In fact, Curmudge, I would consider you to be an unrealistic zealot.”

“No, Julie. I mean really basic grade-school stuff. Let’s write a play to illustrate a very simple lesson. The time is almost 400 years ago, and the setting is the city of Florence in northern Italy. My character is called Cattivo Uomo, and you will be Spossate Infermiera.”

“Which are, of course, Nasty Man and Jaded Nurse in Italian (actually, the adjective should follow the noun, i.e., uomo cattivo).”

“The curtain has gone up, and you and I are up early watching the sun rise.”

“What a beautiful sunrise, Cattivo.”

“It happens every morning, Spossate, just like clockwork.”

“We would be in big trouble if the sun didn’t go around the earth so regularly. It must come closer in the summer when it gets so warm here. Then the glaciers in the Alps melt back. Thankfully, it gets cooler at night when the sun is around on the other side.”

“Can you think of any other explanation for our days and nights, Spossate?”

“It seems pretty obvious to me that the sun goes around the earth. Everyone sees it rise and set, and that’s what they believe.”

“I’ve heard about another explanation…that the sun stands still at the center of our universe, and that the earth rotates once every 24 hours.”

“Outrageous! Who said that, Cattivo?”

“It was our neighbor, Mr. Galilei. His ideas are gong to get him into a lot of trouble.”

“Our play’s over, Julie. Curtain down. Did it teach you a lesson?”

“I’m shocked that 400 years ago virtually everyone thought that the sun moved around the earth every day, but that was the easiest explanation.”

“We know now that the accepted explanation was false. So what is the lesson that our story teaches?”

“I’ve got it, Curmudge. No matter how evident the effect, it does not prove the cause.”

Curmudgeon and Jaded Julie Read the Newspaper

2010-01-22T07:06:00.000-08:00

“Curmudge, I see that you are reading the editorial and opinion pages of the newspaper.”

“It takes less time, Jaded Julie. The regular news pages contain a lot of useless stuff like the latest indiscretions of professional athletes and entertainers, and they often omit information that is truly important. In addition, the ‘news’ sometimes contains ‘spin’ that is hard to detect.”

“Okay, so what’s wrong with spin in the news?”

“If you see the ‘spun’ information again and again, you might eventually believe it. Ultimately, it may become an urban legend (the Brits call it an urban myth) in which you acquire unquestioning faith.”

“That doesn’t sound good, Curmudge, especially if the info is wrong or at least uncertain. So why should this subject be of interest to people working in health care?”

“Virtually no one that I know in health care has time to read the news critically. Perhaps we can provide some guidance to help them avoid getting hoodwinked by what they read. We’ll also give a refresher on the ethics of ‘speaking with data.’”

“How can we do that, Old Guy?”

“In our next few conversations we’ll suggest some cautionary signals that will alert the reader to possible spin. Things like confusion over cause-and-effect and the possible impact of vested interest in reported information. We’ll also mention some less familiar, but in-the-news, topics like mathematical models and peer-reviewed research publications. One story will be a parable, and another will be a play starring you as a tired-out Italian nurse, Spossate Infermiera.”

“Wow! I can hardly wait. But I’ll bet there are some people out there who are so set in their beliefs that they will consider your ideas to be just the ranting of an old man.”

“That’s okay, Julie. My age is my license to rant.”

“I presume that every one of our conversations will have a lesson. Can we add a short lesson to end your tirade for today?”

“Sure, Jaded Julie. Here it is: When a writer quotes a politician who is talking about science, put on your skeptic’s hat.”

Curmudgeon's Wastebasket--a Companion to Kaizen Curmudgeon

2010-01-10T14:09:00.000-08:00

“It’s a new year, Jaded Julie, and change is in the air.”

“I thought it was just a breeze blowing in from a farm outside of town. So what’s the change, Curmudge?”

“Do you recall our holiday greeting last month? To say the least, it was not all sweetness and light. I was concerned that we might offend someone by referring to Orwell’s book, 1984. There are over 4,000 employees at Affinity, and we dare not offend any of them in a corporate blog like Kaizen Curmudgeon.”

“It sounds as if you are saying that the content of Kaizen Curmudgeon must be plain vanilla, pristine pure, and squeaky clean. But a totally noncontroversial curmudgeon is an oxymoron. I suppose you’ll change your name to Santa Claus and mine to Snow White.”

“No way, Julie. Kaizen Curmudgeon will be unchanged. We’re going to start a personal blog to be a companion to the Kaizen Curmudgeon corporate blog. Let’s call the new blog Curmudgeon’s Wastebasket.”

“Might as well. That’s where the Kaizen Curmudgeon rejects go when we deep-six them, especially if they contain something controversial.”

“What is controversial, Julie, depends on the reader’s outlook. Nevertheless, our intent for Curmudgeon’s Wastebasket is just like that for Kaizen Curmudgeon—to share information with readers that they might not otherwise encounter. Our focus will continue to be Lean, health care, and leadership, but we’ll leave room for other topics—stuff that is so compelling that it demands to be shared.”

“I’m concerned, Curmudge. How will readers know about Curmudgeon’s Wastebasket? Should we publicize it by shouting from the top of the parking ramp? Maybe we could establish a ‘Code Curmudgeon’ to be announced whenever there is a new posting.”

“It shouldn’t be hard. We’ll just put a link in Kaizen Curmudgeon to direct readers to each new posting in Curmudgeon’s Wastebasket.”

“With all of these changes, I hope you are not forgetting about Lean.”

“This is Lean, Julie. We are respecting our readers’ sensitivities and continuously improving our blogging.”

“I’m with you, Curmudge. See you in Curmudgeon’s Wastebasket.”