Monday, October 26, 2015

Focusing on the Goals of Sepsis Treatment: Early GOAL Directed Therapy

Recently CMS released a new guideline on Sepsis benchmarks, called SEP-1. The protocol calls for resuscitation with fluids and antibiotics and blood cultures and serial lactates if the patient has "severe sepsis" or "septic shock" but not "sepsis" alone (sirs plus suspected source). The deep dive into this guideline is reproduced below, for the purpose of highlighting that to be excluded the patient must have a specific order for "comfort care". A better deep dive is here  and here

 Now anyone who knows anything about CMS and medical review knows that if you write the words "comfort care" on the chart, the patient does not qualify for inpatient status unless they are on hospice, and that is not a benefit that can be elected in the 3-6 hour time period by an altered septic patient who cannot make decisions, and the hospital cannot admit them unless they are admitted to a hospice program through the hospice itself. Further, unless I am mistaken,  SEP-1 does not include "altered mental status" as evidence of 'end organ dysfunction" and medical delirium is common in patients with severe sepsis and septic shock. These patients are not good decision-makers. I reiterate that the words "comfort care" are not reimbursed for inpatient status as medically necessary. Medicare is a defined benefit plan that denies payments for non medically necessary patient convenience or comfort. 

From the reimbursement perspective, hospitals cannot bill inpatient claims for patients who are "comfort care". Patients who do not meet expectation of surviving beyond two midnights under the Medicare two midnight rules must be placed in observation, unless there is a reasonable expectation that they would survive more than two midnights and require medically necessary care. Palliative treatment in the inpatient setting for sepsis would be such a condition, only if the patient is reasonably expected to survive on admission, and with a near 40% mortality for sepsis, this is a big question. However, if this is the case, the treatment would be palliative, and therefore it would not for example be wise to give a 30 ml/kg bolus to a patient with an EF of 15% who has severe sepsis who does not want positive pressure ventilation or intubation. What is concerning is what the medical review criteria for auditors would be for these patients now that CMS has benchmarked the standard of care for patients with severe sepsis or septic shock and whether that gives ammunition to recovery audit contractors to deny claims. Further, these patients, DNR/DNI but not hospice, will apparently be quality and value based purchasing fallouts for the hospital UNLESS they have a comfort care order on the chart. This will have a hospital payment penalty in the not too distant future.  

The available data from the PROCESS , ARISE and  PROMISE studies do nothing to assist in answering the plight of the septic patient who needs palliative care and is not a candidate for aggressive resuscitation. These patients were all excluded from these trials. Recently, Ashley Shreves highlighted the question of what is a good death here and here

It is obvious that a delirious death from sepsis is not a good death, whether it is associated with EGDT or not. I would hope we would focus more on addressing the care of these patients whom we know will likely die and focus on the GOALS of end of life care for these patients as THERAPY. Unfortunately, with this new SEP-1 benchmark I am afraid there will be a push to really push patients into two different black and white groups, either full code with EGDT and SEP-1 benchmark, or comfort care. This push will come from hospitals who will be under payment pressure for meeting standards of care. There will be another push when patients who then have the "comfort care" order are denied from inpatient status and the claims will trend to observation care for patients not expected to survive two midnights and not on hospice. This will result in increased patient financial obligations and lack of effective palliative care for critically ill patients who are too sick to go home and not expected to die imminently in the Emergency Department unless the Emergency and Critical Care community is vocal in voicing our concerns on this issue to CMS. CMS must reform the way that patient needs are met at the end of life and how the payments to hospitals and providers are structured to match the care that is delivered, whether in hospital or out of hospital. 

CMS SEP-1 Guideline
Sepsis from CMS point of view is defined as SIRS plus suspected or documented infection, severe sepsis indicates some element of tissue hypoperfusion or end organ dysfunction and septic shock indicates the presence of a shock state (inadequate delivery of metabolites to meet tissue demand) as defined by failure of resuscitation with crystalloids.

The specific definition of severe sepsis for CMS purposes goes by certain criteria, notably not including “altered mental status” as a measure of end organ dysfunction and the specific criteria are a little different than what is noted in some trials. These are the definitions in the 2012 SCCM guidelines.

3 Hour and 6 Hour Benchmarks for Severe Sepsis and Septic Shock
The new CMS guideline for sepsis, termed SEP-1, calls for basic care elements within the first 3 hours of presentation of a patient with severe sepsis or septic shock, (each category having their own 3 hour and 6 hour clocks), but the time stamps and benchmarks do NOT apply to patients with sepsis only (they are in the denominator).

  1. 1. draw lactate
  2. 2. draw blood cultures
  3. 3. administer antibiotics before 3 hours,
  4. 4. if initial lactate is elevated above the lab reference, or there is hypotension to give a 30ml/kg crystalloid bolus before 3 hours.

This clock starts from the time that there is the earliest documentation of meeting sepsis criteria while the patient is in the hospital (SIRS plus a source) and can be from the nursing notes, triage vitals and triage statement, or later in the hospital stay (even on the floor). If the patient has only sepsis criteria first (SIRS plus suspected source) then LATER becomes hypotensive or has an elevated lactate, then the clock presumably only starts at the time those occur.

The second element requires by 6 hours of care
  1. 1. apply pressors for persistent hypotension not responding to 30 ml/kg  to maintain MAP >65
  2. 2. to perform volume status reassessment by 6 hours if there is persistent hypotension not responding to 30 ml/kg fluid bolus OR lactate greater than 4.0
  3. 3. to redraw lactate only if elevated above lab upper limit of normal (even if below 4.0)

Notably absent is the old NQF requirements for CVP or ScVo2 measurement for patients who are persistently hypotensive or with elevated lactates, however this has been replaced by the “volume status reassesment” which can be met in the following way:

• Repeat focused exam (after initial fluid resuscitation) by licensed independent practitioner including vital signs, cardiopulmonary, capillary refill, pulse and skin findings
Or •
Two of the following:  
Measure CVP  
Measure ScvO2  
Bedside cardiovascular ultrasound  
Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge

Specific guidelines about how these data are abstracted were reviewed in a CMS webinar on Oct 26  

and an October 6, 2015 Webinar with Dr Townsend, Dr Tefera, and Dr Rivers was broadcast and a recording can be accessed here:

Importantly, patients are not excluded from these measure collections if they are DNR, they are only excluded if there is a specific order for comfort care in the first 3 hours for severe sepsis and the first 6 hours for septic shock.

Saturday, October 24, 2015

Boris, the Robotic Car, Here to "Pickup and Dropov"

I asked my 2 year old son what t-shirt do you want to wear today and he said, "the Robot shirt".  Like most 2 year olds he has a fascination with robots, cars trucks and all sorts of other machines. His fascination is a mixture of fear and excitement;  Drones, he says, "no, no like it" but very excited by things like garbage trucks which to me are far more dangerous and smelly. 

Shortly after my son was born and I tried to take him hiking with a carrier pack I traded my Mini Cooper in for a Subaru. My Subaru is nothing like Bill Gottlieb's green station wagon which once haunted the streets of the meatpacking district in New York,  nor like the Volvo owned by Ikea magnate Ingvar Kamprad, nor like the Subaru Brat driven by Reagan before he became president.  

" I don't even like old cars.
I'd rather have a goddamm horse.
A horse is at least human,
for God's sake." -J.D Salinger
Mine is thoroughly modern, with Eyesight, obstacle avoidance, and adaptive cruise control, lane change warnings, such that I can just set the cruise control a little above the speed of traffic and it will keep up with the car in front of it. It almost drives itself, so every time I drive, I long for the time cars become driverless robot machines. For, once cars become driverless, instead of horseless carriages, they become removed of any nostalgic connections, animism or personification. For centuries, humans rode horses, then about three generations ago they stopped doing so, and the love of horseman for his steed needed to be channeled into something, it is my own personal theory that America's love affair with the car is less about their curves and the freedom to explore than some misplaced anachronistic devotion to their horse. Some authors cast the "love affair with the car" to a PR campaign by the auto industry  , and Daniel Lazare has described the dominance of auto industry in crafting the structure of the built environment epitomized in the freeway systems of the 50's and the idea of the automotive city advanced as an adaptation of English common law in which not all users of a right of way have equal rights, primacy being given to automobiles. This leftist  and to a degree anarchist viewpoint spews and fumes anger towards cars and their negative externalities, but seems to ignore the negative externalities which must be born by anyone who has to navigate horse poo, or deal with the negative externality of a mud stripe on one's back side when riding to work on a bicycle in a rain. No transport is perfect. No, I prefer to take the attitude that Americans love their cars because they were taught to love their horses, much like the Hindu love their sacred cows. I must admit, in fairness, that my surname literally means in Gaelic, a man who rides a horse, so this is coming from a biased source. 

Polishing the bumper of a monster
truck in a handicapped spot.
This theory that Americans love their cars much as appendages of themselves, in the way one loves one's pet, or horse is the only way that I can explain why in American culture, particularly in the suburban American cities west of the Mississippi and mostly in California, we have devoted a massive swath of the physical real estate footprint to cars. I think that it is because we think of the car as an extension of our self, it goes everywhere with us, we think of it as an expression of our personality, we live out of our cars. As cars were once extensions of ourselves, so too have phones, and selfies, become extensions of our selves in our narcissistic culture. The idea of robotic cars is closed connected to another utopian ideal, that of car sharing. In a former life, I did live in New York and did make use of Zip Car occasionally. Yet the car sharing mentality, like the bike sharing mentality, while certainly having it's merits, namely almost completely eliminating the need for parking in the public doman,  simply will not catch on in a self absorbed, individualistic culture that exists in America today. People will not be dropped off in driverless cars and then wait for the next one to come in an endless cycle of musical chairs shuffling from one driverless taxi to the next. As this man polishing his bumper demonstrates, Americans love their horses far too much. 

 I went to the doctor the other day, and as I was in the elevator going back to my car, I glanced at the emergency exit map for the property and snapped a photo of the map of the medical offices that sums it up fairly well, the majority of space on the property is taken up by cars.
Just imagine what the world would be like if, instead of using that space for cars, it could be dedicated to solutions for homelessness, or a market for healthy food co located with the doctor's offices, or gym space, or a park, or a community garden, just any number of wonderful uses instead of cars. As I walked to my car to go home, I wished I had not driven to the doctor's office, and as I listened to the radio program about the controversy around SANDAG's transportation plan , the controversy about carbon emissions and public transit in San Diego rumbled through the back burner of my mind like an N or Q train rolling over the Manhattan bridge at midnight. I thought back to all the ways my life has changed since I stopped using public transit. It is impossible basically to get around and make appointments on time without a private vehicle in California, yet it occurred to me that the only way to get me out of my car now is if the line in the Starbuck's drive through is too long, or there is literally no place to park. Driverless cars will change all that. 

If our streets and roads and highways are hot hostile expanses of noisy concrete and asphalt which drag all aesthetic appeal from any urban environment, think how this might change with driverless cars. Recently I had the opportunity recently to visit Rome a fitting example for the development of this idea, as all roads, to borrow a phrase, do lead to Caput Mundi. To see how things can change over centuries, consider the Piazza Navona. On the left, the Piazza Navona can be seen at dawn as the remnant of the inner ring of a large athletic competition arena, in which the dawn solitude makes it easy to imagine back to a time of cheering gladiators and chariots racing around that ring, much as cars today dominate urban streets.
To the right is a video of the Piazza Navona in late afternoon, from essentially the same vantage point, when it is swamped by pedestrians and tourists. Now imagine, the consequences if what used to be city streets clogged with cars and parking for the last fifty years became pedestrian avenues. Every main street and downtown district in the US would cease to have a requirement for parking on the main street with driverless cars, as cars could simply valet their occupants to the desired destination, and then be off to park in a single centralized urban parking garage, and summoned to wherever the owner desired once the pedestrian had finished their urban walkabout. Several years ago, I had a conversation with a friend who became the mayor of a small California city. One of the challenges facing the city was a debate as to whether the main street and downtown parking should be free, or should incur parking charges and meters, and at what cost.
The nature of this debate would be fundamentally different were driverless cars an option, as driverless cars could simply valet their occupants, and urban retail streets could be given over to outdoor cafes, beautiful fountains, gardens, and play areas for children. The regional planning budgets and frameworks for civic and regional planning are about to be thrown completely out the window when driverless cars become standard in the next decade,as referred to here, think of the disruptions the technological revolution will have on airport rental car parking garages, the city codes one must revise to turn a mega mall parking lot into a city park or a community farm, and the effect on housing in what are forecast to be the megacities of the future. One only has to look to Piazza Navona to see that the same space can look dramatically different when taken over by pedestrians, and that over the years, a public space can morph into many different uses.

Our ideas of parking garages might change dramatically if cars became driverless, as options to pack, store, and wedge cars systematically and by algorithm without the need for occupant egress could increase the efficiency of the parking process. Instead of being driven, cars could be hung via cable on the sides of buildings, stacked, and taken into deep underground storage locations with less need for ventilation due to the cars being driverless and, in the near future, with an emission free electric drive mechanism eliminating the need for underground ventilation almost entirely. 

As I walked around Roma and later, Firenze, I began to wonder how it was that people with
wheelchairs managed to navigate the city, with it's steps and difficult streets. It became clear to me that by having to navigate such a difficult urban terrain on foot, people became used to it and this kept them fit to a degree not found in the daily navigation tasks of American daily life. One of the possibilities that driverless cars open up is the idea that the village can be reclaimed by pedestrians, that package deliveries within villages and to stores can be achieved by small electric robotic trucks or drones operating from smaller distribution nodes, and that multiple small trips can be achieved on foot or bicycle and that one could walk around and send the robotic car to pick up preselected physical items from distribution points. In this way, rather than spending all of the time getting in and out of a car going from store to store, one could take a pleasant walk and spend time exercising while the robotic car met you at some location different from where you started. For example, one morning in Firenze I walked from my bed and breakfast to Piazzale Michelangelo. As I had no car, I was able to do so, and later take a taxi back in the evening. My daily routine and ability to walk wherever I liked could change quite a bit if, with the option of a driverless robotic car, I could at the end of the walk summon the car to pick me up with a fresh change of clothes and water, rather than having to spend my walk in a round trip pattern, exercise could head off wherever one wanted to go, being limited in no way by the need for a place to park at a trailhead, For example if I wanted to run along the Hudson river, I could in New York run from Battery Park and then up to Central Park and have my own robotic car meet me at the destination with a change of clothes for a morning meeting. In fact, the ability to configure internal space for multiple purposes, robotic cars in the future might have the ability to include a personal hygiene space, allowing for women to change outfits or even use the space to use a breastpump while taking a lunch break and then transport the breast milk for storage.

If we see further, it is because we are
standing on the shoulders of giants. -Isaac Newton
As I wedge my son into his rear facing car seat, I am confident that in the next two decades, as he becomes a driver himself, some of these changes will come to fruition, and the world we will see unfold before our eyes will be as breathtaking to us as geosynchronous satellite orbit would be to Galileo. I am also wondering what will be the fate of municipal bonds used to finance current construction projects that do not account for driverless cars in regional planning budgets of the future. 

Saturday, January 31, 2015

World War 1 Memoirs of an ENT Physician

My great grandfather kept a journal throughout World War 1. He was serving as an ENT physician at a forward American hospital located near the birthplace of Joan of Arc at Domremy in the spring of 1918 at Base Hospital 36 near Vittel, France. I excerpt some interesting passages from his autobiography concerning gas cases seen during World War 1. He was in charge of ENT at hospital A.

The video above narrated by Dennis Skupinski
details the layout of Base Hospital 36.

The French had suffered from lack of electricity, which was sought by Capt. Haughey on two trips to Nancy and Paris, in which he had to resort to stubborn dedication to secure electricity.
Phillips was pleased with my report and chuckled about General Ireland, whom he knew very well, but did not know that I knew. The next day he called me in and wanted me to go the opposite direction to Nancy on another errand. We had been having trouble with electricity. There was a small steam and diesel plant that ran from 4 p.m. to 10 p.m. each day, and from 6 a.m. to 8 a.m. each morning. The rest of the time it’s a storage battery plant and will only make the lights glow. We are unable to use the x-ray machines except these odd hours. The headquarters of General Electric Company was at Nancy. The quartermaster had been there with no results, really no contact, and letters had brought nothing. I took an interpreter and driver and had no trouble getting an audience and fond out that we were located in what is known as the Zone of the Army where no shipments may be made except food and clothing and military necessities. The electric plant at Vittel cannot run on the coal they are able to get and the oil for the diesel engine is also scarce. Ma y repairs were needed, which we might be able to supply. If we could get them, the necessary repairs would be made and the expense credited on our electric bills. I told him that was absolutely impossible. We couldn’t wait the time necessary to import that material, and besides it was impossible for the Army to supply such to any but its own units. If we owned the plant we could repair it. He jumped at the chance and said they would sell. I was stumped, but agreed, as there was no other way. Our hospital had been located where the French had had to abandon two hospitals because they could not solve the electricity problem. It was an emergency, and I bought.
Major Phillip telephoned to headquarters, the result of my trip to Nancy and was told to send an officer to Paris to see the Chief Surgeon LOC. At noon on December 20th, Major Phillips asked if I would go to Paris. I caught the train fifty-six miles away at 5:30 and was in Paris that night. I took two enlisted men with me for some special errand. I had enquired and decided to go to a small hotel near the Louvre.... At 9 the next morning I was out at Medical Headquarters, quite a way out by subway. As I entered, General Winer was putting on his coat and hat. I asked for an interview, told him the story of x-ray and other electricity use, the condition of the electric plant, what it needed and of our needs – especially x-ray. “But”, he says, “Wait and you will get all those things in time.” I answered that we now have about 600 patients and need this electricity now, and why were we located at a place the French had to abandon on account of electricity. He asked my solution and I told him I had been sent to straighten out the problem and that the only solution was either to buy or lease the plant, and put it in shape ourselves. We had the men who could do it and who in the meantime would operate it full time. Besides this was an emergency and some one should have the authority to solve it if he would only assume it. No war can be won unless someone assumes authority. “”Alright”, he says, “tell Colonel here what you want and he will issue the necessary orders.” To the Colonel he says, “Captain Haughey knows what he wants, see that he gets it. I will be back next Thursday.” And he was gone. I went into the Lieutenant’s office and had to tell the story all over again. He said that the Colonel did not have that authority, and I withdrew promising to be back the next morning in case he changed his mind. The morning of the second day I was at headquarters again and was then told to go back to Vittel as my request would not be granted. I walked out and told him I would see him tomorrow. Saturday morning I was again at Headquarters. I saw the Colonel and he threatened to have the MP’s send me back to Vittel, but I showed him a pass for two weeks to accomplish a certain mission, and told him I would be back every morning at 9 o’clock until the General returned, but hoped he would see fit to fix things up before that as I had pretty nearly exhausted Paris. He promised the papers for late that afternoon.
In the first months of service the hospital was already beyond capacity.
January 19, 1918, only two months and three days after settling at Vittel, we had 1600 patients. My notes for that day are: “I did a cataract operation on a civilian, also straightened out and investigated troubles with the feeding of patients in Hospital A, visited every floor making inspections, saw bed patients, read histories and card records of about 100 patients making corrections and seeing that the records are properly kept. I went to town to see a patient. I called on Fr. Marechal and got his sermon for tomorrow, translated and typed it to be read at the service for Americans, took care of twenty-four eye cases in my office, including three refractions. Several of these cases were very interesting. I helped set up the plumbing for our big sterilizer, went to Hospital B in consultation in a mastoid case – had him transported to Hospital A, did paracentesis and had x-ray for mastoid diagnosis. I investigated and fixed blame for discharging a patient to the wrong place, went for mail, wrote two letters of recommendation for commission, conducted summary court, trying a case with several witnesses. And I advised with four ward surgeons on some of their cases.”
Much medical knowledge was obtained through this war. For example, Base Hospital number 5 saw such doctors as William Cannon and Harvey Cushing and Ophthalmologist George Derby serve together in the same hospital. The story of Base Hospital Number 5 is good reading from a military medicine point of view. Suggested by none other than William Osler, the base hospital system mobilized teams from across the US to be deployed in forward service Base Hospital 36 was visited by General Pershing and likely lacked the distinction of Base Hospital 5. His opinion of the place was told as follows:
Major Shurley said he would be at Hospital A and meet the General and conduct him through the hospital. I remarked that feeding trays had just come downstairs and were not yet cleaned, but were stacked back of a big screen at one side of the entrance in the kitchen. Shurley didn’t listen. I met the General at the door, saluted and he of course returned it. I then took him to Major Shurley, our Director, who spoke and started showing him around. The General looked and Shurley saluted, then they started out. Things were going fairly well, everything was in good order except the kitchen stoves, which were not burning, and were all torn out trying to repair them while we used field kitchens. That passed after explanation about the coal and showing of samples. Just before the General was through with our building I could see Shurly was bursting. He called attention to the feeding trays for our bed patients and scooted behind the screen to get one to show. The General took it and exclaimed, “Filthy – dirty”, and threw it across the floor, very carefully wiping his hands on a handkerchief. Then came Shurley’s downfall. He tried to explain but the General said, “Get your heels together when you talk to me.” He added a few other remarks and walked off. Shurley was busy for months explaining that his britches bagged at the knees so he could not get his heels together. I heard that when the General went into the Headquarters office, Captain Theodore McGraw, the adjutant, stood there with an overcoat with a fur collar. The General ordered the fur collar off at once. From Hospital A (Central), Pershing, Phillips and McGraw went to Hospital C (the Palace), under Major Channing W. Barrett, a world famous surgeon from Chicago. Barrett met the General at the door, shook hands and took him by the arm to show him around. The General’s comments when he left were that we were very unmilitary and he was sending an official inspector to straighten us out. A few days later the Inspector General and his staff came. They called together the officers of Base Hospital 36 and 23 and lectured us for an hour, telling all the things the General found – dirty, undisciplined, and unmilitary. The crowning insult was when a mere doctor took the General by the arm, as he would any crony, and lead him around the hospital. He talked fast and furious and told us everything the General had found, and that was plenty. Then he dismissed us like whipped school children, and told us to go and clean things up. He was going to make a real inspection. For three days we had an hour’s lecture on how bad we were and how incensed the General was, with an inspection tht would have found a flyspeck on a skylight. That man saw everything and knew how to ask questions. I simply threw myself on his good graces and asked, “Tell me how to make this dirty hotel clean and able to pass your inspection. If it is humanly possible after we have cared for our patients we will do so.” He weakened and said, “You fellows are doing a swell job, but the General expected more strict military discipline and courtesy, but we recognize you are doctors and not soldiers.” He also recognized that Major Barrett was a big a doctor as Pershing was a soldier.
Dr Haughey attended undergraduate school at the University of Michigan where he was a demonstrator in chemistry. He also detailed his experiences as a student of Dr. Warthin, a pathologist
"There was a rumor in our class that Dr. Warthin was not a doctor of medicine, but of music. At any rate, he was the most disliked on the faculty. Everyone admitted he was tops in pathology, but he was as unbending as they go. I had his lecture course and supposed I knew the subject. I had a good quiz record, had the work all up to date and was ready for his laboratory course next semester. He gave us a stiff written exam, and then called each one in by himself for an oral. When I cam in he held out his hand, looked my class book record over, says “Good, Haughey, better arrange to come this summer school for your laboratory, then you might make my staff next year.” I made my mistake and a senseless one. I said, “I will not be in your laboratory class, Doctor, I am going to Detroit College of Medicine next September.” He jumped “Why go to that second rate school? I have a notion to flunk you, you are not so good in pathology anyway.” He gave me a passing grade and I continued my Pathology at Detroit"

The first cases of American mustard gas poisoning seen at Base Hospital 36 were seen in 1918. Warthin would in fact later study the effect of mustard gas on the eye, referred to in the Transactions of the American Ophthalmological Society Annual Meeting 1919 "Ocular manifestations following exposure to various types of poisonous gases. Derby 1919
On May 24th we sent two ambulances, with two from Base Hospital 23 and others from various places to Bacarat to pick up patients. Smith and I went along to see the new regions and we went through Bacarat to the regimental hospital about six miles from the front. The roads are all curves, the villages badly damaged and some destroyed. Near the front this latter description held mostly, sometimes mere walls were left standing. We took back with us, sixty gasses patients and many more came later. These were the first American gassed cases, and I was busy for a while with them. The mustard gas still stuck to their clothes. The eyes were swollen shut, very painful and sensitive to light. The noses were swollen shut and the throats raw and parched. Where the gas touched the mucous membrane, or skin, was a raw sore and some patients were a pitiful sight indeed. Some we had to strip and put in a tent-like arrangement with only cotton over them. Some months ago I had begged to go someplace and see what was done with these patients, but without avail. The surgeons went instead. But now I had the patients with these eyes and no help from the surgeons… I washed them out with bicarbonate f soda solution, put in atropine to dilate the pupil and particularly to relieve the spasms and photophobia. Then I used some of Major Shurly’s guiacol carbinate in olive oil as a dressing. My theory was atropine for spasm and oil for dressing, but an alkali to neutralize what mustard gas might be left. The next day these patients were all comfortable, the swelling lessened and the spasm about done. Two days later Col. George Derby, M.D., from Harvard and Inspector of eye cases in the A.E.F., came and wanted to see my “striated corneae”. I did not know what he meant and he said, “You have not studied your cases. The French and British have been caring for these gassed eyes for three years and they find that 25% of them are permanently damaged and have striations on the corneae. You have ninety out of 360 of these cases, let’s see them.” I told him I had no permanently damaged eyes and then we started out on inspection. There were no permanently damaged eyes or striations. Soon he began asking what I had done for them, but I insisted on completing he inspection first, then return to my office and talk. When we were through he demanded to know what I had done and I told him. He said I had disobeyed orders which had been not to use atropine, oil or an alkali. I insisted I had no orders. He said a pamphlet of instructions had been issued, which we found over at headquarters in a pigeonhole. It had never been delivered to me. Col. Derby said he was going on an inspection trip to all the hospitals in the front areas and he would pass along my treatment. Col. Greenwood came to see me a couple of days later and asked to see my gassed eyes. He said headquarters would publish the new treatment for gassed eyes to all the hospitals. He must have done that for a few days later Capt. Page (Indianapolis) Base Hospital 31 called me over the telephone. He said he had just received some gasses eyes and Col. Derby had told him my procedure, but he had forgotten. He had sent over for some of my Guiacol Carbonate in Olive Oil. In the summer of 1919 when the Academy of Ophthalmology and Otolaryngology met in Cleveland, some of us attended still in uniform. Drs Greenwood and Derby made a report of the eye service in France. They told of the original treatment and results and said “a Captain atone of the Base Hospitals at the front” did so and so and the eyes all healed so that in the American Army there were none of the striated corneae that were the aftermath of English, French and Italian gas casualties. Some years later in a discussion published in the AMA Journal, Page claimed to have been the one to first use this treatment. I believe that was probably my most valuable contribution to the Science of Medicine. It certainly saved thousands of eyes and as occurs so many times, the credit was meager and even that someone tried to appropriate. Derby and Page are now dead, but Greenwood has confirmed my statements, which are, published records.
Unfortunately, and ominously, Haughey reported the following.
While on a service tour with a surgical team at the front, one of our officers saw an exploded gas shell with the manufacturer’s date of 1908, which meant two things. The Germans were preparing for this war ten years ago, and were preparing to use gas at that time.

The pace of care was extreme. For those of us modern ER physicians balking at ER registrations numbering in the 200-300 range during our peak influenza seasons, Haughey writes in 1919...
We received two trainloads of patients from the Verdun section during the day and another during the night. The Meuse Argon offensive was on. It was of terrific force and intensity for days, then would lag and commence again. Searching through my notes and letters home, there is a very marked dearth of material. There were three or four weeks of strenuous work. I remember one particular day when we received over 1,500 patients, three train loads, and evacuated 750 to the rear, to the south of France or to ports of embarkation for return to the United States. Those that came in were given necessary care and some of our staff didn’t have shoes off for three days. We gave anesthetics or operated as long as we could stand, then the mess crew would come along with some hot coffee, a hot steak or something equally as good. We would stop for a few minutes and then go at it again, but the soldiers were taken care of and the work was done. When we could stand no longer we wrote up the histories. I hope some future research man will not be too disappointed when he finds most of our case records rather short. I know I did not waste much time on unessential details, and my man, Averil, who copied this on the typewriter sometimes used his imagination t figure out what I said. Some of those case records (and I have duplicates) I cannot now read myself. During this time we were all busy and short-handed when we had a batch if influenza cases. Each of us had to take over a ward and I had fifty-five cases of influenza, some of them pretty severe, but they all recovered. I had not done general work for eight years but soon got into the routine. The surgery continued every day and this work told conclusively which of our men could stand the gaff and take it, and which could not. We took care of wounds, infected or not. The bacteria in open wounds were always checked before closing. This made them clean and closed them in a remarkably short time. This type of traumatic surgery was a war development and quite an advance over previous practice. I did not think it would prove practical in private practice because of the wide debridement, but it saved much time and is good surgery twenty years later. My own work had developed into real war surgery. We found during the St.Mihiel offensive, and before, that there was a large predominance of head injuries. I had them in quantities, but we had no time to segregate them into one room. There were shots through the face, head, jaws, ears, every conceivable place almost with clean penetrating wounds or jagged tears, with small or large pieces of face, or bone torn away. At one time I had eight serious brain injuries, one of which died of cerebritis with herniation of train tissue the size of a large orange. There were several fractured skulls.

One experience is detailed suggesting the possibility of diphtheria being a bioterrorism agent, a consideration which indeed sprang to Haughey's mind in his recounting.
During the height of the Meuse Argonne drive, starting late in September and continuing most of October, I had a very unusual experience. I mentioned before that I was always at the hospital when patients were coming in. One day we were expecting a trainload from the Meuse Argonne fighting and I was back at the hospital about 2:30 a.m. when they arrived. We were using the large front porch and reception hall as an entrance station. The patients were brought in on stretchers from the train and deposited in long rows until someone (the orderlies or nurses) could see them, make out tags and send them to their places in the hospital. While that was going on I passed along and spoke to each one, enquired about their injury and looked to see which ones required immediate attention, as many did. These were sent first to the dressing room and cared for before going to their beds. Of course we always tried to have some hot soup or coffee for them. This morning along the middle of the line, one of the bouys said he felt “down” and his throat bothered him. Not exactly sore, but felt queer and he felt rotten. He had been getting worse all day. I sent him to my office and soon sent along another with similar complaints. As soon as I could finish my inspection of the trainload, I went back to see these two boys, examined their throats and found a suspicious membrane and an odor I knew. I had our bacteriologist, Lt. Font, called and we made a diagnosis from direct smears of diphtheria. I then routed out the CO headquarters and told my findings. Chamount was called and before daylight a sanitary corps was on the way to the 26th Division in the battle lines of the Argonne and within twenty-four hours I had an additional 127 cases with positive diphtheria cultures. We isolated the wing of the Central Hotel, giving about 150 beds, put in nurses and orderlies and a doctor and started our isolation and care. It was my responsibility, being in charge of Hospital A, so I made three or four tours of that section of the hospital at odd times. We never found the source of that infection. Naturally there was a question as to whether some of the germs had been sent over as a particularly vicious mode of warfare, the same as the first gas attack, but that could never be proved. There was an epidemic in that one division on the fighting front, with no other cases anywhere else.


Transactions of the American Ophthalmological Society Annual Meeting 1919 "Ocular manifestations following exposure to various types of poisonous gases. Derby 1919

Transactions of the 24th Annual Meeting of the Academy of Ophthalmology and Otolaryngology

A History of US Army Base Hospital No 36

Organization of the US Medical Command

Saturday, March 05, 2011

Sun Sea Surf and Serious?

The title of this blog is supposed to remind me of my blissful days when all that mattered was paddling out to a breaking set and getting hammered by breakers pounding the shore. In life so many things seem like breakers pounding us.. threatening to drive our efforts at making things better into the rocks. When viewed this way, life seems too serious, too much captured in the vortex of energy that occurs at the shoreline. The shoreline offers much besides, and closing my eyes, I try to remember sitting in the wet sand, letting my feet be washed by the water and the warm sun beating down on me and the cool taste of a pina colada... is there only seriousness to be had at the vortex? Or does the vortex of sun, sea and surf offer misty spray? Delights of dolphins? Children playing in the sun? Frisbees and beach blankets?

Tuesday, May 11, 2010

Physician Duties/Ethics in Public Health Emergencies

In light of previous posts on physician ethics in natural disasters such as the Haiti quake, and public health emergencies such as the H1N1 outbreak, I watched an interesting related discussion on UC TV by Ben Rich, bioethicist at UC Davis.

Tuesday, January 19, 2010

A hundred dead people in my truck

Shortly after midnight January 10th, 2010, a magnitude 6.5 earthquake hit Northern California according to the US Geological survey.

Trivial news coverage included this story from the Times Standard in Eureka on NBC about a dog who sensed the quake and bolted out of the room before shaking started

The US quake caused some property damage, but our neighbors to the south were not so lucky.

Three days later, on Tuesday Jan 12th, the Haiti quake was faithfully recorded by the USGS and the tsunami system even predicted there would be NO tsunami.

According to the timeline published by the Merced Sun Star, aid started pouring in to the country quickly, however delivery of that aid was problematic due to the security situation.

By the time the USS aircraft carrier Carl Vinson brought it's aircraft to bear on the situation on Friday, the Israeli defence forces had already set up an advanced field hospital and begun saving lives.

In other words, Israel, a country in ANOTHER hemisphere, had boots on the ground and a secure hospital next to the airport in the amount of time it took the Americans to send an aircraft carrier.

To summarize, the American military response to the Haitian disaster was to send an aircraft carrier when there was a functional airport capable of handling an advance field hospital and supplies, then they proceed to airlift water by helicopter to this airport and guard it with paratroopers from the US 82nd airborne.

The paratroopers which could have been flown FROM the continental US within minutes of a disaster are sent to guard supplies at the airport. Shouldn't the US have started airlifting supplies to drop points from it's Air Force bases rather quickly? Couldn't the 82nd Airborne be sent to guard these drop points? Why in an age of air superiority is the US Military relying on ships to get it's troops in theater?

Why wasn't an advanced US field hospital simply airlifted to Haiti immediately with a unit of troops to guard it? Israel managed to achieve that from another hemisphere, without an embassy undamaged by the quake (the US embassy was not damaged in the quake)

In the US, by the time the Israeli forward field hospital was ALREADY set up, volunteers from local universities such as the University of California at San Diego were shown on local news, packing medical supplies. Desperate emergency physicians in the US were prepared to go to help armed with bandaids, when what was really needed was surgeons and operating rooms for debridement.

The desperation on the faces of these American Physicians and the CNN reporter is evident. They are amazed Israel has managed to achieve what they cannot.

While most media coverage focuses on who is wearing what at the Golden Globes, the football playoffs, and the Leno/Conan controversy brouhaha causes the media to point fingers at NBC, NBC news has reporters and physicians on the ground in advance of the real substantial aid arriving. Dr Nancy Snyderman at NBC called the response within 48 hours and up to 148 hours a "civil war kind of medicine".

A facebook post by a surgeon lamented that he was unable to assist because MSF did not have him on their list of emergency doctors. This reminds me of my residency colleague lamenting the fact that during Katrina the US government sent a swamp boat full of soldiers armed to the teeth to a hospital in New Orleans without space to evacuate casualties.

According to the Merced Sun Star, civilians were treated in Haiti on the USS Carl Vinson on Saturday only after being diverted due to weather. News broadcasts showed Haitian civilians being evacuated by US forces clutching their US passports. What about the quake victims without US passports?

The United States has never winked at invading, sponsoring the military coup of Haiti's original democratically elected president.

As proven in Rwanda, in New Orleans, and every day in America's inner cities, it seems the US Government just doesn't care about black people. Happy MLK Jr. Birthday America. It's a week after a terrible disaster gave you an opportunity to shine, and so far Lady Liberty is looking pretty tarnished for those poor sick hungry masses.

The title of this blog post comes from an aptly named 2008 Irish documentary about Haitian aid workers, in which a weekly convoy of trucks set out to bury people in Haiti. This was BEFORE the earthquake.

I couldn't say whether dogs can really predict earthquakes, but I can say that it doesn't take a genius to spot institutionalized neglect and racism.

The sad thing is that this Haitian tragedy didn't have to happen. It could have been prevented. As Three Cups of Tea author Greg Mortenson and Bill Moyer explained on PBS, for every American troop sent to Afghanistan to be maintained there for a year it costs a million dollars. How much could that money achieve with simple seismic improvements, basic preventive medicine, and a ready and able worldwide disaster relief task team which could be dispatched on a moment's notice anywhere in the world? Sounds like a job for Israel.

Tuesday, September 08, 2009

Coaster Tour of Coastal San Diego

Tourists in Carlsbad often stop and ask me where to go to see the highlights of North County San Diego. For the best tour of Coastal North County San Diego, hop on the Coaster, a regional transit service running from Downtown San Diego to Oceanside. The views from the train are stunning, and coastal lagoons can be seen in a way not appreciated from the freeway or beach. The Coaster allows access to prime beach communities, outdoor activities, and shopping along the way, and is a great way to see what the region offers. Here are some of favorite picks.

The train leaves views of Mission Bay and Old Town to weave through the Sorrento Valley and Eastern Miramar Region. Along the way, keep your eyes peeled for rustic scenes reminiscent of California's ranch days. The satellite dishes near Qualcomm in Sorrento Valley and the occasional fighter jet or helicopter overhead from Miramar Air Station serve as a reminder of the high tech activities of the area.

Leaving the Sorrento Valley behind, the train breaches onto the coast near Torrey Pines. If your eyes are peeled you may see a deer or many birds off to the left. Runners and hikers alike appreciate the trails that run from Torrey Pines to Del Mar along a bluff protected from the hum of cars. The Coaster runs right through Del Mar and the racetrack is visible from the train. Stop in Solana Beach to stay in resorts like the Auberge, or dine along the beach at Poseidon or Jake's. Head to Pizza Port in Solana Beach for grub and grog before hitting the Belly Up for some live music or stroll through the Cedros Design District.

Cyclists love North County for the ability to ride unimpinged by cross traffic from North to South along the Ocean. To get to Cardiff, get off at Encinitas and go south. In Cardiff, you may spot surfer Rob Machado at Swami's , or meditate inwards at the Self Realization Fellowship. At the end of the day, for seafood try the Chart House or the Beach House in Cardiff by the Sea.

Get off the train in Encinitas for shopping at the Lumberyard or Encinitas Main Street, or just walk north up the Pacific Coast Highway and enjoy a coffee at Pannikin in Leucadia. If you are just after some simple eats, stop in Encinitas and you are sure to find what you are looking for, even if it is hard to find a raw food dish. Don't miss Lou's Records or Shatto and Sons Shirts in Leucadia.

The Coaster allows you to see some wildlife that is otherwise vanishing in Los Angeles and downtown San Diego. See birds in the numerous North County Lagoons north of Torrey Pines, and walk alongside coastal sage at Poinsettia Station. It is too far to walk, but from the Poinsettia Station you may access Lego Land, the Four Seasons at Aviara,shopping at the Carlsbad Forumand the Carlsbad Outlets, and the La Costa Resort and Spa.

Thursday, August 13, 2009

AED needs of the mariner community

OK, so this is a gem, I received this email (edited for privacy) from an emergency medicine interest group. Why didn't I try and study the AED needs of the mariner community?

When I was doing my residency in New York I sent an email to the FDNY EMS and they weren't interested in putting AED's in the main subway switching stations. They did a preliminary look at the rates of cardiac arrest near a subway station and found it would not be cost effective.

I had an idea to create legislation to put AED's in every television in America, with onscreen instructions in how to use them.. That would probably have saved lives.

Clearly I was not thinking along the right path. I should have taken off and sailed for a month and put the whole thing to rest.

"My name is XXXXX and I am currently a chief resident of the XXXXX Emergency Medicine Residency Program. I have sailed for many years and have an interest in the field of maritime medicine. I plan to do a one month elective at sea on a XXXX sailboat in the Caribbean. I plan to study the medical needs and insight of the mariner community's medical needs, specifically as it relates on on-board AEDs. I was interested if you could forward this to section members that I might talk with further about their expertise relating to this issue and possibly partnering with them on this research initiative. I appreciate your assistance and look forward to hearing from you."

Thursday, July 30, 2009

Every seat a window seat

So if Jet Blue would put a webcam on the wing and have it look down or ahead, or heck, even back at the plane, then display the image on their seat back monitors they could make every seat a window seat! They could even put a cam in the cockpit so we could see the crew in flight! Wait. Maybe we don't want to see that. Is this just another idea for halfbakery?

Thursday, March 12, 2009

Union Square Clock

I just ran across this pic as I was reorganizing my photos. It is a pic of the clock in Union Square, New York taken March 12, 2009.The clock is called "The Metronome", and is part of an art installation. I learned this mostly by talking to a homeless man asking for money. The numbers from the left signify the time of day. Thus, this photo was taken at 07:14. AM, forty five seconds into the minute. The numbers reading from the right indicate the time remaining in the day. Thus, from right to left, there are sixteen hours, forty five minutes, and fourteen seconds left in the day. The numbers in the middle signify tenths of seconds.

Sunday, December 28, 2008

Emergency Medicine In Training Review

It's that time of year again. Time for the in-training exam. Here are my review notes for this year, updated as I compile them. Originally posted to Google Docs but there is a 500 KB limit on files. Re-posted to my drop. If you would like to contribute, comment.

Friday, December 05, 2008

Awake Cardiac Bypass Surgery

There is nothing quite like watching surgery, as viewers of Gray's Anatomy will agree.

However, when the surgery is on yourself, and you happen to be having open heart surgery and you happen to be awake the whole time, I am not sure I would agree. This study, from Italy, examines the outcome of patients who undergo open-heart surgery while on cardiac bypass, while awake. Awake bypass surgery has actually been around for several years, first performed in the UK in 2003, first performed in the world in 1998, and in the USA in 2000. To watch an operation, check it out here. It's not quite like this dramatization, in which a talk show participant takes out his own heart.

Wednesday, December 03, 2008

Can you warm up that ultrasound gel for me?

So, the eternal kvetching point for patients exposed to ultrasound in the Emergency Department is, oooooh, "that ultrasound gel is cold".

I wondered why it feels so cold when it is kept at room temperature? For that matter, why can you touch a blanket when it is at room temperature, and it does not feel cold, whereas a stethoscope, or a metal counter may feel cold.

What is it about the sensation of cold that makes some things which may be 78 degrees seem freezing when your body is at 98 degrees, yet when the temperature of the air is 78 degrees you do not feel cold?

And as another question, does this have any diagnostic significance? Does a patient's response to cold indicate anything clinically? There are conditions with weird temperature findings, so-called hot cold reversal or dysesthesia. For example, ciguatera is a condition in which involved seafood can contain ciguatoxin, which can cause strange neurologic findings, including hot cold reversal.

I went back into the advanced thermodynamics and sensory physiology of my youth and looked all this up...hmmm. Didn't find much.Probably something to do with the specific heat of a substance.

Apparently there is something which scientists are calling the menthol receptor. There is even a knockout mouse!

However, you can actually purchase ultrasound gel warmers. Now that is a posh ER that has those!

Saturday, November 22, 2008

New York Harbor Police

Most days I take the D, N or Q train across the Manhattan bridge from Brooklyn to Manhattan. This is an excellent time to check your email, send a text message, or just take in the view.

The pic above is of a boat named for PO Scarangella, taken by "Tom Hoboken", from flickr.

One morning, I happened to have actually had a cup of coffee prior to getting on the train, and was looking at the wonderful view of lower Manhattan across to the Brooklyn bridge when I saw the harbor police boat... The police officer appeared to be throwing something overboard, perhaps an anchor... The boat appears to be there every morning, and it seems like it would be a wonderful job- to be paid to sit on a boat in the morning and watch the sunrise and just hang out with the waves rocking against your boat...then I thought about it some more, since my secret ambition apart from working an emergency department would be to save lives on the water... What does the harbor patrol officer do?

Is this part of the counter-terrorism effort? Does this boat come to the assistance of people who fall off ferries? Shouldn't the Coast Guard be doing this instead of interdicting drug traffickers? Then the terrible thought crossed my mind.. do they look for jumpers ? Are they paramedics, all set up to intubate the jumper with signs of life? Do they do chest tubes for the inevitable pneumos and have a thoracotomy set up?

I did a little research, and found the story of a woman who apparently jumped from the bridge and was rescued, a Boston paramedic assigned to harbor patrol who hilariously tells the story of a Chinese sailor talking back to Coast Guard dispatch, "never mind color of boat! halfway down!,you come now!", a feral cat rescued from a liveaboard boat by a California harbor patrol, a story about a man who jumped off a gay pride party yacht and was then shot and killed after scuffling with harbor police after his rescue, a story about a beaver rescued from the East River while Harbor Police were on patrol during the Pope's visit to NYC, and a piece about kayakers who got too close to the waterfalls and had to be pulled out of the East River, and the interdiction of drug smugglers by police divers who have been known to sleep in the rudder compartment of cargo ships.

So that's what they do!

While looking around, I found an impressive collection of photos of water traffic in this blog about New York Harbor...

Bodegas and street cats

So it is exceedingly cold now in New York, and most likely for this reason, a mouse appeared in my house. Now, the ecology of urban living is most interesting. I have noticed in the past few days a peculiar smell in the local bodega, it smells like cat piss. Now, this is the whole reason I started going to this Bodega, because it did not smell like either cat piss or gas from the gas refrigerators. So I asked the staff in the bodega and they said they had a cat, but that they have not seen the cat in a while... so perhaps the street cats are pissing in the bodega because it is so cold outside... I will be most happy when the street cats learn to use a litter box.

Wednesday, November 19, 2008


A concise listing of things to know about shock, hopefully to be updated frequently.

Shock is defined as inadequate perfusion to meet the needs of tissue metabolism.

Shock can be compensated or decompensated.

Decompensated shock is defined as shock plus systolic hypotension, or
IF BP is unmeasurable, defined as absent distal pulses, prolonged capillary refill, cool extremities, tachycardia, altered mental status (decreased level of consciousness/responsiveness)

Maximum allowable heart rates.

newborn-to 3 months- 85-205.
3 months to 2 yrs- 100-190.
2 yrs to 10 yrs 60-140.
>10 yrs 60-100

MINIMUM acceptable blood pressures
below 12 hours of life and less than 1 kg of weight. 39 systolic.
12 hours of life, 3 kg neonate- 50 systolic
neonate- 96 hours of life- 60 systolic.
Infant- 1 month to 1 year- 70 systolic.
child from age 1-10 =[70 + (2x age in years)]
child age 10 plus= 90 systolic

Criteria for dehydration in children.
minimal (<5%)dry MM, plus or minus tachycardia plus or minus decreased UO.
there will be NO depressed fontanelle, sunken eyeballs, abnormal turgor, cap refill prolonged, weak pulses, hypotension, hyperpnea, altered mental status, or acidosis.

moderate (5-10)positive for dry mm, tachy, depressed fontanelle, sunken eyeballs, decreased uo, PLUS or MINUS turgor, altered, acidosis.
severe (>10) requires weak peripheral pulses, hypotensions, hyperpnea, altered mental status, acidosis, high urine sp grav.

class 1,2,3,4 hemorrhage
class 1-
up to 750 mL blood loss, pulse less than 100, normal BP, normal or increased pulse pressure, rr 14-20, UO >30 mL/hr (0.5 ml/kg), slightly anxious mental status, replace with 3:1 crystalloid:blood.

class 2-
up to 1500 mL blood loss, pulse >100, normal BP, decreased PP, RR 20-30,UO 20-30,mildly anxious. replace with 3:1 cystalloid:blood.

class 3-
up to 2000 mL blood, pulse >120, decreased BP, decreased PP, RR 30-40, UO 5-15, anxious/confused, replace with crystalloid and blood.

class 4
>2000 mL blood, pulse >140, decreased BP and PP, RR >35, negligible UO, confused/lethargic, replace crystalloid and blood.

Metabolism generates ATP which keeps biological membranes intact and functioning (brain and cardiac).

ATP can be generated through anaerobic and aerobic metabolism.

Although seemingly logical, ATP cannot be injected directly into a tissue to improve performance, for a variety of reasons. British Journal of Anaesthesia 94 (5): 556–62 (2005)

Anaerobic glycolysis does not require oxygen or mitochondria, it occurs in the cytoplasm. It generates lactate and acid as a byproduct, leading to lactic acidemia.

Aerobic metabolism requires oxygen and the electron transport chain of the mitochondria, it takes longer than anaerobic glycolysis.

For perfusion to occur, cardiac output must be maintained, which requires heart rate and stroke volume. CO=HRxSV

trauma activation
ejection from auto
death in compartment
pedestrian thrown or run over
speed > 40 mph
deformity >20 inches
intrusion > 12 inches
extrication >20 min
fall >20 ft
auto vs pedestrian >5 mph impact
motorcycle > 20 mph or separation of rider and bike.

flail chest
two or more prox long bone fx
amputation proximal to wrist/ankle
pen trauma to head, neck, torso, extrem prox to elbow and knee
open and depressed skull fx
limb paralysis
pelvic fx
combo trauma plus burn
major burn

Sunday, July 20, 2008

Empty Stretchers, Sunflowers and Waterfalls

My hiatus from blogging of late has been more to do with commuting to Elmhurst than with an absence of things to say... The empty stretchers are how I like to leave the ER every morning, the sunflowers welcome me home, and the waterfalls mark the ebb and flow of each day. Poetic, hmmm?