Hughesair (Inflection Point)

Retired physician and air taxi operator, science writer and part time assistant professor, these editorials cover a wide range of topics. Mostly non political, mostly true, I write more from experience than from research and more from science than convention. Subjects cover medicine, Alaska aviation, economics, technology and an occasional book review. The Floatplane book is out there. I am currently working on Hippocrates a History of Medicine and Globalism. Enjoy!

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Location: Homer, Alaska, United States

Alaska Floatplane: AVAILABLE ON KINDLE

Thursday, May 28, 2020

Public Health Authority to Test, Quarantine and Trace Contacts

     Besides the security vulnerability exposed by our COVID19 pandemic, the conflict between individual liberties and Public Health’s ability to test, isolate and trace, re-emerges. A similar conflict plays out as State Governors order continuing shutdown or reopening along Federal and Public Health guidelines or not so. In either case, lock down, contact tracing and quarantine appear to violate Civil Liberties.
     HIV as of 2020 infects 1.1 million of the US. There have been 700,000 total deaths and    presently about 16-17 thousand deaths per year.
     Influenza, on the other hand, infected 41.3 million last year with 57,300 deaths.
     COVID19 so far (5/28/2020) infected 1.7 million with 101 thousand deaths.
Public Health has their hands full with COVID19. Their tools are limited by their ability to test, quarantine, contact trace and treat. HIV initially was uniformly fatal, so there was every reason to use draconian measures to achieve the first three above strategies. Public Health and both public and private medicine, however, were denied the use of quarantine and severely limited in testing by political legislation. That limitation lead the US to lead the World in HIV.
     Our mishandling of HIV, no fault of Public Health, serves as an argument favoring Citizens relinquishing some of their civil liberties to their public health departments for the common good.
PublicHealth appears to be exercising that authority rationally with this pandemic, despite some non compliance among young people. Our liberty is great, and with it comes a requirement for cooperation and citizenship. Public Health needs the authority to evoke these austere measures in any future epidemic without obstruction. Obstruction in this epidemic came from China cutting off both supplies and giving false information.

Friday, May 22, 2020

Election, Globalization or Democracy, The Real Choice


             

           Globalism Promised a one world economy, which was to create such an overriding business prosperity as to end wars. Globalization would bring competing nations into compliance with world trade and governing bodies such as the World Trade Organization (WTO). What evolved, however, looked more like an Oligarchy and an elitist shadow government undermining our Democracy. Free trade sounds good, in theory, except that it was not free, and the outcome was not good. We exported manufacturing and jobs with far more destructive consequences than even the skeptics anticipated. Furthermore, China’s Communist Party and the People’s Liberation Army waged a twenty-years’ “unrestricted war” against the US and the West with devastating economic consequences for the US and accelerating growth and expansion for China. 
            Demonstrations erupted from the left in Davos and from the right with the tea-party movement and again with the election of 2016. What was prosperity in Washington was despair and stagnation on the street. A heavy-handed countermeasure is in play. With even greater polarization, we now have AOC in one corner, oligarchs in another, and moderates in another, all looking for power, plus the PLA buying influence with politicians and educators from the top right down to the local level. Let’s look at what’s happened and explore what’s at risk.
               Coming soon, publication date a moving target.

Wednesday, May 20, 2020

COVID19 Diagnosis and Treatment

Early diagnosis is confounded by the fact that the contagious condition of this virus precedes symptoms. Therefore, temperature and symptom screening yields false negatives at the point of maximum spread. The PCR test while giving accurate results in the early stage, requires often days for the result. By then it’s irrelevant. The antibody test while the results are quickly available, only tells whether the patient already had the virus and is producing immune antibodies. The on-site, immediate result PCR test is a US new invention needing time for manufacture and distribution.

More important, is the quick staging of this fast moving infection. Stay home and recover from mild cases, risks getting behind on more sever cases, in that sever lung damage is already there by the time the patient recognizes shortness of breath. ICU and a respirator offer only desperate measures with poor efficacy.

The challenge of early diagnosis, monitoring-progression and staging, leading to early drug therapies before the respirator, offers a better promise. However, there are so many mild cases not requiring any treatment, some asymptomatic, that the monitoring will have to be limited to contacts and known explosions. Monitoring might consist of a simple finger pulse oximeter that you have probable seen used in your doctors office to detect sudden drop in O2 saturation.

From JAMA  May 12 , 323 #18 P1825
Of the several antiviral drugs being tested, one works at the entry level, a couple at the attachment level and several at the viral reproductive level. Only three are available in any quantity, the chloroquines and the 2 ACE inhibitors. The specific antivirals are: available in limited quantities from previous or other viral disease outbreaks, imported with questionable or over burdened supply chains, in research only and or extremely expensive.

Another factor inhibits treatment, and that is the FDA and the evidence based medical bureaucracy. In the old days, every physician would have thrown many drug combinations at the problem. limited only by his or her own knowledge, circumstances and bravery. Not today, drugs must be proven by best evidence and approved by treatment guidelines and the FDA. Dealing with massive numbers of desperately ill patients in over crowded ICUs does not lend itself to the rigid stepwise approval, one size fits all, modern system. Better the on-site multiplicity of individual trials limited only by rationality and “Do no harm.” A working combination, or "cocktail," would rapidly emerge. Such might be more scientific as well considering the infinite multiplicity of combinations -- not to discount the systematized in vitro search through millions of drugs done in advanced laboratories and the gold-standard, double blind clinical trials.

The results of clinical trials are about to be released. We will know more for the next outbreak if it’s the same virus and not mutated to another form of drug resistance. Watch out for drug company studies touting  their own expensive drug candidate and the study that somehow belittles any available affordable alternative.
Click the JAMA illustration for the full free summary.



Friday, May 15, 2020

A Tribute to Professor John Christopher Ise



1885-1969, JD Kansas, Masters and PhD Harvard, past president American Economics Association. An agrarian economist, Sod and Stubble, KU professor 1920, lauded as the hardest and smartest professor on the hill by student campus consensus. 

Phrases like: allocation, marginal propensity, diminishing return. Factors of production: land, labor, capital, entrepreneurial ability, cheap, abundant sustainable resource and elasticity of demand.
The American Way 1955

Professor Ise was famously contrarian. Without my all to brief a time as his student, this book would not be possible.

Thomas Paine



The American Crisis "These are the times that try men's souls. The summer soldier and the sunshine patriot will, in this crisis, shrink from the service of their country; but he that stands for it now,  deserves the love and thanks of man and woman."

“Those who want to reap the benefits of this great nation must bear the fatigue of supporting it.”

“Time makes more converts than reason.”

“We have it in our power to begin the world over again.”

“I never considered a difference of opinion in politics, in religion, in philosophy, as cause for withdrawing from a friend.”

*I have always strenuously supported the right of every man to his own opinion, however different that opinion might be to mine. He who denies to another this right, makes a slave of himself to his present opinion, because he precludes himself the right of changing it.”

“We hold these truths to be self-evident: that all men are created equal; that they are endowed by their Creator with certain unalienable rights; that among these are life, liberty, and the pursuit of happiness.”

Tuesday, May 12, 2020

The Wrong Question

    The better question might be, why didn’t the guidelines of isolation and distancing work as well as in some other countries? We have over the past several generations evolved the most highly self centered, polarized and non compliant population imaginable. If the original guidelines were followed uniformly, COVID19 would be gone.            
    Now, we are asking about testing, as if that would have lead to a different outcome. If we tested every American in the morning before he or she went to work, and self-quarantined those that were positive, would that work any better? Would We not repeat the same level of noncompliance?
    Such a testing strategy begs the question of feasibility. The test would, of necessity, have to detect the presence of the virus, real-time, with instant results, high specificity and high sensitivity. The cost would have to be very low, the manufacturing and distribution would need to be in the billions of units, but again, would thee be any better compliance.
   

Wednesday, April 22, 2020

The American Hospital Association, a School for Scoundrels


Years ago, hospitals were truly focused on patient care. Non profit community hospitals were truly non profit. The hospital administrator was a mother superior, the protestant equivalent or a dedicated administrative or accounting type, sometimes a physician or nurse. The medical staff played a major role in standards and nursing staff in operations. Both were highly organized and dedicated to patient care. The Joint Commission for Accreditation of Hospitals was an effective inspector general auditing standards of care, despite resistance from the AHA since 1995.

Progress imposed by the Medicare bureaucracy, limited beds requiring a certificate of need, and hospital administrators became more organized. Seeking greater authority, ability and pay. Administrators organized accredited schools for hospital administration and a national association of administrators dominating the once venerable American Hospital Association, founded 1898. The national organization gave hospitals bargaining power in the purchase of supplies and the sharing of knowledge, a great help in the running of widely dispersed hospitals. However, the imposed limitation of hospital beds gave hospitals an unintended monopoly and hospital administrators nearly unlimited power in wielding that monopoly.

There was always a natural tension between hospital administration and both of the professional staffs. Now, with the power of monopoly the cartel of administrators became CEOs with  the wet dream of displacing both physicians and nursing staffs’ authority in defining patient care, into a source of power and financial benefit for themselves. The American Hospital Association directed a disinformation campaign against organized medicine claiming medical societies were in violation of antitrust laws they themselves were violating. First they removed the requirement that any hospital staff member be a member in good standing with the local county medical society, effectively castrating the medical societies’ ability to regulate and discipline its members. They did the same with their organized nursing staff limiting salaries, numbers and authority, no longer management. Then and maybe worse still, CEOs converted the nursing lounge, physician and surgeons lounges into “all employee lounges” or eliminated them altogether with new hospital design, thus eliminating or limiting  collegial communication and to a real extent continuity of care.

CEOs’ salaries now nearly all exceed a million dollars a year. Patient care now evolves into administrative priority and profit. Nosocomial infection rates soar as do medication errors and wrongful deaths. Autopsies are a thing of the past. Conveniently, patient confidentiality eliminates bedside teaching, accompanied rounds and access to the patient chart. Electronic health records confuse the patients notes with volumes of extraneous data. Specialists caring for the same patient don’t talk to one another. Hospitalists, now in the employ of the hospital, are needed to keep track of what’s going on. Nurses, now unionized and diminished to non-exempt hourly employees, don’t share patient information between shifts – no pay for the overlap – and no longer a voice in patient care. Doctors staff privileges are now at the discretion of the BOD, which in effect falls to the CEO. Universal precautions – a thing of the HIV epidemic and patient privilege of information, now replaces isolation, wherein any laps of technique or sanitation, means no infectious disease protection at all.

So, with the SARS-COV-2 pandemic, there comes no surprise that hospitals are overwhelmed. Supplies are lacking. Operations fall back on the professional staff but without control of the logistics necessary to ramp up isolation, testing or expanded ICU. To their credit professional staff rose to the occasion. With financial relief for hospitals, however, will we do more than secure the CEO’s obscene salary? CEOs should be demoted to administrators, preferably hourly with operations, decisions involving patient care and logistics once again in the hands of professional staff. The public health statistics of US health care compares unfavorably, to the rest of world’s  industrialized nations. This pandemic may provide an opportunity to reevaluate and restructure our health care systems, not by further privatizing, monopolizing and incorporating, but by recognizing health care as a vital universal infrastructure.

Monday, April 20, 2020

Logistics and the Pandemic

Logistics, nothing could better dramatize Globalism’s dangerous domestic vulnerability than the COVID19 pandemic. With a “just in time” source for diagnostic kits, reagents, protective gowns, masks, medicines and ventilators dependent on Chinese manufacture, supply and transportation, we suffered massive shortages. The supply chain was unreliable or cut off and our laboratories and ICUs were overwhelmed. We lacked both the manufacturing and logistic systems to immediately respond. Adapt we did in typical American style, but it took time, and we may never again depend on a questionable or global source for medical supplies.

COVID19 further highlights the weakness of a public health system that does not have the authority to isolate, and a portion of the population less willing to comply. This failure to isolate was a problem with the HIV epidemic and again posed a problem with youth continuing to party in the face of calls to isolate and perhaps an unwillingness of some to sustain isolation. Is Public Healths order to quarantine or isolate a violation of civil liberties? In the distant past Americas frontier and religious ethic of cooperation overruled the concept of civil liberty in the face of adversity. Today, however, personal freedom and rejection of institution rather dominates the ethic of liberty. The trauma we face with this pandemic, however, will hopefully drive a return to a greater spirit of cooperation and egality. 

Small Business Corona Virus Payroll Loans


Harvard University receiving 9 million dollars of the limited small business corona virus payroll relief funds provided by Congress, seems an obscenity when intended for struggling small businesses.
Recovery loans force banks into a reverse paradigm for lending. Banks make loans to businesses on the basis of security, promising return, and secure balance sheet – in other words, lack of need. The recovery loans are for those with inability to make payroll, facing bankruptcy and enormous need. How are we to police banks into actually lending to small business rather than to their favorite large depositors? Perhaps POTUS could ask the senate to appoint Senator Warren to oversee the actual lending practice. 😊 Then someone needs to watch Elizabeth. 
Why was the 2 trillion Corona Virus Relief Bill so soon depleted? The Harvard loan amounts to theft. If there are other egregious examples, they all need to be called in and re issued by the intended guidelines.

Wednesday, April 15, 2020

Recovery

Reading between the lines of the COVID19 databases of distribution, geographic concentration and death rates world wide, one can imagine differences in public health systems, technology and the quality of healthcare systems. Discounting the false information from China, Germany comes out on top with lower death rate per case and per population with the US not far behind. In my view, these numbers credit the medical technology in Germany and maybe a superior public health and healthcare system. S Korea’s favorable response may reflect a more disciplined population response based on prior experience with similar epidemics. Logistics looms as a huge factor delaying response in the US, necessary protective and treatment items nearly all imported.

Recovery demands, continued safeguards until widespread vaccination and more effective treatment. Additionally, three priorities emerge.

  • Education
  • Healthcare 
  • Logistics
Education in cooperation, discipline and knowledge, not just the virus, but our culture, our government and our constitution. Our education system lags far behind both Asia and Europe. We need lower cost education and much mo re of it.

Likewise, our healthcare system, despite the high tech quality centers, lages far behind in relation to Europe and Japan. The public health system especially and outcomes reflect this weakness.  We need our states to redevelop high quality and imposing public health as well as medical education. Our greed driven, hospital, drug company, insurance and central government bureaucratic health care system needs overhaul. Perhaps along the lines of Germany and France, or doing one better in partnership with States. One size or system does not fit all.

Logistics poses an obvious problem, both for security and economic survival. We need to secure, not just our borders, but ports, our shipping, and our transportation. Air carriers may need subsidizing as in the past to insure their viability, safety and passenger health. Over crowded passenger sections must end affording adequate personal space, ventilation and air quality. Transportation is vital, but over crowding must end. High speed ground transportation could ease the over crowding of air travel.



Wednesday, February 05, 2020

Globalism or Democracy

Book will be out soon
Globalism or Democracy
Globalism brought the Western World a spectacular level of cooperation, openness, competition and trade. Business and trade interdependence held in check unwanted nationalistic expansionist forays. Economists, military strategists, young people, the media and academia embraced Globalization in solitary. What could possibly go wrong?

Sophistical Refutations, Aristotle’s 13 Fallacies, 350 BC


1.     Accent: changing the meaning of a quotation by changing or ignoring the accent on certain words, common journalistic or political spin.
2.     Amphiboly: use of language that has multiple meanings to obfuscate or mislead.
3.     Equivocation: deliberate misuse of language to obscure, confuse and belittle a concept
4.     Composition: Assertion that an overall principal is true when only a part it is true
5.     Division: Assert an overall truth as support that a part of the overall is true also.
6.     Figure of Speech: using the vagaries of language, gender or cases to assert fallacy
7.     Accident: use of a general rule in support of a false specific.
8.     Affirming the Consequent: arguing backwards from a true consequent to a fallacy, used repeatedly by journalists in what can only be called perception management.
9.     In a Certain Respect/Simply; True in small area, therefore true in larger area, as in the application of medical statistics
10.  Ignorance of Refutation: Evidence leads to X, yet conclusion Y is drawn.
11.  Begging the Question: If a topic is not wrong, it is right. If you’re not good, you are bad.
12.  False Cause: X and Y are associated; therefore, X causes Y without any proof.
13.  Many Questions: to change the subject slightly in order to answer a similar question and assert a false or unrelated answer.

Monday, January 27, 2020

EHRs

EHRs are trying to do the wrong thing. A clinical note, consultation or completed H&P express an elegant succinct communication between physicians and an ongoing novel of a patients progress. Not only does each encounter, each patient, each disease present a unique narrative, but each specialty and each physician contribute a unique perspective. No way can a team or an EHR reflect the color or content of a patient encounter. The physician dictated note alone can capture the subtleties of an encounter or facilitate continuity-of-care. The nightmare of entering EHRs in the presents of a patient pales by comparison to reading an EHR and trying to find what the previous physician was thinking among the vastness of irrelevant and superfluous misinformation, pages and pages of it.
       EHRs should be the preview of nurse alone and relegated to a separate file, Nurses Notes. Physician notes, dictated by the physician alone should constitute the official record. All the legislated requirements and their execution can remain in the nurse’s EHR.