Yes I do need a hight capacity magzine.  Here’s why!

Who needs a high capacity magazine? Who needs a weapon capable of firing more than ten rounds?  These questions echo across the airwaves and in the pages of magazines, newspapers, blogs and every conceivable outlet.  Well guarded politicians and cultural figures wring their hands in safety and newspaper offices post guards as they debate the merits of regular people with scary weapons.

For what it’s worth, I don’t like the tactic of anyone appealing to what I ‘need.’  It conveys a false concern at best, and at worst a terrible paternalism; the sort of paternalism that the American Left has railed against for decades, whenever fathers told daughters, husbands told wives, churches told believers or government told citizens what they should ‘need.’  But now, it’s positively fashionable to tell gun owners what they do, or don’t, need.

So, since ‘need’ is all the rage, let me explain why we ‘need’ those magazines and those rifles and handguns that use them.

First, our Leftist friends have been misled by media.  I fear that they believe the movies and television shows in which the intrepid, rebellious, foul-mouthed detective always comes out smiling when he uses his snub-nosed .38 caliber revolver to take down bad-guys with automatic weapons.  He pushes the female lead out of the way and fires a snap-shot at the roof-line, and Voila!  The cartel member with the AK-47, 100 yards away, plummets to the ground.  He was dead before he fell.

In short, gun-control advocates like to think that every gunshot wound is the end for the person shot. However, let me lay a little medicine down.  It isn’t true.  While being shot is sometimes fatal, very often it isn’t.  And even if it is ultimately, the ‘shootee’ often has time to a) call 911 for help b) drive away or c) continue to do terrible things to the object of his or her rage and violent impulses.

Many years ago I was privileged to help teach a class on wounding.  The students were a sniper class, which was mixture of city police officers, FBI hostage rescue team members and SEAL team members.  I was an emergency medicine resident then, and it was a hoot.  They were some of the nicest people I had ever met, and after the talk my fellow instructor and I were allowed to ‘play’ with their toys,  such delightful treasures as suppressed sub-machine guns and sniper rifles.  It was, in short, a gun-lover’s dream come true.

But before we went to the range we discussed some important points.  Mainly, for a shot to be instantly incapacitating, it has to do one of three things.  It must either cause complete vascular collapse; for instance, it must cause the heart to cease to function or a large blood vessel like the aorta to be penetrated and cause sudden, massive hemorrhage.  Or, it can strike the central nervous system in such a way that complete neurologic incapacitation occurs.  For instance, it must strike the brain-stem, which is the lower portion of the brain behind the mouth and ears.  If this happens, the heart stops beating and breathing ceases.  Other brain shots may, or may not, immediately incapacitate the individual so injured.  Finally, the wound can cause sudden structural failure; for instance, shattering a femur or pelvis, or shooting away a spinal segment that causes the individual to be unable to support his or herself.

Short of these situations, a person may be shot and continue to fight, continue to kill, well after a wound is inflicted.  The FBI learned this the hard way in Florida, in 1986, when agents found their service weapons inadequate in the fight against two bank robbers, resulting in the deaths of two agents, and ultimately of both criminals.  And in the re-arming of the entire agency.

Now, the average person defending hearth and home may be able to inflict a fatal wound on an assailant. But their odds go up dramatically with a larger number of rounds fired.  Five or six rounds from a revolver might look good in a Western, but the Duke is gone (rest his soul) and Jose Wales has retired, and it’s up to regular folks to do the work of protecting the ranch from marauders.  A rifle with ten, twenty or thirty rounds available might be necessary.

Why is this?  In part, it’s because the kind of practice necessary to make those incredible, one shot incapacitating wounds is not easy to get.  Life is busy.  Suburban and urban shooters can’t go into their back yards and fire off rounds the way rural dwellers, like me, can.  And it requires good coaching from skilled teachers.  A Marine marksman or sniper takes time to create.  In fact, one reason the M-16, and its civilian brother the AR-15, came into the US military arsenal is that it is easier to give soldiers a light weapon, with light ammo and lots of it, capable of semi-automatic and (for the military) automatic fire, than it is to train them to be long-range marksmen.

In addition, those well-placed shots are difficult because of duress.  As an emergency physician, I’ll attest to the fact that stress makes seemingly simple physical skills more difficult.  So when we are afraid, when we are stressed, when we are worried about protecting our spouses and children, when we are fearful for our own lives, it can be tough to keep that weapon on target.  Tough to get the correct sight picture.  Tough to pull that trigger without moving the barrel too much.  Thus, having extra rounds is a good thing, not a bad thing, for lawful citizens.  The police understand this.  Most city and county police officers are no more at war than the people they protect.  But they want weapons that can fire lots of bullets.  Even they are subject to the vagaries of training and the physiology of stress.

But there’s more.  Drugs, and even alcohol, change the equation.  Having seen a 90 pound woman on drugs bite and kick her way through several security guards, having seen the crazy look in the eye of quietly menacing mental health patients whose violent impulses are escalating, having met people in custody for murder and rape, having lived in a county where home invasions have resulted in terrible deaths, I feel that I can safely say that while the world has lots of good people, bad people are more dangerous than ever.  Not only so, home invasions are often accomplished by more than one assailant.  Bad guys have no sense of honor, and aren’t interested in even odds.  More than one bullet, more than one magazine, may be necessary. Especially for those who live in areas further from police protection.

In addition, as drug addiction rises not only to Methamphetamine but to narcotics like Vicodin, Klonopin, Oxycontin, Fentanyl, Morphine and everything else imaginable, (including ever new drugs like Bath Salts being manufactured in clandestine labs), people become more desperate than ever to feed their addictions. They rob pharmacies and break into homes.  They steel from the chronically ill and the dying and they will not hesitate to kill you to obtain money or drugs.  And if you doubt me, ask your friendly local narcotics officer, ER nurse, physician or paramedic about the level of crazy out there these days.

Finally, however, there’s another reason.  You see, we now live and move in a world in which we have ceased to believe in right or wrong.  A society that rejects not only God but natural law; that finds it moralizing or fundamentalist to suggest that we inflect (God forbid) our values on young minds.  Far better if Hollywood (known for its peaceful, gun-free films), or college professors teach our young how to behave.  Well we have sown the wind, and now reap the whirlwind.

The Left has won the debate over morals so far.  They are busily expunging faith from the public square and happily teaching the young that the individual is the only arbiter of right and wrong.    My liberal friends, you got it.  The least you can do for creating generations of violent criminals with no fear of God or man is to allow the rest of us the tools with which to defend ourselves.

In all honestly, I don’t have a black rifle with all the protruding bits that give Leftists nightmares. But if, and when, the price ever drops again, and ammunition and magazines are available again, (thank you Mr. President for stimulating that bit of the economy!) I’ll likely buy one.

Because I do, in fact, need a high capacity magazine.  If you don’t want one, don’t bother.  But my life, and the lives of my wife and children, are worth protecting in the best way I know how.  And as far as I’m concerned, if I should have to protect them with a firearm, I want lots of bullets; which translates into lots of reasons for addicts, psychopaths and every other dangerous nut to leave me alone.  And if they won’t, lots of chances to make them drop where they stand.  That’s what I need.

What you need is for you to decide.

Here is my latest column in Emergency Medicine News.  I hope you enjoy it!

http://journals.lww.com/em-news/Fulltext/2013/02000/Second_Opinion__When_Leading_is_Following.8.aspx

My wife just built a pergola in our yard.  Mind you, a pergola is a thing I never knew existed until it was pointed out to me by my darling.  If I had been asked, ‘what do you think of her pergola,’ I might have thought, ‘well, it certainly fills out that dress nicely,’ or perhaps, ‘I remember that from pathology.  It incubates for four weeks, causes fever and weeping skin sores and is common in the Pacific islands.’

Turns out it’s that structure you see in elegant yards, or in the sacred pages of our Dixie Holy Book, Southern Living.  A pergola is the wooden framed structure that ladies of taste have in their yards, and on which assorted vines grow for shade, and beneath which said ladies and their charming children have cakes and lemonade in oppressive summer heat.  Incidentally, I have explained to my wife that Southern Living is merely house porn…images of things that one desires but which do not actually appear in nature and which are not actually available to mere mortals.  I now stand corrected, though our pergola may have wild animal carcasses dragged beneath it, unlike those in Southern Living.

Our pergola is almost finished. Thanks to the skill and vision of my Jan (who probably should have been an engineer), and thanks to the strength and agility of my children, the tools and experience of my various in-laws, it has risen from the ground behind our house.  Its posts are set in concrete, its beams securely nailed.  It’s tall posts and well-measured intervals caused me to ask Jan if it were aligned with the summer and winter solstice, and if we’d be dancing naked beneath it.  She smiled and said, ‘maybe!’

Pergola entered my vocabulary because it was something my wife desired; something of interest to her.  I’ve learned other things from that girl.  I’ve learned about leadership skills, which she used to teach to college students and still teaches to our church youth.  I’ve learned about volunteerism, and historical romance.  About Japanese words and her love of Ireland, land of her ancestors.  I’ve even learned things I can’t discuss here.

But she isn’t my only teacher; not at all.  From my children I learned many things as well.  If not for my son Seth, I wouldn’t have my deep love of the bag-pipe.  Many years ago, when he was small, we heard the band Albanach play a show.  They are a group of Scots who play pipes and drums the way Ted Nugent plays the guitar.  Watching their show, one understands why the English viewed Highland combat with a certain reluctance.  But they inspired my son.  And he has played the pipes, better and better, for years.  It was also Seth who led us down the path of learning the ancient art of blacksmithing.  A smithy sits in our yard, and we fire it up whenever we need to shape metal and feel the heat, see the sparks and ‘get our iron on.’

My daughter Elysa taught me the fine art of playing dolls, and endlessly teaches me about fashion and contemporary culture.  She makes me dance in the dining room, and asks me questions about my past, and her mothers.  She shows me how to make movies on an i-Pad and how to do all of the things on my computer I should understand, but don’t.  She also teaches me to see inside the hearts of others, for she is a born healer, all compassion.

Elijah, my 13-year-old, forces me to learn.  I am always behind his vocabulary, and interests, as he quizzes me on German words (I don’t know any, I try to explain), relativity (zoology degree, not physics), Norse Mythology and ancient combat.  (OK, I know a little.)  But his passion for knowing forces me to read, to learn and to never stop loving the act.

And my oldest, Sam, teaches me that there’s always a reason to laugh, always a new ‘Meme’ online that I need to see, always a new idea on BBC news or somewhere else that we need to discuss.  He introduced me to the band Muse, and is my guide to the modern music scene.  In fact, his enthusiasm for his favorite band led his mother and I to drive family and friends to see the band in Indianapolis in the summer of 2011.

What’s my point here, you may be asking?  Not to catalog my family hobbies, certainly.  My point is this.  We physicians can be a focused bunch.  We work, we study, we write or do research, we speak.  For so long, we’ve listened to our own interests and followed our own requirements.  We get lost in education, then in continuing education and in the vagaries of practice.  So lost, in fact, that we lose touch with the very interests and tendencies of the people we love.  And we forget that love is more than an emotion.  Love involves engagement in the lives of others, and sacrifice of some our time, some of ourselves, for their good.

If there’s one thing I’ve learned as a husband and parent, and not always done well, it’s that we have to open our eyes, ears and hearts to the passions of the people we love. I could have devoted my entire life, and all of my time, to me.  But what a loss.  I have learned so much more by being led by my dear family!  Lead on walks, lead to play X-Box, lead to imagine, lead to dance, lead to build a coal smithy and make things, lead to play airsoft, to listen to concerts, to read widely and always embrace life in its wonders.

In the process of following, of letting go of my own agenda, I was lead deeper into the hearts of my wife and kids.  I am safely ensconced there now, and their interests and joys have been welded to my own.  I couldn’t undo it if I wanted. But I don’t.

Because in the process, we have had laughter and love, games and trips, learning and adventure.  I have become so much more than a physician, so much wider in scope, wiser in life, richer in knowledge and skills.

And we have a pergola, for crying out loud!  How cool is that?  And I for one can’t wait to sip lemonade beneath it.

Bagpipes and anvils and music from alt bands

German and physics and myths out of Iceland,

Pergolas, dancing and daughters with bling,

these are a few of my favorite things!

Deciding who needs what can be risk business!

http://www.greenvilleonline.com/article/20130203/OPINION/302030022/Ed-Leap-Deciding-who-needs-what-can-risky-business

What do you need?  It’s an interesting question, much discussed in the wake of the current gun debate.  I frequently hear this statement:  ‘no one needs a rifle with a magazine that holds more than ten rounds.’  One caller on a radio show said, ‘nobody needs more than six bullets.’   Others have said, ‘I can’t see why anybody needs more than one gun; it’s ridiculous.  I certainly don’t need one!’

Obviously, there are millions who take the opposing view.  But gun-control aside (as if that were possible in the current political climate), it’s time we start to ask ‘who decides who needs what?’

I can tell you a lot of things I don’t think anyone needs.  Nobody, in my opinion, needs Methamphetamine. Well, not at first, anyway.  In the big picture, it isn’t essential to life.

Of course, having cared for countless intoxicated individuals, young, old, male, female, rich, poor, comic and tragic, I can say that I don’t need alcohol, so perhaps nobody needs alcohol.  Yes, some research suggests a health benefit to certain amounts of alcohol consumption.  But it’s likely that humans were healthy before the first one found a container of fermented fruit juice, drank it inexplicably and woke up with the first hangover.

Cigarettes come to mind.  Who needs them?  Not me.  They cause enormous suffering and death, even though many find them relaxing and pleasurable.  But then, over-eating causes harm as well.  Do we need access to endless calories all day long, as much as our prosperity and ingenuity provide?  Nobody needs cheeseburgers or fried mushrooms.  Of course, I love them just the same.

Americans love their pets.  But are pets necessary?  Who needs a Pit-Bull? Who needs a Burmese Python? I’ll take the former over the latter any day, but I would never feel that I needed either one.  And really, as much as I like cats, who needs a house full of them?

Advocates against over-population often suggest that no family needs more than one or two children. Polygamists might feel that they need more than one wife.  One man feels he needs to leave his wife for another; one woman is confident she needs to hit her husband with a ball bat.  Need is a little subjective, isn’t it?

Is the Church necessary?  I think so, although I wouldn’t impose it on anyone.  I find it necessary for me and for my family.  I’m certain I could find those who would suggest that it is a remarkably destructive force and not only unnecessary but dangerous.  They would say I don’t need it.

Who needs a fast car?  Who needs a large house?  And what about money?  How much money do the rich need? Or the poor, for that matter?  So much of our economic debate hinges on the idea that some people have more than they need, and some have less, and that some transfer based on need has to be effected.  But who can decide such a thing as financial need?  Oh, right, the government.  But is it based on some algorithm?  Some formula?  On dated, failed economic and political philosophy?  Or perhaps on future votes…

Unless by ‘need’ we mean only the most common and basic things like food, water, clothing and shelter,  the rest of our attempts to determine need are often based on ideology and emotion.

You know the perennial argument that ‘ you can’t legislate morality?’  Well, we do it all the time; sometimes wisely and sometimes poorly.  But seldom do we legislate morality more than when we discuss who needs what; whether it’s money, vices, food, weapons, freedom or family.  Because when you tell me what I need, or I tell you, it’s a ultimately a moral judgment about what one of us ‘ought to do.’

We all have different motivations and different reasons to try to shape society and culture in the way that seems best to us.  But whether the issue is taxes, guns, relationships, free speech, school prayer, or any other hot-button topic, we should remember something important.  That is, our claim to know exactly what another free citizen needs only leads to frustration, bitterness and ultimately revenge, once the pendulum of opinion, or power, swings the other way.

Isn’t it wonderful how enlightened our betters are in the UK?  With all due respect to the mother country, of course, it’s become a rather scary place.

http://claytonecramer.blogspot.com/2013/01/british-rape-rates.html

Advocates of gun control should be more circumspect in who they follow to the protest.  A convicted rapist obviously finds gun-control a bit of a hazard, no?

http://www.buckeyefirearms.org/node/8759

More inconsistency and manipulation from our betters in Washington.

http://www.weeklystandard.com/blogs/feinstein-gun-control-bill-exempt-government-officials_697732.html

Makes me crazy!  At this, the founders spin in their musty graves.

Edwin

Hey dear friends and readers!  I’ll be speaking at Resuscitation 2013 in Las Vegas! Follow the link below to see a summary, but it’s going to be about life in Emergistan!  I hope to see you there.

http://resus2013.com/optional-ultrasound-pre-session/

Edwin

Here’s my column in today’s Greenville News.

‘Evil is restrained by the courage of armed citizens.’

http://www.greenvilleonline.com/article/20130113/OPINION/301130016/Ed-Leap-Evil-restrained-by-courage-armed-citizens?odyssey=mod|newswell|text|Making

Despite the assertion that gun-owners like me are dangerous Neanderthals, we do have a few good points to make in the current debate.  So allow me to ‘fire-off’ some reasons the current initiative is, quite frankly, stupid.

Gun control advocates are typically ignorant of the objects of their disdain.  Most of them don’t know the difference between automatic and semi-automatic; nor that you need a special FEDERAL permit for automatic weapons. (You know, the kind of weapons used by the body-guards of important politicians, businessmen and celebrities, and used in every violent film vomited from endlessly sanctimonious Hollywood.)

And few of them know the difference between a pistol and a revolver, a 12 gauge and a .38.  One of them wrote on my blog, ‘I suppose I could see having a .22 for hunting, but I don’t understand why you need anything else.’  Which .22 is that, ma’am?  Because there are a boat-load of them, and some are meaner than others.

I suppose her reasoning is that if you don’t understand, just ban all of them.  They’re guns, after all!  Of course, I don’t know why anyone needs more than one type of beer or wine.  They’re all alcohol, and lead to drunk-driving!

Another ridiculous part of the current media fire-storm over gun control is the deeply held belief that concealed weapons permit holders are especially dangerous and that gun owners should be ‘outed’ to the public. In a kind of homage to the much detested (by Communists) witch-hunts of ‘tail-gunner’ Joe McCarthy, gun-owners have been ‘outed’ by some newspapers.  Painting with a broad-brush, they’ve been ‘profiled.’  A thing which we x-ray, grope and strip to avoid in the nation’s airports.

The uncomfortable reality is that states with concealed weapons permits have seen decreased crime rates.  And even if they hadn’t, the permit holders aren’t committing crimes.  A person willing to have fingerprints and background checks, and even take a class, is not the guy we need to fret about, or identify.  (Unless it’s to make friends.)

But there’s more from this conservative curmudgeon.  And this is more personal.  I’ve seen people who have been killed and cruelly attacked.  I’ve seen them killed with guns, of course, but more killed and maimed with knives, blunt objects, boots to the throat and assorted other weapons. Death is death.  (Hammers and ball-bats killed more Americans than rifles last year, incidentally.  Even black, scary rifles!)

The thing is, the enlightened UK (which indeed has a lower gun-crime rate than ours) is one of the most violent nations in Europe.  It turns out, you don’t need a gun to be violent.  Who knew?

Sadly for civilization, in such ‘gun-free’ settings the strong and brutal thrive.  Small women or men, senior citizens and disabled individuals are all victims ripe for picking.  Abused spouses or single parents, citizens with alternate lifestyles, late-night clerks and all kinds of others are sacrificed on the altar of ‘safety.’  Darwinian survival of the fittest at it’s most despicable.

A gun in the hand of a physically weak person makes that person safer…in evolutionary terms, we could say it gives them a ‘survival advantage,’ maybe the chance to live and reproduce, or protect their young.  Unfortunately, victim-hood is the new religion of our elites.  (Who often have body-guards, incidentally).  It’s better for everyone if a mother and child are murdered, rather than a firearm be in the hands of anyone outside the military or police.  Ideology trumps biology.  And ethics.

I understand the desire to keep firearms from the mentally ill, so long as we’re careful about that determination.  But are we really ready to use emotion to trump logic, fact, evidence, tradition, law and culture?  Is the President prepared to instantly criminalize millions for owning something that had been legal all along?  To confiscate property and prosecute people who never harmed anyone with their weapons?  Especially when our own government has been supplying the same weapons to criminals in Mexico?  (And can this nation even afford such an initiative?)

I hope we can come to our senses.  I hope we can realize that new laws don’t change the hearts of law-breakers.  That collective punishment is tyranny.  That since about 47% of US adults own a firearm, the numerator of criminals is tiny compared with the denominator of the lawful.

And I hope to heaven we can embrace the fact that evil is not restrained by law, but by force of arms and the courage of free, and armed, citizens.

Here’s the link to my January EM News column on the symbiosis between emergency medicine and hospital medicine.  Text follows.

http://journals.lww.com/em-news/Fulltext/2013/01000/Second_Opinion__The_Hospitalist_s_Wing_Man.8.aspx

Dear hospitalists,

This is just a note to say that we, in emergency medicine, appreciate you.  Like all of us, you are stuck in an endless loop of unending residency.  Don’t worry, it isn’t an episode of The Twilight Zone.  It’s just your life.  No, it’s our life!

As specialty after specialty withdraws from the practice of medicine, you, and all of us, are left holding the bag.  We’re the college wing-man, sitting at the table with the hot girl’s weird friend.  That is, the rest of medicine skimmed off as many normal, paying customers as possible, and the rest of them were granted graciously to us.

We feel your pain.  Heck, we adminster your pain. But not because we have any options really.  Every neighborhood clinic that has a slightly sick patient sends them to the ER.  Each and every nurse’s aid or home-health worker who notices a blip in blood pressure, a faint murmur or something black or red in a body fluid sends their charges our way.  Every family medicine office or urgent care that feels beyond their capacity, or is approaching closing time, tells the patient to go to the ER.  Sometimes they call, sometimes they don’t.  But ‘go to the ER’ is one instruction that they always follow.

So, when they arrive at our door, some of them are actually sick!  The nerve!  At that point, either their physicians have astutely chosen to surrender hospital privileges in exchange for more money and time off, or they don’t have a physician at all.  And so, when the work-up is done and it becomes clear that discharge is no longer an option, we ring you brave lads and lassies.

We recognize the empty souls behind your tired eyes as you admit the 105 year old dementia patient with, yep, weakness.  Your tenth admit for weakness in 12 hours.  We know that the average age of all your admissions is somewhere around 85.  We hear your souls die a little when we say, ‘the family wants to put him in a nursing home and says he’s more confused than normal.’  It’s sad to hear you sobbing to yourselves over the phone, wondering why you didn’t study just a little harder and become an opthalmologist.

But we know it hurts in other ways.  It hurts when you have those days.  Those days when you have all the same patient.  Eight chest pain work-ups.  Six Xanax overdoses.  Nine TIA’s.  Seven syncopes.  And a partridge in a pear tree. The thing is, we see them before you do, and we understand.  We just realized, early in our career, that two hours of anything was more than enough.  You have them for days.  Bless your hearts!

We also feel for you when it comes down to the patient dumping contest.  You know, the ancient hip fracture with 26 meds whom the orthopedist says, ‘have the hospitalist admit them, we’ll consult.’  The GI bleed, of whom the gastroenterologist says, ‘have the hospitalist admit her, we’ll consult.’  The nosebleed on Coumadin dodged by ENT and gifted to your capable hands.  The post-op cellulitis, the post-partum pneumonia, the vague abdominal pain.  ‘Have the hospitalist admit them.’  The very words must haunt your nightmares, as assorted specialties leave the annoying work, the admission orders, sliding scales, pain meds, dispositions, social planning and midnight phone-calls…to you!

Sure, we have our differences.  I have nothing to offer the patient who refuses to go home, and you can’t admit them or you’ll be hauled off to Medicare prison and water-boarded by government functionaries.  We have our tiffs.  But the thing is, we’re BFFs. We’re soul-mates.  We’re ‘brothers by another mother.’

Medicine keeps getting harder.  And fewer and fewer folks are doing it.  America has no idea that the weight of it all is falling upon the shoulders of the emergency physicians and hospitalists who lurks inside the trauma rooms and inpatient floors, the fast-tracks and ICU’s of their community and university hospitals.  The pasty-pale, coffee-sucking, junk-food eating Spartans of health-care, who will bear the full Persian assault of health-care reform when there aren’t enough primary care doctors to manage an AARP convention, much less all of America.

So let’s stick together, shall we?  In point of fact, we might need to form an organization, a common political advocacy group.  If nothing else, a fraternity.  Tau Iota Lambda Mu…Take it like a man.

Bottom line, hospitalists, we respect you and we need you.  So don’t get mad when we call you.  Just think of it as a little note from someone who, for assorted reasons, understands you.  Someone who ‘gets you.’  And someone who has already endured the same patient and has simply run out of ideas.  And has to go home at the end of the shift…

Hospitalists, we heart you!  We’ll have your coffee waiting.  The hematologist says that the grandma in Room 8 has ITP. Call him if you need him.

So often we think of the frustrations and failures that visit is in emergency medicine, or indeed in any specialty of medicine.  These are memorable.  For whatever reason, we jettison the good, we suppress success, and we hold tightly to criticism, pain, loss, failure, imperfection, complaining patients, oppressive rule-makers.

But we succeed; we really do.  I should know. Two years ago my wife Jan was diagnosed with stage 4 oropharyngeal cancer.  It was just before Christmas.  Our youngest age 9, our oldest age 15.  Hearts were heavy, though of all the cancers she could have had, it was one of the most cureable.

In the course of her therapy she developed a saddle pulmonary embolus and was critically ill.

Thanks to the grace of God and the devotion of her physicians, she sits with us this Christmas day, beautiful and healthy as ever.

How many of our patients are the same?  Rescued from trauma, resuscitated from MI, retrieved from over-dose, diagnosed early enough for cancer-therapies, lifted up from suicide attempts, suicidal thoughts.  Fractures repaied, pneumonias cured.  The list goes on and on.

Sometimes we fail miserably.  But more than not, we succeed.  Sometimes medicine is a drain on body, mind and soul. Some days it is an epic victory. And many times, the victories are hidden from us down the fog of the years.

Today, however frustrated you are, know that somewhere, a family enjoys this day, this season together because you did the right thing, found the problem, treated the injury, took the risk, looked deeper, failed to surrender your patient to inevitability.

Merry Christmas dear doctors, nurses, PAs, medics and all the rest!  Be proud that you made another year a reality for someone, and likely for many someones, whether you realize it or not.

Almost every significant gift I purchased was accompanied by an offer for an ‘extended protection plan,’ intended to repair the item, or replace it, if damaged.  My thought, after being offered this when purchasing a Big Wheel for a child, was ‘if it needs an extra warranty, is it really that sturdy?’

Fortunately, Christmas requires no warranty.  Christ is the same now as ever.  His life, work and redemptive sacrifice still as powerful as ever.  The gift will never break, however broken we are.  The gift will never be lost, however lost we were when we received it.

The gift is guaranteed for all eternity.  It needs no battery, and will never run out of power.  The gift is beautiful but will never need polishing or maintenance. The gift will always be useful.  The gift will never be irrelevant.  And we will never be disappointed with what the gift offers us, in this life or the next.

Merry Christmas!

Edwin

This is my column in today’s Greenville News.  Merry Christmas!

http://www.greenvilleonline.com/article/20121223/OPINION/312230016/Ed-Leap-Sending-son-into-world-can-painful?odyssey=mod|newswell|text|Opinion|p

Today is the 18^th birthday of our my first-born son, Samuel.  It’s a shocking thing, to see the transformation.  18 years ago he was new to the world, tiny, needy, vulnerable and awash in the love of his parents.  Now he is a man. He is bright, articulate, kind, Godly, physically and intellectually strong and capable.  (And still loved.)

He will soon go out into the world with as much as we could give him of ourselves.  He bears our genetics and our tendencies, his mother and I.  Which means he’s a music loving, book reading, deep-thinking, compassionate and gracious card shark who loves ancient history, languages and has a competitive streak and big dreams.  (Among other things, of course.)

He takes with him all that we taught him over the years.  And as much as I’d love to shelter him until I leave this world, as much as I’d love to have him in my home and at my side forever, to do so would hold his destiny hostage.  He is meant for greater things, even if they involve trouble and risk.

We celebrate another birth this week. We celebrate the birth of the Christ child, the God-man.  He bore to earth His Father’s traits as well.  He was, in fact, the very embodiment, the very incarnation, of His Father.  (A fate my son, fortunately, does not have to endure.)

God sent Him down as the prophets foretold, to save the people from their sins (that means us, by the way).  And in order to do it, God equipped Him fully. He lacked nothing necessary to the ministry and the mission in all its wonder, from showing mercy to the poor, miracles to the sick, dominion over nature, kindness to the displaced, hope to the lost and redemption to all.

But as I consider this, today, this day, I realize a little better what God did.  He sent His Son.  He sent The Son.  His beloved.  He sent Him into a world, and a life, of beauty mixed with pain, of wonder mixed with terror.  He sent Him to a glorious birth, which we celebrate with light and music and gifts. And He sent Him to pain and death in order to defeat sin and death. He sent his dear one to people who would disbelieve Him, disregard Him and finally murder Him.

As my wife and I send our son into His future, it is with trepidation and hope.  Will he be loved?  Will he be safe?  Will he succeed?  Will he live long and well?  Will he be happy?  Will He remember us? I pray that all of those are answered with a yes.

But as we celebrate the nativity, we must remember that God, all knowing, knew the answers for His Son, and sent him anyway.  Will He be loved?  By some, and hated by many. Will He be safe?  No, unequivocally.  Danger will stalk and overtake Him.   Will He live long and well?  No, and yes.  His earthly years some 33; his days, ultimately, endless.  Will He be happy?  At times; and sometimes weep over friends.  Will His mission succeed? Absolutely, and for all eternity.  Will He remember me?  Oh yes.  A thousand times yes.

Nevertheless, there was separation, if only for a while. And for this father, and for that Father, even the hint of separation, even a slight lack of communion can be difficult. Love is like that.  I hope that Samuel and his mother, his siblings and I are always dear to one another for he is certainly cherished by us.

And from the intimacy with which Jesus speaks of His Father, and with which the Father speaks of Him, it seems certain that their love for one another never ebbed, but only grew stronger.

At Christmas, we talk about the gift of the Christ child.  But every good gift costs the giver something. This year, I’ll try to remember what it must have been like for the Almighty to send His Son out, even for a while, for the likes of me.

Because even as we know that they are ready, and that they have great roles to play and great destinies to fulfill, it’s hard.  Even if we know that they have work to do, lives to save, souls to rescue and a universe to set right, it’s painful to let go for even a short time.  For a Son (or a son) is a treasure of untold worth.

As I contemplate my time with my sons and their friends, talking, laughing and doing ‘guy things,’ I am reminded that it may be that much of the aggression in the world today would be attenuated if fathers were active participants in the lives of their sons.  Generations of absentee fathers, or fathers in biology only, have left young men without a true north, without anyone against whom to measure themselves, without anyone to teach them morality and manhood, and without anyone to remind them that they aren’t the biggest or baddest.  All laws aside, I suspect that fathers are the key to the problem of violence.   “And he will turn the hearts of fathers to their children and the hearts of children to their fathers, lest I come and strike the land with a decree of utter destruction.”  Malachi 4:6

‘Hi, I’m Edwin, and I own firearms!’

Right now, in the shadow of the horrors of the Sandy Hook shooting, it feels as if every gun-owner is on edge.  Some are apologizing, distancing themselves from gun advocacy groups.  Some are saying all the right words, ‘well, my target gun is locked in a safe.’  Like telling your Baptist Preacher grandpa, ‘my whisky is in a cabinet and is only for medicinal purposes, of course.’  Some are saying, ‘well, I like guns, but nobody needs automatic guns that can be sprayed across a room.’

The thing is, we didn’t want to talk about this. We wanted to let people grieve, to try and find solutions to unpredictable events.  The gun control crowd politicized this first. They launched into the predictable tirades against the very people who, after all, didn’t commit the crime.  So we’ve responded.

The arguments and tirades go on and on.  But here’s the salient point.  I didn’t do it.  I hate that it happened.  I grieve for lost children and teachers, for hurting family members.  But I didn’t do it. My guns didn’t do it.  My friends didn’t do it, and neither did their guns.

I have my guns in a safe.  But they don’t stay there all the time.  I have nothing that qualifies in the minds of most progressives as an ‘assault weapon,’ but if I could afford one I would.  They’re interesting, and enjoyable to shoot.  I have had friends who owned them, and I still do.  I knew people with fully automatic weapons; none of them killed anyone.  They were lawful, contributing citizens. Several were physicians.

So what I want to know is this:  what do you want us to do?  For those of you uninitiated into firearms, you don’t just walk into a store, pick one up and leave.  There’s paperwork, ID to show (it isn’t like voting, after all).  There’s either a background check or presentation of a concealed weapons permit in states, like mine, where they are available.

But what about those machine guns?  To belabor a point that should already be well understood by all, fully automatic weapons are not legal without further permits.  (You pull the trigger and it fires until empty.)  And they haven’t been since  1934.  Semi-automatic weapons (one round per trigger pull) are very common among various styles and purposes of rifles, pistols and shotguns.  And in fact, semi-automatic handguns may be safer to keep around than revolvers.  I know, too much detail, scary guns, etc.  But a semi-automatic handgun can have a magazine of ammunition loaded in it, without a round in the chamber to fire. Whereas a loaded revolver will fire whenever the trigger is pulled.  Of course, both are perfectly safe when treated safely and owned by lawful, responsible and trained individuals.

So which thing do we need to limit? Which part of the process do we need to tighten?  If you want to expand psychiatric background checks, I can get on board with that.  Depends, of course, on how you define mental illness.  If the desire for a gun is a sign of mental illness, we’ve made no progress.  But if you mean a history of suicidal or homocidal behavior or committment for such, fair enough.

And if you say, ‘we need more mental health care,’ I’ll say ‘Amen.’  You send me some more psychiatrists and I’ll forward to them all the patients that they can bear.  There just aren’t many of them around.  Furthermore, their work is frustrating, often thankless and populated with patients who are mentally ill, as well as with those who want mental illness rather than actually having it.  It’s hard to care for the sick while sifting through the lot.

So let me be clear.  I have a concealed weapons permit.  It took a background check, fingerprinting, a class and a test.  I have a gun safe.  I have taken extra training in the effective use of my weapon.

What would you like me to do differently?  What would you like to take from me?  If I threw open the safe and said, ‘come take what you want to make society safer,’ what would you take?  Would the world be better?

The thing is, I’m representative of the vast majority of America’s gun owners.  Like it or not, we’re a boring, law-abiding bunch.

Of course, those are the ones it’s easiest to regulate, I suppose.

Even when it doesn’t help.

http://sultanknish.blogspot.com/2012/12/guns-guns-guns.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+FromNyToIsraelSultanRevealsTheStoriesBehindTheNews+%28from+NY+to+Israel+Sultan+Reveals+The+Stories+Behind+the+News%29

It’s not so simple to stop gun crime, it seems.  Even on an island with cameras on every corner and self-defense virtually illegal.

http://www.dailymail.co.uk/news/article-1223193/Culture-violence-Gun-crime-goes-89-decade.html

Edwin

I have intentionally avoided commenting on the recent school shooting.  But I must ask, how many schemes will we devise, how many pundits will we consult, how many rules will we impose, how many specials televise, how many false diagnoses and half-truths will the experts offer up before we finally accept that there is evil, and that evil requires redemption?

This is my Greenville News column for this week.  Merry Christmas dear readers!

http://www.greenvilleonline.com/article/20121216/OPINION/312160011/Ed-Leap-fire-transforms-started-Christmas?odyssey=mod|newswell|text|Opinion|s

We have these little stars that cover some of the bulbs on the Christmas tree.  Shining in the dark they cover the tree in tiny representations of the Christmas star. However, as the kids know well, the pretty, spiky stars fall off the bulbs and sometimes lie on the ground, where bare feet contact the stars, loud screams are heard, and children (and parents) are seen hopping about and nursing puncture wounds.

Christmas trees are also more than beautiful. Real trees ultimately shed needles and weep resin and before you can sing For Auld Lang Syne, they’re off to the landfill, or the lake to serve as cover for Bass.  But worst of all, trees can be a bit flammable.  I always chuckle at old movies, in which the tree is decorated with burning candles and left alone.  Probably a bad idea, especially in the days before fire alarms, fire extinguishers and 911.

But in some ways, both of these things are illustrations of some foundational truths of Christmas.  We have forgotten, to our spiritual poverty, that Christmas is sharp and piercing.  And Christmas is a conflagration.

It’s beautiful, and make no mistake. The story, on the surface, is a simple child’s tale of a baby, poor parents and exotic lands, with stars and angels and kings.  And it is all that!  But it’s more.  Old Herod knew it, as he searched for the infant king and murdered the innocents in an attempt to stop a coming King greater than himself.  Shepherds knew it, abandoning their sheep to danger after the angels told them to see their deliverer.  Wise men knew it.  They brought no toys, no soft blankets, no Baby Einstein tapes or learning blocks. They brought a small child the tributes given to kings, including spices for His burial.  They saw forward to a darker day.

Like our ornaments, the man Jesus was sharp and piercing.  Our culture remembers His words about kindness and love, about the poor and humility.  Our culture forgets that if He had been walking and teaching incarnate today, He would have called out everyone for our hypocrisy, irreverence,  disregard for the holy; for our greed, lies, idolatry and immorality.  He would have been our friend, if we would have him. But not without hard words, for his goal was never to soothe men’s egos, but to save men’s souls.  His words penetrated, as He called all men and women sinners and claimed He was the only way to God.  Words like that don’t earn many followers in the halls of power and fame.  Those words, like our ornaments, cut deeply even though they’re part of the beautiful whole.

Ultimately, the sweet baby born at Christmas would anger others so much that His sharp words, His rapier ideas, His piercing and undeniable identity would make others pierce him.  With thorns and nails and spear.  That’s where the beauty of Christmas finds its culmination, as the lovely infant becomes the lovely sacrifice and lover of all mankind.

But the trees? He became a conflagration as well.  Christmas didn’t end with the manger, or the Magi, or the trip to Egypt.  It went on as Jesus grew and became a man, as He taught His disciples and followers and as His mission and ministry became evident.  And after the piercing one was pierced, after his fire burned away the power of sin and death and lifted him up, after he went back to the Father, the fire went on.

Ignited in the manger and fueled by Jesus’ life, death and resurrection, by the hope of forgiveness and redemption for even the worst, and eternal worth for even the least, the fire roared across the world, melting the icy, dying hearts of ancient empires.  The fire burns on today.

We can try to blunt the sharp points and edges of Christmas with mind numbing lights and colors, gifts and parties.  We can try to smother the fire with Holiday Trees and Winter Festivals, with Santa, Elves, parties and snow.

But be careful where you step.  And be careful of the flames.  For Christmas is the beginning of the wounds and the fire that transformed, and transforms, as nothing ever did.

Christmas is coming folks!  Consider ordering Republic of Emergistan buttons or shirts/sweatshirts, etc.

Remember, our motto is Semper A Decem.  Always a ten!

http://republicofemergistan.com/

Edwin

Merry Christmas!  This is my December column in EM News.  The Nativity in the Emergency Department.

http://journals.lww.com/em-news/Fulltext/2012/12000/Second_Opinion__The_Nativity_in_the_Emergency.9.aspx

I once wrote a story for Christmas in which the nativity happened in an old, beat-up hunting trailer behind a man’s store, somewhere in the South on a cold winter night. From everywhere and all around, rough people and businessmen and politicians found their way to it, situated as it was in a cluttered backyard of a poor but compassionate store owner. Mary and Joseph had a car that broke down, you see, and they were stuck. I doubt if it’s that original. I suspect Hallmark or someone has done this story over and over.

Image… Image Tools

Image… Image Tools

Yet it still resonates; it still bounces around inside my mind. I envision that cold night, and the star, and the people in my neighborhood, camo-wearing hunters and bearded bikers, the guy with the meth lab that blew up (no kidding), the men in the garage across the highway. I suppose it’s because the story fits everywhere.

As you might expect, I have this image of the manger scene set in an ED. I think back over my patients, and it makes perfectly good sense to me. I can’t decide if it’s a busy night or a slow one. But there are Mary and Joseph, maybe homeless. We do see the homeless, don’t we? And certainly the poor. “Doctor, we don’t have any money or anywhere to go. Can we stay here tonight?” We might try social work, but face it, they probably went home already. The poor are always among us.

If it’s a slow night, the nurses are stricken with a kind of magic. They fluff Mary’s pillow, and one of them (who used to do OB) notices the way Mary is breathing and holding her belly. “She’s going to deliver!” (For the purpose of the story, Labor and Delivery is full to capacity.) All of the nurses are hovering, getting ice for Mary and coffee for Joseph, who has not so much as the change to buy one.

If it’s a busy night, everyone is frantic, and when Mary says, “I think the baby is coming!” the staff roll their eyes, as if they needed one more thing between the overdoses and the chest pains, the weaknesses and the demanding daughter in the hallway insisting on endless attention for her aging mother.

But they do the right thing, don’t they? They almost always do. We almost always do. Before you can sing “O Little Town of Bethlehem,” the baby is there. He’s crying because they do that. And Mary nurses him immediately after the nurses clean him off. But the nurses, and the doctor who caught him (fumbling, frightened … he hates delivering babies), all of them are somehow breathless. The hair on their necks and arms rises up, chills run along their spines. It’s not fear; it’s wonder. Inexplicable. Another poor baby. So what? Everyone is crying. Nobody knows why. Mary just takes it all in as Joseph wraps his arms around both of them, still in the same dirty sweater, still disheveled.

Of course, there are no animals. And yet. If it’s slow, the sleeping drunk in the next room wakes and stumbles in to see. Looking down, he cries, too. He understands something so deep he can’t express it. Something he forgot about hope and love and parents and forgiveness. He reaches into his pocket, pushes $100 into Joseph’s hand, and goes to lie down again. He sleeps in lovely dreams.

If it’s busy, things suddenly move slowly. Things happen. The mumbling, confused lady with dementia (whose daughter is so demanding) speaks for a few minutes with utter clarity, and finds her way to the door of the baby’s room. She holds her daughter’s hand and laughs, and recalls the details of her own maternity. The meth addict, tweaking and rocking back and forth, sits on the floor and just watches. He is calm. He does not scratch or scream. He is transfixed by the inexorable wonder he always hoped to find in drugs, and by the possibility that he might be whole again, that he might have his own wife, child, and delight. The man dying of lymphoma, passing the room as he is wheeled up for admission, asks the nurse to stop so he can look, and the child fixes its tiny eyes on him. He still dies, but he does it in peace.

The cardiac patient’s chest pain resolves, and the febrile infant in the hall-bed (the one who looked so sick) begins to laugh, cackling, breathless laughter. His fever is gone. Only the babies can see the angels swooping round, touching, healing, encouraging.

I can imagine all sorts of things. An angry mayor, searching for the child. Or professors and priests and ambassadors looking for him later, giving him gifts.

But all I see now is the dawn. Mary is strong. She has no time to be admitted. Joseph says they have to go. They are loaded with formula and money, with snacks and blankets (and diapers). They are hugged and kissed by strangers, and everyone waves goodbye.

The next shift asks, “What was that all about?”

“Don’t know,” is the answer, “but I’m glad I didn’t miss it.”

And the chaos descends again, tempered by inexpressible hope, washed in love.

My patient was brought by EMS after a respiratory, and subsequent cardiac, arrest.  She could not be intubated in the field, and I did so on her arrival.  We actually restored some circulation, albeit not much.  Over the course of an hour, despite our best efforts, she became blue again, with lividity pooling in her flanks.  I had spoken with her husband over and over, and he knew that the situation was grim.

It was just after Thanksgiving, and he was wearing Christmas sweatshirt.  His family was gathered all around, as families do, especially here in the South.

We decided that it was time to stop.  That she had, in essence, already died. That we were only supporting a shell.  The family cried as we escorted them to the bedside before we stopped everything.

It was a busy night.  All around were university students sleeping off their alcohol, consumed during a football game.  There was flu, there were colds, there were ankle sprains.

And it struck me, as I walked from a family’s nightmare to a college girl’s injury, and then to an obnoxious 19-year-old drunk (facing the wrath of his extremely angry mother), that this is a serious emotional roller coaster.

To laugh with one patient, comfort another, save another and lose another, to mourn and to smile all in the span of some 20 minutes is a bumpy ride.

We ask, of burnout, ‘why is it happening?’  We ask why physicians leave the specialty.  Is it money?  Is it lack of education?  Is it insufficient empathy?  Is it alcohol or priorities?

I think it may be this.  That we see too many extremes in the course of our days, and have to meet each one with appropriate skill and proper emotion.  And we have to little time to process any of it.

I used to like roller-coasters.  I’m older now, and I can’t handle the twists and turns as well.

Not even in amusement parks.

Here’s an excellent call for a return to Federalism by Glenn Reynolds of Instapundit.

http://www.usatoday.com/story/opinion/2012/11/26/hunger-games-washington-economy-glenn-reynolds/1725783/

Enjoy…and think.

Here’s my column in today’s Greenville News, on the blessings of not flying this Thanksgiving.

http://www.greenvilleonline.com/article/20121124/OPINION/311240004/Staying-ground-blessing?odyssey=mod|newswell|text|Opinion|p

As I contemplate the Thanksgiving just past, I am thankful that friends and family traveled to my home. In part because I’m blessed with family, blessed with house and job, food and health.  But I’m thankful for another reason.  The location of my various family members does not require me to set foot on an airplane.

I recently took a whirlwind trip to San Diego, California for a speaking engagement.  How amazing flight is!  We can cross mountains and oceans, continents and hemispheres. We can make meetings hundreds of miles away and be home for dinner with the family.  And all of it while watching the news as if we were in our living room (except eating what we want), in a climate controlled,  ever-so-slightly reclining chair.

And yet.  Among the many activities of modern life, I doubt if any are as demeaning to the human spirit as commercial air travel.  For instance, on my recent flight from GSP, I checked in a few minutes past my 60 minute window.  I know, there has to be a cut-off.  But it required me to go home (to Oconee County) and wait 12 hours for my next opportunity to fly.  (It was a blessing, as I had church and lunch with family.  And mind you, it’s rather serene passing through Seneca, Clemson, Easley and Powdersville at 4:30 and 5:30 am.)

I returned and wound my way through security.  Ah, security.  When I travel with my wife, she says to me (as I begin to take my shoes off and grumble), ‘be polite…you don’t want to go to jail.’  I find our current system of airline security…’less than optimal,’ as it were.  ‘Take off your belt. Put your laptop on the conveyor belt.  Take off your shoes.  Move it along people.  Come on. Step through.’  Since Jan wasn’t there, I was reminded by the sign that said, in essence, inappropriate joking might result in arrest.  So I kept my raging thoughts to myself and smiled.

I ultimately made my flight, checking my bag to the tune of a soul-sucking $25, then wedging myself into a small seat on a small aircraft on the way to Houston as non-checked bags, possibly containing bodies, were forced into various compartments by people still in possession of their $25.  In Houston, I snacked quickly, boarded, then wedged myself between two individuals whose dimensions made it more comfortable to merely hold my hands above my head all the way from Texas to San Diego, as if being robbed.  Not to mention that my ‘row-mate’ to the left made odd grunting noises over and over, while awake, and while both playing on his iPad and watching the pay television mounted in front of him.  ( I wondered if he were contemplating eating me…grunts can sound rather like ‘yum’ in a dark cabin.)  I remained vigilant and survived, arriving in San Diego late at night but safe and sound.

When I  returned from San Diego back to Houston and Greenville,  I did something I had never done before. I road the  golf-cart/shuttle in the airport.  When I told the driver where I was headed, a little proud of my ability to walk quickly, he said, ‘you better get on.’  It turns out I had arrived at Concourse C but had to find my way to Concourse Z, subsection 15, sub-subsection alpha, orange, gate square root of 6.

You see, when one goes to Greenville, SC from larger cities, one often has to leave from remotely located, obscure parts of large airports.  After riding on the transport, riding on the train, running some more and finding my way to what I thought was the tiniest concourse in Houston, I was directed down another hallway, and another, and yet another until I came to a small door with a sliding panel and had to knock three times then whistle. A man slid it back and asked if we were there for the flight or the poker game.  Outside our biplane was ready and waiting.

I’m not blaming anyone.  Lots of people, lots of planes, lots of destinations.  It’s difficult to keep flight affordable, safe and (relatively) on time.  I understand.  And I felt for the dejected, overworked clerks, flight attendants and pilots I saw, for whom the glory of flight had long since passed, as evidenced by their mussed hair and desperate sprints for the exit doors.  God bless them all.

I’m just saying, ‘thank you Lord for keeping me on the ground for Thanksgiving.’

This is my column in today’s Greenville news, on the topic of time wasted and time well used.

http://www.greenvilleonline.com/article/20121118/OPINION/311180007/Get-rid-useless-stuff-Thanksgiving?odyssey=mod|newswell|text|Opinion|p

I sometimes sit and think about the things that have wasted my time.  It’s a long list, and  probably would exceed my word limit for this column.  Regret can be very destructive if it isn’t accompanied by change.  But as I am trying to change, I feel like it’s alright to list some of the activities that have consumed my precious heartbeats.

For example, there’s worry.  I come from a family of worriers, so I’ll claim some environmental and genetic factors. But I also embraced it.  From worry about my future and education when younger, all the way through worry about the health and safety of my loved ones and on into worry about the future prospects and safety of my kids, worry has been a dark hobby of mine. More to the point, it has been an idol, before whom I have spent too many long nights in worship.  It’s worthless.

Next, said the writer, is communication.  Not that communication isn’t important.  It’s critically important!  I mean pointless communication. For instance, I have used too much time having e-mail arguments with people whose minds I will never change.  I have done the same engaging in political debate with opponents on Facebook or some other electronic black hole of time usage.

I’ve wasted time with television, flipping channels as if my body were riveted to my chair and no other option were available.  I’m not too much of a television guy, but I’d venture to say that I have, in total, used up weeks to months of otherwise productive life sitting before the glowing box.

A few other things come to mind.  For instance, I don’t know how much of my life has been devoted to trying to start small engines.  Lawn mowers, weed-trimmers, chain-saws and all the rest have consumed my limited span over and over.  Each summer I wonder how many hours will go down the tubes pulling the starter cord, adjusting the choke, checking oil and filters and replacing the string on trimmers.  I don’t know how to avoid it, but it still tends to trouble my summer days.  Living in the midst of what amounts to a jungle, weeds must be battled.  I just haven’t figured out how to make it a fair fight.

I could go on.  But it might be better to think about the things that haven’t wasted my time.  For instance, dates with my wife, shopping with my wife, talking with my wife or even napping with my wife.  Not a one, in all my years with her, has been a waste of time.  And playing with my children!  Whether board games or word games, whether tag in the pool or Halo 4 on the X-Box, dancing or wrestling, dolls or toy soldiers, not a second has been wasted.  Conversations with my wife and kids, in which we discuss everything from daily activities to philosophy and theology, are times that are always valuable.  Visiting with parents and grandparents, remembering past times, sharing wisdom and laughter, never a waste of time.

Reading my Bible, prayer, worship, alone or with my church family, or my own family, has always been a worthwhile expenditure of my limited heart-beats on this earth.  They make me wiser, kinder, humbler, more loving and more at peace. Reading in general!  (I can pretty quickly identify those books or articles that are pointless and I now move on right away.)  Reading has never seemed a waste to me.

This list, like the list of wasted time, is pretty exhaustive and could go on.  But let me also say that Thanksgiving represents much of what is good in my use of time. Thanksgiving is never a waste.  It incorporates time with the people I love, worship and praise for all my blessings.  It leads to laughter, games and rest.  And it involves food!  Preparing, cooking and eating good food is never an abuse of our fleeting time.  Turkey, dressing, gravy, assorted casseroles, bread, cranberry (fresh or jellied), pumpkin pie and all the rest are never, ever to be calculated as poor investments of our few decades on earth.

So this Thanksgiving, clean house. (No really, especially kids and husbands, clean house.  It will make the ladies happy.)  But also, clean house of the things that use your time, and your life, poorly.  And focus on the good.  You won’t miss the useless stuff.  And you’ll have that much more time to give thanks, eat, laugh and nap.

Dear readers,

Below is a letter from one of my dearest friends to his hospital administration.  This year, the administration has mandated Influenza vaccination.  Short of a few accepted exemptions, it is a requirement for continued medical staff participation by physicians or employment by other staff.

Those who do not receive it must wear a mask while working for the entire duration of the flu season, as well as a badge stating that they did not receive the vaccination.

It has become an issue of great contention among staff, but has been largely dismissed as of insufficient concern to the administrative staff.  Another facility near his has excused its staff from this requirement on moral grounds.  Most others are requiring the vaccine.

Whatever you believe, or do not believe, about vaccines in general or Influenza vaccine in particular, My friend, emergency physician Dr.Doug McGuff, makes a reasoned, sound and scientific argument against the requirement.

Hardly the rant of an uninformed individual, Dr. McGuff is without question one of the most intelligent and articulate people I am honored to call friend.  In addition, he is an author and nationally recognized fitness expert.

His websites are, as follows, with links to his recent McGraw Hill publication, Body by Science: 

http://www.bodybyscience.net/home.html/

http://ultimate-exercise.com/

As physicians are slowly, but surely, edged into employment positions, as we find ourselves forced by government and various regulatory bodies to do whatever we are told, as we move from professional to commodity, it would be wise for us to ask, ‘how much more?’  First a flu vaccine, easy enough.  But at what point will our freedom, our judgment, be compromised past the breaking point?

Read Dr. McGuff’s outstanding response to his hospital administration and consider the situation for yourself.  And pass it on.  He gives you permission to do so.

To hospital administration,

I am writing this letter to inform you that when I take my mandated influenza vaccine I will be doing so under protest and with the understanding that failure to do so could result in loss of my ability to earn income for myself and my family.  Unfortunately, I do not qualify for any of the exemptions allowed by our facility.  Since I am not religious, I have no religious objections, I am not allergic, and I have never had Guillane-Barre as a result of a flu vaccine.  My objection to the vaccine is based on rational evidence and moral indignation.

From the standpoint of rational evidence, I was amused that Dr. Eric Kasowski (of the CDC’s influenza division) in his  position paper “Healthcare Workers Must Be Vaccinated Against Influenza” cited no research papers.  This is very unusual given that this is a document directed at health care professionals.  No papers were cited to support this statement because there are no such papers.  The gold standard for evidence-based decision making in health care comes from The Cochrane Collaboration.  This group of experts makes recommendations on all aspects of medicine and science based on a pooling of the best research studies and with a strict avoidance of all commercial or coercive interests.

In their paper titled “Vaccines to prevent influenza in healthy adults” the Cochrane group concluded “In average conditions 100 people need to be vaccinated to avoid one set of influenza symptoms. Vaccine use did not affect the number of people hospitalized or working days lost but caused one case of Guillane-Barre syndrome for every one million vaccinations.  Fifteen of the 36 trials were funded by vaccine companies and four had no funding declaration.  Our results may be an optimistic estimate because company-sponsored influenza vaccine trials tend to produce results favorable to their products and some of the evidence comes from trials carried out in ideal viral circulation and matching conditions and because the harms evidence base is limited.”  This is hardly compelling evidence.

In the Cochrane paper “Influenza vaccination for healthcare workers who work with the elderly” found “that vaccinating healthcare workers who look after the elderly in long-term care facilities did not show any effect on the specific outcomes of interest, namely laboratory-proven influenza, pneumonia or deaths from pneumonia.”  Thus, even in the most high-risk health care population and scenario, there is NO evidence that influenza vaccination protects patients.  In fact, vaccination may actually increase risk because the health care provider, feeling that they are protected by the vaccine, may be less likely to carry out the behaviors that do protect patients.  In their paper “Physical interventions to interrupt or reduce the spread of respiratory viruses” The Cochrane group reviewed 67 studies and found that simple measures such as hand washing, and simple masks were effective in reducing viral (including influenza) transmission.  Further , they “found no evidence that the more expensive, irritating and uncomfortable N95 respirators were superior to simple surgical masks”.   Thus there is NO evidence that not taking a vaccine poses any risks to patients and thus the requirements to wear an arm band (similar to a Star of David or Scarlet Letter) is exposed for what it really is…a way of shaming non-compliers.  In fact, evidence would suggest that it is the vaccinated that are less likely to carry out the behaviors that do work, and it is perhaps they who should wear the arm band.  Furthermore, individuals who are coerced to take a treatment are more likely to experience adverse reactions due to the nocebo effect, which is like a placebo effect but with negative effects.  Such nocebo reactions would likely result in more days lost than days lost due to influenza contracted because of a lack of vaccination.

I would now like to address my moral objections to this requirement.  Let me preface my statement by saying that if the organization had simply been honest and stated that they were requesting employees be vaccinated because less than 90% compliance would be met by a financial penalty from our government payers at a time when the hospital was already under financial stress, I would have been first in line to get my vaccine.  Every day I make personal sacrifices in order to support the financial interests of the hospital in which I work.  I continue to work in an ER that is severely understaffed relative to its workload.  Every shift I arrange for serial ER visits and rechecks of non-paying patients with pyelonephritis, PID, cellulitis, MRSA abscesses, pneumonia, etc rather than having them admitted where they would cost the hospital even greater lost revenues.  This is done at great personal expense (and medico-legal risk) to myself and my group.  I say this to demonstrate that I would do almost anything to help the hospital’s bottom line, and I believe that is true of almost anyone in the organization.  But rather than banking on this goodwill from the employees and staff, the institution chose to frame this as a patient care issue.  Worst of all, it portrayed the providers of healthcare as some sort of danger to the patients that the hospital cares for, as if we were potential vectors of disease should we not comply with this mandate; essentially painting as a threat those that provide care under a real threat of contagion, violence, stress, litigation, government fines and circadian disruption.  This was all done with overwhelming evidence to the contrary.

But even if it were true that healthcare workers were transmitting flu to patients and that vaccination could prevent this from happening, forcing a professional to do even that which is beneficial is profoundly immoral.  Values can only exist when there is freedom of choice.  As philosopher Harry Binswanger recently observed; “You cannot achieve anyone’s good by force, because values are objective.  Values only exist if they are judged by the acting party as beneficial to him.  No one can be forced to make a rational judgement.  The only effect of the force is the destruction of the alleged beneficiary (and everyone else).”  This was probably expressed best by the philosopher Ayn Rand who stated: “A value which one is forced to accept at the price of surrendering one’s mind, is not a value to anyone; the forcibly mindless can neither judge nor choose nor value.  An attempt to achieve the good by force is like an attempt to provide a man with a picture gallery at the price of cutting out his eyes.”  So even if there were a benefit to be had from flu vaccination, it would be wrong to force us to have it.  It is even worse when it is done with evidence to the contrary.

I will therefore submit for flu vaccination on or before November 1, 2012; but please be aware that I am doing so under compulsion and the threat of losing my means of earning a living.

Sincerely,

Doug McGuff, MD, FACEP

These days, the word sin is considered kind of ‘sinful.’  The secular world finds it entirely offensive, since they consider every human behavior to be natural and therefore appropriate.  The religious world, ever more sensitive to offending anyone these days, often veers away from discussions of this fundamental part of Judeo-Christian theology.  (No wonder.  Any mention of sin gets believers smacked down as hateful and judgmental.)

We are often asked, ‘why is it wrong to do x y or z?’  For example, why should adultery be a sin, when it is committed between consenting adults?  Why should fornication (a word so underused as to be almost an etymologic antiquity) be considered wrong when it is between two consenting…well, sometimes adults, sometimes adolescents)?

Let’s pause to recognize that when we say there is ‘no such thing as sin,’ our culture usually means ‘no such thing as sexual sin.’  We tend to agree that theft and murder are wrong. We accept lying if it is expedient.  We absolutely deny that any inappropriate thought or motive can be considered sin.  All of those are consigned to mental illness or to neurobiological dysfunctions.

So why is a thing wrong?  Well, in the case of adultery, it is obvious that even if the adults consent, others will be wounded.  Try as you might, your spouse’s attorney won’t be interested in the ‘consenting adults’ argument, and your spouse will not buy the ‘nobody gets hurt,’ argument.  Furthermore, your children will simply be wounded.  One can dismiss that as one is able, but the research abounds on the effects of divorce on children…and it’s not pretty.

But all that aside, why should any sexual sin be ‘wrong?’  This is at the heart of many objections to Christianity.  That is, it places prohibitions on certain behaviors.  Behaviors that others very much want to enjoy.

Of course, we have learned over time that there are costs.  Diseases such as HIV or HPV (and associated cancers at times) are prevalent. Herpes is epidemic.  Chlamydia leads to pain and infertility.  Multiple ‘hook ups’ leave people feeling disconnected, dehumanized and depressed.  The list goes on.  So, before the era of modern microbiology, infectious disease research and psychology, someone (a very, very long time ago) recommended that humans not behave in certain ways.

And yet, there may be more.  I recently had the thought that the human soul must at least as complex, if not more so, than the human body.  After all, from a Christian viewpoint, the body is temporal, but the soul eternal.  It should make sense, therefore, that we must attend to issues concerning our souls and avoid sins (actions, thoughts, attitudes) that cause the soul ill health.  In much the same way as we attend to our physicality.

Sometimes, I suspect, we are told not to do a thing because frankly, we aren’t prepared to understand the full reasons why we shouldn’t.

Example:  If my daughter, when she was two, was about to touch a hot burner on the stove, I would have  stopped her.  When I did, she might have asked  ’why not.’  I could have then launched into a physician’s discussion of skin layers, thermal injury, delayed healing, loss of function, proloned therapy, pain, infection, recovery and all the rest.  But I would have said, at that point, ‘it will hurt you!’  She would have been satisfied then, though now she might want more depth.

I believe that many of God’s prohibitions are like that.  Why not?  Because it will hurt.  Because it will kill.  One day, when our hearts and souls, and minds, are ready, we’ll understand.  Until then, we have to trust that the rules set down for us have validity, for now and eternity.

If we don’t, we will simply find ourselves burned; over and over.  And wondering why we didn’t listen in the first place.

So, here’s the link to my new blog, focusing on Emergistan.

http://travelsinemergistan.blogspot.com/

If you’re interested, send me photos of yourself/your staff in explorer garb or gear, or in some way illustrating your work in the far distant, and most bizarre, land of Emergistan!

I’ll post them!

Also, feel free to send ‘Travel tips for Emergistan,’ and I’ll give you credit as well.  Stories, written in an adventure style, will be welcome contributions.

Sincerely,

Edwin

This is my column in this month’s Emergency Medicine News.  In Medicine, Atlas endures.  For now…

http://journals.lww.com/em-news/Fulltext/2012/11000/Second_Opinion__Atlas_Endures___For_Now.6.aspx

Most modern American are familiar with the classic political novel, Atlas Shrugged.  Love or hate it, the novel had a great impact on political thinking in the West.  If you haven’t read it, or aren’t familiar, one of the fundamental questions author Ayn Rand asks is this:  what if the producers and innovators of society simply stopped trying?  What if they became tired of contributing and being abused, demonized and taxed for their efforts, and simply withdrew their contributions?

Atlas is straining in medicine as the weight of contemporary healthcare continues to fall upon  emergency departments and as increasing numbers of physicians in other fields either retire or escape from call duties.  I don’t necessarily say this by way of critique.  I understand the perspective of those who have, quite reasonably, made tactical withdrawals from the losing battle.

We face fewer available specialists.  Drug shortages are rampant.  Psychiatric beds are a rarity as state budgets plummet.  Committees and professional societies heap volumes and volumes of new rules on the practitioners of medicine, as if it weren’t difficult enough.  And yet, at the end of the day, the answer is typically:  go to the emergency room; they’ll sort it all out.  And we are full, overwhelmed, understaffed, underfunded and overextended.

So what if we took a cue from Atlas Shrugged?  What if, in one grand, unified effort, emergency physicians decided to stop doing their work, if only for a day?  Or what if we all found another permanent way to earn our incomes?  What if we said ‘no’ to further satisfaction surveys, endless psych holds, innumerable Medicare regulations and pointless JCAHO visits?  If we refused to be fined for not washing our hands every five seconds, if we said ’15 minutes to a doctor’ is ridiculous.  If we explained that blood cultures didn’t matter for most patients and that we were finished giving thrombolytics for stroke when we felt it was the wrong thing to do? What if rule-makers and fine-givers and policy-writers were stuck, for just one day, sorting through the madness that was born of unfunded mandates and unintended consequences?  What if we just said NO!

Well, like that game we all play called ‘what if I won the lottery.’  It’s all academic.  That is, an Atlas Shrugged moment would be a very unlikely event.   For one thing, we aren’t organized enough.  For another, we couldn’t replace our incomes (and therefore pay our debts and bills), that easily…or that quickly.  In addition, we generally dislike change and we have a wonderful, awful habit of following orders and doing ‘the right thing.’  It’s what got us into medicine.  But it’s also what will keep us there far beyond reasonable levels of endurance.

However, another reason emerges.  We feel a sense of duty, a sense of obligation, to the patients who come through our doors.  No matter how bizarre or difficult the work, we press on and do it.  At all hours of the day and night, we station ourselves between patients and death, between patients and disability (no matter how much some of them want it!) and between patients and suffering.

I realized the dedication of my partners and staff recently, as I watched a drunk ‘patron’ pick up his walking stick and pull it back to hit our security officer, even as a deputy politely said, ‘excuse me,’ pushed his way past everyone and fired a Taser into the stick-wielding gentleman.  He dropped fast and was hauled away to the law enforcement center in handcuffs.

I realized it a few months ago when an angry psychiatric patient, who had a ‘sitter’ while he awaited placement, picked up the sitter’s laptop and smashed it through the clear plastic window around the nurses’ station.

My stories are mild compared with some of yours.  You face violent gang members while I more often face obnoxious drunk Southerners.  Many of you face illegals with drug resistant Tb while I am scalpel wielding warrior facing MRSA abscesses by the bucket.  I sort through rattlesnake venom and Xanax overdoses while some of you face designer drugs of no known origin, composition or effect.

Of course, we do it all professionally.  We do it the best way we know how, with fewer and fewer resources.  We do it with falling reimbursement and increasing regulatory burdens.  We do it day and night, holidays and weekends.  It lacks the glamor and gloss of sexy doctors on television shows. It falls short of the moral clarity actors, and politicians, seem to bring to modern medicine.  It is murky and difficult, even on the best days.

Our ‘office’ is the place of chaos.  An administrator once told me, on a day of terrible crowding and dangerous volume, that he couldn’t move patients upstairs to the hallway.  His reason was this:  ‘Dr. Leap, when people leave the ER, they expect to go to a better place.’  I walked away, unable to speak.

Outside of law enforcement, EMS or the military, what work-places are like this?  And who would face such things with regularity even as their reimbursement was cut, their threat of lawsuit ever-present and their every move regulated and watched as if living on parole?

Atlas, at least in medicine, isn’t likely to shrug off his duty.  Oddly, we love what we do even as there are days we despise it.  But that’s a pretty frightening ‘what if.’  All of the senators and congressmen could walk out tomorrow and we’d experience little more than a sudden burst in economic activity.  Most of the attorneys could do the same and our litigation would remain gridlocked…like much of it is already.  But some things matter every day of the year.  Gas has to be refined and pumped.  Cars, buses and airplanes have to move people and material.  Electricity, along with water and food, has to be available.  And disease and injury need to be treated.  And even Atlas needs some relief; needs to make a living, needs to pay his bills.  For Atlas, at least in our profession, the ‘honor and glory’ of carrying everything is wearing off.  And yet, Atlas endures.

What am I trying to say today?  Well, it’s Thanksgivings this month, so here’s a reason for thanks.  America should be thankful that emergency departments are open, and that they are staffed around the clock by well educated, dedicated professionals who don’t shirk their duties.

And thankful that they so far haven’t shrugged off the enormous weight that daily rests upon their broad shoulders.  America should pray that they never do.

If Atlas shrugs off healthcare, it will be a dark day indeed.

Here is a link to the youtube recording of my recent appearance on the Peggy Denny Show.

Have a great day!

http://www.youtube.com/watch?v=9ViBWk6wlAM&feature=youtu.be

This is my column in today’s Greenville News.  A topic I’m passionate about, in no small part thanks to hearing Glenn Reynolds, of Instapundit.com, speak on it at Clemson University.

http://www.greenvilleonline.com/article/20121028/OPINION/310280008/Ed-Leap-Make-college-relevant-not-resort-vacation?odyssey=mod|newswell|text|Opinion|s

My oldest son is now a high school senior.  Therefore, we have been looking at college options in South Carolina.  He is a born and bred South Carolinian who doesn’t really want to leave his home state.  He has a sense of family, and a sense of place.

I have made several observations while reading brochures, comparing prices and traveling to different locales in the search for the right school for him to attend . First, this is a beautiful state with some magnificent centers of learning.  I had no idea how many majors there are now, how many opportunities to study abroad, how many honors colleges and possible career paths!  When I was in school it was, you know, wheel making and Mammoth studies.  But I digress.

Whenever we have toured a center of learning (and I won’t name them specifically) my wife and I have heard great things about the way our son will mature, will be exposed to opportunities, will ‘develop as a human being.’  (Which I thought was kind of a given, being a human and all.)

We’ve been assured that kids who attend those schools make great progress, and become fully actualized, able to impact the world in a diverse, cutting edge, technologically savvy, multi-cultural, sustainable, tolerant and environmentally friendly manner that would be the envy of anyone in the world.

I had no idea that college was all of that!  You see, silly old person that I am, I thought that our colleges and universities were supposed to help students learn to think clearly, accumulate knowledge and enter useful graduate programs or find meaningful, gainful employment in the world.  I didn’t know it was all about ‘development.’

But since it is, let me tell you what I’ve developed.  I’ve developed a little bit of cynicism about the four-year university.  Why is that, with such magnificent institutions?   Well, a couple of things come to mind.  First, marketing.  My son is constantly introduced to images of lovely dorms and cable television embedded in every treadmill in the shiny gym. He is told about how the sushi bar is a great place to use some of his meal program money and how certain dorms allow opposite sex sleepovers during the week. He learns about the fun of the Greek system and the delights of the town.

And what his bitter, cynical, sometimes wise father knows is this:  college graduates currently have a 50-53% unemployment rate, and nationwide, the college drop-out rate is around 40%.  That student loan defaults are rising and retirees are having their Social Security checks docked for old student loans.  (Which cannot be erased in bankruptcy, by the way). What I know is that across the country, administrative burden is killing education (much as it is in medicine), that all too many fascinating majors lead to low-paying work in the food service industry and that the whole experience generally comes to around $20,000/year for a state run four-year university in SC.

What I have to ask our state educators is this:  have you read about the plight of students?  Are you concerned that many students can’t find work related to their degree, if they find work at all?  Are you at all troubled that without serious scholarships they may enter life with tremendous debt, or that their families will bear the debt?  (And that the ones going to graduate school or professional school will be hundreds of thousands of dollars in debt?)

I challenge the higher education officials of South Carolina to do what Texas did and develop a 4 year degree for $10,000.  I want them to encourage more college-bound students to use technical and community colleges for part (or all) of their educations. And I dare the educators of this state to be honest about the realistic job prospects associated with some of their fascinating, but fiscally shaky, programs of study.

I love South Carolina.  My son does too.  He wants to go to school here.  And so do many of his friends with less material blessings than my family.  But our state, indeed our nation, had better pay attention to the plight of its students. We need to stop marketing college as a four year resort vacation and start having compassion for the kids we send off in the tired old belief that college guarantees a good future.

Because it doesn’t anymore. And educators have to either admit the truth, or make college relevant, and affordable, once again.