Kicking North Koreans Down the Bloody Road of History

I don’t think that anyone really wants a war with North Korea. The potential use of nuclear weapons on either side is the stuff of nightmares; but even without nuclear weapons, the death tolls from conventional munitions such as artillery, small arms, non-nuclear missiles and air-strikes would be extraordinary.

Thus, many have been shocked that President Trump has seemed openly hostile to N. Korean Supreme Leader, Kim Jong-un. They have blamed him with escalating the conflict, with prodding the rogue nation to the brink of nuclear conflict.

In the end, it sounds as if North Korea were a gentle, quiet land of rural majesty that just wanted to be left alone, when along came Donald Trump, who started being mean to the cuddly Teddy Bear president of exotic, far-off North Korea.

And yet, we forget. We forget that the Korean war of 1950-53 began when North invaded South and that it ended in an armistice, not a peace treaty. That war cost an estimated 1.6 million civilian casualties and some 1.2 million combat casualties. I’ve met veterans of that nightmare. It was a horrible war, and would be again.


However, we also forget that since that truce, North Korea has constantly provoked South Korea with infiltrations by special operations soldiers, with naval and border clashes, assassinations, terrorist events and artillery fire. We forget that North Korean operatives have kidnapped citizens of South Korea, Japan and other nations. (Many of whom never saw their families again.) Go through the list in the link below. It’s not stuff we hear much about, but it’s truly shocking. And the list only goes to 2007.

Beyond that, we in the West (and particularly college educated Americans) have a stunning ignorance about the singular delights of the land above the 38th parallel. We forget that North Korea, that undying zombie of Communism, is a land of terrible cruelty, torture, imprisonment, starvation and sorrow. As we in the West decry oppression in all its real and imaginary forms, the people of North Korea understand it in full. Over the decades of North Korean tyranny, since 1948, hundreds of thousands have died at the hands of their own government in prison camps and reeducation centers. Attempted defection to China usually results in either more abuses, or return to North Korea with further torment. Starvation, beatings, rape, forced abortions and executions are tools of state, and entire families are punished for the transgressions of one. (I suspect no small number of those crushed souls would say today, ’bomb it, bomb it all; it really can’t get a whole lot worse for us here, eating bugs and rats, and hoping our children aren’t murdered.’)
If you think I’m confabulating, follow the links below.

So it’s all well and good for us to oppose nuclear war, and to oppose war in in general. But the sudden discovery that North Korea was a super friendly place until Donald Trump? That’s not historically accurate or intellectually honest.

If it all cools off and calmer heads prevail, North Korea will still have hundreds of thousands of citizens living in conditions that rival those of the Soviet Gulags, or the Nazi concentration camps. They will survive day to day, eating starvation rations, being beaten or raped, tortured and murdered; the lucky ones exported abroad as wage slaves.
Those not in the camps, even the true believers, will continue to live in the constant fear that they’ll be arrested. And in the knowledge that their success, their survival, depends on showing unwavering devotion to Kim Jong-un and his family’s dynastic brand of tyrannical thuggery. Political opponents, religious believers, families of those suspected of dissent, all will fear the government or be punished by it. Because that’s how it goes down in the Democratic People’s Republic of Korea.

Assuming, again, that the war clouds pass, free people can wipe the sweat from their furrowed brows and allow the horrors of North Korea to go on, safe in the knowledge that diplomats will continue to talk as nuclear weapons and delivery systems continue to be developed in North Korea. All funded by the slave labor of untold, unknown citizens. And as men, women and children continue to suffer and starve.

What a relief that will be! And those who say ‘not my president’ can meet in safe cafes and discuss how ‘that crazy Trump’ nearly caused a war with a country that has been provoking free nations, and torturing its own citizens, for over 70 years. Safe out of the view of sensitive American citizens who oppose oppression.

I also hope we’re all prepared for what we see when, and if, the DPRK ever falls and the West has access. Because when we go in at last (hopefully through diplomacy or some miracle), when we see the camps and hear the stories, and witness the broken lives and weeping, gaunt faces; when we at last grasp the misery and sorrow that generations of people endured under that regime, we’ll be ashamed. And it will take decades for those people to escape the toxic cloud of imposed fear that enveloped them for so long.

But then, the world let it happen in exchange for the comfort of empty discussions and endless sanctions as we (the West and China) kicked North Korea and her people down the bloody road of history.

God forgive us when we see what that ‘peace’ cost.

In an Age of Terrorism, do Something!

Here we go again.  In London three are dead and many injured thanks to the low-tech use of a car and knife in yet another act of cruelty and cowardice in the name of terrorism.  If you’ve been on a retreat, in a coma or hiking the AT, here’s a link:

Brits rise up in unity and solidarity, etc.  Great.  We should all show unity and solidarity.  But we should all be able to DO something since the political class as a whole, around the world, seems to think the whole terrorist thing is like a teenage phase and has nothing to do with any particular belief, ideology or policy.  Witness the endless handwringing we usually see as police and officials struggle to figure out the attacker’s motivation.  ‘Gee, what could it be?’

Fortunately, the Brits have put more police on the streets.  ‘Armed and unarmed.’  It’s a great strategy really.  One of the dead was an unarmed police officer who clearly distracted the attacker and absorbed the knife so that others could use, you know, weapons to aid him in his pursuit of martyrdom.

I rant on.  But what I want to say is this.  We individuals cannot predict terroristic acts, and we certainly can’t stop them before they start. That’s the job of law enforcement and the military.  We can only do what we can, when these events happen, if we happen to be present.

So I’ve been thinking about things people should know how to do.  First of all, we should know how to PAY ATTENTION!  I have recently seen a commercial for a cellular company in which a young man streams movies and TV everywhere he goes, on the street, on the sidewalk, on the bus. The world around being, apparently, just too boring.  This is dangerous.  We should watch and learn.  Is that a suspicous package?  What does it mean that smoke is coming from under the hood of that parked car in the crowded area?  Is that a real gun the scary man pulled out?  Or is it just an oddly shaped, giant cell-phone? Why is that gentleman speeding towards me on the sidewalk?  Wait, am I on an episode of Impractical Jokers?  Paying attention to danger leads to running or fighting which leads to being the guy interviewed the next day about what happened, instead of the one remembered as ‘a really great guy who will be missed.’

We should also read.  Learn, from news, books, websites and classes, how to identify concerning behaviors and situations.  What does a firearm sound like?  What does a bomb blast look-like? (Clue, TV and movies get it wrong a lot.)  It’s easy to hear or see something dangerous and immediately think it’s nothing; we want it to be nothing, after all.

One of the sites I visit is Active Response Training. They have lots of articles about self-defense, as well as reviews of mass terror events, etc.  They also have excellent classes; I’ve taken one myself many years ago.

Furthermore we should stop being lazy slugs and get in shape.  Sheesh, America, there are lots of great reasons to be fit; being attractive to your mate or potential mate is a good one.  So is living long and staying away from ER doctors like me.  But another is that when you are fit, you can run and fight.  This isn’t some right-wing way of looking at things.  It’s called an ‘evolutionary advantage.’   Run, bike, lift weights, hit the punching bag.  Do it until you’re exhausted then do it some more.  Say it with me:  Fitness = Survival.  It isn’t hard.

As a child I loved the Chuck Jones cartoon production of Rudyard Kipling’s mongoose story, Rikki-Tikki-Tavi.  In the movie, Rikki the Mongoose says:  ‘A fat mongoose is a dead mongoose.’ That is, a fat mongoose can’t fight poisonous snakes.  I’ve never forgotten that lesson. Thanks Rikki!  And thanks Mr. Kipling!  (Not sure if it’s in the book, but the cartoon message really impacted this kid…)


So what else can we do in an age of terrorism?  Emergency physicians like me understand  how to manage serious injuries, but we need to encourage citizens to learn 1) first aid with hemorrhage control and 2) CPR.  CPR classes are everywhere and typically include use of Automated External Defibrillators or AED’s.  In fact, in trauma situations like those involving terrorism, CPR and AED’s are probably not going to be very useful.  But it’s good to know for other sorts of emergencies.

DHS has a website and initiative called ‘Stop the Bleed.’  It’s worth a look as there are training videos.  Many companies also sell bleeding control kits that citizens can, and I think should, keep in their vehicles or on their persons.  A tourniquet and dressing don’t take up much space.

I would encourage young people to consider taking local First Responder or EMT basic classes.  It’s information you’ll never regret having, and it looks great on a resume.

We need a veritable army of first responders out there, ready to help while police and EMS are either tied up, on their way or being attacked themselves.  Physicians should be part of the effort to teach this material as well.

Last, but not least.  Those so inclined should learn to fight.  Obviously, the average person isn’t Rambo or an Army Ranger.  Most of us will never be up the the level of an MMA fighter.  But it may not take all that.  MInd you, self-defense classes can be absolute crap.  Especially the stuff they foist on nurses and physicians in order to handle attackers and dangerous patients (since security is usually told not to touch anybody…).

And self-defense skills need repetition like all motor skills.  But those people who want to learn can learn.  Learning to fight, whether boxing, wrestling, martial arts, etc., is hard, painful work.  It isn’t for everyone.

.However, sometimes, it takes just a willingness to do something, or anything. I saw a video this week in which a citizen and CWP holder shot, and killed, a man who was holding down a police officer and beating said officer badly.  Now, he was armed with a pistol, but might just as well have used the shovel I keep in my truck to hit the guy on the head.  Or might have thrown a rock.  Or picked up a stick.

In a building, a fire-extinguisher might be just enough delay and distraction.  A can of wasp and hornet spray kept in the office is mighty nasty stuff if sprayed in the face.

If so inclined, as many of us are (and far more physicians, nurses, medics, etc. than you might imagine), carry (legally) a firearm or reasonable knife.  If the attacker is bent on killing you anyway, can you do worse than fight?  You may slow him (or her…sorry). You might keep them from killing anyone after they kill or maim you.  Or, if you’re in good shape and have trained in some sort of class or fighting discipline (or just get really lucky…or have angels fighting with you), you might win!  Sure, sure, people will call you a monster.  But lives will be saved.

It’s a dangerous world, and always has been. But there are things we can do to make it less so.

Sitting back while the danger grows with our fear, apathy and inability?

Those are just bad options.

So:  Put down the phone, pay attention, read and learn, get in shape, learn to help the injured and learn (or at least consider) how to resist.  America, heck, civilization, needs this now more than ever.



Happy Veteran’s Day, Pop

Happy Veteran’s Day Dad!


first cav

I want to take a minute and honor my dad, the Rev. Keith Leap.  I have a pretty keen memory, and it reaches far into my past.  So one of my earliest memories is of my dad taking me fishing the day before he shipped out to Vietnam.  Dad was a company clerk with the 1st Cavalry Division, Airmobile.  He was in country in 1968.  There, he was in constant peril from small arms fire, rocket and mortar attacks and all the other endless ways that a war zone can end one’s life.  He was young, and thin as a rail. I can see the photos in my mind, although I don’t have any of them. But what I remember vividly is that day fishing at Twin Lakes in Huntington, WV.  I seem to recall that it was foggy, and that because I was three, most of our fishing consisted of me dropping a line into the grassy shallows next to our feet.  We never caught anything. We’re both, quite frankly, pretty abysmal outdoorsmen.  But he took the time before leaving.  That sticks. When he returned, thank God, he was posted at Fort Monroe in Hampton, VA.  We lived there a time and I loved the military feel of the place.  I remember the commissary, where there were dioramas of POWs in fake grass huts over the freezer section.  And I remember the PX, where (in that time in history) a boy could find the coolest toy guns ever, from toy belt fed machine guns to toy bazookas.  We took our guns seriously back then! I had a little uniform, with a 1st Cavalry unit patch and my name.  It was the old olive drab, and I had a helmet and a wood and steel bolt-action toy rifle with a real fake bullet in the breach.  I was the baddest of the bad!  But only because I was trying to emulate my hero. I have had an adventurous life.  I have flown to car crash scenes in a medical helicopter.  I have opened the chests of those with wounds to the heart. I have traveled the world, and I have been a consultant on WMD for the DoD.  I have married and loved a dream of a woman, and raised four children to be his grandchildren.  And yet, so much of my adventure was my attempt to equal my father’s courage and service. I was in the Air National Guard for a number of years.  I was a flight surgeon, in fact, with an F-16 squadron in Indiana.  And on the night that Desert Storm began, I was rocking babies in the nursery, an intern desperately frustrated that there was an honest to God war and I couldn’t be there.  Not that war is good.  But a man wants to match his father.  When veterans stand in church, I am always a little slow to stand.  My service cost me so little.  His could well have cost his life.  That’s why we went fishing that misty WV morning, a day so full of  import that a boy little more than a toddler still remembers it at 51. Dad ultimately became a much beloved pastor, now retired.  War did not end for him, it just became the war for the soul of man, the war eternal, of which our temporal and frequent outbreaks of international blood-letting are merely the consequence.  And for that I honor him as well.  Having been a church attending Christian for most of my adult life, I suspect that enemy fire is easier to bear than the bitter attitudes, stubbornness and outright cruelty that can emanate from so-called Christian church members. So here’s to you, Pop.  Happy Veteran’s Day. Veteran of war, veteran of fatherhood, faithful husband, committed pastor and longtime lover of Foghorn Leghorn. I say, I say, I say, You da’ man! Love you, Ed

A Fresh New Fundamentalism Threatens America

My column in yesterday’s Greenville News.


If you haven’t heard the name Kim Davis lately, you’ve either been in a coma or stranded on a deserted island. If either applies to you, she is a county clerk in Rowan County, Kentucky, who refused to issue marriage licenses to same-sex (and straight) couples because of a faith-based stance against same-sex marriage. She was subsequently ordered to do so by a judge, continued to refuse, was jailed for contempt of court and then released.

She has become, in the eyes of many, the great Satan of American Christian conservatism. Unimaginable numbers of news stories, blog posts, panel discussions, op-eds, Facebook and Twitter posts and all the rest have been devoted to her. The majority of what I’ve seen are well-crafted to highlight the way in which she is a hypocritical Christian (who has been divorced more than once and has children by more than one father). Furthermore, photos of Ms. Davis are not flattering. She is, to cultural progressives, the perfect bedtime monster. She is seen as an overweight, unattractive, fundamentalist Christian hillbilly who dares to stand against both the courts and popular cultural opinion (emphasis on the second) on the issue of same-sex marriage. In other words, it’s perfectly acceptable to hate, and fear, her.

For the record, as the reader prepares an angry invective against me, I believe that Ms. Davis should have accepted the judge’s accommodation to remove her name from marriage licenses, or she should have resigned. Accommodations are compromises at the intersection of religious belief and work. Still, the law is the law and whether she agreed or not, she should have obeyed it. Render unto Caesar and all that.

Except, it doesn’t always work that way. For instance, sanctuary cities like San Francisco have officials who, on moral grounds, refuse to enforce federal immigration law. Four states have legalized recreational marijuana; thus, their state politicians simply choose to ignore federal drug laws. Anti-war protestors in the 60’s, civil rights activists in the South, radical environmental groups, all stood (or stand) against the codified laws of the time on moral (if not religious) grounds. In fact, there was a time when the granting of marriage licenses to same sex couples in California was illegal. It still happened. The furor over this issue, in light of other, more ‘acceptable’ instances of defiance, is a hypocrisy far more stunning than that of divorcee Kim Davis’ chaotic personal life.

Because of Ms. Davis, our country has again been warned of the incredible dangers of letting religion into politics. We are told that we can’t have people using government position or authority to force people to embrace a set of beliefs. Why, just think about the Christians of history and all of their cruelty towards non-believers! How horrible! Wait, that seems odd. Kim Davis was imprisoned for a belief. But remember, she’s a hick who deserves to be taught a lesson! I mean, just look at the pictures!

The most striking thing about this entire issue, and the cases of bakers and photographers declining to do same-sex weddings, etc., is that America, taught to be deathly afraid of people imposing their beliefs on others is now all about forcing beliefs on certain people. Comply, in public life and private, or be fined, jailed or asked to the door. Brendan Eich, developer of JavaScript and (among other things) Chief Technical officer and CEO of Mozilla, was forced to resign over a $1000 donation he gave, in 2008, to the California’s Proposition 8 pro-traditional marriage initiative. The Denver City Council may well refuse to allow Chic-Fil-A in the Denver International Airport because the company’s owners are opposed to same-sex marriage. The list goes on.

In truth, I’m much less worried about who marries who than I am about the religious and free speech implications that come along with same-sex marriage. And I’m far less concerned about Kim Davis being jailed than I am about the giddy delight expressed nationally by US citizens who want to see people punished for having the wrong beliefs.

Anyone who thinks this behavior isn’t the same as ‘forcing your beliefs down someone’s throat’ is simply choosing a new, shiny, post-modern fundamentalism. And First Amendment or not, it’s a dangerous and remarkably hypocritical way to run a country.

The World Saw What Heroism Looks Like

This is my column in today’s Greenville News.  Go forth and be heroes.

Last week, a Moroccan immigrant was on a train traveling from Amsterdam to Paris. He was armed with an AK-47 rifle, a Luger handgun, hundreds of rounds of ammunition and a box-cutter. A French passenger, three young Americans (one active duty Airman, one National Guard soldier fresh from Afghanistan and their civilian friend) as well as a 60-year-old Briton saved untold lives when they deduced that the heavily armed individual in their train car probably wasn’t out for a day of target shooting.

So, forming a committee they deliberated about the best course of action. They issued surveys to the other passengers on the train to make sure that they were in line with current cultural, political and economic trends. They posted their thoughts to Twitter and Facebook and took a short class on tolerance.

Finally, they contemplated their European privilege, and the ways in which they might well have personally caused the obviously oppressed and disaffected individual to want aerate the passengers with 7.62 x 39 mm ammunition and filet them with a razor blade.

No, I’m just kidding. The five rushed him, tackled him, disarmed him, beat him with his own rifle, John Wayne style and choked him unconscious. They then left him hog-tied, after which he was arrested and the injured heroes given medical treatment for the serious wounds they incurred.

Subsequently, the French media asked everyone to be concerned about the feelings of the poor terrorist, who was not at all responsible for his actions and who was just holding the weapons ‘for some guy.’ The men who attacked the unfortunate rifle bearer were held and their motivations questioned by gendarmes who consider Americans uncouth and barbaric. Charges were filed for disturbing the peace and for handling unlicensed illegal firearms (disarming someone is no excuse to touch a gun).

Nope, still kidding. The same week it happened, French President Hollande presented these heroic gentlemen with the Legion of Honour, the highest French award for heroism. I suspect that the five have been gulping down free champagne and dancing with hot French girls, even as their knees occasionally go week with the realization that they were each about one trigger-pull from eternity. But that’s what heroism looks like. And God knows the world could use some more of it.

During the tragic, fatal shooting at the recruiting station in Chattanooga over the summer, one or two active duty members returned fire with with personal weapons. There were serious discussions about the legality and propriety of this action and the Navy commander of the site may still face disciplinary action. Personally, I believe he deserves praise and honor. If he did shoot back, he did the right thing, at the right moment, when there was no time to ask for permission or contemplate the larger implications of the action.

We live in a difficult, troubled world. I believe that all free people should be able to protect themselves, because the police and military (God bless them) can’t be everywhere. Only when predators do not know who will resist, do not know who is armed or prepared, will they have reason for pause. But the issue for our time is far more than terrorism.

It is too often the belief that regular citizens should not be expected to protect the endangered, rescue the imperiled, contribute to the needy, feed the hungry, fight evil with force, free the slaves, educate the illiterate. That only through the inefficiency of government and the relative anemia of our own favorite politicians is good accomplished. But this is merely moral sloth; little more than the transfer of our own human duty to other agents (who care far less about our own problems than we), in order to assuage our guilt.

Most of us will never see, much less assault, a terrorist. However there is other heroism to be accomplished. We can give to the needy, comfort the hurting, educate and feed the children, visit the aged. On our own dime, and on our own time. It requires only the personal decision to act and the courage to sacrifice time and resources. Well, that’s not entirely true. We have to take time out from screaming at each other online and actually do something other than hoping for the next politician or election to make our ideological dreams come true or our wallets fat.

Ultimately, heroism comes in many incredible forms. But to act heroically we need (as the King said) ‘a little less talk and a lot more action.’

If Ebola can do anything good, it might be this…

Whatever our individual belief systems, here is a cause that can unite us. Whatever our party affiliations, this can cause us to ‘reach across the aisle.’ Whether or not we are religious, or believe in this life only or the next, this is a cause we can agree on, here and now. Conservative or liberal, right or left, theist or atheist, libertarian or green, male, female, gay, straight, we must surely admit our common interest. American or Saudi, Indian or Russian, Nigerian or Liberian, how can we dissent? If there is anything about the Ebola Virus that is beneficial, it must surely be this.

I saw the beginnings of this realization a few weeks ago, in an article in Slate magazine by writer Brian Palmer. Mr. Palmer there bemoaned the fact that so many of those treating Ebola victims in Africa were, to his admitted discomfort, Christian missionaries. He reported that he was glad they did it, but he was troubled by their motivations and wondered about their skill. He finally concluded that the world needed them and we might as well let them get on with it. In the comments, he was roundly condemned by believer and atheist alike. Perhaps he had never heard the maxim, ‘The enemy of my enemy is my friend.’ But ‘bless his heart,’ he at least conceded the point.

Frankly, I don’t care what you believe when it comes to finding constructive solutions to this current epidemic. When we are faced with dangerous events in the world, we have to unite. Whoever ends up treating Ebola victims, I’m confident that they will happily use a drug developed by an atheist, or a vaccine discovered by a Hindu. We’ll all gladly work with side-by-side with Taoists or Bahai, with Sikhs or Yazidi. If things are bad enough, Communist and Libertarian might actually save lives, or do critical research, together. For all we know, Democrats and Republicans might even work hand in hand. (Hey, miracles happen you know!) And it is my hope that we’ll all be hoping, or praying, with the same fervor for the mess to be over.

I hope that somewhere, Buddhist monks are praying for the suffering even as Catholic nuns do the same. I hope that in budget meetings worldwide, wise leaders of all races and nations are trying to figure out how much money they can commit to the fight, with the same fervor they would approach arms purchases. And I hope that Muslim scientists and physicians, and maybe even terrorists, are thinking that this might be a really, really good cause for Jihad. Jihad against Ebola! That’s a Jihad we can all agree on, can’t we? (What a PR opportunity for oil-rich nations Islamic nations, too!)

Perhaps this has the potential to rally our common humanity. Maybe, if only for a while, an epidemic could make everyone think less of war, less of conquest and political maneuvering, and more about issues as fundamental as the health of their citizens, the futures of their children.

Sadly, humans are humans. We are violent and we are greedy, and we care all too little about people who are different, people who believe or look differently from us. But now and then, in the midst of difficulty, we can rise above our darker natures. We can rescue those ravaged by storms. We can feed those crushed by famine. We can liberate those oppressed by the tyranny of wicked men; or deadly illnesses.

It sure would be nice if we could see, in the misery and suffering of Ebola Virus Disease, a ray of light, shining out of our common cooperation and our shared humanity.

If that happens, then maybe something magnificent will have been born out of so much misery.

How ironic it would be if, in the face of so many problems the world faces, it finally took a bizarre virus from the edges of civilization to make us act as one.

How could an ER miss Ebola? Let me explain…

How did the emergency department staff of a Texas hospital see, and discharge, a patient infected with Ebola? Despite the fact that blame spreads through hospitals faster than hemorrhagic fever viruses, I’m not interested in pinning down a single person, or a single thing, which may have allowed that to happen. I am very interested, however, in offering a few insights into what combination of factors might make it easy to send home a West African with a fever, without establishing the fact that he had a dangerous, contagious disease which finally caused his death.

First of all, America’s emergency departments are straining to keep up with the volume of patients that come through their doors. In 2010, the number of visits in the US was 129.8 million, according to the CDC. This numbers rises every year, despite the belief that the Affordable Care Act would direct people to primary care doctors and away from the ER.

The emergency departments of America bear the brunt of trauma, poisonings and drug abuse, of chronic diseases and social drama. They hold suicidal and psychotic patients for days to weeks when there is no other option available. An Ebola victim, with general, initial symptoms of fever, chills, vomiting, diarrhea, abdominal pain and headache, is a small needle in a big hay-pile of feverish, vomiting, suffering humanity.

Furthermore, many people with insurance (including Medicaid and Medicare) can’t find doctors, and large numbers who had insurance before subsequently lost it in the reshuffling of health benefits that has been going on since the ACA was passed. The emergency department is often all they have.

Second, it’s getting much, much harder to focus on that pesky but ubiquitous feature of the modern hospital, the patient. There is data to enter (which keeps nurses and physicians more focused on screens than adolescent boys playing on their Xbox). The electronic medical records systems are unfortunately complex and rarely intuitive. They require so much information that often, relevant points like ‘fever and came from West Africa,’ can be lost in the midst of endless time stamps, and required fields like ‘feels safe at home,’ ‘denies suicidal thoughts’ and ‘bed rails up, call light at bedside.’

Also, there are rules to follow to avoid censure. There are metrics to measure: time to stroke treatment, time to the cardiac cath lab for heart attacks, time from lobby to room, time from triage to doctor, time to discharge and many more; all of them contributing to the Holy Grail of modern health care, the high patient satisfaction score. (Which is being increasingly tied to job security and reimbursement, despite the bad science involved in the process.) Who has time to focus on a single, sick patient when so much depends on screens, rules and data entry?

Third, the rules for admission are ever more complex, based on what Medicare, Medicaid and private insurers are willing to cover. Patients we admitted without question ten years ago are now sent home and told to ‘come back if you get worse.’ In fact, it’s so hard to admit people that I now send home patients I would never have discharged, simply to avoid the misery of explaining the problem to already over-taxed hospitalists who are themselves constrained hand and foot by impossible rules. In this milieu, an otherwise healthy man with a fever is barely a blip.

I know this because earlier this year I was working in a teaching hospital and called the infectious disease specialist on call. My patient had just returned from a mission trip to the Caribbean and had a high white blood cell count, a fever, chills and rash. I was curious if I should have any particular exotic concerns. The specialist’s annoyed answer was this: ‘Sounds like he has a virus. He needs to see his family doctor this week.’

Now that we have Ebola in the US we are reminded that we in medicine, on the front lines, might miss something important. The medical pundits are wagging fingers and lecturing everyone about how best to manage this crisis. (Lecturing, that is, from the relative calm and safety of television studios, rather than the in the mind-numbing chaos of the ER.)

I agree. We need a plan. But the system, as it stands, functions every day on the very razor’s edge of disaster. We need to address that fact if we’re going to have any hope of dealing with Ebola, or other disasters, in the future.

Ebola is not the only danger. My column in today’s Greenville News.

Ebola is only one fiend in the pantheon of human diseases.  This is my column in today’s Greenville News.


Ebola Virus Disease is rampant in West Africa. So far, the death toll is around 2,296, which makes it one of the largest outbreaks ever. Ebola is what’s known as a ‘Hemorrhagic Fever Virus,’ and belongs to a large family of nasty viruses that are widespread around the world. There’s even one in the American Southwest known as Hantavirus, that lives in a species of mice. Yellow Fever, which killed so many before a vaccine was developed, was once widespread as far north as Detroit. Some of these viruses are extremely deadly and some less so, but all of them are dangerous and miserable to endure.

One of the common features of these illnesses is bleeding; that’s why they’re called ‘hemorrhagic fevers.’ They cause blood vessels to leak and clotting to work poorly; victims sometimes bleed under their skin, internally, or in the eye, mouth or nose. Those who die seem to die from shock; the bleeding itself isn’t necessarily the main cause of death.

So to summarize, a week or more after exposure to fluids from an infected person or animal, the Ebola victim develops aches, fever, chills, weakness, vomiting, diarrhea and progresses to liver failure, kidney failure and bleeding from various parts of the body. He or she then goes into shock and in many cases (depending on the outbreak) dies. Death rates have been as low as 25% and as high as the mid 90% range.

From the standpoint of modern medicine, and even popular culture, it’s a fascinating disease. Think about it. It’s exotic, and it comes from the jungles of Africa. It’s natural host is a fruit bat. It makes people bleed out of their eyes! This sort of disease gets press. Books are written. Movies are made. Reporters send back gruesome images of bodies covering sheets outside sun-baked hospitals.

In medicine, we sometimes characterize things like Ebola as ‘sexy.’ Not literally, of course. It’s our way of saying that they’re cool, fascinating, anything but mundane. Between hypertension and Ebola, we we may prefer to stand next to the first, but we’d rather hear about the second.

It’s evident in the fact that four Americans have been evacuated out of Africa for treatment in high level containment areas in the US. The experimental drug ZMapp was manufactured by a small company in California called Mapp Pharmaceuticals. It has not undergone formal trials, but seemed to be life-saving for two American missionary physicians who received it after being afflicted with Ebola.

It’s a wonderful time in medicine. Strange and deadly diseases can sometimes be stopped. It matters more now than ever because those same strange, ‘sexy’ diseases can now jump off the images on the web-page or newspaper, climb on an airplane and land in Atlanta, or Greenville, in about twelve hours. (Pay attention young GHS doctors!) We need flexibility and research to face such mobile terrors in a widely interconnected world.

However, we need perspective. While four Americans were evacuated to high-tech care in shiny hospitals, thousands of Africans still languish with little hope in countries with less than optimal hygiene, healthcare, food and water.

We also need to remember that for all the horrors of a disease where you bleed out of your eyes, other diseases, less fascinating, less worthy of books and television, continue to grind and crush humanity. Malaria infected an estimated 207 million human beings in 2012, resulting in 627,000 deaths. Among those were 1300 children dead of the disease each day. Read those numbers again and think of your family. Treatments are improving, but there’s a long way to go.

Vitamin A deficiency results in 250,000 to 500,000 cases of blindness in children each year, with about half of them dying within 12 months. Worldwide, some 35 million people have HIV. In 2013, 1.5 million died from AIDs. In America, in 2012, there were 21 million diagnosed diabetics. In 2010, there were over 300,00 people for whom diabetes was listed as the underlying or contributing cause of death.

I could go on and on, with death rates from hypertension and heart disease, pneumonia and influenza. It’s just easier to focus on the flashy and newsworthy. So much so that the suffering of millions, of billions, can seem like background noise.

But we would be wise to remember that even as we are intrigued by darkly fascinating tragedies, that background noise is the sound of human sorrow and loss on scales we can still scarcely imagine.

Be proud of returning to the fire, doctors

This is my column in the October Emergency Medicine News.  ‘No matter how hot it gets, doctors, be proud of returning to the fire.’

(Who knew that blacksmithing and medicine had so much in common?),_Be.6.aspx


When I want to clear away the chaos and confusion of medicine, I walk down the worn path in our back-yard (followed by children, dogs, cats and deer). At the end of the path is the shop, which the kids and I helped a friend to build for us. We helped set the foundations and nailed the floor; we raised walls and put in roof trusses.

The shop sits in an area that was once a garden, but a soil-poor garden that yielded more blackberries, brambles and hornets’ nests than corn or beans.  The best crop of the garden was a treasure trove of arrow-heads and Native-American pottery; what still lies there I can’t imagine, but it is evident to me that someone, some people, camped or lived in what is now my yard a very, very long time ago.  They would be surprised to see my shop.

Under the extended roof at the back of the shop is our smithy.  Years ago, my son Seth asked if he could learn to blacksmith.  He may have been born in the wrong century.  He plays the bag-pipes and banjo and black-smiths.  (And is addicted to science.)  But to condense the narrative, we have.  Well, I should say we’ve learned a bit thanks to our gracious teacher George, the man who cannot seem to feel the heat of the hottest fire.  We don’t really even rise to the level of his apprentices,  but we can build and tend a coal-fire, we can handle a hammer and anvil, we can forge-weld iron, twist iron and curve iron; we can quench the iron and we can do most of it without being burned (very often) by the lemon-yellow and orange colored metal.

When I want to let my mind rest from medicine, I walk down that path and look at the old tools and the old anvil and vise.  I look first for wasps and rattlesnakes, of course. But then I just take it in.  The old colors, the bits of rust, the ordered disorder of a work-place; gravel on the ground, coal in the corner.  It isn’t professional and it isn’t perfect.  But it’s beautiful.

Rarely has a hobby captured my mind like this one.  And seldom has any activity enabled me to slip the bonds of medicine so readily.  From the moment I start the walk, I drift into a different place and time.  And when I start the fire, when the coal burns, the green sulfur clouds the air and blows around me, as I turn the crank of the blower that feeds air to the fire, well from that moment I am meditating.

It can be a hot day or a cold day, but cold days are best; cold days when standing by the fire is a comfort; cold days when it’s so hot there that a t-shirt is enough.  It can be a sunny day or a rainy day.  Rainy days fill our bucket with water from the sky with which to quench hot metal from the earth.  It is mystical.

And taking that metal, cutting it, heating it until it is over 2000 degrees, then shaping it from a mundane round or square stick into a wall-hook, a decorative leaf or even into a new tool, well that’s pure joy.

It’s unlike the emergency room.  It is single-minded.  The interruptions are virtually non-existent; and if they exist, they are laughter and jokes between my sons and me; or gentle arguments about how best to accomplish the task at hand.  Or the warning shout, ‘Hot Iron!’ which reminds us to watch lest we be burnt.

There are mistakes, but they are of small consequence.  Burnt metal can be cut off and thrown on the ground.  Crooked metal can be hammered straight.  An item made poorly can remain as a reminder of what not to do next time.

It’s so unlike the emergency room, where mistakes can be life-ending.  Where danger lies at every turn and if we shouted every danger we would shout for 8 hours.  And yet. There’s the heat and smoke.  There’s the risk of injury.  And there’s the shaping of something.  The transformation of something.  Hammer and hot iron and anvil and water; tongs and vise.  The change from what was to what is.  The rescue of an old piece of scrap, a lawn-mower blade, a piece of re-bar and the gift of watching those things have new life.  And the ring of that anvil, made around 1850, that says ‘I’m alive!  I’m alive!  I’m still here and needed!’

They seem connected to me, those two divergent places.  Writers see everything in metaphor and simile. Maybe the heat is metaphor for the pressure and stress of our work in emergency medicine.  Or maybe hammer striking heated metal on anvil is a metaphor for the way we want to shape a new reality; from sickness to health, from injury to healing.  We are blacksmiths of the human body; or red-smiths, maybe, for the blood we see spilled.

I know that as I grow older, I see another metaphor here.  I see my patients like those unshaped bits of iron; of uncertain value and utility, dirty and sometimes abandoned. But I know that in them lies potential; beauty and goodness beneath years of rust and disuse and neglect.  Like the way I put the grinder against my 150+ year-old anvil and when I stopped, it’s rough surface shined like a new platinum ring.

Most of our hobbies, our ‘avocations’ give us insight into our medical work.  Perhaps we choose them for that reason.  Or maybe just for the escape; for the Zen moments of ‘no-mind’ that allow healing and rejuvenation as we work at a thing without feeling as if it is work.

All I know is this.  Medicine seems to be getting more difficult all the time.  And the house of medicine is leaning on our specialty more heavily than ever before.  But whatever your hobbies, let me assure you that we have walked through the smoke and fire, all of us. We have all been ourselves shaped by the fire, hammer and anvil of suffering and struggle.  We have also shaped new realities for the people we have treated and saved.  And most of us keep coming back because we feel a comfort in the artistry that medicine has become; a deep, abiding pride in our craft.

So I say this, friends:  be strong. Do not be afraid of the struggles to come.  Embrace them with joy. Find the peace that comes from artistry well-practiced; for remember, medicine is art.  And however hot it gets, however choked you are by smoke and ash, however tired your limbs, be proud of the skill and strength that brings you back to the fire each day.

Only a few could do it.  And you are numbered among them.

If you’re looking for me, I’ll be down the path, hammer in hand.





Mental health issues emerge again in Navy Yard

This is my column in today’s Greenville News.  It’s much more complicated than ‘we need better mental health care.’|newswell|text|Opinion|s

Another tragedy, another tragic series of errors, another avalanche of debriefings and politicization, and in Washington, DC, there are 12 more dead.  What can we say about this?  It seems that the standard commentary fails.  Aaron Alexis was not an angry white man, nor a conservative.  He carried no assault rifle and he had a secret security clearance. He doesn’t seem to have been motivated by race.  He was a educated consultant.  He certainly wasn’t a radical Islamist.  In fact, he was allegedly a Buddhist.  (A demographic not known for violent outbursts these days.)

We can talk about effective security and we can write about background checks and all the rest. All of these are relevant points.  But the other relevant issue is that the shooter was a man who seemed to have mental illness.  We now know that he had a history of violent outbursts.  It is also alleged that he ‘heard voices.’  In the coming weeks experts on mental illness will hold forth in every conceivable venue.  Thanks to the inconvenient absence of the shooter, who was killed by police, the analysis will be largely speculative.  That won’t stop anyone.  We will hear impassioned please for better mental health coverage and we will hear bold declarations that ‘something has to be done’ to improve access to mental health.  And when thegrass begins to grow over the graves of the deceased, not much will have happened.

I know this because I see the mentally ill all the time.  Why do I see them? If you read my column with any regularity you’ll know that I’m not a psychiatrist.  I practice emergency medicine. And I see the mentally ill because emergency departments are where many of society’s mentally ill find themselves, if they interact with ‘the system’ at all.

Indeed, we have a system of mental health hospitals and clinics, in this state and in others.  And bless their hearts (as we say here), those state mental health workers, nurses, counselors, psychologists and psychiatrists alike, are a dedicated lot.  They spend their days and nights trying to sort through the thoughts and behaviors of untold men, women, boys and girls who are confused, broken, hallucinating, homocidal, suicidal, anxious, depressed, addicted and everything in between.

They take the story they are told, by family, friends, police or other physicians, and find the best treatment, then make the best predictions about what might (or might not) happen when the patient is released.  Furthermore, they are woefully underfunded and understaffed.  And they are crushed (overwhelmed is too soft a word) by rules, regulations and forms built to protect individual’s rights, but which sometimes make intervention a thing of legal peril.

Furthermore, and I tread lightly here, the mental health system is also stretched a bit thin by patients who are not, in fact, mentally ill.  A small but significant subset use ‘mental illness’ to achieve the requisit incapacity necessary for disability claims or to avoid accountability for their actions.  They create a lot of hay through which the mental health system must sift to find the needles, as it were.

But I doubt if anyone will mention what makes mental health care the most difficult.  We all know that the workers are understaffed and underpaid and the patients typically uninsured.  But there’s something else.  You see, if a patient has chest pain, a fever or a broken arm, they aren’t generally afraid to acknowledge it and their loved ones know exactly what to do…and feel no shame about it.

This is not the case with mental illness.  Many self-aware patients acknowledge their problem.  But a significant number of those with the most dangerous and difficult conditions don’t.  Or can’t.  They aren’t hallucinating, they’re just seeing things more clearly than everyone else.  And they aren’t delusional; it’s just that the CIA and the aliens actually are after them…if only we could understand!

When the mind is impaired, the very tool we use to make decisions about our health and welfare, then it becomes remarkably difficult for even the best system to make a difference. And when patients (and many of their loved ones) see mental illness as a moral failure, not a disease, then all the money and staff in the world won’t solve the problems posed by men like Aaron Alexis.

I have more questions than answers. But the pundit’s cry, ‘we have to address mental health in America’ is just so much window-dressing.  In the real world, the solutions continue to evade us all.