There’s some commentary over at CNN.com from Jack Cafferty, titled War on drugs is insane.
Editor’s note: Jack Cafferty is the author of a new book, “Now or Never: Getting Down to the Business of Saving Our American Dream.” He provides commentary on CNN’s “The Situation Room” daily from 4 to 7 p.m. ET. You can also visit Jack’s Cafferty File blog.
Well, the “War on Drugs” is insane. Yes. We’ve been saying so for years. But here’s where ol’ Jack goes off the rails:
They [Mexican drug gangs] have been able to infiltrate those 230 cities because we have not bothered to secure our borders. In addition to illegal aliens who come here to work and avail themselves of our social programs, we have criminals from Mexico bringing drugs in, taking money and guns back, and recruiting American kids into their criminal enterprises while they’re here.
Because we have not bothered to secure our borders? Oh, come on. Get real. Drugs are available to the prisoners inside Federal prisons. Are you trying to say that prisons haven’t bothered to secure their walls? Exactly how much securing are we talking about, here? Find something else to hang the right-wing Evil Foreigner Border Wall tripe on.
Depart Amsterdam Centraal, 7:04 AM
Arrive Frankfurt(M) Flughafen Fernbf, 10:43 AM
Depart Frankfurt(M) Flughafen Fernbf, 10:54 AM
Arrive Mannheim Hbf, 11:24 AM
Depart Mannheim Hbf, 11:36 AM
Arrive Basel SBB, 1:47 PM
Depart Basel SBB, 2:03 PM
Arrive Arth-Goldau, 3:45 PM
Depart Arth-Goldau, 3:50 PM
Arrive Lugano, 5:45 PM
Depart Lugano, 5:48 PM
Arrive Milano Centrale, 6:50 PM
Depart Milano Centrale, 7:30 PM
Arrive Roma Termini, 11:29 PM
Seven trains. Four countries. One day. Everlasting thanks to Elise Matthesen for working it all out, and figuring out that a pair of Eurail passes would be the sensibly cheap way to do it. (Also, of course, thanks to Abi and Martin Sutherland, the world’s best hosts, for putting us up for over a week in the Netherlands and getting us to Amsterdam Centraal at oh-god-oh-clock in the morning.)
We made it, including the terrifying three-minute connection in Lugano. The train from Arth-Goldau pulled in over a minute late, and just as we stepped out of our car the train to Milan across the platform began shutting its doors. From the mass growl from our fellow debarking passengers we were able to intuit that we weren’t the only ones trying to make that train. Perhaps the Milan train’s conductor heard the growl—at any rate, the doors opened again, and we all scampered across, bags in tow.
Speaking of Switzerland, allow me to just say this. We’re both people who spent most of our childhoods in the American West; we’re used to smiling indulgently at the rolling hills that people back east call “mountains.” However, the Alps? Those are mountains. More than that, they’re an endless series of illustrations of the Romantic Sublime. Cliffs that go up and up and up and don’t stop. Crevasses that seem to lead to the center of the earth. Landslides, fresh-looking ones, the size of Central Park. All of which we got to see from the comfort of very nice Swiss trains. There were probably long periods yesterday during which we entirely lost the power of speech.
Now we’re in Rome. And if you’ll excuse us, we’re going to get out of our hotel and go look at the place.
It’s been widely blogged, and discussed even in our own comment section, but if you haven’t yet read Simon Johnson’s “The Quiet Coup” on the Atlantic site, you really should.
Johnson is a former chief economist of the IMF, and his argument is that the US’s current troubles are more similar to than different from the problems that have led many other less consequential powers to seek IMF help: a set of crises brought on by a self-dealing elite, which can’t be addressed so long as the government is in the oligarchs’ pocket.
One doesn’t have to be a fan of the IMF, or an uncritical believer in its good intentions, to be struck by how much our problems resemble those of countries we’ve been accustomed to condescend to.
Those who wish to contemplate how the world might be different if more people read Making Light may consider Teresa’s post from October, 2002, The underlying forms of fraud.
Ah, for those simpler days when a TNH post might only get 41 comments. But had more read and understood, the entire world banking meltdown, from Bernie Madoff on down, might not have gone unnoticed until too late.
Here you may see the woe that is the prophet’s.
So there I was in Nashua, doing some back-to-school shopping with my younger daughter at the Target in the Pheasant Lane Mall (a charming place where the parking lot is in Massachusetts, but the mall itself is in sales-tax-free New Hampshire). To pass the time I looked through the bargain PC game rack. There, in the under-ten-buck section, I found a game called Emergency 3 from Strategy First.
The box looked interesting: “Accidents, natural disasters, police operations, your decisions can mean life or death for those involved!” Hey, I’m there for that. “New: Real-time physics: falling debris, crashing buildings.” Price was right — I picked it up.
There are twenty missions on the game disk for the campaign game. All but one start with a short (approx. 30 sec.) movie showing how you got into that situation to start with. (In the video clip I just linked to, the train consists of boxcars filled with fireworks and tank cars filled with liquid oxygen.) During game play, you’ll be interrupted from time to time by more cut scenes as the world turns progressively to dung in front of your eyes.
This game was originally produced by a German company, which explains the German uniforms worn by the firefighters, the European-style sirens, the German scenery, and the bizarre abbreviations for the vehicle types. DLK, for example, stands for Drehleiter (mit Korb), and is a ladder truck. RTW stands for Rettungstransportwagen, and is an ambulance. RW is Rüstwagen, an equipment truck (which you’re going to need if you want your Jaws of Life or chainsaw).
The game is rated T for blood and violence. (After you have your EMTs pick up a patient from the ground a little red pool of blood remains.)
There’s a Los Angeles mod you can download that puts in US trucks and uniforms, and adds another 19 missions to the game. I believe there are other mods, too. That one’s housed at a Dutch fan site (waves to Abi).
So, anyway, after firing this puppy up I’ve hardly returned to The Sims 2.
I am now about to comment on a review of Emergency 3 from Gamespot, pointing out a few places where the reviewer went astray.
Emergency 3, the latest real-time strategy game from publisher Strategy First, attempts to capture the urgency of life-and-death situations that arise from sudden and unexpected events like train wrecks, automobile accidents, structure fires, explosions, and even failed bungee jumps. But as exciting as it may sound, Emergency 3 delivers much more frustration than dramatic tension, thanks to clumsy controls and the trial-and-error nature of the mission design. The flaws are made all the more apparent by the fact that most of the missions are actually creative and interesting, and that the overall premise of the game is a promising one.Exciting, aye. I found the controls pretty straight-forward. And, my friend, there’s nothing trial-and-error about the mission design and solutions, provided you apply the principles of the Incident Command System.
First, as soon as you have an inkling of what kind of situation you’re looking at (which will be during that mini-movie and the screen listing mission objectives while the scenario is loading), try to figure out what kind of incident—police, fire, EMS—and what general type of unit you’ll need initially. Then, as soon as you can, start ordering up strike teams (multiple units of the same kind) and staging them around the game map. It takes time for the units to arrive on scene, so if you’re waiting for need rather than anticipating need, you’re not going to do too well.
Up here in the Great North Woods, if I need a medical evacuation helicopter there’s a minimum of 42 minutes flight time from the moment I call for it until it arrives. Heck, it can take me half-an-hour or more before I get to the location to see what’s going on. Therefore it behooves me to call for one long before I know for certain whether I’ll want one.
So, if you think there are going to be casualties, order up a bunch of ambulances now and stage them somewhere nearby yet safe. (In this game you can kill your responders. Which, just like in the real world, decreases the number of responders and increases the number of casualties at the same time. Which puts the “uck” in “suck.”
You’re aided in this by the fact that you can highlight multiple units at once and send them to the same location as a group. And when some person or unit gets finished with a task, send him or it back to staging to rejoin the pool. You’ll find it’s handy if you know where to look for the resources you need.
…You’re given specific objectives to complete and you must use a variety of rescue units to do so.We do get a bit unrealistic here. Under ICS the span of control is three to seven, with the optimum being five. In this game, once you get beyond the simplest scenarios, you’ll be giving orders to lots more than seven individuals. This makes it lots more challenging than it strictly needs to be. On the other hand, how often do you get to simulate the Finance Sector?
…Once you figure out how to address each type of scenario, the challenge is derived from micromanaging several units at a time and balancing your budget.
But as compelling as the setup is for each of these missions, they play out in an aggravatingly rigid step-by-step process that leaves little room for error.Well, yeah. There is just about no room for error out here, and the only way you’re going to have a chance in heck is by using a step-by-step process. You had darned-well better ensure scene safety (e.g. sending a cop to stop traffic or an engineer to secure the power) before you send in your other people. If you don’t you’re going to have rescuers lying on the ground needing rescue themselves.
Out here in the world, because we all use the same step-by-step process, a passing paramedic on holiday was able to join in one of our recent snowmobile rescues as if she had been a member of our team and trained with us for years, even though none of us had ever laid eyes on her, or she on us, before that particularly rotten night by a trail deep in some woods.
The missions will try your patience by requiring you to follow a very specific course of action every step of the way. It’s up to you to figure out what you need to do, be it hunting for a tiny, nondescript control box to turn on a traffic signal to divert traffic away from an accident, or searching for a fallen jumper who has been washed downstream and ended up underneath some underbrush. Chances are the jumper will die a dozen times before you actually find him, and when you do find him, you’ll have to figure out exactly which rescue unit to use to save him.I’ve found there’s quite a lot of freeplay and options in the way you go about solving each scenario, provided you use sound principles. And you do have to pay attention to details. If you don’t notice the tire marks and the broken guard rail by the river, you’ll never win the scenario because you won’t find all the patients. For that missing bungee jumper, please note that search dogs are available to you. (There are three different rescue units you could use, as it happens, of which the best is probably the helicopter.)
Once you’ve got your strike teams staged around the area, you can start forming up task forces (groups consisting of different kinds of units joined to carry out some specific task).
That brings up another flaw in Emergency 3. There are more than 30 rescue vehicles in the game, but there’s no explanation of what each one actually does, or how to use them. There are the standard fire trucks, ambulances, and rescue helicopters, but then there are much more specialized units like fire boats, K9 units, and salvage trucks. Each unit serves a very specific purpose, but there’s often very little indication as to what that purpose actually is. There .pdf manual included with the game doesn’t explain much of anything, and the in-game tutorial only shows you how to use a handful of different units. There is a bit of brief text accompanying each unit, but you can’t access that until you’re already in the midst of a mission.Okay, the manual could contain the unit descriptions. And you may not know at first (though it seems pretty obvious in retrospect) that the little guys who have rotating yellow pyramids above their heads marked with a nuclear trefoil are contaminated by HAZMAT (which suggests that you ought to set up a decontamination station to herd them all through before everyone in town is contaminated, and before they keel over and die).
For one thing, the units don’t always go where you tell them to. Occasionally they’ll find their way without any problems, but other times your medics will end up wandering off into the middle of a forest when you try to get them to cross a bridge or enter a building. Other times, your units will get stuck in a confined area and will just give up and quit moving.You want to bet me that doesn’t happen real-world? That isn’t a bug, it’s part of the simulation.
Even more frustrating is the artificial intelligence (or lack thereof) of the civilians. Rubberneckers will stroll out into the middle of traffic on a four-lane highway to get a look at an accident; pedestrians will walk right up to a burning building, and so on. Since most missions require you to keep the casualties to a minimum, it can be extremely frustrating when absolutely everyone in the game has a death wish.Oh, baby, let me tell you about that. That’s maybe the most realistic part of this game. (Even after you use the police helicopter to tell people to evacuate you still have to send in firefighters to pull some of ‘em out by their collars.)
The artificial intelligence in this game will have you questioning whether or not any of these people are actually worth saving after all.A conversation that all of us have had back in the ambulance garage at one time or another.
The game sounds considerably worse than it looks. Even if you forgive the blaring sirens, which seem somewhat necessary given the subject of the game, the sound quickly gets repetitive, even annoying. Each time you issue an order you’ll hear the same confirmation phrase from your workers, and you’ll always hear the same grunts and moans from the people you’re trying to rescue.When I give an order I expect to hear it acknowledged with the exact same words each time. Sailors never get tired of saying “Aye, aye!” or of hearing it. And after a while you notice that the grunts and moans of the people you’re trying to rescue do all sound the same.
Despite its flaws, Emergency 3 does have a few enjoyable moments, due entirely to its unique premise. Unfortunately, that isn’t enough to carry the tedious mission design, awkward controls, and aggravating artificial intelligence that pervades almost every moment of the game.I don’t know about that. I’ve been playing it a lot, and as soon as I get through all the missions with outstanding scores (you get medals if you do well enough on one scenario or another), I’m going to pick up Emergency 4, maybe without waiting for it to hit the bargain shelves. (Emergency 4, so I’m told, has highway flares and traffic cones. A whole new world opens up….)
Brain injury is much in the news these days, following the death of Natasha Richardson of a seemingly minor fall.
So, let’s talk about Traumatic Brain Injury (TBI), with a small side-venture into strokes.
The reason head injuries can be so devastating is because the head contains the brain. The brain controls the central nervous system, and without that, we rapidly get dead. The brain is composed mostly of nervous tissue, and, as such, is very sensitive to any lack of oxygen and glucose. For example, four to six minutes without oxygen is all it takes to kill the brain. The body is very, very good at making sure the supply, via the blood stream, doesn’t stop.
Like many other vital organs, the brain is protected by bone. We’re talking the cranium, here, that part of the skull that surrounds the brain. Outside of the cranium we have the skin of the scalp. This is highly vascular (which is the fancy way of saying “It’s full of blood vessels”), then covered with an insulating layer of hair. The reason the scalp is so vascular is because it plays a role in maintaining the brain at an even temperature. Even minor scalp injuries look dramatic, because they bleed heavily. Scalp and facial wounds tend to gape open because, unlike the rest of the body, the skin attaches directly to muscle. (There’s one other place on the human body where this is true: The scrotum. Insert the obvious joke here.)
The skull is made of a number of bones that fuse in very early childhood into a solid piece. Like other bone, it’s a living tissue, and its outer layer is a thick, fibrous material called the periosteum (the Latin word for “around the bone).
Hard against the periosteum on the inside of the cranium you come to the meninges. These are three layers of tissue that surround the brain. When they’re inflamed, the condition is called meningitis, and a nasty, horrible disease it can be, too. The first layer on the way in is the dura mater. That’s Latin for “tough mother.” There isn’t any space between the dura and the periosteum, when things are all okay. Under the dura mater comes the arachnoid membrane, which looks sort of like plastic wrap. (The Romans thought it looked like a spider web, hence the name.) Under the arachnoid comes the pia mater (Latin for “tender mother). The pia mater is attached to the surface of the brain itself.
Between the dura and the pia you find cerebro-spinous fluid (CSF). This bathes the brain, surrounds it, cushions it. The brain floats in it. It’s watery, clear-to-straw color, and seeing it pouring out of your patient’s nose or ears is what we call “a bad sign.”
How to tell if what you’re seeing is CSF: You can do what’s called the “halo test,” where you put a drop of the bloody fluid in the middle of a gauze square. If there’s CSF, you’ll see a red center with a yellow halo around it. Or, if all you have is some clear fluid coming from your patient’s nose, you can test it with your glucometer. If it’s CSF, the glucose reading will be approximately one-half of the glucose reading of his blood.
The meninges don’t just cover the brain; they cover the spinal cord as well. You can think of the spinal cord as a long, thin extension of the brain if you wish. The CSF also surrounds the spinal cord. When someone does a lumbar puncture, they’re sticking a needle between a couple of vertebrae in the lumbar spine, through the dura, and sucking up some CSF to check it for bacteria, or blood, or what-may-have you. When nice young ladies get epidural (from epi- above, and -dural, of or pertaining to the dura mater) anesthesia during childbirth, the drugs go into the spinal column, around the spinal cord, above the dura mater.
There’s a space between the periosteum and the dura mater, but usually it’s a potential space. That is, there could be a space there if something were to go there. We’ll be back to the epidural space anon.
So let’s get to the brain injuries.
The first mnemonic is DIC-HEAD. If the patient is Disoriented, Irritable, Combative, consider Head injury. (That’s right, people with brain injuries can be dick heads. What you don’t know when you arrive on scene is what they’re like day-to-day. Maybe the guy is just naturally a dick head. As in all emergency medicine, assume the worst.)
The brain actually is about the same consistency as Jell-O. When you smack someone upside the head, the brain kinda sloshes around in there. This leads us to the first, easiest, least-damaging TBI: the concussion. You get hit, you see stars. You’re briefly dizzy. You may even get knocked out for a moment. There aren’t any lasting effects (though you should be aware that all brain injuries are cumulative: several concussions and you have people who are permanently punchy, like the palookas of comedy). Post-traumatic amnesia is common. (You don’t remember the events immediately after the injury.) Antegrade amnesia, where you don’t remember the events leading up to the injury, are a bit more serious as symptoms go.
What went on there is an electro-chemical disruption of the brain. It’s a common sports injury. (Note: If your sport traditionally requires a helmet, wear the friggin’ helmet, okay?) Someone who’s had a concussion should be out of the game. A serious concussion, out for a month. A second concussion; out for the season. A third concussion, out for the year. Concussions are cumulative.
One thing that I see a lot: A patient has a concussion. Three days later, he or she has the injury that requires EMS and puts ‘em in the hospital. Their reflexes are just a bit off. Their peripheral vision is just a bit limited. So. If you have a concussion, at the very least, take it easy. And seriously, seriously consider following up with medical assessment, because there’s worse things to come as we look further into Traumatic Brain Injury.
Here’s a description of what it’s like to have a concussion, from one of our own, in this LJ post et seq.
The inside of the skull isn’t soft and smooth. It has all kinds of edges and protrusions. As the brain moves around, it can be bruised. It can bleed. You see brain injury not only at the site of impact, but on the opposite side where the brain sloshed, then sloshed back. (That’s coup and contracoup injuries.) You find lacerations and contusions in the brain itself.
The brain is made mostly of nerve tissue. Nerve tissue does not recover well. Those primary injuries, and any loss of function associated with them, are probably going to be permanent. But this doesn’t mean that you look at someone with a TBI and say, “Oh, well.”
The primary injuries are there. What you want to work on are the secondary injuries.
Like any other body part, when the brain is injured it swells. Unlike any other body part, the brain is trapped inside a hard bony shell. When it swells it doesn’t have anywhere to swell to.
Let’s step back to the dura mater, if you please. The temporal bones (the temples; the sides of the head where the lower jaw hook on) are particularly thin as skull bones go. And directly under those thin bones lie the middle meningeal arteries. A fracture of the temporal bone, say from a low velocity blow (e.g. a baseball), can tear one of those arteries. The epidural space starts to fill up with blood, backed by arterial pressures.
Or, in the course of the trauma, one of the bridging veins gets ruptured. These lie under the dura, so you have a subdural bleed. It’s only backed by venous pressure, though, so it’s usually slower than an epidural.
Cast back your mind to my earlier post on Levels of Consciousness. (Lots of things are going to start coming together, folks.) Recall the mnemonic AEIOU-TIPS? Remember that T was for Trauma and S was for Space-Occupying Lesions. We’re in S territory now. And as I promised back then, now’s the time to introduce the Glasgow Coma Scale.
The Glasgow Coma Scale is a tool for measuring level of consciousness. It goes like this:
Record the patient’s best response:
|Withdraws to pain:||4|
You’ll notice that normal folks walking around have a Glasgow score of 15. This desk here has a Glasgow score of 3. Recording the Glasgow score, and how it changes, will give you a good idea of what’s going on, and how fast, and how likely it is that you’ll have a live patient a week from now.
Okay, back from that little digression: A drop of two points in the Glasgow score is a bad sign.
We have our friends with the head injuries. Their brains are swelling, or there’s blood collecting inside of their skulls, at some rate. NOTE: That rate could be measured in minutes, in hours, or in days. For a time their bodies compensate for that swelling, or for those masses.
At the mass builds up, the first thing that happens is that the inter-cranial pressure (ICP) increases. There’s more stuff inside the skull, so pressure goes up. As the ICP goes up, the patient’s blood pressure goes up too, because the body desperately wants to get oxygen and glucose to the brain. Lack of oxygen, and lack of glucose, can, all by themselves, cause brain swelling.
While there’s no give to the skull, there is some give in other places. As swelling happens, cerebro-spinal fluid gets forced out. Pressure normalizes, the patient is asymptomatic, and you’d never suspect anything was wrong.
You’ve probably got about 75 mL of CSF that can go that way. Also, as swelling increases, or the size of the hematoma increases, venous blood gets forced out. You probably have another 75 mL of that that can get squeezed out of the skull. But when that 150 mL of reserve is gone, stand by. It’s like you were getting cranked to the very top of the first hill of a roller coaster and the ride is about to get very fast, and down hill all the way.
Pressure on the brain shows up in certain signs. Remember the cranial nerves (previously discussed at Making Light)? One of them is Cranial Nerve III, the Oculomotor nerve. Pressure on that nerve makes the pupil of the eye on the side closest to the injury expand and get sluggish in response to light. A difference of 1 mm between the pupils can be a bad sign (although a significant percentage of the population has unequal pupils normally). Next, as pressure builds up, you start getting weakness in the muscles in the opposite side of the body. Depending on exactly where the injury is, you can see changes in hearing, in verbal response, in sleepiness….
Intercranial pressure is still building up. The blood pressure is still going up. This triggers another mechanism, called “Cushing’s phenomenon” or “Cushing’s reflex” (named after Dr. Harvey Williams Cushing, 1869-1939, a giant among neurosurgeons): The baroreceptors in the carotid bodies and the arch of the aorta notice the increased blood pressure, and stimulate the Cranial Nerve X, the Vagus nerve, to correct that problem. The heart rate slows. The brain continues to swell. The ability of the blood flow to bring in sufficient glucose and oxygen is compromised. The brain swells even faster.
There’s only one place for that swollen brain to go: out through the Foramen Magnum (Latin for “Big Hole”). The brain is soft, and it’s getting squeezed out through that hole, brainstem first, like toothpaste. You’re going to start seeing motor changes as the brain takes mechanical damage from being squeezed out: Posturing. First come “decorticate posturing.” That’s when the arms bend in, taking the hands up in front of the face. (Remember it by Decorticate = movement to the core.) Then comes decerebrate posturing, when the arms are fully extended and the back may arch.
Then we come to patterned respiration, as the part of the brainstem that controls breathing starts to take damage. You can see Cheyne-Stokes breathing, a repeated pattern of slow, shallow breathing, going to rapid, deep breathing, then back to slow and shallow. You can see Central neurogenic breathing (continuous rapid deep breaths — they look just like the Kussmaul’s respiration you get in diabetic ketoacidosis, only the mechanism for why you have ‘em is different). At this point you’re well into Cushing’s Triad: High blood pressure, slow heart rate, and patterned respiration. You are also well behind the power curve.
Then comes ataxic breathing: breaths with no discernible pattern. Then comes apnea: no breathing at all. This is what we call an end point.
Typically, you see a person get a head injury, be unconscious for a while, wake up and be apparently normal (this is called “the lucid interval”), then going unconscious again, and deteriorating rapidly. The initial unconsciousness is from a concussion. The lucid interval is the period while the body is compensating by draining CSF and venous blood from inside the skull while the hematoma is growing. Then comes the bad part.
So, what do we do about all this?
First, if you suspect traumatic brain injury, due to mechanism of injury, get the patient somewhere with a CAT scan or an MRI, and a neurosurgeon on call. You may not have a lot of time to do this; meanwhile the patient’s signs and symptoms may be mild or nil. At a minimum, any head injury involving loss of consciousness deserves close and continuing observation, where any sudden change or deterioration becomes a call for rapid action. Remember that signs and symptoms of a subdural or epidural hematoma may not show up for a significant period.
Any time you have a person who’s on blood thinners, or who’s drunk, assume the worst and treat for same. Alcohol masks the signs and symptoms, and a person who’s drunk has a good chance of falling and striking their head. Just because they act drunk, and smell of whiskey, don’t assume that’s all that’s going on.
A serious TBI is about 30% fatal. Of those who recover, around 99% have permanent neurological deficits.
I promised a side excursion into strokes: Here it is. You have two kinds of strokes: Occlusive, where a blood clot blocks an artery in the brain causing tissue death, and hemorrhagic, where a blood vessel in the brain bursts. The later is indistinguishable from a traumatic brain injury as far as its physical effects; the only difference is why the blood vessel has broken (I urge everyone to check their blood pressure regularly: hypertension is related to stroke). In occlusive strokes, tissue damage due to hypoxia causes brain swelling, with all the rest of the lovely signs and symptoms noted above.
Once in hospital, with neuro services, though, a hematoma can be drained; often with minimal after-effects. (This is particularly true of epidural hematomas since the broken arteries are well away from the brain, no liquid blood enters the brain tissue, and there may be no underlying trauma to the brain itself.) To do this, though, the CAT scan is vitally important.
As for getting to the hospital, here’s what you need to remember. You can’t do anything about the primary injury. But you can slow the secondary injury due to swelling by keeping the patient well-oxygenated, and keeping their blood pressure above 90 (that is, you have to be able to feel a pulse at the patient’s wrist). Your goal is to keep oxygen and glucose going to the brain tissue, to limit swelling. (Note: Do not hyperventilate the patient: Blowing off too much carbon dioxide will also cause brain swelling.)
There isn’t any good place to put this, so I’ll put it here: There’s another kind of brain injury that doesn’t involve bleeding inside the head, doesn’t involve brain swelling (or not much), but is still devastating. That’s the Diffuse Axonal Injury. It’s caused by shearing forces inside the brain, due to the different rates at which gray matter and white matter accelerate. The axons of the nerve cells stretch, break off, and retract. While death is rare, and the lesions often can’t be detected with current imaging devices, 90% of the patients who present with DAI remain in a permanent vegetative state. This is a primary injury; it exists from the moment of the trauma. You most often see it in rotational injuries in high-speed automobile crashes, and in blast injuries. Nothing you can do, prehospital, will make this one better or worse.
Can you tell the difference, pre-hospital, between an epidural hematoma, a subdural hematoma, an intracerebral hematoma, or a hemorrhagic stroke? No, and usually you can’t tell in the ED, either. You need specialists with special equipment to differentiate.
A person with a head injury often has other injuries. Treat for shock. Stop bleeding. Keep the airway open. And good luck. These are scary, scary injuries.
Take away lessons:
Copyright © 2009 by James D. Macdonald
I am not a physician. I can neither diagnose nor prescribe. These posts are presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.
TMI about TBI by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.
(Attribution URL: http://nielsenhayden.com/makinglight/archives/011126.html)
Certain neighborhoods of the blogosphere are in raptures over Ron Miller’s Silk and Steel, a fantasy novel published by Avon in 1992, then republished in 2001 by Timberwolf in a revised POD edition.
Her legs were quills. They were bundles of wicker, they were candelabra; the muscles were summer lightning, that flickered like a passing thought; they were captured eels or a cable on a windlass. Her thighs were geese, pythons, schooners. They were cypress or banyan; her thighs were a forge, they were shears; her thighs were sandstone, they were the sandstone buttresses of a cathedral, they were silk or cobwebs. Her calves were sweet with the sap of elders, her feet were bleached bones, her feet were driftwood. Her feet were springs, marmosets or locusts; her toes were snails, they were snails with shells of tears.You have to see the whole thing. I can’t improve on—indeed, I very nearly repeated—the first comment on Vandonovan’s post:
Lizblackdog: WHAT THE FUCKING FUCKITY FUCK.And then there’s “Valmont,” who reviewed the book on Amazon:
This book is a treasure mine for metaphors such as “her neck was a bottle of wine covered in dew and otters”. Yes. Otters. There are also interesting comparisons between the aforementioned young lady’s feet and marmosets (i.e New World monkeys). This book might be a literary Hindenburg, but it has made me laugh like few others before.”But really, no one can top Ron Miller himself:
Then, as quickly as a balloon inflated at a vendor’s tank, and with much the same hiss and squeak, the gryphon was as large as a Great Dane. Bronwyn felt the recoil from a sharp glance of molten copper eyes, before a final burst flung the monster to its full height, far above her head. She held breath and heart still in utter, utter awe. …The book’s new fans have busily gone to work upon it, and Vandonovan’s been collecting the resulting links:
Its steel claws had enveloped her like a cage when, with a shriek like a steam locomotive, the gryphon disintegrated. Bronwyn was scooped from the earth, tumbling into a huge, soft hollow, and the pit of her stomach wrenched with the sensation of rising rapidly. She looked up and for the one dizzying moment before she lost consciousness she saw, towering above her like a mountain, the abundant, boundless, heaven-crowned figure of Thud Mollockle.
Scans:Watch out for your keyboard.
Just a couple of hours ago, the New Hampshire Legislature voted to make same-sex marriage legal. That makes us third in the nation (Drat! Not first in the nation!) after Connecticut and Massachusetts.
The margin of victory was seven votes. Now the bill goes to the senate, then to the governor for his signature. Governor Lynch is a Democrat, but has said that he opposes gay marriage. He hasn’t said that he’d veto such a bill, though.
The governor’s address, should anyone from New Hampshire be reading this, is:
Office of the Governor
25 Capitol Street
Concord, NH 03301
The Skynet Funding Bill is passed. The system goes on-line August 4th, 1997. Human decisions are removed from strategic defense. Skynet begins to learn at a geometric rate. It becomes self-aware at 2:14 a.m. Eastern time, August 29th. In a panic, they try to pull the plug.
The warnings are circulating again: Botnet 2.0 is on the way, scheduled to go live on April First.
Already we’re seeing some skepticism: The Conficker Worm: April Fool’s Joke or Unthinkable Disaster?
See also: Social Disease
[UPDATE] This tool will find and remove Conficker.
[UPDATE] The Conficker Eye Chart. (Fast, easy, no-installation check to see if you’re infected. Thanks Kathryn from Sunnyvale.)
On March 23, 1979, Patrick Hayden married Teresa Nielsen.
Coincidence? You be the judge.
Congratulations, Patrick and Teresa. May there be many more happy anniversaries to come.
An interesting point from the generally excellent Mark Schmitt:
As has often been noted, while AIG’s bonuses were apparently bound by the sanctity of contract (and the ruthless Connecticut Wage Law), the autoworkers’ contracts were renegotiated as a condition of the industry recovery plan. Mostly this is treated as a matter of class justice—the workers made sacrifices, the Wall Streeters (or, more accurately in the case of AIG-FP, the Wiltonians) were untouched.Schmitt’s observation parallels a point made repeatedly in the work of the brilliant Thomas Geoghegan, that the American labor movement at its post-WWII peak was, for all its flaws, a mechanism by which millions of people learned how to do civic participation—how to negotiate, horse-trade, and persuade.
But there’s more to it than that. How were the auto workers’ benefits cut? Not involuntarily. They agreed to it. They agreed to it because they were able to act collectively. The United Auto Workers came to the table and agreed that the survival of GM and Chrysler was a more important common goal than everyone getting exactly what they were promised. The presence of the union created a collective sense of loyalty to the industry as well as to their own self-interest.
[…W]hat if you were able to get all the bonus-eligible employees at AIG together, and ask them to jointly make a choice—give up much of their bonus, and the company might survive and remain eligible for federal cash, or demand exactly what they were promised a year ago and watch the company die, in part because of political backlash?
Who knows what the collective choice might be. But since these are all individuals, with individual contracts, the logical move for any one person, acting alone and not knowing what others might do, is to demand every penny. If you agree to reduce your bonus, and the others don’t, you are the classic loser in a Prisoners’ Dilemma—you don’t get the money and the firm goes under. In this case, the incentive is for the individuals to take the money, and then leave the firm.
The classic argument for unionization is that acting together, workers have a stronger negotiating hand than workers acting alone, negotiating individual contracts. That’s demonstrably true. But it also works in the other direction. When the time calls not for soaking as much profit out of the company as possible, but for making some sacrifices, out of loyalty and a sense of shared economic destiny, unions can do that too. Individuals cannot. Solidarity is good for the economy.
Losing that mechanism wasn’t just a blow to hazy ideals of social justice. It was also a blow to American society’s practical ability to function, to our ability to negotiate among ourselves. Like all attempts to radically simplify society (think of Henry VIII breaking up the monasteries), the largely-successful war against American unions has left us all fundamentally stupider, less capable of working complex problems out.
This afternoon, at Cafe Ot en Sien in Amsterdam Noord. As Martin Wisse wrote in the current open thread, “Drinks were had, Dutch pub food was tried and merry was made.”
Clockwise from left: TNH, Abi, self-described lurker Bo, commenter Thomas, self-described lurker Auke, Jenny Glover (face obscured), Steve Glover, Aaron-from-Boston, Martin Wisse. Briefly out of the room: Martin’s partner Palau. Behind the camera: PNH.
Left to right: Thomas, Palau, Steve & Jenny Glover, Abi, PNH, Martin Wisse. Behind the camera: TNH.
An amiably international gathering—thanks to all who turned up!
We’re here. If you look at the larger version of the above snapshot on Flickr, you can see the rapidly-receding figures of Abi and Teresa far ahead on the path, blithely unaware that their companion, trying to retrieve a camera while cycling, had moments ago managed to hook a foot into the soil to the side of the path, consequently sailing over his handlebars and executing a perfect Comedy! Tonight! landing on the softly yielding Dutch soil. After which, I got up and TOOK THE DAMN PICTURE ANYWAY. Okay, the horizon line’s a little crooked. So sue me.
More to come as we adjust to the daily patterns of Planet Europe. Early indications are that we could adjust dangerously well.
It’s just over a week till the meetup in Amsterdam, and despite the best efforts of the universe, we have managed to make a plan. Here it is in its cunning entirety.
Be there or be…elsewhere.
Jim Macdonald, pasted straight from my chat window:
Have you found the opening credit montage from _Watchpersons_ on line yet?The opening credit sequence made my head explode. It made me urgently desire to go out and see the movie as soon as possible. Warner is crazy.
Warner is apparently hunting ‘em down and C&Ding ‘em as fast as they pop up, but it’s all over the place, and it’s brilliant.
It was originally posted on the site of the effects house that did it (they have the opening titles from all their films on their site, so it shouldn’t have been a suprise that they’d post this one too).
When you consider that the opening is worth the price of admission all on its own, and is far better than any of the official trailers, and when you figure that Watchpersons opened far below what Warner had expected over the weekend, why they’re doing this baffles me.
[UPDATE]: The sequence is now available here. (Thanks, Sumana Harihareswara.)
One of the most astonishing pieces of newspaper journalism I have ever read. I hesitate to say anything to introduce it; just read. But brace yourself first.
It’s not the story you think it’s going to be from the lead.
“I will tell you a story,” Schmendrick said. “As a child I was apprenticed to the mightiest magician of all, the great Nikos, whom I have spoken of before. But even Nikos, who could turn cats into cattle, snowflakes into snowdrops, and unicorns into men, could not change me into so much as a carnival cardsharp. At last he said to me, ‘My son, your ineptitude is so vast, your incompetence so profound, that I am certain you are inhabited by greater power than I have ever known. Unfortunately, it seems to be working backward at the moment, and even I can find no way to set it right. It must be that you are meant to find your own way to reach your power in time; but frankly, you should live so long as that will take you. Therefore I grant it that you shall not age from this day forth, but will travel the world round and round, eternally inefficient, until at last you come to yourself and know what you are. Don’t thank me. I tremble at your doom.’”Addenda: from the thread
—Peter S. Beagle, The Last Unicorn
Fragano, 161: Spring break coming up. Essays being marked as midterm grades are due. Fascinating things, as always, being learned:“Emma questioned how those who dictated social moirés could place such a limited and finite view on what was considered morally sound.”Serge, 164: Social moirés? Was the rest of the essay as lamé?
Steve C., 170: I giggled when a commenter in another forum went on at great length about social morays.
Ajay, 172: Questioning moirés can weaken the fabric of society.
Irritatingly, “mores” is one of those words that doesn’t have a singular (like “measles” and “smithereens”). The Latin is mos, plural mores. Hence the saying that, if you travel too much, you’ll effectively be a stranger everywhere, unfamiliar with the customs of your own country as much as with those of any other: a rolling stone gathers no mos.
Last September, in the midst of the presidential campaign, a certain Sarah Palin hit the news. And along with her, came the story of how the citizens of Wasilla, Alaska, were charged for rape kits under her administration.
This was reported and discussed over at McClatchy newspapers (whose web comments I have the honor to moderate), including these stories/threads: Critics: Under Palin, Wasilla charged rape victims for exam and Anne Kilkenny’s e-mail about Sarah Palin.
Anyway, in the comment threads on the latter story, we come to this exchange from last September 11/12. I post it here because McClatchy is about to change its software and the archives may (will) be lost:
Wow. One word comes to mind
Submitted by TexDoc on September 11, 2008 - 7:18pm.
Wow. One word comes to mind as I read this letter…Lame. Sounds like Palin took Anne’s boyfriend away at the senior prom. Seriously, this wreaks of petty jealousy. I for one would be ecstatic if my government refunded a surplus to me, instead of spending it on some misguided program just to get some politicians name on it. Remember, we the people own and run the government..theoretically..so the money is ours if their is a surplus and should be returned to the people. Some politicians like to think it is their’s but they are wrong…they are called liberals. A good example is the charge for the rape exam..nothing wrong with it at all. Someone has to pay for the services…and if I or you is rammed in a wreck,no fault of ours,but go to the ER, we have to pay for the medical care. Yes, the rape is horrific, but so is cancer, so is diabetes, Lupus, etc,etc….when will you people stop thinking that the government has to pay for everything and take of us? Get out there and do a little work. There once was a liberal young daughter who hounded her old conservative father. He calmly later asked his daughter about her college classes. She responded how tough they were and how she was having to bust her butt to make an A. That she had no free time. He asked how her friend Sally was doing and she responded having a great college life but making terrible grades. Her Dad said well that’s horrible…I think you should go to your teachers and ask if you could give some of your good grades to Sally,maybe even average your grades to help her out. His daughter was outraged…stated are you crazy, I’ve worked hard for those grades,no way am I giving her anything - she’s goofing off and having fun and I’m busting my tail every day….her father smiled and said…. well,well, my dear..welcome to the Republican Party!A good example is the charge
Submitted by James_Macdonald on September 11, 2008 - 7:33pm.
A good example is the charge for the rape exam..nothing wrong with it at all. Someone has to pay for the services…and if I or you is rammed in a wreck,no fault of ours,but go to the ER, we have to pay for the medical care. Yes, the rape is horrific, but so is cancer, so is diabetes, Lupus, etc,etc….when will you people stop thinking that the government has to pay for everything and take of us?
This has already been comprehensively answered in another thread, but I’ll answer it again here.
“Nothing wrong with it at all”? There’s a great deal wrong with it. A rape exam isn’t a health-care procedure. It’s a police investigative technique. When you get rammed in a wreck the police don’t send you a bill for the time they spent measuring tire marks on the pavement, or for the lab costs of the drug-and-alcohol screens they did on you, nor for the photographs they took of the scene.
Law enforcement and justice are public; and law enforcement and justice must be paid for from public funds.
Forcing the victims to pay for the police investigation is not only immoral, it is also (very likely) illegal. When someone is burglarized do the police say, “Sorry, not going to investigate this if you can’t pay for the fingerprint powder.” (And good luck getting your homeowners’ insurance to pay for the policework.)Apparently Mr McDonald is
Submitted by TexDoc on September 11, 2008 - 7:46pm.
Apparently Mr McDonald is some expert on rape exams…according to him. I’ll grant him that one aspect is legal or procedural…but an equally important aspect is the medical exam for injury or psychologic damage. How do I know this..I’ve done it..it’s called a Rape kit in many ER’s ..I’m a gynecologist and I’ve done them. Please refrain from addressing topics that you know little about..that’s what’s wrong with internet blogs…people speak as authorities and usually have an extremely limited fund of knowledge…its a typical left wing tactic also..Please refrain from
Submitted by James_Macdonald on September 11, 2008 - 8:00pm.
Please refrain from addressing topics that you know little about..
Indeed, Doctor. Good advice for everyone.
Tomorrow when I go back to work shall I pull a rape kit off the shelf and embarrass you by going through it step by step and asking you if each step is more related to patient care or to police investigation?
people speak as authorities
Submitted by James_Macdonald on September 12, 2008 - 5:32pm.
people speak as authorities and usually have an extremely limited fund of knowledge…its a typical left wing tactic also..
Well, I’m going to beg the indulgence of the good people here to go a bit off-topic and tell you, at some length, about rape kits.
I have a rape kit right here. Let’s look at it…
The first thing I notice is that its official name, printed right on the cover of the box, is “Sexual Assault Evidence Collection Kit.” Hmmm… nothing there about patient care or treatment. “Evidence Collection” sounds more like a police function. Let’s open it up and see what’s inside.
Hmmm. A number of paper bags and some instruction sheets. No bandages, no sutures, no antibiotics….
Step one is the authorization for collection and release/transfer of evidence and protected health information form. That’s a paperwork drill. It gets the patient’s name, date of birth, the date of the exam, and permission to collect the evidence. It says “Evidence” right on the form. This resembles healthcare only in that healthcare requires similar information and permissions.
Step two. Sexual assault evidence collection kit inventory. A list of what’s in the kit, with checkmarks for “Collected” and “Not Collected.” What’s interesting here is line 11, “Additional evidence (Please list).” Evidence. Still no health care.
Step three. Sexual assault medical/forensic report form. Patient identifying information, then check boxes: “Indicate by checking the appropriate box what the patient has done since the assault (if unsure, please state the reason why) Douched; Yes, no, unsure. Bathed/showered; Yes, no, unsure. Urinated; Yes, no, unsure.” And so on. Then: “At the time of assault was: A condom used by the assailant? Yes, no, unsure. Patient menstruating? Yes, no, unsure. … Weapon used/threatened by assailant? Yes, no, unsure.” And so on. “Within the past five days has the patient engaged in consensual sexual activity? Yes, no.” And so on. Then: “Details of the assault (check all that apply): Penile/oral, penile/genital, penile/anal, digital/genital…. ” And so on. “Describe any pertinent details of the assault.” Fill in the blank.
Step four. Liquid blood sample. An envelope with a foam-padded insert for blood tubes. Additional blood and urine samples are required if a suspected drug-facilitated sexual assault occurred. The tubes are sealed in the provided envelope. Not too useful for patient care, sealed like that, is it? “Note: In order to minimize patient discomfort, blood needed for other tests, including pregnancy, should be drawn at this time. THESE TEST RESULTS SHOULD NOT BE INCLUDED IN KIT, BUT SHOULD REMAIN AT THE HOSPITAL.” In other words, the Sexual Assault Evidence Collection Kit is separate from health care requirements.
Step five: Paper bags for collecting the victim’s outer clothing. “If patient changed clothing after assault, inform officer in charge so that the clothing worn at the time of the assault may be collected by the police.” How’s that related to patient care, Doctor?
Step six: A paper bag labeled “Underpants.” “Collect in all instances. If patient not wearing underpants, collect item of clothing that had contact with the patient’s genitalia.” How’s that related to patient care?
Step seven: Oral swabs and smear. The smear is allowed to air dry and sealed in the provided envelope. Not too useful for patient care, eh, Doctor?
Step eight: Foreign material collection. Remove folded sheet from Foreign Material Collection envelope. Unfold and place on flat surface. Collect any foreign material such as dirt, leaves, fiber, hair, etc. (found on body) and place in center of paper. Then refold paper in manner to retain material…. Note location from which sample(s) was taken on anatomical drawings on envelope. Seal and fill out all information requested on envelope.” How’s that related to patient care, Doctor?
Step nine: Rectal swabs and smear. “Return smear and swabs to Rectal Swabs and Smear envelope. Seal and fill out all information requested on envelope.” How’s that related to patient care, Doctor?
Step ten: Pubic hair combings. “…remove paper towel and comb provided in Pubic Hair Combings envelope. Place towel under patient’s buttocks. Using comb provided, comb pubic hair in downward strokes so that any loose hairs and/or debris will fall onto paper towel. Refold paper towel in manner to retain both comb and any evidence present….” Evidence. What part does this step play in health care, Doctor?
Step eleven: External genital swabs. “If cunnilingus or fellatio was performed on the patient within five days of the exam, and the patient has not bathed/showered, or the patient is pre-pubertal….” Again, the swabs and smears are sealed and not otherwise used at the hospital. How is that related to patient care, Doctor? Is there a step in healthcare that you wouldn’t perform if the patient had bathed recently?
Step twelve: This is the one you’d actually be involved in as a gynecologist, Doctor. Vaginal swabs and smear. “Note: Any other examination of and testing of the ano-genital and pelvic area should occur simultaneously with this step.” I think you’re the “any other examination.”
Step thirteen: Medical/forensic examination form. “Physical examination: Was patient bleeding from wounds sustained during the assault? Yes, no. Were photographs taken by examiner? Yes, no, how many? Digital, Instant, Colposcope, Film, Other. Was Medical Examiner consulted? Yes, no.” And so on. Paperwork. This resembles documentation that would be produced in a health care setting.
Step fourteen: Patient information form. “With your consent, the following tests were completed (check all that apply): Blood test for syphilis, pregnancy test, blood test for Hepatitis B, …” Finally, something related to health care! “At the time of your evaluation, specimens were obtained in order to look for suspected drug-facilitated sexual assault. The specimens are not evaluated by the hospital laboratory, but forwarded to the State Police Forensic Laboratory. Information regarding the results should be obtained through the investigating law enforcement agency….”
Okay… here’s the part that tells me why Palin didn’t want the town of Wasilla to pay for rape kits:
Step fifteen: Emergency Pregnancy Prevention. “Fill out all information requested on form. Give one copy to patient. Retain one copy for hospital records.” Yes, part of the rape kit is offering the so-called “morning after pill.” That’s contraception! We can’t have taxpayers paying for contraception! Contraception is wrong!
Step sixteen: Photographs. “If photographs are indicated follow the guidelines outlined in the Protocol.”
Step seventeen: Postcard. A stamped, addressed postcard to tell the state crime lab that that kit is coming: “Please complete the information on the enclosed stamped postcard and put it in the mail.”
After telling the examiner to place all materials (except bags containing outer clothing and underpants) back into the original box, “Hand sealed kit, sealed bags and appropriate forms to investigating officer, and obtain your signature as well as that of law enforcement to ensure chain of custody requirements have been met.”
Law enforcement officer. Chain of custody. Tell me, Doctor, what’s that have to do with health care? Isn’t that an evidence gathering procedure? “I’ll grant him that one aspect is legal or procedural…” How about “all but one or two aspects are legal or procedural”?
“Note: The kit needs to be picked up by Law Enforcement in the jurisdiction where the crime occurred, unless otherwise arranged by the law enforcement agency. If officer is not present at this time, place sealed kit and bags in secure and refrigerated area, and hold for pick up by law enforcement.”
That’s what a rape kit is, Doctor.
Please refrain from addressing topics that you know little about..that’s what’s wrong with internet blogs…people speak as authorities and usually have an extremely limited fund of knowledge…its a typical left wing tactic also..
TexDoc never replied.