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July 30, 2007
“Because one of the people she was learning how to hate was me.”
Posted by Patrick at 06:17 PM * 315 comments

I try to avoid the sort of lazy blogging that consists of quoting someone else at length and then adding “What she said” and “Read the rest.” But some things just demand to be passed along.

Superb political reporter and sometime blogger Rick Perlstein recently posted this:

Shortly before she died, my grandmother—one of the people, naturally, I loved the most in the world—broke my heart. Celia Perlstein, like most of our grandparents, didn’t get out much in her final years; in fact, for the last few years of her life, I’m not sure she got out of her old folks home at all. I don’t think she really wanted to. She was sure that beyond its threshold lay dragons: far-far-far leftists out to steal her Social Security; turbaned terrorists just itching to fly a jet into the First Wisconsin tower a few blocks to the south; quisling Democrats itching to help them do it; grandma-gutting criminal marauders just outside her door.

I’d look out of her eighth floor picture window, down at the scene she saw every day, half expecting to find that nightmare landscape before me. Nope: same as always, the brightly colored sailboats on Lake Michigan, kids and their parents feeding the ducks (Grandma used to take me to feed the ducks), happy, strolling Milwaukee couples—paradise. Where was she getting these fantasies?

One evening’s visit, all became clear. She gestured at the blaring TV set. The excruciating grandma-volume was even more excruciating than usual, because she was visiting with her best TV friend. She told me how much she adored Bill O’Reilly. My wife and I cringed. Watching our latter-day Joe McCarthy on TV every night, she had learned, late in life—for this development was entirely new—how to hate her fellow Americans. I almost cried, because one of the people she was learning how to hate was me.

What he said. Watch the video. Read the rest.

If “the arc of history bends toward justice,” it’s only because people got up off their behinds and started bending it for themselves. Moral progress isn’t something we can count on the rest of the world to take care of for us. If you want to live in a world in which multimillionaire perverts pile up ever-higher fortunes by encouraging Americans to hate and fear one another, simply do nothing. If you want a better world, start thinking about how to make this stuff stop.

Mike Ford: Occasional Works (Pt. Nine)
Posted by Jim Macdonald at 11:41 AM * 14 comments

Xiiiiiiii-linx fpga
As the stack rolls down and changes state
At the end of run, it’s Nought or One
And the invert comes behind the gate
Xiiiiiiii-linx fpga
Every night the Booley boys and me
Shove a bunch of code
Up someone’s node
And we don’t need no CPLD
Our honey will ping us at home
And we’ll take her out to the PROM
Exclusive AND
Defines our operand
We’re truthly tabled
You’re solid state, Xilinx fpga
Xilinx fpga, QA!

— Oscar Hammerstein IIbis

You really thought they weren’t going to start using all that surveillance on their political opponents?

Continue reading Mike Ford: Occasional Works (Part Nine)

July 28, 2007
Open thread 89
Posted by Teresa at 01:58 PM *

Also Englischmen, þeyȝ hadde fram þe bygynnyng þre maner speche, Souþeron, Norþeron, and Myddel speche (in þe myddel of þe lond), as hy come of þre maner people of Germania, noþeles, by commyxstion and mellyng furst wiþ Danes and afterward wiþ Normans, in meny the contray longage is apeyred, and some useþ strange wlaffyng, chyteryng, harryng and garryng, grisbittyng. … Al the longage of the Norþhumbres, and specialych at ȝork, ys so scharp, slyttyng and frotyng, and unschape, þat we Southeron men may þat longage unneþe undurstonde. Y trowe þat þat ys bycause þat a buþ nyȝ to strange men and aliens þat spekeþ strangelych, and also bycause þat þe kynges of Engelond woneþ alwey fer fram þat contray.

—Ranulf Higdon’s Polychronicon, c. 1350; trans. 1387 by John of Trevisa; printed 1482 by William Caxton

July 24, 2007
Here’s the deal
Posted by Patrick at 11:58 PM *

Teresa has taken a full-time job at Federated Media Publishing, the firm founded in 2005 by John Battelle to provide advertising revenue and other business-and-technical back-office support to a select group of best-of-breed blogs and web sites by putting them together with advertisers who are looking to reach their particular audiences. Federated Media clients include many of the more interesting web sites around, including 43 Folders, Ars Technica, Autospies, Thomas Hawk, Laughing Squid, Digg, Metafilter, and, perhaps most notably, our old friends at BoingBoing, one of the most widely-read blogs in the world.

As an Account Manager in FM’s “Author Services” department, Teresa will be deploying her ninja community-engineering skills, honed in decades of activity in SF fandom and the online world, on various projects with various FM clients, all of which you’ll be the first to hear about as soon as they stop being sooper seekrit kill-yourself-before-reading on-beyond-classified big hot hairy deals. Honestly, I’m not even allowed to know about some of this stuff.

Of course, Teresa will continue to be a consulting editor for Tor Books, because nobody ever stops being a consulting editor for Tor Books, bwa ha ha ha. So Steve Brust can relax; little Vlad won’t be turned over to the understudy at the beginning of the third act.

Yes, this is what was previously [REDACTED]. We expected to be able to talk about it earlier. Humans having been involved, misunderstandings ensued. Reading the comments, we note that even our gnomic silence failed to prevent you from making brilliant sense of our own nonsense. I swear, some days, it seems like this blog writes itself.

Gaming Wikipedia
Posted by Patrick at 02:13 PM *

From reliably-levelheaded SF fan and professional Eurodiplomat Nicholas Whyte, more evidence that Wikipedia is being gamed with increasing success by people with bad agendas. In this case, a dingbat from New Zealand eager to persecute those he determines to be following “the homosexual agenda.” (Follow Whyte’s links, and the links from those links.)

Whyte’s most searching point, buried in his own comment section, is that the system appears to not only allow people to be banned for alleged sockpuppetry on no good evidence, it also further punishes them for attempting to appeal the ban—the crime of “self-confessed block evasion,” i.e., trying to log in from an unblocked IP in order to protest one’s innocence.

Ironically, Wikipedia itself features a reasonably decent summary of Kafka’s The Castle:

The narrator, K., is a land surveyor summoned to the castle to perform a survey. K. arrives in the village, governed by the castle, under the impression he is to report to a castle authority. He is quickly notified that his castle contact is an official named Klamm, who, in the introductory note, informs K. he will report to the Mayor (also known as the Council Chairman, depending on the translation).

The Mayor informs K. that, through a mixup in communication between the castle and the village, he was requested erroneously. Trying to accommodate K., the Mayor offers him a position in the service of the schoolteacher as a janitor. Meanwhile, K., unfamiliar with the customs, bureaucracy, and processes of the village, continues to attempt to reach Klamm, who is not accessible.

The villagers hold the officials and the castle in the highest regard, justifying, quite elaborately at times, the actions of the officials, even though they do not appear to know what or why the officials do what they do. The villagers simply defend it.

K’s problem, no doubt, is that he failed to master the intricacies of Checkuser. He just wanted to survey land, poor fool.

July 22, 2007
Thoroughly spoiled Harry Potter
Posted by Teresa at 12:56 AM * 743 comments

A thread for everyone who wants to discuss Harry Potter without having constant recourse to circumlocutions and ROT-13. (Thanks to Susan for the suggestion.)

July 21, 2007
And their heptalogies are just noise
Posted by Avram Grumer at 02:15 PM * 372 comments

I’ve seen articles and blog posts about the finish of the Harry Potter series that mention that fans have been waiting for the seventh book for ten years, as if that’s a long time. I suppose it is, if you were eleven years old when the first came out, or if you don’t usually read long book series, but my first thought, when I saw one of those articles, was John Crowley fans are just rolling their eyes. Check out the publication history on Crowley’s Ægypt tetralogy:

  1. Ægypt (aka The Solitudes) — 1987
  2. Love & Sleep — 1994
  3. Dæmonomania — 2000
  4. Endles Things — 2007

But at least it finished. So did Stephen King’s Dark Tower series, which took 22 years between Book 1 and Book 7. When I was in high school, I was into a series by David Gerrold, The War Against the Chtorr:

  1. A Matter for Men — 1983
  2. A Day for Damnation — 1985
  3. A Rage for Revenge — 1989
  4. A Season for Slaughter — 1993
  5. A Method For Madnessunpublished
  6. A Time for Treasonunpublished
  7. A Case for Courageunpublished

Gerrold says he’s still working on it. I’ve lost interest.

And there are Samuel Delany’s Stars in my Pocket Like Grains of Sand (published in 1984, sequel still unfinished) and Alexei Panshin’s Anthony Villiers books (first three published in 1968 and ’69, fourth never published, but at least each book stands on its own as a story).

How about Steven Brust’s Vlad Taltos books? A projected ninteen-book series, the first of which (Jhereg) was published in 1983, and the eleventh of which was recently delivered to Brust’s publisher. At that rate, the series ought to wrap up around 2028, a total of 45 years from start to finish.

And I’m not even going to bring up comics. Like Cerebus, which took 27 years from first to last issue, and the author went crazy about two-thirds of the way through and invented his own religion. But I’m not going to mention it. Nope.

“Waiting for ten years.” Hmph.

July 20, 2007
Flamer Bingo
Posted by Teresa at 03:01 PM * 374 comments

I’m collecting those indomitably stupid lines and memes that recur whenever there’s interpersonal friction on the net. For instance:

All you people/folks/guys—

I love how everyone feels the need to put words into my mouth.

It’s like you all have something to prove.

I’ve been in contact with my lawyer.

Get a life.

Give me some more.

President Cheney
Posted by Jim Macdonald at 12:41 PM * 79 comments

Breaking news at CNN:

WASHINGTON (CNN) – President Bush will undergo a routine colonoscopy Saturday, and will transfer power to Vice President Dick Cheney during the procedure, expected to take about two and a half hours, the chief White House spokesman said.
Doctors are attempting to discover exactly how far up his ass George’s head is located.

July 19, 2007
Hey, nineteen!
Posted by Avram Grumer at 08:15 PM * 54 comments

Bush’s approval rating in Wisconsin has dropped even lower than the Crazification Factor would allow — 19% according to a poll by Strategic Vision. Unfortunately, he seems intent on taking the country along as he slides on down.

(Is there a Bloggie award for most strained musical reference?)

(Poll link via Tapped.)

July 17, 2007
Index to Medical Posts
Posted by Jim Macdonald at 02:12 PM *

Emergency Medicine entries I’ve posted so far:

Emergency Preparedness:

Related interest:

Some of Teresa’s emergency posts:

Abi’s emergency posts

Copyright © 2007-2009 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.

Creative Commons License
Index to Medical Posts by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.

(Attribution URL:

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July 16, 2007
Peppers and Raclette
Posted by Teresa at 09:50 PM *

Raclette is a Swiss cheese that’s specially engineered to melt. This makes it the exact opposite of Queso para freir, a Latino cheese that’s specially engineered to not melt. Raclette is aggressively smelly until it melts, at which point it becomes delectable.

The classic thing to do with raclette is to toast it in front of a fire, scraping off the top layer as it melts, and serve that over French bread with bits of ham, other nibbles, and little cornichon pickles.

I don’t have a fireplace, and anyway it’s midsummer in New York; but melted raclette is still yummy stuff.

Peppers with Raclette, Raclette with Peppers

2 small or 1/2 each of two large bell peppers
1/3 - 1/2 pounds of raclette, roughly sliced
two-thirds or so of a fresh baguette
a nice white Chardonnay, chilled
a couple of tablespoons of butter
dried crumbled oregano
coarsely ground black pepper

Slice the peppers medium-finely, cut them across a few times so they won’t behave like pasta, toss the butter into a good nonstick pan, and toss the peppers in after it. Saute, stirring occasionally. Dose well with salt, black pepper, and crumbled oregano. Meanwhile, slice up the raclette. When the peppers have gone limp and aren’t throwing off enough liquid to indefinitely protect themselves from scorching, toss a half-cup or more of Chardonnay on top of them, stirring a bit. While that simmers, cut up the bread into thick slices and arrange them closely on a serving plate. When so much liquid has evaporated that the peppers are only ankle-deep in it, throw in the raclette. Stir a few times while it’s melting. Meanwhile, pour a couple of glasses of the Chardonnay. When the raclette is all melted, pour it out evenly over the rounds of bread. Eat soon, while drinking Chardonnay.

(Patrick, I didn’t use up all the raclette. I can make this for you when you get home from Clarion.)

[Recipe Index]

Trauma and You, Part Two: Shock
Posted by Jim Macdonald at 12:23 PM * 106 comments

Now it’s time to have our little chat about shock. Shock is what kills people. Shock, dear friends, is what will eventually kill you, personally. The only question will be how you got into shock to start with.

Shock is the simple word, hypoperfusion is the fancy word. That is hypo (low), perfusion (delivery of oxygen and nutrients to the cells throughout the body).

Some of those body cells are more sensitive to low perfusion than others. Brain cells, now, can go without oxygen for between four and six minutes. That’s why we’re checking Airway, Breathing, and Circulation every five minutes. Big chunks of emergency medicine, and all of CPR, is about getting oxygenated blood to the brain. Skin cells can go hours without oxygenated blood. Maybe days. Other tissues have other thresholds.

There are four main classes of shock:

  • Hypovolemic (from hypo, low, and volemic, of or pertaining to volume). Bleeding is the most obvious way to get there, but dehydration from whatever cause (burns, diarrhea, etc.) will get you to the same place.
  • Obstructive (something is stopping the blood from picking up oxygen) (examples: pulmonary embolism, tension pneumothorax, cardiac tamponade),
  • Distributive (something is preventing the oxygenated blood/nutrients from reaching the cells), with its subcategories and
  • Cardiogenic (the heart isn’t beating well enough to push the blood around).

But now for the good stuff: Hypovolemic shock.

Usually in trauma the kind of shock you see is Hypovolemic shock—there just isn’t enough blood to move oxygen around to everywhere, because that blood is now in a puddle on the ground. As the body loses blood, it compensates by shutting down peripheral circulation. Skin and muscle can go for a long time without nutrients and oxygen. Then the various internal organs get their blood supply shunted to the heart/lungs/brain area. And here is where the Golden Hour—the hour from when the trauma occurs to the moment the OR doors close behind the patient—comes from. Just as the brain lasts four to six minutes without oxygen, the kidneys last forty-five minutes to an hour and a quarter without oxygen. And if your kidneys die, you’re dead, and not in any kind of quick and pleasant way, either.

Your patient will complain of being thirsty. Don’t give him water. He’ll just vomit it up, because when he started going into shock one of the first systems to shut down was the digestive system. That gives you the added problems of ruining his blood pH by dumping stomach acid, and compromising his airway from aspirating the vomitus. Besides, who wants to get puked on?

The adult human body contains between four and six liters of blood. That isn’t a heck of a lot. Kids and babies have less.

A sign is something that you can see for yourself. A symptom is something that your patient tells you. The first symptom of going into shock is a feeling of anxiety. The patient is restless and apprehensive. As time goes on and shock progresses, the skin gets cool and pale as blood is shunted away from the skin and into the deeper organs. The heart rate goes up, to move what blood is still in the body around, the respiration rate increases to get more oxygen on the red cells that are left. The body releases adrenaline, which causes sweating. The body temperature goes down. The patient becomes listless, speech becomes confused, blood pressure plummets, the pupils get sluggish and dilate, breathing becomes slow and irregular. Then the patient dies.

This is all no fun for you, and less fun for the patient. The abbreviation for this is CTD, for Circling The Drain.

Even if you can’t see a pool of blood, the patient can be bleeding out internally. One of the tiny little costal arteries (the ones that run along the bottom edge of each rib) can bleed 50 mL per minute. The femoral arteries are as big around as your thumb: you can lose a lot of blood out of one of those puppies, very fast.

Less than 15% blood loss is referred to as Class I shock. The only thing you’ll see in Class I shock is that anxiety. The patient remains alert, the blood pressure, heart rate, and respiration rates stay within normal limits, and the skin’s temperature, color, and condition are unchanged.

For an adult with the average 5 liters of blood, that’s up to 750 mL. 750 mL is the amount in a wine bottle. For an adult bleeding internally with a torn costal artery, that’s fifteen minutes.

Next comes Class II shock. 15-30% blood volume loss. The patient is more anxious and restless. The skin gets pale, cool, and dry as blood is shunted to the vital organs. Blood pressure remains within normal limits, The heart rate increases to over 100 beats per minute, the respiration rate rises above 20 per minute. Capillary refill slows. (To check capillary refill, pinch the fingernail. It’ll blanch. Release pressure. The color returns. Normal is less than two seconds. (Not a reliable sign in adults.)) The pulse becomes thready (that is, hard to feel).

Class III shock is 30% to 40% blood volume loss. Up to two liters (a large plastic Coke bottle) in that average adult. The body’s compensatory mechanisms start to fail. The blood pressure plummets; you lose the radial pulse (in the wrist), then the femoral pulse (in the groin), then the carotid pulse (in the neck). Only now do you get the classic “signs of shock”: pale, cold, clammy skin; confused verbal responses, rapid heartrate, rapid respirations; cold extremities.

By the time you see the classic signs of shock you are on the edge of Too Friggin’ Late.

Next stage is Class IV shock. 40%+ blood loss. Forty minutes for that guy with the tiny little costal artery bleed The vasoconstriction from earlier, compensated, shock starts to be a complication itself. The heartrate continues to rise, then falls. Blood pressure continues to fall. Respiration rates rise further still, then fall sharply. The patient becomes incoherent, then unconscious. The pupils dilate. On a scale from good to bad, the needle is now pegged out on Bad.

What to do about this: Establish an IV (or two) and put in crystaloid (normal saline or Lactated Ringer’s) to a max of about two liters. You don’t want to raise the blood pressure too high, because that can blow off any newly-formed clots that are limiting bleeding. Take it up to about a systolic pressure of 90mm Hg (the point where you can first detect a radial pulse). Likewise it does you no good just to run water around in the patient’s veins. Without red cells (which are likewise lying in that pool on the ground) oxygen won’t be transported. This patient needs a nice blood transfusion, which you probably don’t have in the trunk of your car.

Another way we categorize shock progression is as:

  • Compensated shock,
  • Decompensated shock,
  • Irreversible shock.

Friends, you don’t want to get to Irreversible shock.

Little kids are very good at compensating. They maintain their blood pressure, and they maintain their blood pressure, and they maintain their blood pressure … then they crash and there’s no coming back. Don’t look at blood pressure in kids. Look at heart rate.

Here’s something else you can do: take your Sharpie marker. Feel the kid’s arm. You’ll notice a place where the arm starts getting cold. Draw a line on his arm at that level. Do the same again a while later. If what you’re doing is working, the line between warm and cold will have moved down the arm. Keep doing it. If the line is moving up the arm, what you’re doing isn’t working. Find something else to do (or continue what you’re doing only more, and better).

The signs and symptoms for all varieties of shock are very similar, and the treatment for all of them is nearly identical in the field.

Some brief notes on some kinds of shock you might see on a trauma scene.

You can see Neurogenic shock and Obstructive shock in trauma cases. Distributive and Cardiogenic less often.

In Obstructive Shock the blood is prevented from picking up oxygen. Some examples of this include cardiac tamponade (the pericardial sac is filling with blood, preventing the heart from expanding and moving blood), tension pneumothorax (the chest is filling with air and is squeezing the lungs and heart), and pulmonary embolism (there’s a blockage in the pulmonary artery (blood clot, fat, marrow, air) that keeps blood from moving through the lungs to pick up oxygen.

Some of what I’m going to talk about is Black Belt EMS-fu. Don’t try this at home, kids. You need training, equipment you probably don’t have with you, and a license, to do it.

That being said: Cardiac tamponade. You’ll suspect cardiac tamponade when the patient’s pulse pressure is narrowing (the top and bottom numbers on the blood pressure are getting closer together), the heart sounds are muffled, the mechanism of injury suggests trauma to the mid-chest, and the guy is developing signs and symptoms of shock and you’ve already fixed everything else but it didn’t help. What’s going on: The heart is inside of a tough fibrous sac called the pericardium. If the heart is lacerated and is bleeding into that sac, eventually the pericardium will fill up with blood and the heart won’t have room to expand. No expansion, no blood being pumped, no oxygenated blood reaches the cells, the organs die, no fun for anyone.

What to do about it: Hook the guy up to an EKG. Get a big-ass needle attached to a syringe. Go in below the rib cage, angled slightly up. When you touch the heart you’ll seek EKG changes. Put the needle through the pericardial sac. Pull out the blood. It’ll be dark and very liquid. When you’ve done this, the guy should improve.

Another cause of obstructive shock is tension pneumothorax. The chest is filling up with air, leaving no room for the lungs to expand and the heart to beat. You can get this from a ruptured lung or from a sucking chest wound.

Ruptured lungs. Gotta love ‘em. You see this with “paper bag syndrome.” The guy sees the tree approaching the nose of his car. He reflexively takes a deep breath and holds it—then his chest hits the steering wheel. Should have been wearing his seatbelt.

Tension pneumothorax is bad — you can tell you’ve got that because you have an injury to the chest, absent lung sounds on one side, diminishing lung sounds on the other, and the trachea moving (tracheal deviation — it isn’t just for breakfast any more!) away from the injured side toward the uninjured side. That’s happening because the contents of the chest are all moving over toward the uninjured side, smushing them, and the trachea is attached to the stuff that’s moving. Plus, the patient is CTD and you’ve already fixed everything else that you’ve found. Oh — and it’s getting increasingly difficult to ventilate the patient with a BVM. (BVM is not only the Blessed Virgin Mary. It’s also a Bag Valve Mask, used for artificial ventillation. Sometimes called an Ambu Bag because they’re made by the Ambu company.)

Tracheal deviation is a late sign. How to look for it: Put your thumb and forefinger on either side of the patient’s windpipe and trace it down. The trachea should be vertical. Shifting to right or left is bad. If the trachea shifts toward the injured side, it’s simple pneumothorax, which is merely bad. If the trachea is shifting away it’s tension pneumothorax, which is Bad.

One thing to do (and again, this is high-level EMS-fu, don’t try it at home): Needle decompression: Put a big-ass needle through the chest wall just above the third rib on the mid-clavicular line. Wait for a nice gush of air and the patient’s condition to improve. This is what we call “an invasive procedure.” If the guy didn’t have an open pneumothorax before he does now.

In practical terms, get a large-bore IV catheter. Snip the tip off one of your spare latex gloves. Shove the needle through the tip of that cut-off finger (this will form a one-way valve). Find the space between the second and third ribs. (Here’s how: Find the suprasternal notch (the little dished out bit at the top of the breastbone at the neck, centerline). Trace down to the Angle of Louis, which is the bump you feel as you run your finger down the sternum. That marks the gap between the 2nd and 3rd ribs. (You can’t count ribs directly because the clavicle overlies the first rib.) Now trace the space between the ribs at that level over toward the injured side to the mid-clavicular line (the vertical line that bisects the collarbone), and stick the needle with its little glove-tip through into the the chest. If everything is working right, you get a rush of air, and the patient improves. You want to go on the top of the rib rather than the bottom of the rib, because there’s a little costal artery and a nerve that run along the bottom edge and hitting them would be bad.

If you don’t have the needle, and the training (or better still, a chest tube), the quick hold-what-you’ve-got fix is to roll the guy onto his injured side and let gravity help keep the uninjured side open.

Another cause of Obstructive Shock is Pulmonary Embolism (PE).

For Pulmonary embolism check the ABCs: Adios, Buy Flowers, Call the Coroner.

Actually, seriously, a PE is a blockage in the pulmonary artery that is bringing blood through the lungs to pick up oxygen. Lots of things can block that blood vessel: a blood clot that’s broken loose (which is why DVT (Deep Vein Thrombosis) is so dangerous; that’s what kills people who’ve been sitting in one position for a long time (for example on a long air flight in a cramped position, or when attached to a cell wall with handcuffs at Abu Ghraib)—a clot forms due to sluggish circulation, then breaks free, travels through the Vena Cava (a big vein), through the right side of the heart (still large-bore) then into the pulmonary artery, where the diameter of the blood vessels get smaller and smaller until at some point it’s too small to pass the clot. Other things that might form emboli include fat, marrow from broken bones, air, and little bits of plastic from very bad technique when you’re starting your IVs.

With blood blocked from dumping carbon dioxide and picking up oxygen, bingo, there you are in hypoperfusion. Shock.

What to do about it? Provide oxygen so that if any part of the lungs is getting blood flow around the aveoli that it’s oxygen rich there, and get your patient to the hospital.

Now that we’ve lightly touched on Obstructive shock, time to move on to Distributive shock. Oxygen is getting to the blood, the heart is beating, but the oxygen isn’t getting distributed to the organs.

First up is Neurogenic shock.

As you know, Bob, the veins and arteries have layers of muscle that are under control of the autonomic nervous system, to change their diameters and thus control exactly where the blood goes. If the body loses that ability to constrict the blood vessels and they fully relax, there just isn’t enough blood to fill all those miles and miles of veins and arteries and venules and arterioles and capillaries and so on. You might as well have that pool of blood on the ground, because there isn’t enough fluid to move oxygen and nutrients to the vital organs. You get this if the spinal cord is disrupted, or in certain disease conditions.

You can tell you have neurogenic shock because the patient has the classic signs of shock (pale, sweaty, cold) above a horizontal line on his body, but below that line he’s all warm, pink, and dry. You’re also looking for mechanism of injury: did he get hit in the spine? Also, in males, he has a raging erection. This is the ever-popular priapism (named for King Priapus, who apparently had it), a Bad Sign. (The blood vessels below the injury have fully relaxed, and that’s blood pooling in those open veins and arteries.) This may be part of why the Marquis de Sade thought that hanging was the most sensual way to die. The trauma to the spine puts the person into neurogenic shock.

Very similar in most respects is Psychogenic shock. That’s when the Publisher’s Clearing House Prize Patrol arrives at your door, gives you a check for ten million dollars, and you faint. What’s happened there is again your nervous system not controlling the blood vessels, the vessels dilating, and oxygen no longer reaching your organs. The brain being most sensitive to lack of oxygen you pass out and down you go.

Psychogenic shock is self-limiting. Once you’re unconscious your autonomic nervous system checks back in and gets oxygen back to your brain.

At an accident scene you can’t tell if your patient is in psychogenic shock because his new Beemer is now junk, or he’s in hypovolemic shock because he’s bleeding out into his pelvis, so you treat ‘em the same.

You don’t generally see toxic shock (aka septic shock) or anaphylactic shock on trauma scenes, except maybe Granny fell down the stairs because that urinary tract infection got to her, or maybe the reason Fred crashed was because he was stung by a bee and he’s allergic. In both toxic and anaphylactic shock the root cause is the blood vessels getting porous and allowing fluid to dump into the intercellular space, not leaving sufficient to move the red cells around to perfuse the organs.

Similarly for cardiogenic shock — having a heart attack can make someone fall in the shower.

I haven’t touched on asphyxia (a kind of obstructive shock) or diabetic shock (distributive) or many other things. I did talk about diabetes in general elsewhere.

What to do about this?

First, assume that your patient is going to go into shock if he isn’t there already. Once the patient starts to slide it’s awfully hard to get back up the slope, so start treating for shock early, before any signs or symptoms develop.

To treat for shock, get the patient lying down. A person in shock can’t control body temperature well, so wrap the patient in a blanket (under them as well as over them). Raise the patient’s feet twelve to eighteen inches. Provide oxygen if you have it. Establish two large-bore IVs in the best, most proximal veins you can find. Stay with the patient, hold their hand, talk to them.

Do all of these things for any variety of shock and you will be doing well.

Trauma and You will return in Part Three: Sticks and Stones.

Copyright © 2007 by James D. Macdonald

I am not a physician. I can neither diagnose nor prescribe. This post is presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.

Creative Commons License
Trauma and You, Part Two: Shock by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.

(Attribution URL:

Index to Medical Posts

July 15, 2007
We’re back
Posted by Patrick at 08:23 PM *

And yes, we were seriously munged much of today. For details, start with this comment, read the rest of the thread, then jump to the conversation here. Briefly, we couldn’t publish new posts to the front page, and although new comments could be posted to individual threads, the front-page comment counts and sidebar recent-comment list weren’t updating. The one thing we could do was post to Sidelights and Particles, so we used those to send up the bat-signal. Thanks to the many, many people who gave us help and advice, including Ken Snider, Mary Dell, Kathryn-from-Sunnydale, Abi Sutherland, Cory Doctorow, Lisa Spangenberg, Michael Croft, Todd Larason, Erik V. Olson, and the many people in the two discussion threads.

Just what I wanted when I’m in Seattle trying to get ready to teach a week of Clarion. And just what Teresa wanted when she’s about to [SENTENCE REDACTED]. As you might imagine.

The hell of it is: we still don’t know for sure what happened. Hosting Matters, our hosting provider, had a planned outage at 6 PM EDT tonight. After that happened, they had a plan to try to replicate the problem while they monitored server logs in realtime. But what happened? You guessed it: the act of rebooting the server made the problem go away. This sort of thing is why Nielsen Hayden’s First Law of Computers is “computers don’t work.” Take this as axiomatic and the stress you derive from modern life will diminish markedly.

July 14, 2007
Open Thread 88
Posted by Jim Macdonald at 09:36 PM *

Happy Bastille Day!


I love this series of messages: 97, Susan; 103, Ajay; 105, Jakob; 110, Nerdycellist; 123, Ethan; 124, Ajay; and 132, Susan.


Trauma and You, Part One: The Basics
Posted by Jim Macdonald at 09:30 PM * 118 comments

Trauma is a surgical disease. It is cured with bright lights and cold steel.

Okay, everyone, it’s time to talk about trauma in general. Between the ages of one and forty, trauma is the number-one killer of Americans. (After age forty trauma drops to number four, after heart attack, stroke, and cancer.)

As a citizen on the street, what you need to know about trauma:

If you get your patient into the back of an ambulance, and the ambulance headed to an emergency room, you have done right.

I’m still going to do future posts going into more detail on diseases and injuries, I’m sure of it. Head injuries by themselves could (and do, believe me) fill volumes, and the crossover point between trauma and disease can sometimes be obscure.

What I’m looking at here is more the First Aid side of things. I’m not going to make anyone into an EMT (that takes a 140 hour course, memorizing a thousand-page book, and passing a test), but instead just chat about Dreadful Things. I’ll give you aphorisms and guidelines, mnemonics and cookbook recipes that you can follow without knowing all of the ‘why’ and still get to a good outcome. Sometimes.

Here’s an example of the Dreadful Thing from the patient’s point of view. Notice the patient going into shock. That’s good for the patient—being in shock means that it doesn’t hurt any more. Bad from the responder’s point of view: Shock is what kills people. More on that in a bit.

So, what’s trauma? It’s the physical world impinging on your tender body. Not to be confused with biology happening (in the form of bugs and germs), or chemicals (poisons, overdoses) happening, or your body breaking down and wearing out and going mysteriously wrong. No, this is more the Force of Gravity sort of stuff. Big classifications: Penetrating trauma (where something went through the skin), Blunt trauma (where the skin isn’t broken) and Burns (which I sorta discussed already at Stop, Drop, and Roll and may breeze right by here). I’m also assuming that you aren’t in a Multiple Casualty Incident (MCI) situation. If you are, it’s triage time and the game is really different. (See Triage For Fun and Profit for more on that.)

Now, what you’ve been waiting for! Everything you need to know about Trauma in just thirteen words:

Air goes in and out. Blood goes around and around. Variations are bad.

For reasons that I hope will become clear, to give your patient their best chance you want the operating room doors closing behind them no more than one hour after the injury. Therefore, the first and most important thing you can do when you see trauma is:

Get help rolling. Now.

How to get help rolling: Turn to the nearest bystander. Look them in the eye. Point to them. SayYou. Go call 9-1-1. Now. Come back and tell me when you’ve done it.”

If you’re alone, go and call 9-1-1 yourself. Nothing else you can do is more important.

Great! You’ve got help on the way. Next (and some authorities place this ahead of calling for help, but I don’t agree with those authorities), make sure the scene is safe. There is something over there that munches people. You are a people. Don’t get munched yourself. If you do get munched what you’ve accomplished is this: you’ve incremented the patient count by one and simultaneously you’ve decreased the responder count by one. On a scale from good to bad this is bad.

In order of priority here’s who you care about on scene:
1) Yourself.
2) Your partner.
3) Other public-safety personnel (police, fire, highway department, utilities, etc).
4) Random bystanders.
5) The patient.

Reason for this is: Maximize the number of responders and minimize the number of casualties. That poor suffering SOB with tire tracks across both thighs? He’s already hurt.

This leads us to the next general principal: No matter how bad things are, make sure that after you arrive that’s as bad as they’re going to get. This goes back to the very earliest days of medicine: “First, do no harm.” Primum non nocere.

My adage:

Hold what you’ve got.

If the scene isn’t safe, make it safe. You wouldn’t run out into the middle of the street on a normal day, would you? Having a kid and a car tangled in the middle of that street doesn’t change things. Don’t run into the middle of that street without taking steps to make it safe. Grab a couple of bystanders and say, “You. Go there. Stop traffic.”

Myself, I carry highway flares in the trunk of my car, and more in my Bag Of Tricks. Depending on where you live you might get fold-up reflective triangles. Here’s where to place them: 100 feet from the scene, two hundred feet from the scene, and three hundred feet from the scene. Here’s how to do that: Walk away from the scene. Every time your left foot hits the ground, count “one.” Drop a flare or a triangle at 20, 40, and 60.

Pay special attention to power lines down, smell of gas, fire, smoke, and other hazards. When a phone pole is down the danger zone extends to the second intact pole from the point of impact.

Now let’s get to the good stuff: Bleeding bodies. We’re inching away from personal safety. Last note: Wear gloves (latex, nitrile, vinyl). You don’t want what the patient has, and the patient doesn’t want what you have. The two things I have on my keychain (besides keys) are a pocket mask and a whistle. And when everything is over, wash your hands in hot soapy water.

With the scene safe and help on the way, walk up to the poor suffering SOB on the ground and say, “Hi! My name is [your name here]. Can I help you?” If the patient says “Yes,” you’re golden. If the patient doesn’t say anything at all, silence implies consent. If the patient says “No!” and a) is unimpaired by drugs or alcohol, is b) of legal age, and c) understands what’s going on (“Are you aware that your arm is off at the shoulder?”) then just back off until the help (that you already have rolling) arrives.

As long as you’re doing the best you can the Good Samaritan laws that most states have in place shield you from liability.

Now you’re at your patient’s side and have permission to proceed. Emergency medicine is really simple. It’s totally kindergarten stuff. If you can remember the letters ABC you have it.

ABC stand for Airway, Breathing, Circulation. If you ever get lost, if you can’t figure out what to do next, drop back to ABC.

The first, most important thing to deal with is Airway. If you don’t have an airway, you don’t have a patient. Get an airway (a connection from the lungs to the outside atmosphere via the trachea (i.e. windpipe)) any way you can. A human being can last from four to six minutes without air. That’s how long you have to get that airway.

The most common thing that’ll block a patient’s airway is his own tongue. An unconscious person loses muscle tone; if he’s on his back the tongue slumps down and occludes the airway.

These days the American Heart Association (in their First Aid course) teach lay responders to use head tilt/chin lift for opening all airways. I’m not sure I agree with that. Sure, it’s easy to teach, and easy to perform, but if your patient has a broken neck it could cause problems down the road (like severing the spinal cord, turning the poor suffering SOB into a quadriplegic, which probably isn’t what he had in mind for how to spend the rest of his life).

So: when you suspect a neck injury (an automobile accident, a fall, any time you see injury north of the collarbone), I’d say open the airway with a jaw thrust. That is:

Kneeling above the patient’s head, holding his head stable with the heels of your hands, push up on the angle of the jaw with your fingers, moving the chin up. This will lift the patient’s tongue out of his airway. Video of How To Do It.

If you’re in front of the patient, put your thumbs on his cheekbones, your fingers behind his jaw, and kinda do a scissors maneuver to move his jaw forward. Do this without twisting his head around.

When you hear gurgling in the airway, that’s fluid. If you don’t have a vacuum pump (or a big ol’ turkey baster) to suck the stuff out, remember that you’re standing on top of a 6.0 x 10^24 kg suction machine. While holding the patient’s head in line with the rest of his body roll him onto his side and let the fluid drain out.

You may need to use your (gloved) fingers to sweep out big chunks, broken teeth, mud, blood, and vomit.

If you don’t have an airway, you don’t have a patient.

Bottom line: Do what you have to in order to get an airway. Be as creative as you need to be. Let your conscience be your guide.

After A for Airway comes B for Breathing. Put your ear right next to the patient’s nose and mouth (if you can’t find the patient’s nose and mouth you’re in a whole different area of challenge—be creative) and Look, Listen, and Feel for air exchange. Occasional gasping breaths don’t count. That’s called Agonal Respiration for exactly the reason you’d think.

If the patient isn’t breathing, breathe for him, using that pocket face mask (see above, you don’t want what he has). The rate is one breath every five seconds, how much is until you see chest rise. You should be able to feel the air going in—that’s called Compliance. You don’t want to blow too fast or too hard because that’ll put air into the stomach instead of the lungs which a) doesn’t get any oxygen into the bloodstream, and b) makes it more likely that the patient will puke. A puking patient can lose his airway real fast, knocking you right back to step A.

The rule is you don’t go on from A to B until you have A. You don’t go on from B to C until you have B. So you’re going to be breathing for this guy until a) he starts breathing on his own, b) you grab another bystander who isn’t doing anything worthwhile and give him the job, c) the pros take over (which is why you got help rolling as Act One, Scene One in this whole comedy) or d) you fall over exhausted.

C is Circulation. Is the guy’s heart beating? If not, pump on his chest (hard, fast, deep, rate of 100 per minute, one and a half to two inches). You’re now doing full CPR, and the success rate for CPR in the case of traumatic arrest is abysmal. But you might as well, right? You aren’t going to just stand there waiting for the ambulance. But let’s say the guy’s heart is beating, and you know this because he’s breathing, he’s moving, and you see blood spurting in bright red arcs. Circulation also covers those ten-foot arcs of blood. The pools of blood. Anything to do with blood.

Check the patient’s skin temperature, color, and condition. You’re going to find out if internal bleeding is going on that way. If you find external bleeding, control it.

How to control external bleeding: put the heel of your hand against the bleeding spot and press, hard. Take the cleanest cloth you can find and press it onto the bleeding place. If it soaks through, put on another cloth and press, hard. Keep adding cloth and pressing, hard, until the bleeding stops, or, if that doesn’t work, in addition to pressure, raise the bleeding spot above the patient’s heart. (Be aware of where the patient’s heart is, particularly if he’s lying on a slope.) If that still doesn’t work, find a pressure point (anywhere an artery passes next to a bone, where you can feel the pulse) between the injury and the heart, and press there.

Tourniquets are the next step, but if you’re using a tourniquet it means that your technique with direct pressure, elevation, and pressure points was lousy. If you absolutely, positively have to use a tourniquet, a) use a wide, soft piece of cloth (wire and fishing line are right out), put it over solid bone between the injury and the heart (not over a joint, not over a fracture), make sure the tourniquet is visible (don’t cover it with blankets or dressings), and write the letter T and the time on the patient’s forehead.

Don’t be stupid about any of this: If the bleeding is coming from the head and you feel broken skull bones under it, you don’t need to press those bone fragments into the patient’s brain. That would be bad. Nor do you want to find pressure points in his neck. There aren’t any pressure points for the chest and abdomen, and raising those above the patient’s heart isn’t going to happen.

Special cases of bleeding include Sucking Chest Wounds (those sorta fall under breathing, as in, if you don’t fix this breathing will be affected) and Sucking Neck Wounds.

Remember how Air Goes In and Out? You want it to go inside the lungs, not anywhere else. In a sucking chest wound, there’s an opening from the chest out to outside, and as the patient’s chest expands air gets sucked in through that hole. If you’re lucky this just gives you a simple pneumothorax—a collapsed lung on that side. If you’re unlucky, this gives you a tension penumothorax—everything starts squishing over toward the other side, collapsing not only this lung but the other one, compressing the heart, and generally making life difficult.

How to tell the difference between simple pneumothorax and tension pneumothorax: look for tracheal deviation. Run your fingers down the patient’s trachea in his neck. If it’s shifted over toward the injured side, you have simple pneumothorax. If it’s shifted toward the uninjured side you have tension pneumothorax. These are both late signs, but they’re neat to know.

Luckily, the basic first-aid treatment for both kinds of sucking chest wounds is the same: Use an occlusive dressing. That is, something that air won’t go through. If you have tape, tape it down on three sides (forming a one-way valve—air goes out but can’t come in). If all you have is plastic wrap, use that. Other things include the wrappers that Tastykakes come in, the patient’s credit cards or driver’s license. Remember to check the patient’s back as well as his front. Holes can be anywhere.

If you have the occlusive dressing in place and the patient starts to go downhill (increasing difficulty breathing, tracheal deviation to the opposite side) you may have induced tension pneumothorax. Take off the occlusive dressing, burp the wound, and reapply.

Sucking neck wounds, now: If the major veins in the neck are open to the air, they can actually suck air into the circulatory system, creating an air embolism. This stops the Around-and-Around part of Blood Goes Around and Around. The fix for this: Occlusive dressing. (Other occlusive dressings can include petroleum jelly on gauze, bandage wrappers, and playing cards.) Be creative.

Sucking Wounds Imply Occlusive Dressings.

When you’re dealing with trauma, your life is pretty easy. You have 1) Things that’ll kill your patient in the next five minutes, 2) Things that’ll kill your patient in the next hour, 3) Things that’ll kill your patient today, and 4) Things that you don’t really care about.

When you’ve hit the ABC steps, you’ve taken care of the things that’ll kill your patient in the next five minutes. EMS is easy: If you ever get lost and can’t think of what to do next, drop back to A and go from there. You should be re-doing the ABCs every five minutes anyway, regardless of what else you’re doing and what else is going on. Patients who had an airway lose ‘em. Patients who were breathing stop.

You can perform all the steps in an ABC survey in under thirty seconds.

Do something else for four-and-a-half minutes. Then do ‘em again.

There are some cases when, once you’ve called for help and secured the scene, all you do is stand around waiting for the ambulance. Those are: decapitation, bisection, incineration, rigor mortis, dependent lividity, and decomposition. For everything else there’s something you should be doing.

At the minimum, if you suspect neck injury (falling off the swings at the playground, falling off the roof, a tiny little motor vehicle accident, the patient says “my neck hurts”) you should be holding c-spine. That is, keeping the patient’s head and neck from moving by using gentle pressure with your hands to keep his head in a normal in-line position. You can turf this off to a random bystander because you can teach this skill in under a minute, then move on to the next step.

The Boy Scout First Aid merit badge requirements

My personal first aid kit

Medical Emergency Response Team (MERT) training

Trauma and You will return in Part Two: Shock.

Copyright © 2007 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.

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Trauma and You, Part One: The Basics by James D. Macdonald is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.

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Index to Medical Posts

July 10, 2007
Found in the mail
Posted by Teresa at 09:52 PM *

Woo! Jhegaala!

Y’all’ll excuse me for a while here …

Peddling comment spam (again)
Posted by Teresa at 10:53 AM *

Remember PayPerPost and Paid Posting Tools? The bad idea that refuses to die? Yet another idiot (this time it’s twenty-year-old entrepreneur Jon Waraas) has come up with a scheme to make a stable business out of peddling blog comment spam to advertisers. He’s calling it Buy Blog Comments. To quote Josh Catone:

Buy Blog Comments charges $.20 per comment for what they say are “quality blog comments.” To write truly quality blog comments that won’t be flagged by site owners as spam like the site promises one would have to find related blog posts, read them, and compose thoughtful, on-topic replies that subtly weave in a marketing message with a link that is worthwhile to readers. If we can assume that takes at least 10 minutes per comment, then this site is paying its writers probably less than a $1/hour. That makes me skeptical that the site could deliver on its promise of comments that don’t look like spam. But I’ll let the site speak for itself and you can judge the “quality.”
He then quotes a representative sample of Jon Waraas’s own prose:
We dont use people who cant even speak english. It is important to have well written blog comments so that they wont get deleted by the blogger. All of our trained staff are currently from the USA and Canada and speak english very well.

I expect Waraas will run into the same problem encountered by all the other badguy-wannabe comment spam marketers: the excessively high per-comment cost of hiring writers who can turn out believable comment spam. Writers are cheap, but advertisers are cheaper. I don’t look for stealth comment spam to be a real problem until there’s a large pool of people in underdeveloped countries who can write undetectable standard English, but not get a better-paying job doing something else.

What I find funny about the comment-spam marketing business is that it would work much better as a “make money fast” scam. Check out my previous post about commercial comment spam to see a long but incomplete list of startups that’ve had the exact same bad idea as Mr. Waraas.

Obviously, the way to make money is not to run a business that commissions writers to hack out stealthy comment spam on behalf of clients’ marketing needs; it’s to sell the idea of starting up such a business, and let your hapless customers find out the hard way that hand-tailored comments of passable quality cost too much to be attractive to advertisers.

Come to think of it, the same is true of display sites (see also): they’re a bad idea that’s forever being reinvented and touted as the Next Big Thing, and they’re always miserable failures. The trick is not to run one; it’s to advertise that, for the low, low price of (mumblehundred) dollars, you’ll let your customers in on the secrets of running a display site. Given how often this unworkable idea gets reinvented, there’ve got to be suckers out there who’ll think it’s plausible.

Resurging “The Surge”
Posted by Jim Macdonald at 10:37 AM * 64 comments

Today on CNN we have the headline White House touts ‘retooled’ Iraq mission, which leads to this story:

Under pressure, White House predicts ‘new way’ in Iraq

In that story we read this fascinating bit:

Sources inside and outside the White House told CNN that discussions are taking place about what the alternative U.S. policy in Iraq would be if the troop increase does not work as planned.

And my instant reaction was, “They’re only thinking of that now?!

Year of the jackpot
Posted by Teresa at 08:13 AM * 170 comments

Teresa’s embroiled in some kind of project she’s not talking about. Patrick’s very busy being the head of Tor SF, especially since he needs to get a bunch of stuff done before he goes off to teach at Clarion. Jim Macdonald is currently the only available intermediate-level EMT in his neck of the woods, and since it’s a resort area during high summer, people will keep getting into trouble and needing to be rescued. Avram Grumer just moved house.

We’ve just stepped out to run a few errands. Back soon.

July 04, 2007
Fourth of July
Posted by Patrick at 12:19 PM * 28 comments

Off to the traditional festivities! Take care of yourselves and blow something up.

Posted by Patrick at 09:22 AM * 123 comments

“Those who profess to favor freedom and yet depreciate agitation, are people who want crops without ploughing the ground; they want rain without thunder and lightning; they want the ocean without the roar of its many waters. The struggle may be a moral one, or it may be a physical one, or it may be both. But it must be a struggle. Power concedes nothing without a demand; it never has and it never will.”
—Frederick Douglass

“In a time of universal deceit, telling the truth becomes a revolutionary act.”
—George Orwell

“If ye love wealth better than liberty, the tranquility of servitude than the animating contest of freedom—go from us in peace. We ask not your counsels or arms. Crouch down and lick the hands which feed you. May your chains sit lightly upon you, and may posterity forget that ye were our countrymen!”
—Samuel Adams

“This country, with its institutions, belongs to the people who inhabit it. Whenever they shall grow weary of the existing government, they can exercise their constitutional right of amending it, or their revolutionary right to dismember or overthrow it.”
—Abraham Lincoln

“Being afraid of monolithic organizations especially when they have computers is like being afraid of really big gorillas especially when they are on fire.”
—Bruce Sterling

“Somebody has to do something, and it’s just incredibly pathetic that it has to be us.”
—Jerry Garcia “Be not intimidated…nor suffer yourselves to be wheedled out of your liberties by any pretense of politeness, delicacy, or decency. These, as they are often used, are but three different names for hypocrisy, chicanery and cowardice.”
—John Adams

“No matter that patriotism is too often the refuge of scoundrels. Dissent, rebellion, and all-around hell-raising remain the true duty of patriots.”
—Barbara Ehrenreich

July 02, 2007
Get Out of Jail Free
Posted by Jim Macdonald at 08:28 PM *

The headline at CNN is Scooter Skates.

The headline at MSNBC is No Prison.

The story at McClatchy reads:

President Bush commuted the sentence of former White House aide I. Lewis “Scooter” Libby Monday, keeping him from serving a two-and-a-half year prison term meted out in the CIA leak case.

Calling the sentence “excessive,” Bush’s last minute commutation came after a federal court refused to allow Libby to remain free pending the appeal of his perjury conviction. Libby, who was convicted of perjury and obstruction of justice in the CIA leak case still faces a $250,000 fine.

More to come…

Isn’t obstruction of justice a High Crime and Misdemeanor? Can we impeach the stupid SOB now?

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