Am I the only one . . .

August 30, 2009 at 1:31 pm (By Rodjean)

. . . who doesn’t get the level of coverage of recent celebrity deaths. From Princess Diana to Anna Nicole Smith to Michael Jackson to Teddy Kennedy, it seems the media has to focus endlessly on a the most recent celebrity to die.

I understand the focus when the President is shot, but the youngest Kennedy brother was, in the immortal words of a former Texas Senator who once ran as a Democratic candidate for Vice President, “No Jack Kennedy.”

Of the four people I mentioned above, one was a nice girl who got stuck in an unhappy royal marriage. Another was a gold digger who shocked everybody by marrying for money, then got caught in a lengthy court battle over the millions she inherited. The third was a pop icon who was so strange he became an emblem of strangeness. The fourth was a guy who got into the U.S. Senate because he was the President’s brother, weathered some scandals, aspired to a leadership post in the Senate, but was ousted as Majority Whip, ran for the Democratic nomination for President and lost, then settled into a long term career in the Senate.

These musings came to the surface as my granddaughter saw her beloved Saturday Morning Cartoons preempted for live coverage of Sen. Kennedy’s funeral. It is not that his death wasn’t noteworthy, but simply he was not a great man, and the media are pretending that he was. If his death demands a week of fawning praise, what level of of adulation should we save for people who were actually accorded the top leadership positions in their party’s delegations, like Harry Reid or Bob Dole, or were nominated for the Presidency by their party and sparked a fundamental paradigm shift, like Barry Goldwater, or were actually elected President, like Jimmy Carter or George Bush, Sr.? Compared to Ted Kennedy, Bill Clinton is a giant.

Compared to Anna Nicole Smith, we’re all giants.

Michael Jackson was, in his prime, a gifted entertainer. His scandals probably made his passing more noteworthy, and the manner in which he died was certainly newsworthy. I can understand why there was a lot of coverage at first, but I don’t get why the country was plunged into weeks of rehashing everything about him.

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Bake Sale Achieves Goal, And Then Some!

August 28, 2009 at 8:44 pm (By Amba)

OKAY!!  WE CAN  STOP!!  A couple of very generous contributions have put us well over the line!  Bless you, my gang!  Long live Ron’s computer!   :D

_____________________________________

A vital member of our community is about to fall silent for a really stupid reason.  We can help.

Ron, of Fluffy Stuffin’ and frequent commenter consolation and laughter, has been hit simultaneously with a dying hard drive and a drought of business.  (FYI, the official unemployment rate in Detroit is 29.7 percent.)  I overheard him telling Ruth Anne on Twitter that he would probably soon drop out of sight.  The prospect of no Ron scared me, so I chased him down and asked him what was up and what it would take to keep him online.  I would not take “never mind” for an answer.

Bottom line, it would take about $300 that he can’t spare now and can’t predict when he’ll be able to.  For that, he can replace his ailing system with a reconditioned machine.

That’s a small amount of money to make such a big difference.  I’m not being paid just now myself (when I reminded Ron that Icepick and I had worked out the salutation for the times — “Glad to hear things could be worse!” —  Ron shot back, “We need a gang sign, too.”  See what I mean?), but I can certainly manage $30.  If ten of us can do that, we can keep that good stuff coming.

So if things could be worse for you just now, go to the hat down the left sidebar at AmbivaBlog (linking to it from here didn’t work) to pitch in.  I’ll put it all together and pass it along.

And if you’re indignant that this isn’t an actual bake sale, just let me know and I’ll make you a batch of Mom’s World War II brownies.

UPDATE: We have $60.  A fifth of the way there.

UPDATE II: Up to $120.

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Repair America!

August 28, 2009 at 3:22 am (By Amba)

If only.

If only we could do nationwide what an unlikely coalition of Californians are determined to do, and actually can, thanks to the oddities of their constitution:

California’s nemesis [the initiative-and-referendum provision that has led to metastasis of its constitution and loss of control of its budget] could soon become its salvation. [...]

Jim Wunderman [...] wrote [in an SF Chronicle op-ed]. “It is our duty to declare that our California government is not only broken, it has become destructive to our future. Therefore, are we not obligated to nullify our government and institute a new one?” He then called for a “citizens’ constitutional convention” to do the nullifying and the instituting. [...]

[The movement that op-ed inspired], called Repair California, is trying to put two initiatives on next year’s ballot. One would amend the California constitution to allow the voters to call a constitutional convention by initiative. (As it is, while specific amendments can be passed that way, it takes two-thirds of the legislature to call a convention. That will never happen.) The other would actually call the convention and specify its scope: governance, including the structure of the legislative and executive branches; elections, including the electoral system and the initiative process itself; the budget-making process; and the state’s revenue relationship with local government.

The genius of Repair California’s approach is twofold. First, it steers clear of “social issues”: no gay marriage, no abortion, no affirmative action.

And here comes the best part:

Second, the delegates would be chosen randomly from the adult population.

It’s the dream of a citizen legislature!  It calls the bluff of William F. Buckley’s marvelous statement that he’d rather be governed by the first 100 people in the phone book than by “the best and the brightest”!  Don’t you love it?!

Read more to find out what unlikely bedfellows are supporting Repair California, and exactly how this new constitutional convention would work.  And here’s the Repair California website.  Read it and weep.  And cheer.

If only!

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“We argue that depression is in fact an adaptation, a state of mind which brings real costs, but also brings real benefits.”

August 26, 2009 at 4:43 pm (By Amba)

Otherwise, how to explain its universal prevalence?  It has been found in just about every culture studied, of all states of social complexity.  So it is not a discontent of civilization, nor is it a dysfunction of older age:  the first episode tends to strike in adolescence or young adulthood, if not even earlier.  And studies show that “between 30 to 50 percent of people have met current psychiatric diagnostic criteria for major depressive disorder sometime in their lives.”

There’s a serotonin receptor in mammalian brains, implicated in depression, that has been highly conserved by evolution:  it is 99 percent similar in rats and humans.  “The ability to ‘turn on’ depression would seem to be important, then, not an accident.”

So given how impairing and even dangerous depression is, what could it be good for?  What could “drive the evolution of such a costly emotion”?  Can you guess?  Read and find out.

These authors think that rather than a malfunction, “depression seems more like the vertebrate eye—an intricate, highly organized piece of machinery that performs a specific function.”

Makes sense to me.

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A Doctor in the Trenches: A Guest Post on the Healthcare Mess [UPDATED]

August 26, 2009 at 3:07 pm (By Amba)

My sister, a specialized internist at a major university medical center and a professor in its med school, has told me more than once that from her position on the front lines, as a physician seeing clinic patients, she would much prefer a government-run, single-payer healthcare system, or short of that a public option, to the chaotic mix we have now.  I’ll post her thoughts, from several e-mails over time, without comment except for the questions that preceded some of her answers.

The conversation began when I wrote my sister about the predicament of an online friend in her city who had been unable to get needed joint-replacement surgery (surely not a waste of money in the case of someone my age, or even in that of our healthy 85-year-old mom who’s walking blissfully all over Chicago on her 3-year-old artificial knee) because she fell into that “too rich for Medicaid – too poor to buy insurance” gap.

So sad.  And such a common story. It infuriates me that people have to spend so much energy/time trying to get the bus fixed (I just LOVE that metaphor) when this should be a given. I feel so strongly that health care is a basic human right. It’s hard enough having to deal with your body falling apart but to have to endure the indignities of having to apply for indigent care compounds the awfulness. She’s right…you have to be destitute to get Medicaid here. . . . I’m helpless in the face of the great bureaucracy. Plenty of people figure out ways to get around things—put property in a spouse’s name and then divorce on paper. What bullshit that people have to go through such things!! . . . [My institution] is usually good about setting up payment plans for people with huge bills—reasonable plans that don’t demand 50% of your monthly income.

A:  Yeah . . . but would you like working in a govt. bureaucracy??

I work in a fucking bureaucracy now!! from my end it’s SO much easier to deal with Medicaid and Medicare than with private insurance. I’m RELIEVED when I have a patient with Federal or State insurance…actually less bullshit to negotiate in this day and age. I’m not just talking about HIV…I’m on the inpatient gen med service now dealing with everything (heart failure, liver failure, cardiac arrhythmias, pancreatitis, suicidal drug OD, obstructive uropathy from cancer, pneumonia with ARDS, pulmonary edema etc etc). You don’t understand what it’s like on the front line.

correction. you know what it’s like being on the front line as a patient in the system but not as a provider.

A:  What is ARDS?

Adult (sometimes acute) respiratory distress syndrome. i hope i didn’t come on too strong…being on the inpatient service is kind of like being in the medical equivalent of combat.

A: How come you are there?  Was it an assignment or a choice?  Or is it a rotation everybody feels obligated to take, like being department chair?

It’s kind of depressing to me that everyone views the same chaos and comes to the conclusions they were brought up to come to.  I bet you know conservative docs who believe the solution is MORE free enterprise, just ’cause that’s “where they’re coming from.”  The conservatives say that government medicine offers more universal low-level coverage but expensive, high-level, high-quality procedures and treatments become scarce and harder to obtain if you need them.

I’m just in between . . . don’t know what to think.  I too was raised to see government as tending to be “good,” big business as tending to be “bad,” and now I’m exposed to this barrage of the exact opposite.  I suspect only people who ARE on the front lines as providers know enough to have this debate.

What a mess it is!!  It must also be frustrating to have to clean up after people’s shitty life choices all the time.

we (all the attendings in medicine) have to do it [inpatient service] 1-2 times/yr. It’s actually “fun” in an insane, all encompassing way. But you’re so right SO many of the people we see are fat/smoke/drink too much/use bad drugs/don’t take their meds.  pick from the choices.  it’s extremely frustrating, especially when they expect us to fix it and get angry if we can’t. And there’s so much passivity and entitlement!!

We don’t need more access to expensive, high level high quality procedures. We need good patient centered primary care, less reliance on testing to rule out everything so we don’t get sued, less financial incentive for doing procedures (yes, including colonoscopy), more studies on the cost effectiveness of procedures on a population scale (are we REALLY saving $ by doing screening colons on everyone.  Yes, you occasionally find cancers in young people and save them. but at what cost? or stenting every single stenotic coronary artery?) and some serious discussions about end of life care. we’re keeping [people] with miserable quality of life alive to torture some more! It makes me feel like a cat!

*    *    *

Today I had to make a decision about a therapy in a patient with a bad disease and the decision point was determined totally by economics instead of what was best for her. (She has very bad pyoderma gangrenosum that I could treat with infliximab (has worked well for her in the past) but this is considered an outpatient med so it wouldn’t be paid for by her insurance (and it’s $$$). So I could either discharge her and give it to her as an outpatient (she’s on a PCA (patient controlled analgesia) pump so I didn’t want to do that) or pick something else. So we’re trying IVIG…also $$$ but I can give it inpatient. What kind of bullshit way is that to have to practice medicine? This is only one of so many daily occurrences. We just incorporate it into our daily decision making like it’s normal.

*     *     *

[AMA came out against public option] A:  Conservative friends on Twitter are ecstatic.  One (Catholic, pro-life, mother of preemie twins) says “Go A.M.A! I would have two dead children if it weren’t for private insurance and the top-notch neonatologists in the U.S. circa 2003.”  These people are fervently pro-capitalist.  They decry making an idol of Obama, yesterday I told them I thought they were making an idol of capitalism.  But I haven’t got a clue what to think.]

Totally predictable that the AMA would take this position…the potential is there for incomes to go down. It’s scary how many people we’re seeing who aren’t poor or disabled but don’t have health insurance. They don’t qualify for Medicare, Medicaid or our indigent care. One hospitalization could wipe out everything they own…it’s insane!!

I totally agree with your blog-friend about late in life care. Look what I’ve helped stave off for a patient  in his 90s with arterial disease!  More testing, more procedures, when he was functioning decently well…I’m thinking of the Podiatrist who was freaked out by his absent pulses and wanted dopplers then Vascular Surgery to do angioplasty when he didn’t have pain or obvious ischemia.  The potential complications in him could be devastating.  We (Dr’s) don’t think downstream–it’s all about fixing what’s broken (or looking for what might break) because that way we a) avoid lawsuits and b) are financially rewarded. And she’s so right about how there needs to be a shift in expectations on the patients’ side.

One thing I am worried about. There’s so much talk about outcome measurements–a good thing IF the measurements are good/accurate/meaningful. Based on one flawed study about giving antibiotics in a timely fashion to pts in the ED with pneumonia the big Joint Commission that does hospital accreditation now uses administration of abx [antibiotics] w/in 6 hrs of coming to the ED for any infection (or suspected infxn) as a quality measure. As a result some pts get abx before cultures are done (the waiting times in big public hospital ED’s can be incredible) which complicates and often prolongs hospitalization. Shitty quality measurement based on shitty science resulting in increased health care costs. This is only one of many such idiocies.

I quoted to her a comment by Ennui:

On the overall question of healthcare costs, if, as I suspect, the biggest factor input (especially for an aging population) is labor, and domestic labor costs cannot be simply reduced, the only way to reduce healthcare costs in a meaningful way is to reduce the quantity of healthcare delivered. The most effective way to do this, I think, is something like what Bruce B described.  Here’s a concrete instance: when I was a TA I had a student who managed to slice the palm side of his fingers with his new knife (which he was proudly showing me – what can I say, it’s Texas).  I took him to the emergency room where he was presented with 2 options.

  • Option 1: Stitch up the skin and hope that the knicked (but not severed) tendons would heal (he was told that it would probably be fine).  Price ~$750
  • Option 2: Call in the specialist to stitch up the tendons as well.  Price ~$5,000

He had no insurance.  But he wasn’t broke.  He mulled it over and chose option 1.  As it happens, his hand was fine.   This, harsh though it may seem, is cost cutting by means of market economics in the health care field.  This is what I am for.

Agree that the reduction in quantity of healthcare is a critical component…ways to do this include tort reform (amazing how much testing is driven by lawsuit fears), decreasing payments for procedures (decreases incentive), also some way of regulating/eliminating physician ownership of testing services they get paid for. For example, many Heme-Onc practices have their own CT scanners and they do frequent CT’s…often more often than is recommended based on evidence based studies. It’s not pure evil greed (although that’s in the equation) since the patients love it because it gives them a (often false) sense of security. But if you’re the MD and you own the CT scanner and private insurance will pay you $800 for a scan of course you’re going to do a lot of them! And sometimes you’ll do them when watchful waiting or some blood work could give you similar info. [Her husband, a gastroenterologist]‘s group owns their own endoscopy center so they get the facility fee instead of the hospital. They charge less than the hospital but it’s still (according to him) an amount disproportionate to the time/difficulty/expense to the practice. Do they do more endoscopies because they get paid directly? I’m guessing yes.

My admissions today so far…1) a homeless woman with horrible lice and a huge abscess on her butt.  also 2 boyfriends who don’t know about each other converging on the hospital  2) a nice lady with an axillary abscess and a UTI with a kidney stone 3) a 24 y.o. Haitian woman who only speaks French with severe abdominal pain that started suddenly while she was on an airplane. The plane was diverted here. Her CT scan showed an abnormal spleen. When we finally found a French speaking med student we discovered she has sickle cell dz (she got splenic infarcts from the low O2 sats on the plane. leading to sickling). The sad thing was she was traveling with her 9 m.o. old baby. CPS had to take the baby (she can’t keep him in the hospital) and her sister is racing here from Connecticut to try to intercept. If she gets here before 5 they’ll give her the baby, if not then the baby goes into foster care for the weekend and she’ll have to go to court to get him back (WTF?????). 5 more (admissions) to go. just thought you might to know what my days are like. I honestly love it a lot of the time.

[On a cartoon I sent her about doctors' callouw black humor]  A:  I’m not sure it’s something to deplore — it’s probably necessary for survival — but it can probably go too far, too.

it is kind of sad and inevitable at the same time. i see it happening and probably feed into it some myself…but you can’t help but generalize from your experiences.  so when I feel/act all jaded about the 5th heroin/crack/meth/alcohol addict that’s being admitted to my team and the medical students see it i try to remember to tell them a story about the time i made assumptions about somebody and was wrong.  it’s actually good for us to have students around because they make you behave.  you have to at least fake being a role model.

in response to a 2008 Pajamas Media article I sent her, by the unpseudonymous Anchoress, “Socialized Medicine Looks Inevitable“:

not bad. maybe Obama’s such a great chess player that he saw all these moves in advance–the private sector will have to scramble to make huge changes to try to head this off and the need for a govt plan will be moot. I guess because I’m a visceral liberal (it was our [family] religion after all) i don’t get the terror that the specter of a government plan strikes in the hearts of conservatives. especially since we don’t even know what it would consist of!

*     *     *

I’m getting sick of all the squawking and the relentless posturing.  How about you? From my in the trenches position I can tell you that the current private system is an inequitable mess that interferes with my ability to practice medicine on a daily basis. We have a large population of patients on Medicare and/or Medicaid and it’s a relief to deal with them! How ironic that there’s less red tape or obstructions to service with government-subsidized plans.  We also have a substantial population of patients who aren’t impoverished enough or sick enough or old enough to get Medicare/caid. Some of them qualify for our indigent care funds and are responsible for some percentage of their costs. Many of these work but have no insurance or inadequate insurance. So they ration their own health care—if you have to pay for 40% of your screening colonoscopy, PAP smear, mammogram, routine blood work etc you wouldn’t be taking such great care of yourself either! Not to mention the folks with HIV who are working and earning more than $20K/yr so they don’t qualify for ADAP (AIDS Drug Assistance Program)—they’ll have to figure out how to pay for their HIV meds which cost 10-15K/yr! Or they can ration their care and wait until they get sick. I don’t see private insurance being an answer to these access problems–they’re in the health care business after all. I feel strongly that a public government-run option is part of the answer.  Measures of quality of care are important but it’s critical that they be meaningful.

A:  Why do you think it is that some doctors in the same trenches are adamantly opposed to the public option?  Do they think they’ll make less money? Or is it just a question of how one is raised?  Do we just see through the eyes we inherited?  I saw a web page about how the hassles and time-wasting with Medicare were making some doctors refuse to take Medicare patients, so obviously some don’t find it refreshing, but maybe they’re going in with a bias against it?  It seems there is no objective reality.  You can go to Britain or Canada and find someone who thinks the world of their national health service and someone who hates it, based not even on their experience but on their demographics and preconceptions.  It sometimes really does seem that believing is seeing.

I’m not sure why some docs hate medicare so much. maybe it’s older docs who remember the days of total carte blanche. or private practice types who are used to raking in the dough with no impdiments. The problem is that we’ve created a two-tier system that really impacts the uninsured—the folks with “good” insurance (i.e. no-holds-barred, OK to see your GI doc when you fart, your neurologist for your HA, have a CT because you’re worried you might have cancer etc) have absurd expectations about what care they’re entitled to and don’t want anything to change. The uninsured can’t even get the basics and “ration” themselves until they’re really sick, then have to declare bankruptcy to pay the hospital bill. How fucked up is that system??? And docs can be greedy pigs too. What about all these oncology practices that have their own CT scanners now, often with an in-house radiologist. They say the patients like it better–but they do an absurd number of scans and get paid fortunes by the insurance company. Oh I could rave on and on. Americans can be so selfish and shortsighted about their health care (“I’ve got mine so fuck you”).  And as to the Canadian model–it’s done really well by [another of our sisters and her husband who had a detached retina], just for a personal example. When she had alarming symptoms last year she got bumped to the head of the line. and he got his eye fixed (or at least worked on) right away AND he doesn’t have to worry about how to pay for it. People get mad at docs because we ask what kind of insurance they have–for me at least it’s because i need to know how much shit i’m going to have to wade through to get done what needs to be done! And it’s not the government that’s providing the shit!

UPDATE: The author responds to the comments.

Cool!  Love the comments. Realpc is a smart dude. So true that we do WAY too much in situations of futility (just put a demented 89 yo on dialysis ’cause his family wouldn’t hear of letting him go. How awful for him and how costly for us). When I say health care is a basic human right I absolutely am responding to the inequities of the current system. “Rich” people can get their diabetes and high BP
treated and “poor” people sometimes can’t. What’s up with that?? So I have to take care of the fat alcoholic and drug addicted smokers who drive too fast and when they’re impaired, don’t use condoms and sleep around? You bet. Since when is society allowed to pick and choose who gets services based on their lifestyle choices? There’s too much of the “I’ve got mine so too bad for you” in these conversations about health care. And re another comment…I can’t remember the last time anybody worshipped me as a doctor. where do people get these ideas?? Too much Grey’s Anatomy and “House”??

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1491

August 26, 2009 at 1:23 am (By Rodjean)

I just read a book entitled “1941,” which was published in 2006 by a science writer named Charles Mann. The book cites a growing number of anthropologists and archeologists who believe that the New World was substantially more heavily populated before Columbus arrived, and that the die-off from European diseases to which native Americans had no defense was faster and more complete than previously believed, such that many areas were largely depopulated between the time of the first explorers and traders, and the first settlers. Included as evidence are reports of previously undiscovered cities in Mesoamerica and South America, and many citations to early explorers who reported large populations living in areas which were far less populated a few decades later.

I can’t do the book justice in a short post. Can the great herds of buffalo first seen on the plains by explorers be an aberration, caused by the disappearance of so many of their most feared predators – the Plains Indians? If so, we have to question the image of the Native Americans as having only a little impact on the environment. What we thought was a natural ecological balance and environment was just another version of an environment greatly affected by mankind.

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Who will own the future?

August 22, 2009 at 7:54 pm (By Ennui)

My money is on the synthetic life forms.  But the flesh eating robots are a close second (especially if self replication is added as a feature – battlefield survivability and all that).  Clearly, those nanobot guys better get their butts in gear.  This is all assuming, of course, that nobody accidentally overwrites the whole hard drive.

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I am not a “progressive”(by realpc)

August 21, 2009 at 1:04 pm (By Realpc) ()

I am not a “progressive” even though I grew up in a blue state, in a blue family. I am not a “conservative” either, and my philosophy is mostly based on systems theory — which includes the idea that evolving natural systems depend on a precarious balance of conservative and progressive forces.

I observed a scene last winter that I thought might help me express some of these ideas without a lot of long-windedness. The following is my very short description of that scene, and I hope it will be obvious what I meant to express.

Please tell me what you think!

—————————————————————-

Why the Lake is Always Beautiful

There is a pretty lake near where I live, a peaceful home to varied water birds. Depending on the season there may be seagulls, ducks, Canada geese, egrets, herons, etc. But there are always, any time of year, two adult swans, with or without their latest brood. I imagine it has been the same couple since I lived here, about seven years. The male is somewhat larger than the female, and one winter day I saw him breaking ice for her. He raised his body up out of the water and slammed it down repeatedly to crash the thin ice. His graceful lady floated ceremoniously behind, through the jagged curving pathway.

Recently I walked past the lake and, as usual, glanced over to acknowledge its calm beauty. But something was obviously wrong this time — there were three adult swans instead of two. The resident couple raised themselves several feet above the water and flustered their wings loudly at a third. The intruder was relatively small, probably young, possibly a grown child of the couple — but I am only guessing. He, or she, refused to be frightened off, but settled back down on the water’s glittering cold surface and paddled slowly to the north, away from the road.

The resident couple swam slowly and sternly after him/her, their wings arched and hollowed in a menacing pose. From the front, they would appear larger than normal, but I saw them from behind, where the deception was obvious. I would have stayed for the outcome of this drama, but I had to be somewhere. So I walked away as the three swans continued their grim procession northward.

Three hours later I returned to see that peace had been restored, and only the resident swan couple remained. Far out in the middle of the lake something white floated just below the surface, something about the size of a swan. I can’t say it definitely was, but it definitely seemed to be, the dead body of the intruder. I can’t imagine what else it might have been.

Some humans might be angered, might consider this murder. They might wish to set up laws and regulations. They might lament other species’ inferior sense of ethics and compassion, and try to round them all up into human-controlled environments. But I do not agree. Nature’s laws could not be made more perfect.

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Product Placement

August 21, 2009 at 12:40 am (By Randy)

al-Megrahi

Nike must be thrilled by this photo of Abdul Baset Ali al-Megrahi as he boards plane for return to Libya and a hero’s welcome. al-Megrahi was convicted of plotting the bombing of Pan Am flight #103, which killed 270 people when it exploded over Lockerbie, Scotland in 1988.

The stairway to the plane which was about to fly al-Megrahi home was emblazoned with the logo, Next Time … Relax before you fly.

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The Worst Thing We Do

August 20, 2009 at 4:37 am (By Amba)

– is make up a story that explains, for us, how life is and how it should be, a story the logic and form of which so captivates and convinces us, so satisfies and seduces us, that we prefer it to actual life.  (Is this why we seem to prefer a screen to the real world in front of our eyes?)  These stories become the greatest obstacles to living.  Forlorn fidelity to them makes us miss many a chance and kill many a spontaneous response.  Through their coarse grid much of life escapes; draped in their fine mesh we drown.  A mind is a terrible thing.

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