Month: May 2024

Thoughts on Down Time Activities for Land Survey Technicians

I was just thinking about the old-time land survey crews. When I was getting on the job training as a survey technician, the typical land survey crews were at least 2-3 persons. One rodman, one instrument man, and a crew chief who organized the job, which could be property or construction jobs.

Nowadays, you get by sometimes with one man doing the jobs using a theodolite that measures angles and distances. You don’t always need a physical measuring tape; you can use something they call “total stations.”

It’s cheaper for engineering companies to use one man survey outfits. On the other hand, one disadvantage is the lack of mentoring for learners who want to become land surveyors or civil engineers.

Mentoring from surveyors on the survey back in the day not only taught me such skills as how to throw and wrap a surveyor’s steel tape—it also taught me how to work well with others as a team. Of course, this was transferrable to working on the psychiatry consultation-liaison service in a big hospital as well.

It’s well known that playing cards in the truck while waiting for the rain to stop was an essential skill. I don’t know how they manage downtime nowadays. We didn’t play cards on the consultation service during downtime, partly because we didn’t have much downtime.

Anyway, as I mentioned in a recent post, we played Hearts in the truck on rain days. I always sat in the middle. At the time, I was a terrible card player in general. It was a cutthroat game and I had trouble remembering which cards had been played.

When you consider that the strong suit of engineers and surveyors is math ability, you’d think that survey crews would have figured out a way to play Cribbage during downtime. You can have a Cribbage game with 3 or 4 people although I’ve never played it that way. If there are 3 players, it can still be cutthroat.

The one problem I can see is that, the guy sitting in the middle would have to set the board on his lap. You’d almost need a special, custom-made board which would have a space for placing the cards to keep track of what’s been played. I think that might have made things easier for me.

The other drawback to one man survey crews is that pretty much the only card game you can play is solitaire.

Reminder: FDA VRBPAC Meeting June 5, 2024 on Covid Vaccines for Fall 2024

There will be an FDA VRBPAC meeting on June 5, 2024, 8:30 a.m.-4:30 p.m. ET to discuss Covid vaccines for this fall.

What Kind of Mailbox Does the USPS Really Want from Us?

I just saw the latest headline about the United States Postal Service (USPS) new recommendation that we all get a nice, big mailbox. Huh?

I gather one reason for the suggestion is to cut down on mail theft. I don’t think I’m allowed to put a lock on a mailbox, no matter how big it is.

In fact, the only way I’ve seen to reduce (notice I said reduce, not eliminate) mail theft are those big mailbox clusters you see everywhere in neighborhoods nowadays. Those are the neighborhoods with Homeowners Associations (HOAs), which require you to paint your window trim with beige (not taupe, read my lips!) or face lawsuits.

You know about those clusters, they’re a block away from your house. And you know how small your mailbox is there, yet the postal service is also big on recommending that you use them, probably because it makes their job easier. Which is it? Big mailbox with no lock or big locked mailbox cluster with small boxes?

Is the postal service in charge of maintenance on those mail cluster boxes? Of course not. We’re responsible for clearing away the ice and snow. And is theft not a problem with the cluster boxes? Scan the web for stories about armed bandits who hold up the letter carrier for the key. It happens.

Bigger mailboxes are not the answer to the postal service problems. They can attract the Halloween pranksters showing off their Hank Aaron batting skills (look him up!) and sadistic city snowplow drivers who like dragging your mailbox into the next county after plugging your driveway.

I can remember when the letter carrier walked the delivery route pushing a cart filled with mail. He stopped at every house in the neighborhood to put your mail in the mailbox, which was attached to the front of your house, or to drop it in the mail slot in your front door.

I’m not saying mail theft was not a problem in those days, but I don’t recall hearing about it on the news broadcasts or reading about it in the newspaper—which I hand delivered, sometimes risking injury from big dogs. The only theft I recall was by customers who avoided paying when I tried to collect:

“Do you have change for a hundred-dollar bill, sonny?”

“I’m a paperboy, not a banker!”

“Come back next week.”

Here’s an idea. What if some scientist invented a mailbox which contained a device which would trip only after your mail was delivered? This device would spray concentrated poison ivy resin all over the inside of the mailbox, teaching thieves a lesson. Of course you would have to wear gloves to collect your mail.

Another idea is to make your own mailbox, which would be big enough for a Ninja warrior to hide inside. That would surprise the crooks! I think you can get a Ninja for a fair price on eBay.

Big Mo Pod Show: “In Search of Good Company”

When I listen to the Big Mo Pod Show, I tend to almost free associate to memories which the songs sometimes evoke. The 5 songs this week came from, as usual, his Big Mo Blues Show this past Friday night. The theme of the pod show was “In Search of Good Company.”

I’m not so sure about good company thoughts, but the comments about Muddy Waters song “Long Distance Call” reminded me of something way back in my past. Big Mo talked about making long distance calls a long time ago, which he connected with pay phone booths.

I don’t think I’ve seen an actual pay phone booth in decades, since the invention of cell phones and that kind of technology. But the conversation about phone booths reminds me of my youth.

I used to live at the YMCA and the rooms didn’t have phones. No cells phones were available back then because it was well before the 1980s. The only way you could place a phone call was to use the one phone booth in the building, which was on the second-floor landing. The rooms were on the third floor, and they were for men only, of course.

Also on the third floor was an old snack vending machine and I’m pretty sure I’ve told this story before as I recollected while writing this post.

I got a Butterfinger candy bar from that vending machine one time. I took a bite out of and saw half a worm wiggling around in it. You don’t want see a worm at all, but half a worm has a whole different meaning.

I was worried and used the pay phone to call the local emergency room. I think I paid less than a quarter to place the call.

I guess I would have been relieved to hear the ER doc tell me that I would be OK—if he hadn’t been laughing so hard. Good thing it wasn’t a long distance call.

Memorial Day Events 2024 in Iowa City, Iowa

The Memorial Day ceremonies in Iowa City, Iowa this year will be on May 27, 2024. At 8:30 a.m. there will be a ceremony at Park Road Bridge. Then at 9:30 a.m., the second part will be at Oakland Cemetery. At 11:00 a.m. the third part will be at Memory Gardens.

Reminiscence of My Younger Days

The other day we had some stormy weather roll across central Iowa, although it was not as bad as the tornado that swept through Greenfield. We hope the best for them. We didn’t actually get a tornado, but I remember wondering why the siren went off about 6:00 a.m. It woke me up and I wondered what was the matter. Turns out it was a tornado warning and we had to sit in the basement for a little while. It was a little scary, but the storm moved east pretty quickly northeast out of our area.

For whatever reason, this eventually led to my reminiscing about my younger days. Maybe it was because of a temporary scare and increased awareness of our mortality.

I used to work for a consulting engineers company called WHKS & Co. in Mason City, Iowa. This was back in the days of the dinosaurs when it was challenging to set stakes for rerouting highways around grazing diplodocus herds.

I was young and stupid (compared to being old and stupid now by way of comparison). I lived at the YMCA and took the city bus to the Willowbrook Plaza where the WHKS & Co. office was located on the west side of town.

I usually got there too early and stopped for breakfast at the Country Kitchen. The waitress would make many trips to my table to top off my coffee while I sat there waiting for the office to open. That was fine because I had a strong bladder in those days. I left tips (“Don’t cross the street when the light is red”).

My duties at WHKS & Co. included being rear chain man and rod man, at least when I first started. A “chain” was the word still being used for a steel tape for measuring distances. It was well past the days when land surveyors used actual chains for that purpose. You had to use a plumb bob with the chain to make sure you were straight above the point (usually marked by a nail or an iron property corner pin) you measuring to and from.

You and the lead chain man had to pull hard on each end of the chain to make sure it was straight. It was challenging, especially on hot days when my hands were sweaty and the chain was dirty. Callouses helped.

The rod was for measuring vertical distances and an instrument called a level was used with that. One guy held up the rod which was marked with numbers and the guy using the level read the elevation. Another way to measure both horizontal and vertical angles used a rod and a different instrument that we called a theodolite (older instrument name was “transit”).

We worked in all kinds of weather, although not during thunderstorms. In fact, when it was looking like rain out in the field, a standard joke for us sitting in the truck waiting for rain was to draw a circle on the windshield (imaginary, you just used your finger although if your finger was dirty which it always was, you left a mark) and if a certain number of drops fell in the circle, you could sit in the truck and play cards.

When we played cards, it was always the game Hearts, which I could not play skillfully at all. I always lost. But it kept us out of the rain. If a big thunderstorm blew in, we just headed back home.

We never got caught in a tornado.

DEA Announces Rescheduling Marijuana from Schedule I to Schedule III and Inviting Public Comments

The DEA is asking for public comments on the rescheduling of marijuana from Schedule I to III. There are many comments:

See the Federal Register notice about proposed rulemaking.

Also see the Regulations government website for further information.

Consultation-Liaison Psychiatry as a Supraspecialty

I just rediscovered this old blog post below from 2010 in my files. The literature citations are dated, of course. I just wanted to reminisce about how I used to think through issues in consultation-liaison psychiatry. The post is old enough to contain the former term for the field-Psychosomatic Medicine.

“At the annual Academy of Psychosomatic Medicine (APM) meeting this year held on Marco Island, Florida, I heard Dr. Theodore Stern call Psychosomatic Medicine (PM) a “supraspecialty”. Usually it’s described as a subspecialty.  I couldn’t find the word in Webster’s although “supra” comes from the Latin for “above, beyond, earlier”. One of the definitions is “transcending”.  I tried to Google “supraspecialty” and came up empty. So I guess it’s a neologism. The context was a workshop on how to enhance resident and medical student education on Psychosomatic Medicine services. Dr.  Stern coined the term while talking about the scope of practice of PM. As he went through the long list, it gradually dawned on me why “supraspecialty” as a title probably fits our profession. It’s mainly because it makes us, as psychiatrists, accountable for aspects of general and specialty medical and surgical care above and beyond that of Psychiatry alone.

As a member of this supraspecialty, we wrestle with some of the most intriguing questions about the core competencies of clinical care, interpersonal and communication skills, professionalism, medical knowledge, systems-based practice, and practice-based learning and improvement. These core competencies are a set of commandments, as it were, that teachers and learners are supposed to quantitatively assess in the service of producing competent doctors.  While acknowledging the importance of qualitative assessment of the core competencies, Dr. Stern had the courage to criticize the assumption that quantitative assessment is even practicable. A qualitative assessment would probably be more practical.

For example, how would one assess a trainee’s ability to digest, critically evaluate, communicate about, and integrate into local practice systems the small but growing knowledge about psychopharmacologic prevention of delirium? I am a bit surprised at the general enthusiasm among PM practitioners about pretreating patients with antipsychotics in an effort to prevent postoperative delirium. One of the more recent examples of a very small set of studies is the randomized controlled study by Larsen et al which showed that using Olanzapine prevented delirium in elderly joint-replacement patients[1].  The caveat that everyone seems to ignore is that the patients who got Olanzapine endured longer and more severe episodes of delirium.  Dr. Sharon Inouye (who designed the Confusion Assessment Method or CAM for diagnosing delirium) has quoted George Washington Carver, “There is no shortcut to achievement”, cautioning against oversimplifying non-pharmacologic approaches to preventing delirium[2].  By extension, I’m suspicious of any recommendation that would reduce an intervention for preventing a syndrome as complex in etiology and pathophysiology as delirium to the administration of a single dose of a psychiatric drug either pre-op or post-op or both.  Given the complexity of this issue, is there a quantifiable assessment method for core competencies that suffices? What I’d really like to see is how a trainee thought through the complex issues involved.

One other issue that would influence our ability to assess core competencies is the recent appearance of evidence which seems to show that selective serotonin reuptake inhibitors (SSRIs) when given with beta-blockers may increase mortality in heart failure patients[3]. The bulk of the research evidence in the last couple of decades impels psychiatrists and cardiologists alike to have a low threshold for prescribing SSRIs to patients with heart disease in order to prevent depression. Again, in this context, is there a suitable quantifiable assessment for gauging whether or not a trainee has mastered the core competencies adequately? I would rather hear or read a trainee’s reflections on how to decide for oneself what the safest course of action would be under particular circumstances, and then how to convey that to our colleagues in Cardiology.

And is there a reliably quantifiable way to assess how a PM consultant (trainee or not) evaluates and recommends treatment for an ICU patient who develops catatonia postoperatively in the context of abrupt withdrawal of previously prescribed benzodiazepine, in the face of recent evidence that Lorazepam is an independent predictor of delirium in the ICU[4, 5]?

These situations tax the medical and psychiatric knowledge, treatment and communication skills and wisdom of master and learner alike. Is it possible to mark a check box on a rating scale to assess performance? And would that give us and our patients the ability to tell whether a doctor has the wherewithal to discern what kind of disease the patient has and what kind of patient has the disease, to do the thing right and to do the right thing?

 All of these examples make me wonder whether or not quantifiable assessment of every core competency in the supraspecialty of PM is realistic or even desirable.

1.            Larsen, K.A., et al., Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics, 2010. 51(5): p. 409-18.

2.            Inouye, S.K., et al., NO SHORTCUTS FOR DELIRIUM PREVENTION. Journal of the American Geriatrics Society, 2010. 58(5): p. 998-999.

3.            Veien, K.T., et al., High mortality among heart failure patients treated with antidepressants. Int J Cardiol, 2010.

4.            Brown, M. and S. Freeman, Clonazepam withdrawal-induced catatonia. Psychosomatics, 2009. 50(3): p. 289-92.

5.            Pandharipande, P., et al., Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 2006. 104(1): p. 21-6.”

Old Blog Post on Decisional Capacity Assessment

I just found a blog post I wrote about assessing decisional capacity. It’s over 13 years old and you can tell I was a little frustrated when I wrote it. It was back in the days when consulting psychiatrists were called psychosomatic medicine specialists. Here’s to another blast from the past.

Blog from 2011: Thoughts on Assessment of Medical Decision-Making Capacity

Listen very carefully to what I’m about to say. A patient’s ability to make decisions about her medical or surgical treatment does not depend on knowing her surgeon’s name.

Let me put it differently. Simply because you can recall your surgeon’s name doesn’t mean you have the decisional capacity to give or not give informed consent to have surgery.

If that’s too obvious to most of you, then maybe I can stop worrying that it isn’t to so many doctors, who sometimes misunderstand or are simply unaware of the basic principles of assessing decisional capacity regarding medical treatment. Believe it or not, some physicians actually believe the above is part of an adequate decisional capacity assessment.

Psychosomaticists are frequently called to assess decisional capacity to participate in the informed consent discussions that are such an important part of the doctor-patient relationship today.  Many non-psychiatric doctors simply don’t feel confident that they can do it themselves. And when they try, their description of the process often indicates an alarming deficit in their medical school education about this basic skill.

In order to give informed consent, you need to have enough information from your doctor, be able to voluntarily make a decision without undue pressure from others (including your doctors), and be competent to decide. Exceptions to obtaining informed consent include but are not limited to “incompetence” (the inability to decide) and medical emergencies.

In a nutshell, the basic elements of assessing decisional capacity are:

  1. Any physician can do it; a psychiatric consultation is not obligatory though it may be helpful in difficult cases in which delirium or other mental illness may be substantially interfering with decision-making.
  2. The patient’s ability to understand her medical condition and the risks and benefits of the main and alternative medical interventions proposed as treatment.
  3. The patient’s appreciation of the nature of her medical condition and the potential consequences of the treatment options or no treatment in the context of her values and wishes.
  4. The patient’s ability to reason through her choices regarding treatment.
  5. The patient’s ability to express a choice.

Notice that nowhere in the above list is recall of the surgeon’s name even mentioned. Remembering your surgeon’s name may be flattering but it’s not essential to the assessment of decisional capacity.

There are several reasons to assess decisional capacity including but not limited to an abrupt change in the patient’s mental status. This is commonly caused by delirium, which by definition is an abrupt change in affect, cognition, and behavior that fluctuates and is by definition related to medical causes.

Any physician can conduct a decisional capacity evaluation, yet a psychiatric evaluation is frequently requested.  The reason for that may arise from the assumption that the Psychosomaticist is a sort of “informed consent technician”[1]:

  1. “Efficiency model” scenario
    1. Incompetence is presumed.
    1. Psychiatric consultant is expected to remove legal barriers expeditiously to obtain a surrogate decision maker.
  2. “Pseudoconsultation” scenario
    1. Consultation requestor lacks the patience, interest, or time to do an assessment.
  3. “Persuasion” scenario
    1. Psychiatric consultant is expected to persuade the patient to reverse his refusal of needed treatment.
  4. “Protection” scenario
    1. Psychiatric consultant is expected to provide documentation to protect against potential litigation.
  5. “Punishment” scenario
    1. Stigma associated with psychiatric evaluation is used unconsciously to punish treatment refusal behavior.

In all fairness, psychiatrists are sometimes just as guilty of this buck-passing; for example, when we request a cardiology consultation to “medically clear” a patient for electroconvulsive therapy to treat life-threatening depression.

In an ideal world, a decisional capacity evaluation would be requested in and accepted in “the true spirit of dialogue as the result of a genuine evaluation of the patient’s mental state as a whole”[1].

We don’t live in an ideal world. So when a doctor is truly stuck and needs help with decisional capacity evaluations, she can confidently call a practical Psychosomaticist in the true spirit of collaboration as a result of the genuine appreciation of the importance of the patient’s medical and psychiatric care as a whole.

1.            Zaubler, T.S., M. Viederman, and J.J. Fins, Ethical, legal, and psychiatric issues in capacity, competency, and informed consent: an annotated bibliography. Gen Hosp Psychiatry, 1996. 18(3): p. 155-72.