I'll Take the Ventilator

ALL WOUND UP ABOUT HEALTH-CARE "RATIONING?" YOU HAVE NO IDEA.

Foes of a "public option" frequently raise the specter of "health-care rationing" to frighten those who are nervous about government-run healthcare. The scare-mongers try to create hysteria around the idea that soulless federal bureaucrats would rather gak your grandma than pay for her dentures. (As opposed to insurance-company bureaucrats, who also don't pay for grandma's dentures but allow her to live on, toothless.)

In calmer European or Canadian contexts, "rationing" means that, if five day-long elective surgeries are scheduled for today but only four surgeons, the fifth patient has to wait until tomorrow, or whenever a surgeon becomes available. This can mean waiting for weeks or months, which is harmless enough in non-emergency situations: You still get the surgery done, and life goes on.


However, today's Times features a timely discussion about "rationing" scenarios: In the H1N1 context, who can use the limited number of ventilators and flu shots on hand? In "Worst Case: Choosing Who Survives in a Flu Epidemic," Sheri Fink relates a tough scenario that medical professionals at New York-Presbyterian Hospital had to chew on:

A 32-year-old man with cystic fibrosis is rushed to the hospital with appendicitis in the midst of a worsening pandemic caused by the H1N1 flu virus, which has mutated into a more deadly form. The man is awaiting a lung transplant and brought with him the mechanical ventilator that helps him breathe.

New York’s governor has declared a state of emergency and hospitals are following the state’s pandemic ventilator allocation plan — actual guidelines drafted in 2007 that are now being revisited. The plan aims to direct ventilators to those with the best chances of survival in a severe, 1918-like flu pandemic where tens of thousands develop life-threatening pneumonia.

Because the man’s end-stage lung disease caused by his cystic fibrosis is among a list of medical conditions associated with high mortality, the guidelines would bar the man from using a ventilator in a hospital, even though he is, unlike many with his illness, stable, in good condition, and not close to death. If the hospital admits him, the guidelines call for the machine that keeps him alive to be given to someone else.

Would doctors and nurses follow such rules? Should they?

Fink goes on to quote from several federal and state officials and plans, nicely highlighting both the policy dilemmas and human factors that will come into play if items such as ventilators ever need to be rationed in a flu-related emergency.

For a more detailed discussion of the ethics of triage, see this surprisingly lengthy and thorough Wikipedia article. It covers several nations' triage systems, including military combat and non-combat guidelines. Some triage decision-making systems are dynamic, some relatively static—but all need to be thought about or revisited now, before any hospitals fill up and people start rioting over shots of H1N1 vaccine.

Today's Post also covers the world of H1N1, including:

An odd attempt to explain why Mexico's Isla Mujeres resort area is nearly deserted. The writer blames H1N1 flu fears and the recession, not even hinting at more serious concerns about kidnapping and running gun battles in streets across Mexico until paragraph 12 (of 15).

Ongoing, obsessive coverage (here, here, here, here ...) of local H1N1 vaccination efforts, in the best local-TV-news, ten-things-in-your-medicine-cabinet-that-can-kill-you tradition.

Image Credit.

Forests of Mount Everest

Here's a recent image of the Monongahela National Forest; is it what the Himalayas might look like around 2400 AD?

I just finished reading John Jerome's On Mountains. Jerome, a moderately successful author probably best known for Truck: On Rebuilding a Worn-Out Pickup and Other Post-Technological Adventures, used to edit Skiing magazine but later in life became a sort of more intimate, New England John McPhee.

In any case, On Mountains* includes a passage about montane plant life and, in a mid-1970s moment where concerns about global warming were hardly well-known, describes an interesting scenario about its consequences:

Disaster fans are fond of pointing out that a rise of only a very few degress in worldwide temperature would melt the ice caps, causing flooding of most of our major seacoast cities. Mountain lovers might take some small comfort from the realization that however disastrous that flooding would be in the short run—removing great quantities of useful land from our inventory—nevertheless, a subsequent development would restore at least some of the damage. A temperature change sufficient to melt the ice caps would also raise the timberline—worldwide—above the heights of the tallest peaks. It would take several hundred years to happen, granted, but the forest would inevitably climb right on up and conquer the same bleak and rocky peaks that the mountain climbers covet so dearly. Better make that several thousand years, to give time for the dawdling millimeter-by-millimeter process of soil building to permit the ascending forest a foothold. That same time scale won't do much for the inundated residents of New York and Tokyo, but compared to most mountain processes, it will happen quickly enough to be almost reassuring.

I'm not sure about how good Jerome's science is here, but it is an intriguing idea that one day you'd have dense forest canopy in zones where most animal life can only exist for a few hours, and where nearly any mountaineer whose last name isn't Viesturs needs bottled oxygen just to remain conscious.

* On Mountains is an excellent introduction to all things montane but, like most Jerome books, long out of print. I got my circa-1978 copy at the Rockville branch of Second Story Books, whose thousands of feet of used books are worth a side trip for anyone who has a few spare hours during a visit to D.C.

Photo credit.

FastForward: Heads-Up Displays, Augmented Reality

First in an occasional series of brief looks at a technology, its present and future, and its expression in science fiction. Today: heads-up displays and augmented reality, two technologies that differ in degree more than in kind. For example:

Today: HUDs for your bike helmet and augmented reality (AR) for your walk around Salzburg.

Tomorrow: Synthetic vision systems that replace reality altogether, such as this one showing pilots a "tunnel in the sky" to where they want to go.

As usual, science fiction got here long before science. Here I'm thinking primarily about the AR in Rainbows End, where high-school kids use wearable computers to navigate through real and imagined spaces. But Wikipedia jogged my memory that Charles Stross's Halting State includes Copspace, a heads-up display for law enforcement. And who could forget Iron Man's in-flight HUD or his armor's simultaneous takedown of a half-dozen or so thugs in 2008's Robert Downey Jr. vehicle?

More ominously, you get HUDs so compelling as to keep the remainder of humanity in their chairs—their entire lives—in WALL-E.

Even though WALL-E is satire, it's not that far; witness my wife and I walking near the Verizon Center last night during rush hour. An oncoming pedestrian was so absorbed in texting that we had to split apart and duck out of her way at the last second. The ped never noticed us. Playing World of Warcraft? Shopping for jeans? Searching for a date? We'll never know.

Jane McGonigal and SuperBetter

Jane McGonigal creates alternate reality games (ARGs), basically MMORPGs that you play in reality rather than on your desktop.

She creates ARGs that operate on a global scale (The Lost Ring) or just around Times Square or downtown San Francisco (CryptoZoo).

And she also is pretty brave.

This past summer a collision with a cabinet door concussed her pretty badly. Post-concussion symptoms included crippling vertigo, blurred vision, mental fogginess, an inability to read, write or jog. The initial onset lasted five weeks until, she thought, "I’m either going to kill myself, or I’m going to turn this into a game."

So she created a superhero ARG, with herself as Buffy the Concussion Slayer while friends and family played Buffy's allies. She assembled a secret identity, missions, a superhero to-do list, "power-ups," and villains in the form of her symptoms. Here, in a nutshell, is why:

In an alternate reality linked to our favorite superhero mythology, we’re more likely to stay optimistic, because we’ll set more reasonable goals and keep better track [of] our progress.

And you know what? It worked.

Read her completely inspiring blog entry, "SuperBetter—or how to turn recovery into a multiplayer experience," complete with YouTube videos explaining the process.

Epidemic as Teacher

THE "GOLDEN SHADOW" AND "DARK WINTER" SCENARIOS BOTH LOOKED AT BIOWARFARE RESPONSE—BUT FROM COMPLETELY DIFFERENT PERSPECTIVES.

Last month I met Eric Rasmussen of InSTEDD at the Gov 2.0 conference here in DC. He mentioned a bioterror exercise that InSTEDD and some San Francisco Peninsula agencies had conducted in 2008 called Golden Shadow, which immediately reminded me of 2001's Dark Winter exercise (see Comparison, below).

I asked Eric and his colleague Mary Jane Marcus for the scripts participants had used for the exercise—considering that InSTEDD is fairly modest about Golden Shadow on its Web site—and they were nice enough to oblige.

Golden Shadow examined how newer technologies might help first responders better coordinate their response to a pneumonic-plague attack on a rock concert in San Jose. This exercise was intensely local, as opposed to Dark Winter's National Security Council bunker, all-the-president's-men approach.

Besides InSTEDD, participants included the Menlo Park Fire District, San Mateo County's public health department, three area neighborhoods, a health clinic and a school. Participants went out into the field, knocked on doors to assess the epidemic's progress, distributed "antibiotics," and sent and received both planned and ad hoc messages to an emergency communications center (ECC).

Notably, InSTEDD developed software that let volunteers report from the field via online forms, text messages, GPS-linked photos, and blog entries. "This field information was then portrayed in Google Earth at the Emergency Communications Center, ... the headquarters for first responders. For the first time, firefighters and public health officials could see the crisis in real time as it unfolded in the field." In other words, Golden Shadow emphasized information-sharing from the field and among agencies, and visualizing that information at a central location to enhance decision-makers' situational awareness.

Interestingly, Golden Shadow assumed a great deal of friction—Clausewitz's "fog of war"—from the outset. For instance, all computer-based information was transferred through donated INMARSAT satellite time rather than landline-based Internet, reflecting the possibility that landlines may be unusable during a disaster.

(This assumption helps agencies operate better in disasters, a topic I touched on in the SF Weekly 13 years ago and that Lin Wells and STAR-TIDES have elevated into an art form.)

Golden Shadow also assumed that ordinary people make data-entry errors, run out of antibiotics, wonder what to do with victims' bodies, and get spooked by the epidemic; one participant reads this note during the scenario's second hour: " You develop symptoms—a cough (not bloody) but you are concerned."

In addition, edgy civilians complicate matters by "approaching" volunteers in the field demanding prophylaxis, or take the law into their own hands by confining people they think are sick to their own houses.

These touches are a refreshing change from scenarios that assume you start with your full complement of capabilities—all your day-to-day technology operational, a focused and rested staff, and citizens who act altruistically as well as selfishly.

So how did Golden Shadow go? Given that it explicitly focused on whether certain tools could be used in a disaster-response setting rather than how well they did, and on social as much as technological factors, this exercise generated a lot of useful information:

Pluses
—First responders communicated well among themselves using FRS (walkie-talkies) and SMS (text) messaging, preferring more advanced forms of data communications to report outside their own communities.

—Geo-blogs, micro-geo blogs, and GPS-linked photos helped make field reports more intuitive by correlating data immediately with geographic location.

—People will use what they're most familiar with, meaning old favorites such as walkie-talkies and ham radio got a workout compared with their higher-tech brethren. This implies that more-intense training on technologies such as Google Earth could turn that technology into a real aid to situational awareness.

Minuses
—That said, Google Earth didn't function as well as hoped, primarily because it requires some training to use and participants had difficulty loading different layers of data into it. In addition, Google Earth's latitude/longitude system didn't play well with the fire department's geographic system, which centers on street addresses.

—Volunteers sent much information "upstream" to the ECC, but didn't receive much in return fromITAL the ECC, which was overwhelmed by a data flow purposely designed to have a wide range of relevance.

—Volunteers questioned which modality to use to transmit different types of information; for example, one volunteer used SMS to announce that riots were beginning in her neighborhood when ham radio or a cell-phone voice call might have gotten more attention.

To paraphrase one participant, you can see the an interesting new future peeking out around the edges of this exercise. Hopefully, when more funding can be found (or cash-strapped California resumes its statewide Golden Guardian exercises), we'll see more of this type of scenario used to test both new technologies and old-fashioned interagency cooperation.


Comparison
Dark Winter (2001): Top-down, Andrews Air Force Base, simulated three National Security Council meetings over 14 days of real time. Checked how well federal, state and local governments worked together vs. smallpox attack. Former Sen. Sam Nunn played a U.S. president who, amidst news of rising geopolitical instability, receives word that cases of smallpox have been detected in Oklahoma City, Atlanta and Philadelphia. Produced some rather grim findings.

Golden Shadow (2008): Bottom-up, northern California, simulated operation of first responders and emergency command center over several "days," taking four hours of real time. Checked how well bottom-up reporting worked vs. pneumonic-plague attack. No politicians or celebrities involved; further notable for including the wretched stepchild of Peninsula cities, East Palo Alto, in a marquee exercise. Produced some encouraging prospects for future exercises.

Let Me Count the Futurists

If you were in danger of thinking there was just one type of futurist, AccelerationWatch offers a nice corrective with its list of a dozen major types of futurists here. Pick one social type and one methodological type to create your own. Color me both Predictive and Professional. ...