Lenk

switzerland

I recently returned from a church Men’s Retreat in the resort town of Lenk, Switzerland. This was MY kind of ‘retreat.’ The majority of our two days was spent on the ski slopes, not talking about God and theology and right and wrong.

 

I’ve been a Christian since I was 8, so the pastoral lectures and Bible verses never feel especially new to me.

I routinely enjoy the music, and in our case a great band led those times in the evenings, but I was happy to attend a retreat that was mostly just a cheap ski vacation. I met some cool guys, got a little better on a snowboard, and stood in absolute awe at some of the most beautiful scenery I have ever known.

 

I don’t worship God very well through study, or through listening to lectures from pastors. Lectures, ever, haven’t worked well with my brain. Ask any teacher of mine all the way back to 1st grade and you’ll probably get some version of the same mildly exasperated half-smile, and a reply along the lines of, “he really, really TRIED to give a crap.”

 

Adelboden-Lenk

But when I’m in the shadow of the Swiss Alps, with 1,000 year old glaciers clinging to jagged sawtooth ridges in a 300-degree ring all around me, I pay attention. Somehow, breathing in crystal-pure air, with rolling forests and organic dairy farms dotting the countryside in every direction far below me, I have no problem thinking about God and wondering how I couldn’t possibly be closer to His almighty Spirit for that moment.

So, it was a spiritual time for me, but with very little preaching or Bible-studying. Perfect.

 

I was also struck by the unity and beauty of the towns we passed through on our way to Lenk. Switzerland has been highly resistant to change over the years, from what little I’ve read of the country. It is fairly hard to immigrate there, and once you ARE there, good luck building consensus around any particular idea or religious creed that departs from the time-honored ways of the Swiss. Du willst ein Minaret? Das wird nie passieren!

Deutsch: Chalet in Pöschenried, Gemeinde Lenk,...
These, dotting the countryside as far as you can see. Plus snow when it’s winter.

 

 

In Switzerland, you know you are in Switzerland. Especially in the countryside. The buildings are stirringly beautiful, most made of a light-colored wood sometimes set on dazzling white painted rock or concrete bases. The barns looks related to the houses. Everything is clean, ordered, pristine.

This unity isn’t by accident. But it takes enormous force of will to maintain a cultural identity in an increasingly pluralistic and mobile society. To do so inevitably becomes political, with increasingly volatile arguments on either side.

My homeland, America, has never really had a unity of culture and history to this degree. We’re a nation of very few subjugated natives, and very very many immigrants. To walk through my country – or any large American city – is to walk around the world.

Both have their merits (except for our treatment of the natives). But there’s something so deeply peaceful about meandering through a place that knows itself so well. A place that is OLD, and has not forgotten the value of of old things. King Solomon was rewarded by God with power and money because when God offered to give Solomon anything he wanted, the young man asked for wisdom. Any place that honors age, honors wisdom, and God seems to have blessed the Swiss accordingly.

I’m not saying Switzerland is paradise or utopia. There are problems. But they’re getting lots of things right. Here, walking is revered over driving. Food is valued for quality and purity rather than quick access or cost.The country has some of the best health care access in the world, with 3.6 doctors and 10.7 nurses per 1000 people. Life expectancy is around 73 years old. Obesity is less than 8% (it’s almost 50% in the U.S.), and it is estimated that 100% of the population has access to clean drinking water and sanitation facilities.

As a Caucasian from the American suburbs, with no knowledge of my heritage further back than my grandparents, this place holds an impossible appeal for me. I don’t know my family history, whether a story of thieves or kings. My nation’s history doesn’t even span 300 years.

As our retreat drew to a close, I knew I could never truly be a part of a place like Lenk, Switzerland. I could only marvel and yearn, watching that priceless world slip past my car window, as we hurried home.

 

Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...
Father Ventura, surely a surfer
Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.

‘Concierge’ Medicine – A De Facto Manifesto

My blogging output has been at an all-time low since moving to Europe.  Who knows why…this place is such a bore.  I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.

The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine.  It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States.  In my email reply to him, I found myself writing my own little manifesto on the subject.  A treatise, if you will.  A declaration.  A primer? A resolution, a promulgation…

William Osler (1849 - 1919), Professor of Clin...
I have a idea...how 'bout I actually know who you are, AND care about your medical issues?

 

I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms.  Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries.  So the idea isn’t new.  It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen.  It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans.  I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap.  If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good.  Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too.  Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply.  Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards.  It requires real cash investment.  But it IS better.  And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different.  We’re talking about your life, here.  Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way.  Most people in the richest nation on earth perceive they can’t afford it, but really can.  I blame this perception on the invention of the 10-dollar co-pay.  This idea was such poison in American medicine.  It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food.  They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels.  But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments.  But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health.  I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous.  On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests.  High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up.  NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making:  that is, if X symptom, then Y action with little analysis involved.  recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment.  When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately.  Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer:  I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians.  Most I’ve met are smarter than me.  But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000).  This differential limits mid-levels to algorithmic, rather than analytical, decision-making.  When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels.  The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.

Health Report – Mickey Mouse

Our family just returned from Disneyland Paris.  We had a great time.  As a doctor, however, I just couldn’t ignore the many health problems clearly evident in the thousands of images I saw of the world’s most famous mouse.

Fictional characters on the Hollywood Walk of Fame

I can say with confidence that this will be the first and only time that I publish the health record of a patient without his/her consent.  But then again, I’m not even sure this little rodent was my patient at all.  Furthermore, I can’t vouch for my physical exam of our storied mouse – given his rather cavalier take on the idea of ‘physical’ – but I do believe we should all be alarmed at the probable health status of our big-eared friend.

Of greatest concern is what can only be described as HUGE feet.  Unfortunately, this does not suggest enviable male endowment, as it is sometimes rumored in those with enormous paws.  Rather, these feet are swollen.  A close look at most pictures of this patient suggest that he in fact can’t wear shoes at all, but instead some sort of stretchy slipper.

The illustration shows the major signs and sym...
I Kept Seeing This Instead Of Enjoying Space Mountain

The best explanation for feet this swollen is congestive heart failure.  This is a situation where the heart has pumped against a dysfunctional circulatory vessel pressure for so long that the muscle fibers have becomes stretched out and weak.  Eventually, the heart becomes incapable of pushing blood around the body effectively, causing pooling of fluids in the extremities, especially the feet.  Judging by the thousands of pictures of him, most drawings were likely done after this patient had been on his feet all day.  Let’s face it, an 80 year old mouse can only walk around smiling waving at kids for so long before problems arise.

CHF is progressive (meaning it just gets worse over time).  Elizabeth Taylor just died from this, for example.  Mick could use any of a number of meds to lower his blood pressure, and (arguable, these days) something to strengthen the contractions of whatever functioning heart muscle fibers he still has.  He should also go with low-salt cheese, lean scraps and whatever else a billionaire mouse might eat.

The little guy also has disturbingly white hands.  Leaving aside the perplexing question of how a rodent has human hands (and feet), what we’re probably seeing here is Reynaud’s phenomenon.

In itself, this is a circulatory system peculiarity that is not medically-concerning.  However, it can be very painful.  Mickey appears to be in the early stages of the process.  Likely shortly after his portrait sittings, his hands turned bright blue, then eventually into a deep red.  Throughout the process, he would be in quite a bit of pain.

Of course, I can’t be sure if he isn’t wearing gloves (assuming that garish white color IS his skin, frequent glove use makes sense).  Gloved or not, we still have the problem of clearly HUGE hands, suggesting edema like that described above in his feet.  Assuming, however, that we do in fact have Reynaud’s here, the concern is of an autoimmune disease in the category of lupus.  “Lupus” is a reference to the facial rash often seen in the disease and how it mimics the fur-pattern of the red wolf.  Given that wolves engorge themselves on mice whenever possible, this diagnosis is insult to injury for our poor little entertainer.

Furthermore, lupus typically causes joint and connective tissue pain.  It can lead to heart problems, anemia, serious lung problems including emboli and hemorrhages, kidney damage and neurological problems.  There is no known cure, although the disease can be managed usually to good effect with oral steroids (not of the Lance Armstrong type…we’ll get to that), but the Mickster here clearly needs to get them started.

Mickey Mouse Bus
On The Way to Rehab?

Next, the rotund belly.  This is the physical sign most associated with diabetes and other metabolic diseases (or could be another sign of his CHF).  Termed by doctors as “central obesity,” this malady affects a HUGE proportion of American men, especially.  To our knowledge, little else puts a person more at risk for big metabolic problems.  Mickey lives at Disneyland, where he can expect to eat things like spun sugar, rock candy-encased apples (I presume of the sort that felled Ms. S. White) and shovel-fulls of sweetened popcorn.  So, as a nearly 90 year-old mouse, he can be forgiven the “Gaston Gut,” as it were.  Still, a strict diet is highly recommended.

Another thing:  look carefully, and you’ll realize that Mickey’s head is larger than his entire thorax (body sans legs).  Babies exhibit this phenomenon – watch a toddler reach overhead…only the hands extend beyond the giant head itself – but adults don’t.  Mickey may have been born with something called hydrocephaly that was inexplicably untreated for 80 years.  Maybe he was too busy as a child prodigy mouse, or maybe everyone thought it was “cute.”  He may also be suffering from Cushings, an overabundance of the steroid cortisol.  He has some other physical signs to support that diagnosis too.

Lance Armstrong and John Korioth in the team t...
THESE Guns Don't Come With Serial Numbers

But he also could be doping.  By doping, I specifically mean HGH, or human growth hormone.  Lots of athletes do (or did) it, like Barry Bonds (yep, I passed judgement…don’t care about some goofy trial) and probably Lance Armstrong.  Here a note to Armstrong supporters:  almost EVERY top-5 pro cyclist, and every one of Lance’s main competitors over his winning years, has been busted for doping of some sort.  Except him.  Savvy, not legitimacy, I say.

Anyway, HGH makes you huge, but it can disporportionately affect the bones, especially in the head.  Of note, HGH isn’t bad in itself, per se.  It stimulates muscle growth in a way that can be very helpful to geriatric patients, for example.  And, as with many Hollywood elites, The Mickster shows his age about as much as Dick Clark who looks 40 but was actually personal friends with Moses.  So, I think Mickey can be forgiven for taking a shot or two from the possible fountain of youth.  But, unfortunately, that HUGE noggin gives it away…to me at least.

So, let me say that DisneyLand was a great adventure for our 4 kids.  I, however, kept getting dragged into unnecessary endeavors like rides or shows even as I frantically searched high and low my latest, and sickest, patient.  Sadly, I never had a chance to warn him of his predicament.  So, the onus is now on you, dear SW101 nation.  Find him.  Tell him.  He’s sick.  He needs help.

Next Week: Goofy comes out of the closet and reveals that he has Marfan’s Disease…and everyone pretends to be surprised.

XBox – A Medical Necessity

“Dr. SW101,” Says the curly-haired assistant, “will you sign this memo.”

I don’t look up.  As usual, I don’t read the memo, reaching for the closest pen and signing as fast as possible.  I look up at him, smiling cheerfully.  “What’d I just authorize?”

This is a photo of my Xbox
Image via Wikipedia

 

“Oh, you just told General Forth that the unit has medical need for 6 additional XBoxes.”

I pause, wondering why I’m so morally opposed to all paperwork that I can’t bring myself to even look at paperwork unless I absolutely have to.

“Xbox,”  I say, brows furrowing.  “Do you get ’em at the pharmacy?”

“No!”  He says, cloyingly earnest.  “You’re SO funny, Dr. SW101.  You should write a blog!”

“I do.”  I say, feeling sardonic, looking dour.  I reach for Volume I of Harrison’s Internal Medicine.  I lick a thumb and start flipping through the thousand-page tome.  “Hmmmm, Xbox.  Nope.  Nothing here.”

Assistant waits dutifully, no doubt inwardly rolling his eyes while clutching his well-typed letterheaded memo, with my signature still drying at the bottom.

“OH!  Right.  I’m only in Volume I.  Stupid me.  I should be in Volume II, where the X’s are.”  I pause.  “Just a minute,” I say, reaching for the second book.  A few minutes of earnest searching, “Nooh.  Darn.  I just don’t see anything talking about how XBox is an accepted therapy for anything.  Not even my favorite disease of all time – mitochondrial infectitis.”

“You’re kidding, right?”  He says, now looking worried.  “We can get the Red Cross to buy XBoxes for the unit if you say they’re medically warranted.”

“So, my patients – most of whom have seizure disorders, PTSD and post-combat anxiety – can sit around all day blowing each other up and staring at flickering lights?  Maybe I should prescribe a Rave too, so we can add drugs to the strobe lights.  Or would they be used for the Xbox version of Myst or something?”

Regions of the brain affected by PTSD and stress.
Bzzzt. What I need is some rapidly blinking lights and simulated death right now.

 

Assistant gets all serious, fearing the loss of his beloved memo.  He starts reading some of the Pulitzer Prize material, “Gaming has become a central element to the Soldier’s past time.  When they return from war zones, the lifelike quality of the Xbox combat games approximate the environment they just left.  For many, this represents a “return” to their former lives, thus producing a sense of calm and reassurance.”

“I said that?!”  I exclaim, eyes wide.  “What kind of crap-pile hash was I smokin’ when I wrote that letter?”

“Oh, huh.  Um.  Well, if you didn’t notice…I wrote it.”  Says the assistant, looking dejected.

Short of tearing the letter out of his hands, and no doubt derailing an already fast-moving train with lots of passengers, I know I’m on the hook.

“Ok.  You win.  Xboxes all around!  On me.”

Relief, profusion, gagging urgency and more of that I-want-to-help-soldiers-but-won’t-listen-to-reason earnestness.  “Oh, THANK you!  Man, you have no idea what this will mean to the guys.”

“Can we just agree that you got me to sign yet another of those goofy Army things where you’re not really asking for medical opinion but if I sign the memo about 25 people will have busy stuff to do and somebody somewhere will get something to further the impression that they’re entitled to things that the average American pays for?”

“Um.  Sure.”

“Can we further agree that Xbox is not an accepted medical therapy for anything?

“Yep.”  Confidence growing…clearly the doctor is too weak to actually stop any administrative freight trains now.

“Fine.  You have your memo.”

He turns to leave.  Then turns back, “Oh, and about that memo for the massage chairs…”

But I don’t hear him.  I’ve crawled under my desk, looking for the Lost Thumbtack.  I don’t “find” the thing until I hear my door open and close.  Carefully I look up….he’s standing there, hand on the doorknob.  He’s smiling, one of those serious smiles that makes perfectly clear that nobody’s fooling anybody.  “Find your thumbtack?”

I sigh.  The sound is tired in my ears.  “Yes.  But I just tossed another one down there to go look for later.”  He doesn’t say anything.  “Yeah, the massage chairs.  Bring me the memo.  Until then, take this script-” I scribble onto a piece of paper.

He crossed the room and takes the script from my hand, smiling.

Massage Chair
1, bid.  Do not swallow.

 

Interview with A Virus

SW101: I’m sitting here today with Herpes Simplex Virus, type 2.  It has agreed to answer a few questions for SW101 Nation.  Thanks for joining us today, um, is it…Mr. Simplex?

HSV: “Mr.” Simplex.  Sure.  I’ll go with that.  (rolls eyes, muttering “humans”).

SW101:  Tell me, what do you regard as some of your greatest accomplishments, to date?

Mr. Simplex: We’re awesome, basically.  We like to consider ourselves ubiquitous, yet cosmopolitan.  We are particularly fond of the human idea of “make love, not war.”  mmMM.  Huge for us, that one.

SW101:  Ubiquitous?

Transmission electron micrograph of herpes sim...
Self-Portrait: Mr. Herpes

 

Mr. Simplex:  You got an ulcer on your nether-parts after a groovy night wearing nothing but beer goggles?  Probably us.  Any version of sexually active with any version of human being (we don’t like animals)?  Excellantae!  30% chance we’ll be right there with you.  Me and my posse are hanging out with 30-45 MILLION Americans.  And that just in the, ah, “middle” parts of the human landscape.  We got some cousins who live in the windy North quite happily.  We cross paths from time to time.

SW101:  Wow.  Qute a party.

Simplex: Yep.  And we’re inviting picking up around 300,000 new groupies every year.

SW101:  How’s that?

Simp:  We’re launching out all over the atmosphere much more often than people realize.  Those blistery sores we cause?  Well call ’em “pleasure domes,” referring to what they do for us as well as how our gracious hosts acquired them in the first place.  Anyway, we don’t just blast out from the popping penile blisters.  Usually, we send out early drones before the sore even forms.  We’re terribly proud of this tactic.

SW101:  Soo, when does the ‘party’ end?

Simplex:  That’s the best part.  Pretty much never.

SW101:  Like, never?

Simplex:  Oh sure, we take a break sometimes.  Lots of times, actually.  We hide most of the time.  But once we’re in a body, we don’t really ever leave.

SW101:  What do you hide from?

Simp:  There’s two things we don’t like in this world, and the Great White Army is the main one.

SW101:  Um, you refer to Tsar Ivan III‘s anti-Bolshevik Imperial Russian Army in the 1920’s?

Electron microscopic image of a single human l...
Human Lymphocyte. Non-friend to HSV's everywhere (everywhere it thinks to look, that is)

 

Simp:  What?!  What kind of freak-show wonk are you?  No!  The human immune system.  All the cells in that army are white.  Or clear.  Or something.  Scary, those guys.  They can blow us up, eat us, chew us up, spit out pieces of us so their comrades can eat the rest of us…it’s disgusting, really.  It’s like a bad horror movie.  Ugh!  Look at that picture of the immune cell!  Don’t you have any shame?  I didn’t walk in here holding up pictures of car accidents, or guys who accidentally fell into meat grinders, did I?  Why don’t we just sit around and ponder Charles Manson, and all his fabulous exploits?  Oh, actually, that guy was pretty good for us, as I recall.

Anyway, where was I?  (fans self, leans back weakly).  Oh yes, when it’s up and running full-bore, the human immune system it a giant headache for us.  We try to lay low.  No sense in getting our heads knocked off.  The good news is that it gets stretched pretty thin trying to cover all the problems that come up in those unnecessarily complex organisms of yours.  It’s pretty easy to come out and play once the person is stressed, sick, too hot or cold or with some disease that naturally keeps the White Army back in the barracks, so to speak.

SW101:  So, you hide in the nerves, right?

Mr. Simplex:  (looks left and right conspiratorially) Yep.  Broadly speaking.  This is the secret to our survival, by the way.  Our lair.  Your nerves.

SW101:  And, specifically?

Simplex:  Well, you guys have no hope of actually finding us, so I’ll just go ahead and tell you.  My guys hang out in the roots of the nerves that extend from the sacrum.  S2-5, usually.  In the ganglion.  It’s nice there.  Our version of what you’d call waterfront property, I’d imagine.  Our cousins hang out in similar nerves in the face.

SW101:  You mentioned two things you don’t like, what’s the other?

Simplex:  Condoms.  We hate ’em.

SW101:  That bad, huh?  Your great nemesis?

Simplex:  Well, actually, our relationship to them is a bit complicated.  Maybe like Ariel Sharon vs. Yassir Arafat.

SW101:  Surely you’re referring to the Israeli-Palestinian former leaders…both dead now?

Yasser Arafat at 'From Peacemaking to Peacebui...
Ariel Sharon thinks I'm a punk. I told him the feeling was mutual over tea this afternoon.

 

Simplex:  Dead?  Really?  I don’t think we had anything to do with that.  We try not to kill our hosts…bad for real estate, as you can imagine.  But yeah, them.  They hated each other, but at the same time, they created lots of business for each other too.  Get it?  People don’t like using condoms, for some reason.  But those that do are WAY lax about concerning themselves with us.  Since we don’t just hang out in areas covered by those suffocating, smothering latex udders, we get around pretty well when condoms are in the mix.  People jump into their illicit affairs, thinking they’re safe…and forget to ask anything about us.

So, it’s a love-hate thing.  Overall, condoms are probably pretty good for business.

SW101: So, you hate condoms.  What do you love?

Simples:  Promiscuity.  We’re BFF’s.  Make love, not war, dude.  Preferably, don’t even look down at what you’re doing.

It’s not personal, by the way.  We’re just doing what we are meant to do…which is reproduce.  Everyone who is living with us now should understand that.  It’s one big happy family of organisms doing what they were meant to do…mate, and reproduce.  It’s natural.  When you’re mating…so are we.  All I can say is, sorry for the inconvenience.

RATIONal!

Yes, throwing a few words out there again.  Can’t help m’self.  Been a bit.

Living in Europe insulates the average human from goofy, over-the-top language meant to get people to do and think in ways that OTHER people want them to.  So, I haven’t been very caught up in, or all that impressed by, all the politics and steamy language coming out of my home country these past months.

Demilitarized Zone, North Korea
We have fast government. No arguing. You like. Like pizza.

Now the election is finally over, we find that Republicans have “swept” themselves into a level of “power” that assures exactly zero will happen unless they work with all the Democrats and Independents that never lost their jobs.  Some people think all the upcoming wrangling is a bad thing; I think it’s great.  A super-active government rarely doesn’t do anything well.  There IS a type of government that “gets things done” almost immediately, with little debate.  It’s called a dictatorship.  If you’re smitten with that idea, move to North Korea and try THAT speedy idea on and see how you like it.

Anyway, I received a link to a very persuasive and scary speech given by an orthopedic surgeon named Dr. David Janda, wherein he outlined the horrors and sneaky tricks piled into the Obama health care bill.  His speech was in support of Rob Steele, a cardiologist-turned-politician likely because he was mad as hell at the terrible direction of the country (*yawn*, aren’t we all?).  Presumably, said cardiologist is now back in the clinic, since he thoroughly

Republican Party Handbill, ca. 1880
Image by Cornell University Library via Flickr

lost the election of the 15th Congressional District of Michigan to John Dingell something like 83k votes to 118k votes.  Apparently, the Dingells have run that district for generations.  If you’re looking for nutty, inflammatory, manipulative language, look no further than at a political battle between a challenger losing in the polls as s/he tries to unseat a longstanding incumbent.

The gist of Dr. Janda’s speech is how Obama intends to RATION health care.  This actually sparked my interest.  I don’t really care about health care system politics; I’d rather just see patients, frankly.  But I have to just say to my fledgling SW101 crowd, I SUPPORT RATIONING.  Of every public resource.  Food. Gas. Sex (um, although I’d readily opt out of the “public” option).

New Orleans, Louisiana, 1943. Line at Rationin...
The whole idea of capitalism is so you don't have to share. Sharing sucks.

So many people take the idea of rationing to be unequivocally bad…as if it’s totally wrong and even beyond debate.  That’s the tack of Dr. Janda.  It’s something we all KNOW is wrong.  Like sticking needles in the eyes of baby squirrels or stomping on halloween pumpkins.

Incidentally, Janda is a specialist, supporting another specialist.  Primary care docs like me aren’t especially pleased with how specialists have garnered power and money for themselves in the AMS (Am. Med. System).  In particular, I’m speaking of orthopedic surgeons and cardiologists.  Specialists make fabulous money by ordering tests and procedures, none of which have ever been regulated or rationed in any way.  Echo’s and caths pay for the boat, private school and vacations to S. Pacific islands nobody can name.  Don’t tell me the only force driving clinical decisions is scientific evidence and standards of clinical care…money is money.  But even so, I’m for rationing.

President Barack Obama speaks to a joint sessi...
Hey friends! Here's a really mediocre idea!!

Let me say that I’m not happy about Obamacare. It was said well @ a recent conference, “who’s going to do a better job coming up with a fair, affordable national health care plan, 189 laywers in a room for half a year, or 10 family doctors in a room for a week? Obama went with the lawyers, he should have gone with the docs.”

That said, I FULLY AND COMPLETELY agree with rationing because it’s a necessity. In training, I followed a patient in the ICU who was costing close to 1 million dollars a day of PUBLIC MONEY for the last 4 months of her life. Somebody, somewhere needed to compassionately deny further intensive care to this woman, instead providing dignified hospice end-of-life management. Her case justified ONLY taxpayer-funded hospice care but nobody had the cajones to tell her that.

Every precious resource, if pooled for the common good, needs to be rationed. It’s where we get the term ‘rational’ and there’s a reason for it. Closer to home, my sister apparently has a University doctor telling her that she needs a thousand dollar procedure (colonoscopy). The procedure is not done by this doc’s specialty, and my sister hasn’t even had a rudimentary work-up to justify the cost of the scope.  She has not had a professional analyze of the risks vs. the benefits of doing it, either.  Yet she’s already being told that she needs this procedure.

Remember…EVERY test and procedure has significant risk associated with it. Wouldn’t it be nice to know that the doc my sis sees for a scope is a specialist? And, since that specialist pays for the Benz and sailboat from scope income, wouldn’t it be nice to know that he moved in a stepwise fashion through the GI workup process, a process that is peer-reviewed and widely accepted as essential before a scope is ordered?  This is the ‘rationing’ process that Obamacare advocates.  It puts serious limits on specialists in the provision of their care when it comes to big-ticket stuff like scopes, imaging and surgery.

But remember, we’re talking about rules in effect ONLY if you intend to get your neighbor to pay for your health care. YOU are welcome to pay for your own scope any time you wish. YOU can fund your own health insurance – one that doesn’t make docs do ANYTHING before they dig into your body – if you want.  I watched it work this way in Israel, and it was a pretty good deal.

However, the fact is most Americans believe they are SO important that they have the right to be treated like kings…paid for by peasants. But ethically, Americans have no right to whatever care they want whenever they want it, if they also expect someone else to pay for it.

Hugh Owen Thomas (1834-1891), British orthoped...
Trust me, I'm a DOCTOR! We ALL are.

The AMS does too many procedures and tests. The result of both is astronomical costs and HARM TO PATIENTS (through false-positive test results and procedure errors). So, not only is care rationing ethical and less costly, it is absolutely safer for patients. Healthcare is NOT safe. There is a risk-benefit ratio that must be considered any time a patient comes in contact with the health care system. Waiting for non-urgent care (knee replacements) and rationing of tests and procedures is ethical, cheaper and flat-out safer.

Incidentally, I argued this point in a debate in med school…waay before Obamacare. I have seen nothing since that time to sway my opinion. In fact, training and practice have only solidified that opinion with real-world facts.

Obama didn’t make our health care system right, but he did make it better. The Tea Party idea of repealing the new law is lunacy. If they REALLY want a free-market system, they need to dispense with EMTALA laws which dictate that ER docs (and now other specialties too) are required to see any and every patient.  THIS IS UNIVERSAL HEALTH CARE!!  It’s just the most inefficient, ineffective and expensive system in the world. We do have a social healthcare system. We just need to make it rational…starting with sensible rationing of limited resources.

It’s Not Just Sex

A good approximation of how sex and intimacy is regarded by the U.S. Armed Forces can be summed up in the phrase I heard recently: “If you needed a wife…we’da issued you one.”

These days, the U.S. Army is perhaps the most chaste and constrained military organization on planet earth.  No drinking on duty, no sex, no pillaging, no cavorting…and go easy on the damn swear words.

Contrast this with the Russian Army, and German, which frequently serves beer with lunch; the harder stuff after dinner.  And numerous armies – no joke – provide prostitutes to their deployed troops.  Effectively, a little mini-platoon comprised of practitioners of the world’s oldest profession gets sent to war zones right along with the soldiers.  No doubt this idea  is regarded by these armies as a Godzillian leap up the ladder of human rights.  In the past, when victorious they just raped the women (and men) of their vanquished quarry.  At times, a veritable sexual bonanza was promised as the leading incentive to engage in vicious battle in the first place.

Members of the U.S. Armed Forces by contrast, seem expected to never have sex of any kind.  If sexual organs didn’t come already attached to the bodies of their troops, I’m rather certain the Army would have confiscated all tissue related to human reproduction – and especially the related pleasures of it – on the first day of basic training, relegating every appendage to iron storage boxes next to the gold bars in Fort Knox.  “You can have your clitoris back after your 20, soldier.  Until then, kill stuff.  And like it.”

I’m a happily-married, loyal-to-death-do-us-part, honest-to-a-fault type of husband who, with the perfectly understandable exceptions of Rachel McAdams and Jennifer Connely, can provide infinite assurances to his wife that she has minimal reason to fear infidelity (in kind, if she ever meets Johnny Depp in a smoky, sultry, bean-baggy, beatnik bar…she has my blessing).  That said, I think the “Hooker Platoon” is a great idea.  Presumably, said professionals are well-paid, in control of their lives, and free of drugs.  Like it or not, humans are sexual beings and they go about obtaining it in a myriad of ways.  Might as well make it safe, fair, protected and consensual, even if questionably moral.

But what about the ones who aren’t deployed?  Or the ones who, by choice, remain celibate as they await – with admirable fidelity – their dear lover back home?  What about the people who have returned from over a year’s deployment, waay beyond ready to re-start a healthy, loving sexual relationship with their spouses?

Unfortunately, many soldiers return from war zones with major emotional and physical damage – and major problems having sex.  PTSD, insomnia, chronic pain, depression and anxiety all affect sexual ability.  And these problems are like cockroaches…if you have one, you probably have others.  Worse, the meds used to treat the above problems often severely inhibit sexual function too.  Am I the only one who sees the Faustian irony in “You can be happy…OR you can have sex.  Not both.  Your choice.”  For many (including me), that choice is an oxymoron…emphasis on moron.

While not always the problem, erectile dysfunction is one of the more common issues I deal with.  Given the ubiquitous commercials displaying medically-enhanced virile men, one would think ED wouldn’t be such a problem.  And it is true…a pill can solve the problem sometimes.  Cool, right?  A nice, easy fix.  The problem is that sex is considered by the Army to be something of a sport.  Golf, but morally suspect and generally distrusted.  As if to clarify their position, one of the more odd policies I’ve seen is the meet-you-1/20th-of-the-way idea of providing 6 pills of Levitra per month for up to 3 months for erectile dysfunction.  6.  For 3 months.  Then…good luck.

But 6 pills?  A month?  I know they’re expensive – something like 10 bucks a pill – but who came up with a number like that?  Was he (or she…or it) ever in a loving, happy sexual relationship?  Had it already donated the entirety of its copulation gear to NORAD for weapons testing?  Turns out the decision comes from the Department of Defense.  Yep.  The guys buying fiber-plated bombers and infra-red rifle sights and inventing bombs that suck your inner organs out through your maxillary sinus, are also the ones who decided that 6 sexual encounters a month should keep the average couple happy.

Truth is, for many of my returning soldiers, sex and intimacy isn’t simply a nice addition to their lives after over a year of living in austerity.  It is life.  This seems to be especially true of the committed, married soldiers I work with.  Their marriage, and the love they share within it, is often the only salve on wounds that cover their bodies and souls.  Imagine falling into the yearning arms of your wife after 15 months alone, after encountering horrors on the battlefield you will never describe, only to have to say you’re sorry, you just aren’t the same as you were…even as a lover.

A patient recently said to me (to paraphrase), “My wife and I LOVE to have sex, doc.  It’s an every day thing, if not two or three times a day.  At least, that’s how it was.  Now we spend most of the time we would have spent in bed – or in the kitchen, or in the microwave, or in the neighbor’s tool shed, or on top of the dresser, or under the aquarium, or in the chimney, or dressed up as Tonto and the short curly-haired lady from Cheers – with a counselor, trying to figure out what’s wrong with me.”

Most (not all) healthy, vital, loving relationships are comprised of sex more than just once a week with an occasional “two-fer” on the weekend.  Especially if one of the partners has been gone for over a year.  If returning injured soldiers have anything to look forward to, for many of them it’s their longsuffering, waiting, pent-up, willing spouse.  Divorce is a catastrophe, especially when it’s between a broken soldier and the person who typically is the last one standing in their corner when the world is running down.  Seems to me that we could forgo a couple of those useless air-to-air combat fighters everyone’s arguing about and use the money to give these soldiers as many nights of intimate bliss as we possibly can.

Reader Comment: A Child’s Chest Pain

A reader recently commented on the SW101 post Will My Child Have A Heart Attack with a disturbing letter about her child.  It has now been granted its own blog.  I have written my own comments in throughout the letter in red italics to make me appear extra important and potentially infallible.

***************************

Thank you for that article. My typically healthy 6 year old daughter has been complaining of chest pain, burning on the left side of the neck and feeling her heart “in her throat” as she says. This is not a big deal.  Kids say this stuff all the time.  It goes along with the ubiquitous “Tummy ache”, “I’m full”, “My eyes hurt”, “I need a drink of water”, and “Where’s my bear you can’t expect me to sleep in such harsh conditions so until you find my bear I’m going to sit here and attempt to poop my pants in protest so start lookin’ quick, POPS.”

She says it goes too fast and she gets dizzy and has actually passed out several times while doing minimal activity. This IS a big deal.  Kids don’t do this…ever.  True loss of consciousness in a 6 year old kid has a genuine cause.  In the elderly, things like autonomic instability lead to syncopal episodes (pass out when they stand up).  Add 90 years to your kid’s life, and your letter wouldn’t have won itself a full blog post.

I have taken her to several Dr’s, only to be told “kids don’t have heart attacks”.  I agree.  Kids don’t.  Adolescents do, however.  And young adults in their early 20’s do too. I’m at my wit’s end with this and worry over it constantly.  You’re right to be.  The hair is starting to stand up on the back of my neck over this one.

She had bloodwork to check her cholesterol about 14 months ago and it was high. Genetics..ding!  ding!  ding!  That, or you’ve set her up with a continuous Big Mac infusion pump through her sleeping hours.

She recently had it checked again and it was 259. That’s worse than mine…and I’m 37 spending most of my time with my butt glued to a chair while I hover like an anxious hen over my blog. Her sister (age 10) had a cholesterol level of 126. Luck of the draw, kid.  I’d see the bet and raise it if I were her. They eat virtually the same thing and my 6 year old is only 40 lbs, so she isn’t overweight. Another sign of a genetic component…which makes this just fantastically unfair.

This is now starting to affect her normal playing routine because she says running/playing make it hurt worse. REALLY bad sign.  Kids run.  Especially skinny kids.  They RUN.

I’ve been told it’s constipation ?, seriously?, reflux probable in ADULTS, heartburn same thing…grown ups, not kids, pulled sternum maybe the strangest musculoskeletal diagnosis I’ve ever heard….but so far no Doctor feels it is anything to worry about.  Are you seeing actual doctors…in actual America?  I hear the medical system on the plains of Balinor is a bit iffy.

She had a EKG and it showed she was tachycardic based on her age?  EVERY kid is tachycardic compared to an adult and a few arrythmias this is like saying “oh, we had some red wine”.  Some arrythmias KILL YOU, others are meaningless…and everything in between.  What kind of arrythmia?, however her pediatrician feels that could be normal for her age. ‘Could be?

Her teacher at school tells me she complains 5-10 times a day and says ‘my heart hearts’.  My 3 year old boy is obsessed with candy, but I’d guess he rarely actually asks for it 10 times in one 24 hour period (considering he sleeps for about 14 of them).

We live in a very small town population 4?, and have to travel 120 miles to a ped. cardiologist worth it…however they won’t see her without a referral and her pediatrician doesn’t feel it is necessary I suspect an insurance issue.  How hard is it to make a referral, even if only to help reassure mom?

If you have any suggestions for me I would love to hear them. I’m worried
that even though diet has been modified and the rest of the family has no cholesterol issues (grandparents do) that this high level is affecting her.  Do you know of any other tests that I could suggest her Doctor perform? Short of a cardiac catheterization, I’m not aware of any other helpful tests in this situation. He has also shrugged off any suggestions of a heart echo.

Final Thoughts – (I’ll dispense with the red italics, even though it makes me feel Extremely Important):

I can’t be certain that your story is completely true, because I don’t know you and haven’t seen your daughter’s medical file.  It also rings a bit fantastical since I’ve spent lots of time around pediatricians and have never seen one as cavalier as what you describe based on the small amount of information you’ve provided me.  As a rule, I do not believe that many doctors are lazy, incompetent, negligent…or drunk.  If you’re going to a licensed child specialist physician, they probably know what they’re talking about.

That said, IF your story is completely true, my advice is to knock on doors – pound on them if you have to.  Walk up to any door with an M.D. on it (be wary of any other initials except perhaps D.O.) – until you get a referral to a pediatric cardiologist for an echo.  Women walked for 5 solid hours under the Haitian sun to have their child seen in our clinics when I did relief work there, so you can cross vast distances for your child too.

The echo, in my opinion, is the first place to start.  Your child also probably needs medication for the cholesterol issue – or will in the very near future – and if your pediatrician seems to be cavalier about this, you may need to look for one that is more aggressive.  But diet changes won’t help this situation much, and exercise could be dangerous until you rule out structural heart disease.  It’s almost impossible to find cardiomyopathy without imaging, and totally impossible to find early atherosclerosis without a significant work up by a cardiologist.

Rest assured, there is a doctor out there who will find in in their writing hand to put in 10 minutes and refer you to a specialist if your story is as legit as it appears on this blog.  If it takes spending a week in a larger city, fine.  If it takes getting on an airplane, DO IT!  If what you said is true, and there are no additional conveniently omitted facts, your child needs to see a specialist.  Do NOT stop pestering doctors until she does.

Finally, let me say that while my heart goes out to you, remember that I am a doctor…but not YOUR doctor.  And this is a blog, not my clinic.  As you can see by my responses, I’m giving my honest opinion, but also being silly.  I write this blog for fun, not to extend my day at the office.  Therefore, these responses qualify only as  suggestions and musings, not medical advice.  A licensed physician, who has actually seen your daughter and evaluated her entire history, is the one who needs to make a real recommendation in this situation.  It completely annoys me that I find it necessary to say that….the world these days is run by lawyers.

All joking and useless lawyer pandering aside, my responses in this blog really boil down to one thing:  Keep knocking….

Movie Review – Avatar

I enjoyed myself fully last night as I entered the world of ‘Avatar’, James Cameron’s new sci-fi epic that already handily broke a 1 billion-dollar landmark record of some kind.  I’d watch the show again tonight if I could.  I’d probably watch it every night for a week like my high school buddies did for “Bill and Ted’s Excellent Adventure” once upon a time.

You don’t have to care – or understand – the point of the movie to completely enjoy the stunning visual spectacle presented in wide-screen, 3D wonder.  In fact, I’d advise constraining yourself specifically to the visual effects and skip putting any real thought to the message of the movie.  In essence, just sing along with the song, but don’t think about what the words actually mean.

The story follows an ex-Marine named Jake as he becomes part of a mission to subjugate – or at least translocate – the natives on a strange new planet (a moon actually, but does it matter?).  On the n0t-so-subtly-named Pandora, the “aliens” congregate around an enormous tree set in the middle of a seemingly endless forest.  They stand about 11 feet tall, with blue skin and luminous yellow eyes and they all seem to carry bow and arrows and daggers.  These blue and tall but otherwise disappointingly human-shaped beings generally seem happiest when attending their frequent tribe-wide drum fests – with a terminally simplistic 2/4 beat rhythm that sounds like it might have been pounded out on cool Senegalese drums the Anglo orchestra bought in bulk.

These earthy aliens have a sacred, mystical, spiritual connection to the forest where they live; generally behaving like any nature-loving tribe the Europeans successfully decimated a little over a century ago in North America.  In a complete creative hiatus, at one point nature is even called a “mother”.  Why not a father, or brother, or just skip the nuclear family reference to nature entirely?  The descriptor ‘Mother Earth’ is so unoriginal, it ranks up there with Bless You and Dot Com.

Although 2 hours and something like 40 minutes, you can easily sum up the movie in one phrase: “Dances With Wolves”…but with pterodactyls you can ride.

Basically – Marine makes contact with natives through project financed by aggressive and ethics-challenged Big Business company.  Marine plans on helping his financiers destroy said natives.  Instead, he inadvertently falls in love with natives in general, and one curvaceous native in particular.  He then becomes the enemy of his former bosses, ultimately leading the meek, dumb, dark-skinned simpletons to victory over superior white man.

I haven’t decided if this REALLY tired theme of the White Male swooping down into a primitive race, seeing their genuine good, and then becoming their Great Savior is completely racist.  Some are saying it absolutely is.  I don’t really think that was the intent.  I just think it was lazy writing by a white male who deep-down believes that white men are still the best hope for the world.  That they still run it, ultimately.  But it is possible that white men really don’t have much to offer the world anymore – that we’ve had our time and made our mark.  Maybe it’s time for some non-white, non-men to run the countries, write the laws, own the companies and save fictional worlds.  Maybe the white boy has done about all he can.

Big Business takes a major hit in this movie.  It gets portrayed as the denizen of all Evil in life.  That said, it’s Big Business that has paid for every iota of scientific discovery that has occurred on Pandora.  The science taking place on this moon (and taking place on our earth) is an elevated form of existence, no question, but in both worlds it mostly exists because of Big Business, either directly or through taxes.  Scientists – and artists – need to accept the fact that to live in that enlightened world of thought and wonder and possibility depends on their benefactor’s mundane ability to sell widgets.  Big Business is rarely genuinely evil.  True, figuring out when to inject some profit-endangering humanistic principles into a business plan does takes some skill and is occasionally gotten wrong. But for the most part, if business didn’t make the poet, at least it feeds him.

The actual “avatar” is a living being made to look like the aliens, but controlled by the mind of a human.  The human links to the avatar neurologically, so it can only be controlled by one specific human.  Thus, the human lies in a coffin-like body-pod that connects him/her to their specific avatar.  Upon falling into a coma in the pod, the avatar wakes up and the mind of the comatose human controls it.

Soohh...who gets to clean this thing?

The doc in me couldn’t help but get hung up on this part of the movie.  First, all humans need to sleep.  But since the avatar wakes up as soon as the human “sleeps”, and since controlling the avatar is a conscious process, the human never actually does sleep.  For some evolutionary reason I can’t fathom, REM sleep is the foundation of all life.  This inconvenient fact defies even the mighty pen of James Cameron.  By the end of the movie, after staying awake vicariously with the characters, I felt like I’d been on call in the hospital for days on end (felt like I was back in residency again).

Also, the human lays in this coffin thing for hours and hours.  At the least, he’s gotta pee himself on a regular basis, to say nothing of the inevitable bowel movement here and there.  Plus, the main character’s avatar hooks up with the sexy female alien.  Depicted as the first consummating night of an eternal love bond – thus likely a multicoital affair – envisioning the scene (and smell) inside the pod after this particular night left me a bit squeamish.

As mentioned, the power of this movie is in the visuals.  It is a “looker” many times over.  But the general message is tired, probably slightly racist, and denigrates the U.S. Military (or at least leads the audience to exult in the widespread slaughter of American soldiers/mercenaries).  That said, perhaps our culture really should take the main theme of the story to heart.  After all, we DID decimate the Native American culture, and based on my experiences on the Crow Reservation in Montana, I’d say we continue to.  We’re also strikingly obtuse in our dealings with tribal cultures in the Middle East today.  Listening to people from a different culture – rather than melting them with daisycutters and circling drones – has some merit.

But I do wish the movie had added a little post-modernism into the mix and eschewed the evil-good idea altogether.  It didn’t have to pit the American Axis of Evil (big business + U.S. Army) against a pristine tribal culture practically perfect in every way.  Historic Native American tribes were often duplicitous, aggressive, thieving and hateful (many still are today).  They rarely trusted each other from tribe to tribe and may have been just as irresponsible had one tribe attained the raw power that the U.S. Government currently has.  The Arab tribes we’re tangling with recently have a litany of faults and cobwebby dark corners too.  But they are also a just, priceless, sacred, honorable people.  This dichotomy exists in virtually every race in our world.  Americans seem to hate this complexity in our fiction – it’s easier to hate one thing and love another and then watch them duke it out.

Yeah, YEAH! Die lame-oh Americans! Wait, didn't an American make this movie?

Thus, the conflict in the movie could have been between two parties filled with faults and frailties but ultimately imbued with genuine honor, honesty and a respect for the rights of others.  Standing between them is something they both deeply need and want (trees, mineral ore…whatever).  In life, conflicts almost always boil down to two parties who both have blood on their hands, but both are essentially good, honorable…and in the right.  e.g., Palestine wants the land, Israel wants the land, both have been evil at times, both have been angelically good at times, and each have some form of legitimate claim to the exact space of real estate.  Stick that conundrum in your avatar’s virtual peace pipe and take a deep drag, nature-brother.

Depicting this nuanced world may have weakened the sense of righteous rage as the Army went Operation Flatten Everything.  It may have lessened the gloating release when the Ultimate Bad Guy finally met his ignominious end.  But it would have made a better movie.  It would have made the written story as complex as those fantastic visuals, and created a worthy counterpart to such a sparkling, wondrous vision.