“You know, Curmudge, the human body is quite amazing.”
“I agree, Jaded Julie, but it’s not always amazingly good. The body I know best seems to be getting older and slower, and the body I loved most shut itself down rather suddenly a few months ago. Perhaps I need more explanation of this ‘amazing’ stuff.”
“Okay. As an example, let’s use the condition called sepsis. Were you aware that only one out of three Americans has ever heard the word ‘sepsis’ and that it is the tenth most common cause of death? In sepsis bad things occur because of actions taken by parts of the body to protect themselves.”
“Julie, if you are inspired by the same sepsis I’ve been reading about, you have a mighty morbid sense of amazement. But as a compulsive learner, if there’s more that I need to know, let’s get on with it. Tell me about sepsis.”
“Well Curmudge, old codgers like you might recognize the term, ‘blood poisoning,’ but that’s an inadequate description. Sepsis is not an infection in of itself; it’s a systemic (whole-body) response to infection or injury. Specifically, bacteria, a fungus, or a virus overwhelm the bloodstream. This is called septicemia.”
“So far so good (or bad), Nurse-Educator, but where do these bad guys come from?”
“Lots of places: the bowel (peritonitis), the kidneys (pyelonephritis), the lining of the brain (meningitis), the lungs (bacterial pneumonia), the skin (cellulitis). In hospitalized patients, common sites of infection include IV lines, surgical wounds and drains, and bedsores.”
“Thus far, everything I’ve heard is bad. Where does the ‘amazing’ stuff occur?”
“Let’s start simple. When the body incurs an insult—from a minor injury to the entry of bacteria and bacterial toxins into the bloodstream—the immune system is activated. Cells of the endothelium—the lining of blood vessels—respond by initiating the inflammation process. This involves dilation of blood vessels and consequent leakage. The cells—seeking to maintain internal equilibrium (homeostasis)—try to reestablish control through the process called coagulation, the formation of blood clots. They are an interlacing fibrous network of a substance called fibrin.”
“Hooray for blood clots. That’s why I grew a beard…so I wouldn’t have to worry about cutting myself shaving.”
“Don’t speak too soon, Curmudge. There’s a lot more biochemistry going on. The body views blood clots as an abnormality, so it cranks up the process of fibrinolysis to get rid of them. Sort of like when a bruise loses its purple coloration. Tissue plasminogen activating factor (t-PA) forms plasmin, the workhorse of fibrinolysis.”
“Hey Julie, I know about t-PA. That’s what they give victims of an ischemic stroke, the type of stroke often caused by a blood clot.”
“Unfortunately in sepsis, inflammation and coagulation overpower fibrinolysis, and the sepsis victim has microvascular thrombosis, i.e., blood clots in his capillaries.”
“I can see now that when that happens throughout the body, the patient is in deep trouble. As you said originally, the human body is amazing; each of these processes is essential. But problems arise when one process becomes dominant and forces homeostasis out of balance. It is just too much of a good thing. So what happens to a body when it is full of little blood clots?”
“It would seem as if the body is trying to self-destruct. Back during inflammation, when the blood vessels are dilating, the body senses that blood pressure is dropping. It’s time to set priorities, so vasoconstrictors are released to constrict blood vessels and elevate blood pressure in order to maintain blood flow to the vital organs, the heart and brain. Of course, that shunts blood away from the ‘non-vital’ organs such as lungs, kidneys, gastrointestinal tract, and skin.”
“Obviously Julie, the patient, who has a whole-body outlook, takes a dim view of the so-called ‘non-vital’ organs’ losing their blood supply and shutting down. It’s evident that without major assistance from skilled health care, the patient will expire.”
“I hate to leave the patient in such a precarious situation, but we won’t talk about the role of health care in sepsis until next week. Until then, Curmudge, please hold your breath.”
Affinity’s Kaizen Curmudgeon
Friday, August 26, 2011
Thursday, August 18, 2011
Hardwiring 2
“Curmudge, in our last conversation about hardwiring you said you would tell me how to hardwire Lean.”
“If I said that, Jaded Julie, I spoke too soon. Lately I’ve been thinking a lot about learning and hardwiring. May I share my cogitations with you?”
“Sure, as long as ‘cogitations’ aren’t something you’ve been drinking or smoking.”
“Back on May 8, 2008 we talked about how leadership often requires doing things which are not truly natural. The things that a young baby does that are natural are cry, nurse, and soil its diapers. As life progresses most of our actions have been taught to us until they become hardwired. You might think that brushing your teeth in the morning is natural, but in fact it was hardwired into your brain by your mother’s repeated insistence and reinforcement. We might feel that driving on the right side of the street is natural, but don’t try it in Great Britain.”
“I’ve got it, Curmudge. Hardwiring requires repetition, reinforcement, and sometimes intense study until it feels natural. If any element is most important, it’s repetition. That’s why my mother took me to religious services every week. We hardwire our morals and the elements of our character, and a society hardwires its mores.”
“So if repetition and reinforcement are essential for hardwiring, how much of it can we achieve in a one-week kaizen event or a one-day Lean Overview class?”
“I’m afraid not very much, and I’ll bet that was the conclusion that popped out of your cogitations. At least an event is usually a hands-on and brains-on activity for the participants. I’ll also bet that we won’t recommend subjecting the students to increasing amounts of ‘death by PowerPoint.’ “
“Excellent perception, Julie. How about this? Although we have the participants’ bodies for only the single day or week of the event, perhaps we could stretch their experience with pre-work and post-work. The pre-work could put their minds in learning mode, and whatever was done after the event would serve as reinforcement.”
“The event should include videos, games, discussions, and team activities. Perhaps even a pop quiz on the preliminary reading. If the event itself is memorable, perhaps more of the subject material will be retained. Of course, if any of the students is like you, Curmudge, we’ll need to keep him/her awake.”
“Although we’d like participants to retain details of the Lean tools used in the event, our most important goal is to hardwire the principles of the Lean culture.”
“Perhaps, Curmudge, we should shout them from the top level of the parking ramp at St. E’s. ‘Show respect for people.’ ‘Eliminate waste.’ ‘Use standard work.’ ‘Promote continuous improvement.’ We could do it every day at noon, just like a town crier.”
“I’d prefer to stay in out of the weather and just write a blog like Kaizen Curmudgeon. Every week we send a reprint of an earlier posting to each graduate of the Lean Overview course. But in the absence of organized reinforcement, you have to do it on your own. For example, there are blogs from many sources that one should follow to get a regular Lean ‘fix.’ Examples are http://dailykaizen.org/, http://leanhealthcareexchange.com/, and http://www.leanblog.org/ (although that author seems to feel that there is only one health care organization in town). While the blogs tend to be repetitive (and sometimes self-serving), they present Lean fundamentals from many different perspectives.”
“I think I know your bottom line on hardwiring, Curmudge, but I’d prefer to hear it in your trite, but umforgettable, manner.”
“A man on the street in New York City asked a passer-by how to get to Carnegie Hall. The passer-by’s answer was, ‘practice…practice.’ “
Affinity’s Kaizen Curmudgeon
“If I said that, Jaded Julie, I spoke too soon. Lately I’ve been thinking a lot about learning and hardwiring. May I share my cogitations with you?”
“Sure, as long as ‘cogitations’ aren’t something you’ve been drinking or smoking.”
“Back on May 8, 2008 we talked about how leadership often requires doing things which are not truly natural. The things that a young baby does that are natural are cry, nurse, and soil its diapers. As life progresses most of our actions have been taught to us until they become hardwired. You might think that brushing your teeth in the morning is natural, but in fact it was hardwired into your brain by your mother’s repeated insistence and reinforcement. We might feel that driving on the right side of the street is natural, but don’t try it in Great Britain.”
“I’ve got it, Curmudge. Hardwiring requires repetition, reinforcement, and sometimes intense study until it feels natural. If any element is most important, it’s repetition. That’s why my mother took me to religious services every week. We hardwire our morals and the elements of our character, and a society hardwires its mores.”
“So if repetition and reinforcement are essential for hardwiring, how much of it can we achieve in a one-week kaizen event or a one-day Lean Overview class?”
“I’m afraid not very much, and I’ll bet that was the conclusion that popped out of your cogitations. At least an event is usually a hands-on and brains-on activity for the participants. I’ll also bet that we won’t recommend subjecting the students to increasing amounts of ‘death by PowerPoint.’ “
“Excellent perception, Julie. How about this? Although we have the participants’ bodies for only the single day or week of the event, perhaps we could stretch their experience with pre-work and post-work. The pre-work could put their minds in learning mode, and whatever was done after the event would serve as reinforcement.”
“The event should include videos, games, discussions, and team activities. Perhaps even a pop quiz on the preliminary reading. If the event itself is memorable, perhaps more of the subject material will be retained. Of course, if any of the students is like you, Curmudge, we’ll need to keep him/her awake.”
“Although we’d like participants to retain details of the Lean tools used in the event, our most important goal is to hardwire the principles of the Lean culture.”
“Perhaps, Curmudge, we should shout them from the top level of the parking ramp at St. E’s. ‘Show respect for people.’ ‘Eliminate waste.’ ‘Use standard work.’ ‘Promote continuous improvement.’ We could do it every day at noon, just like a town crier.”
“I’d prefer to stay in out of the weather and just write a blog like Kaizen Curmudgeon. Every week we send a reprint of an earlier posting to each graduate of the Lean Overview course. But in the absence of organized reinforcement, you have to do it on your own. For example, there are blogs from many sources that one should follow to get a regular Lean ‘fix.’ Examples are http://dailykaizen.org/, http://leanhealthcareexchange.com/, and http://www.leanblog.org/ (although that author seems to feel that there is only one health care organization in town). While the blogs tend to be repetitive (and sometimes self-serving), they present Lean fundamentals from many different perspectives.”
“I think I know your bottom line on hardwiring, Curmudge, but I’d prefer to hear it in your trite, but umforgettable, manner.”
“A man on the street in New York City asked a passer-by how to get to Carnegie Hall. The passer-by’s answer was, ‘practice…practice.’ “
Affinity’s Kaizen Curmudgeon
Friday, August 12, 2011
Hardwiring
“Curmudge, when a fact or concept is ‘hardwired,’ does that mean that it will never be forgotten?”
“To me, Jaded Julie, the term ‘hardwired’ (which most of us learned from the writings of Quint Studer) is not an absolute. Without reinforcement, most of the professional stuff we learned years ago will eventually slip away. However, it’s interesting that sometimes personal experiences will stick with us forever. An example is when my older playmates kicked me out of the sandbox because I was only four years old.”
“I must admit that during the years we have worked together I’ve become impressed by the leakiness of your memory. Is it true that you tell your educated friends that their advanced degrees expired after 40 years?”
“Although I’m just kidding, for most people the concept is probably correct. Exceptions would be some professors and physicians who teach or use their professional knowledge on a daily basis. They support my contention that reinforcement is essential.”
“If as you say mental ‘wiring’ comes in varying degrees of hardness, you must know some convincing examples.”
“At the extreme end of hardness are the connections between the mind and fingers of the professional musician. These people are able to see a multitude of notes on a score and translate them into actions of their fingers (and sometimes feet) at a frequency of several per second. It takes years of practice to develop those connections; and if they stop practicing, they lose their performer’s ‘edge.’ But they never totally forget basic fingering.”
“Do we see some of this in the practice of medicine, Curmudge?”
“We know that it takes years of residency to train a specialist, but the Army is finding that their special skills begin to erode after about four months of deployment away from their specialty. (1) Thus it’s a bit of a surprise when an OB/GYN volunteers to serve a year in a battalion aid station.”
“What about the other end of the ‘forgettable’ scale? We all recall from our formal education years that information in which we had little interest was pretty transitory.”
“Julie, my retention of some courses—especially those that were required—is zilch. In fact, I suspect that when I walked out of the final exam, my brain dumped the whole course content right there in the hallway.”
“I hate to disturb your reverie, Curmudge, but how can we apply these insights to Lean training?”
“Our goal, Julie, is to impart a Lean mindset to everyone and to help them retain and use what they have learned. It’s pretty lofty, but it is expressed well in this quote from Masaaki Imai (in the 6/22/11 posting of leanblog.com), ‘engage everybody in improvement every day, everywhere in the organization.’ We’ll talk later about how to do that.”
Affinity’s Kaizen Curmudgeon
(1) Deering, S. H., et al. Am. J. Surgery vol. 201 (May 2011)
Note: We last wrote about hardwiring three years ago (May 22, 2008). The current posting is consistent with our belief that some repetition of principles is necessary to reinforce knowledge.
“To me, Jaded Julie, the term ‘hardwired’ (which most of us learned from the writings of Quint Studer) is not an absolute. Without reinforcement, most of the professional stuff we learned years ago will eventually slip away. However, it’s interesting that sometimes personal experiences will stick with us forever. An example is when my older playmates kicked me out of the sandbox because I was only four years old.”
“I must admit that during the years we have worked together I’ve become impressed by the leakiness of your memory. Is it true that you tell your educated friends that their advanced degrees expired after 40 years?”
“Although I’m just kidding, for most people the concept is probably correct. Exceptions would be some professors and physicians who teach or use their professional knowledge on a daily basis. They support my contention that reinforcement is essential.”
“If as you say mental ‘wiring’ comes in varying degrees of hardness, you must know some convincing examples.”
“At the extreme end of hardness are the connections between the mind and fingers of the professional musician. These people are able to see a multitude of notes on a score and translate them into actions of their fingers (and sometimes feet) at a frequency of several per second. It takes years of practice to develop those connections; and if they stop practicing, they lose their performer’s ‘edge.’ But they never totally forget basic fingering.”
“Do we see some of this in the practice of medicine, Curmudge?”
“We know that it takes years of residency to train a specialist, but the Army is finding that their special skills begin to erode after about four months of deployment away from their specialty. (1) Thus it’s a bit of a surprise when an OB/GYN volunteers to serve a year in a battalion aid station.”
“What about the other end of the ‘forgettable’ scale? We all recall from our formal education years that information in which we had little interest was pretty transitory.”
“Julie, my retention of some courses—especially those that were required—is zilch. In fact, I suspect that when I walked out of the final exam, my brain dumped the whole course content right there in the hallway.”
“I hate to disturb your reverie, Curmudge, but how can we apply these insights to Lean training?”
“Our goal, Julie, is to impart a Lean mindset to everyone and to help them retain and use what they have learned. It’s pretty lofty, but it is expressed well in this quote from Masaaki Imai (in the 6/22/11 posting of leanblog.com), ‘engage everybody in improvement every day, everywhere in the organization.’ We’ll talk later about how to do that.”
Affinity’s Kaizen Curmudgeon
(1) Deering, S. H., et al. Am. J. Surgery vol. 201 (May 2011)
Note: We last wrote about hardwiring three years ago (May 22, 2008). The current posting is consistent with our belief that some repetition of principles is necessary to reinforce knowledge.
Monday, August 8, 2011
Conventional Wisdom
“Curmudge, if we’re going to talk about conventional wisdom, I hope you will define it for me.”
“O course, Jaded Julie. In my view, conventional wisdom is the generally accepted knowledge about a topic at a given point in time. For example, in medieval times, the accepted way to treat an open wound was to pack it in goat dung. And until the time of Galileo, most everyone believed that the sun went around the earth once per day.”
“Wow! I’m sure glad things had changed by the time I was a child and skinned my knee.”
“Conventional wisdom can do two things; it can stagnate and become unassailable dogma, or it can evolve with the growth of knowledge. Although new knowledge in medicine seems to be slow in its adoption, we’ve seen amazing advances in our lifetime. I remain intrigued by the oft-quoted medical school professor who told entering students, ‘About half of what we teach you here will eventually be proven to be incorrect, but we don’t know which half.’ “
“What about that ‘unassailable dogma’ stuff, Curmudge? How does that come about?”
“It is easy to scare people but hard to ‘unscare’ them. When something frightens people, it is very difficult to change their view. A pertinent example is radiation. Some people fear radiation whether it’s the small amount used in medical imaging or the massive amounts confined in nuclear power plants.”
“Confess, Curmudge. Are you making this up, or do you actually know something about radiation?”
“The latter, Doubting Julie. I spent most of the summer of 1970 studying it in Oak Ridge, Tennessee. Of course, during the intervening 41 years I’ve forgotten most of what I learned. And to make matters worse, the international pooh bahs changed the names of the units of measurement. So I guess the most truthful answer to your question is that I read a lot.”
“So what did you read that catalyzed your concern about radiation and conventional wisdom?”
“Well, years ago we learned that any amount of radiation—no matter how little—had the potential of causing cancer. A plot of cancer occurrence vs. exposure, based on high levels of exposure, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect. This was called the ‘linear no-threshold theory’ (LNT). It was the conventional wisdom then, and over time it became dogma and even the basis of laws and regulations. Additionally, it justified the anxiety of those who were extremely fearful of all radiation.”
“Does your reading suggest, Curmudge, that the LNT theory no longer represents the consensus regarding radiation exposure?”
“That is certainly implied in several review articles published during the past ten years. Here is a typical conclusion, ‘Based on a review of epidemiological and other data for exposure to low radiation doses and dose rates, it was found that the LNT model fails badly.’ (Vaiserman) Other authors have discussed protective effects from low radiation doses, ‘Irradiated cells protect themselves (a) by immediate defense, repair, and damage removal mechanisms and (b) by delayed and temporary protection also against renewed DNA damage, irrespective of its causes—that is, through adaptive responses.’ (Tubiana, et al.)”
“But Curmudge, there have been articles in the recent scientific and popular literature suggesting that the growing use of diagnostic computed tomography (CT) scans might increase the incidence of cancer. (Brenner & Hall, Landro) It sounds as if conventional wisdom is up for grabs.”
“It seems to be. Others have said: ‘There is no credible evidence to support the contention that current routine usage of CT scans in clinical settings in the United States will cause future cancers. Rather, the available data indicate that occasional exposure to diagnostic x-rays could possibly reduce the risk of future cancers among irradiated adults.’ (Scott et al.)”
“How do we resolve issues like this, Curmudge?”
“As you know, Jaded Julie, we’re not qualified to address that question. However, there is one more bit of older conventional wisdom that we should consider even though it contains regulations based on the LNT theory. It’s called ALARA, the acronym for As Low As Reasonably Achievable. Although the regulations might change, the concept is common sense: don’t expose anyone—patients, workers, or yourself—to more radiation than is absolutely essential. In the case of CT scans, one should be especially protective of children and pregnant women.”
“In your work long ago and for more recent diagnostic purposes you have been exposed to a variety of kinds of low-level radiation. Do those exposures leave you concerned?”
“I have always respected radiation and tried to minimize my exposures. However, for old geezers like me who won’t be around long enough to experience long-term effects—good or bad—from low-level radiation, this literature is just interesting to read and share.”
Affinity’s Kaizen Curmudgeon
Literature Cited
Vaiserman, A.M. Radiation Hormesis: Historical perspective and implications for low-dose cancer risk assessment. Dose-Response 8:172-191 (2010). http://pubget.com/paper/20585444
Tubiana, M., et al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 251(1):13-22 (April 2009). http://radiology.rsna.org/content/251/1/13.full.pdf
Brenner, D.J. and Hall, E.J. Computed tomography—an increasing source of radiation exposure. N. Engl. J. Med. 357: 2277-2284 (2007). http://www.nejm.org/doi/full/10.1056/NEJMra072149
Landro, Laura. Radiation risks prompt push to curb CT scans. Wall St. J. (March 2, 2010)
Scott, B.R., et al. CT scans may reduce rather than increase the risk of cancer. J. Am. Physicians & Surgeons 13(1):8-11 (Spring 2008). http://www.jpands.org/vol13no1/scott.pdf
“O course, Jaded Julie. In my view, conventional wisdom is the generally accepted knowledge about a topic at a given point in time. For example, in medieval times, the accepted way to treat an open wound was to pack it in goat dung. And until the time of Galileo, most everyone believed that the sun went around the earth once per day.”
“Wow! I’m sure glad things had changed by the time I was a child and skinned my knee.”
“Conventional wisdom can do two things; it can stagnate and become unassailable dogma, or it can evolve with the growth of knowledge. Although new knowledge in medicine seems to be slow in its adoption, we’ve seen amazing advances in our lifetime. I remain intrigued by the oft-quoted medical school professor who told entering students, ‘About half of what we teach you here will eventually be proven to be incorrect, but we don’t know which half.’ “
“What about that ‘unassailable dogma’ stuff, Curmudge? How does that come about?”
“It is easy to scare people but hard to ‘unscare’ them. When something frightens people, it is very difficult to change their view. A pertinent example is radiation. Some people fear radiation whether it’s the small amount used in medical imaging or the massive amounts confined in nuclear power plants.”
“Confess, Curmudge. Are you making this up, or do you actually know something about radiation?”
“The latter, Doubting Julie. I spent most of the summer of 1970 studying it in Oak Ridge, Tennessee. Of course, during the intervening 41 years I’ve forgotten most of what I learned. And to make matters worse, the international pooh bahs changed the names of the units of measurement. So I guess the most truthful answer to your question is that I read a lot.”
“So what did you read that catalyzed your concern about radiation and conventional wisdom?”
“Well, years ago we learned that any amount of radiation—no matter how little—had the potential of causing cancer. A plot of cancer occurrence vs. exposure, based on high levels of exposure, could be extrapolated to the origin, i.e., there was no threshold below which there was no effect. This was called the ‘linear no-threshold theory’ (LNT). It was the conventional wisdom then, and over time it became dogma and even the basis of laws and regulations. Additionally, it justified the anxiety of those who were extremely fearful of all radiation.”
“Does your reading suggest, Curmudge, that the LNT theory no longer represents the consensus regarding radiation exposure?”
“That is certainly implied in several review articles published during the past ten years. Here is a typical conclusion, ‘Based on a review of epidemiological and other data for exposure to low radiation doses and dose rates, it was found that the LNT model fails badly.’ (Vaiserman) Other authors have discussed protective effects from low radiation doses, ‘Irradiated cells protect themselves (a) by immediate defense, repair, and damage removal mechanisms and (b) by delayed and temporary protection also against renewed DNA damage, irrespective of its causes—that is, through adaptive responses.’ (Tubiana, et al.)”
“But Curmudge, there have been articles in the recent scientific and popular literature suggesting that the growing use of diagnostic computed tomography (CT) scans might increase the incidence of cancer. (Brenner & Hall, Landro) It sounds as if conventional wisdom is up for grabs.”
“It seems to be. Others have said: ‘There is no credible evidence to support the contention that current routine usage of CT scans in clinical settings in the United States will cause future cancers. Rather, the available data indicate that occasional exposure to diagnostic x-rays could possibly reduce the risk of future cancers among irradiated adults.’ (Scott et al.)”
“How do we resolve issues like this, Curmudge?”
“As you know, Jaded Julie, we’re not qualified to address that question. However, there is one more bit of older conventional wisdom that we should consider even though it contains regulations based on the LNT theory. It’s called ALARA, the acronym for As Low As Reasonably Achievable. Although the regulations might change, the concept is common sense: don’t expose anyone—patients, workers, or yourself—to more radiation than is absolutely essential. In the case of CT scans, one should be especially protective of children and pregnant women.”
“In your work long ago and for more recent diagnostic purposes you have been exposed to a variety of kinds of low-level radiation. Do those exposures leave you concerned?”
“I have always respected radiation and tried to minimize my exposures. However, for old geezers like me who won’t be around long enough to experience long-term effects—good or bad—from low-level radiation, this literature is just interesting to read and share.”
Affinity’s Kaizen Curmudgeon
Literature Cited
Vaiserman, A.M. Radiation Hormesis: Historical perspective and implications for low-dose cancer risk assessment. Dose-Response 8:172-191 (2010). http://pubget.com/paper/20585444
Tubiana, M., et al. The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 251(1):13-22 (April 2009). http://radiology.rsna.org/content/251/1/13.full.pdf
Brenner, D.J. and Hall, E.J. Computed tomography—an increasing source of radiation exposure. N. Engl. J. Med. 357: 2277-2284 (2007). http://www.nejm.org/doi/full/10.1056/NEJMra072149
Landro, Laura. Radiation risks prompt push to curb CT scans. Wall St. J. (March 2, 2010)
Scott, B.R., et al. CT scans may reduce rather than increase the risk of cancer. J. Am. Physicians & Surgeons 13(1):8-11 (Spring 2008). http://www.jpands.org/vol13no1/scott.pdf
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