Joseph Cornell vs. Mr. Wilson

So continues documentation of my eclectic vacation...

Today I finished reading a most intriguing book: Mr. Wilson's Cabinet of Wonder. This fantastic non-fiction narrative is a pseudo-biographical account of David Wilson and his Museum of Jurassic Technology written by Lawrence Weschler. It is an excellent window into the subculture of museum quality pseudo-science similar to the kind forwarded by the Athanasius Kircher Society.

The other thing I accomplished today was a visit to the San Francisco Museum of Modern Art. There I made a beeline for the Joseph Cornell exhibit (in the last stop of a traveling exhibition). In many ways, he is the chief influence for my Wunderkammern creations (albeit via David Francis). I spent about 2 hours in the 1000 square foot exhibit, and was thoroughly impressed. This show only lasts until January 6 and SFMOMA is the last stop.

In summary, my New Year's Eve can be summarized as Joseph Cornell vs. Mr. Wilson. To those of you familiar with this art and work (or with the interest in following up on them): which do you prefer?

Christmas Lights

Do you live in the Bay Area? Have you not yet had your fill of Christmas Lights?  Do you have a tank full of $3.50-a-gallon 87 octane anxious to be incinerated?  If your answer to these questions is yes, consider driving to 2724 Ascot Drive; San Ramon, CA.  This writer (known to some in my family as "Mr. Cynical Christmas") drove there twice.  Add hypocritical to that moniker.  Anyway, once you are there, tune in to 100.7 FM.  If you want to surprise yourself, read no further.  If you are actually thinking of going, don't worry - it's much cooler in person!  If you only want to take a virtual trip to this fantastic display, please enjoy the following videos from YouTube.

First, you will need to check your processor speed.

Act One: 34th Street Overture

Act Two: Carol of the Bells

Act Three: Illuminations

If you want to do something like this using a commercially available controller unit, look no further than the Light-O-Rama.  And since you will be able to afford the extravagance of the several thousand dollar computer, the lights and the energy bill, consider offsetting some of your carbon.  Two companies that will take you money to invest in methane and wind projects are terrapass and NativeEnergy.   I have a gut feeling that planting trees is a better idea; the Carbon Trust devotes much of its donations to tree planting and conservation (and it's a non-profit).  Check out this Grist post for more of the gory details of carbon trading.

In the end, I was just as happy with a failed attempt to find the two western screech owls hooting in the trees above my parents' house.  In the process, I only scared one of their neighbors. 

I hope this post was random enough for you.  

Goodnight.

Book Review: Saturday

Today I read an excellent novel and feel like transcribing a response before I retire for the night. This is a mini-review that includes two quotations and a few comments. My intent is to reveal only whether this would appeal to you: a prospective reader. Attention to the diverse tags at the footer of this piece should clue you to this story's complexity.

The review and summary of Ian McEwan's Saturday you'll find at your favorite online bookseller calls this book "post-911 fiction." While I am uneasy about this label, I suppose it is appropriate. The story wraps itself around the events undertaken by one man in a single day in London. The man happens to be a neurosurgeon and the day happens to be Saturday, February 15, 2003 - the day 2 million Brits marched in Hyde Park against the impending Iraq war.

The protagonist - Henry Perowne - continually analyzes his own emotions and his own perspectives. Reflective and introspective are not common descriptors of neurosurgeons. They have a reputation (an unfair caricature, to be sure) as cocky brutes who see the entire hospital as an enterprise to support their masterful handiwork. I suspended belief for this element of plot, but needed not forgive other shortcomings. McEwan accurately (by this med student's appraisal) incorporated both the complexities of numerous neurosurgeries and the uncertainties of neurodegenerative disease.

The contemplative neurosurgeon is hardly unbelievable. His two children are artists: his son a blues musician; his daughter a poet. His pensive musings frequent upon his inability to understand them. By the time I reached this passage on page 54, I had committed to finishing the novel today.

Once, on a walk by a river - Eskdale in low reddish sunlight, with a dusting of snow - his daughter quoted to him an opening verse by her favourite poet. Apparently not many young women loved Philip Larkin the way she did. "If I were called in / To construct a religion / I should make use of water." She said she liked that laconic "called in" - as if he would be, as if anyone ever is. They stopped to drink coffee from a flask, and Perowne, tracing a line of lichen with a finger, said that if he ever got the call, he'd make use of evolution. What better creation myth? An unimaginable sweep of time, numberless generati0ns spawning by infintesimal steps complex living beauty out of inert matter, driven on by the blind furies of random mutation, natural selection and environmental change, with the tragedy of forms continually dying, and lately the wonder of minds emerging with them morality, love, art, cities - and the unprecedented bonus of this story happening to be demonstrably true.

This prose is just my style, the modernist presentation suits my taste in literature and the subject matter is not too far from my everyday life to disorient me on this simple restful vacation I find myself on. A lot of other people said good things about this book, so now I've put my hat into the mix.

I leave you now with verse selected from the climax of the story:

Ah, love, let us be true
To one another! for the world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.

Bonus points will be awarded to my readers who recall the author of these words.

Mele Kalikimaka

Merry Christmas from the windward side of Oahu!

I am taking some much needed rest from the toils related to finishing graduate school and transitioning into medical school. My comments and entries (if you haven't already noticed) will come a little more slowly in favor of boogie boarding and sunrises on the beach.

By the way, I highly recommend having in-laws that live in Hawaii.

End of Days

Okay, so final day (as in day of the final) doesn't exactly count as 'end of days.' None-the-less, it is nice to be almost finished for the year. In about 15 minutes I log on to a web exam for my family medicine clerkship. All over the Pacific Northwest, nervous little medical students (or big ones) will be holed up for three hours in some corner of a hospital or doctor's office answering questions about blood pressure, diabetes, earaches and depression.

At least this exam is a pass-fail test. You have to pass the first time to get 'honors,' but as I understand it, the score is not fed into an algorithm. This is good for me, because as I get older, I do less and less well on standardized exams... More on that later. I have to go complete an academic integrity statement!

Movie Review: I am Legend

I'm no film connoisseur, but I am a scientist and physician. Well, almost a physician. So it is from a biomedical perspective that I present my review of I am Legend, starring Will Smith. This is the first film I have seen on opening weekend in as long as I can remember, and the first I've seen in a theater since Arctic Tale. This article won't be a true spoiler, but I will address several critical plot elements. Stop reading if you don't want to ruin the surprises. First, it was nice to see the movie without knowing any of the story. (Will Smith got me in the theater.) Other reviews point out Smith's excellent acting, the weak CGI monsters and how much the story strays from the original novel by Richard Matheson. And Popular Mechanics assesses the verity of the 'junk science' built into the plot. I take a broader view. In sum, I was pleasantly surprised that not only was science important to this film, but it was the co-star. Enough with the preamble! Here's the review:

How many times have you seen a cocky scientist on TV extolling the unlimited cures science has to offer society? If you lived in California a few years ago, you probably met professor Irv Weissman and others promising that stem cells will cure diseases. (They were actually just hinting at it, but does that really matter now that CA is well on its way to funding $3 billion of stem cell science?) I am Legend opens with a smug blond scientist admitting on local TV that yes, she has cured cancer. Note #1: Scientists, if you want to get visibility for science, you need to get on the local news! Evidently, this scientist has built a virus that prevents either tumorgenesis or malignancy. Fortunately, the film did not get into that detail, because I would have something significant to critique! What is notable is that the plot plays on the public's lingering fear of gene therapy. And of course, the worst nightmare comes true. The virus mutates into a lethal strain that results in symptoms part rabies, part ebola, part bird flu. The virus first requires physical contact for transmission, but soon aerosolizes and crosses species boundaries. I am skeptical that viral evolution could actually occur as quickly as in the film, but perhaps such a trait is what enabled one virus to cure every type of cancer in the first place.

Speaking of curing cancer, our mad scientist (who had a vaguely European accent), indicated that of 10,009 clinical trials, 10,009 people were cancer free. This is likely a consistency flaw instigated by the script writers, since later, Will Smith's character tests his "compound 6" and calls one experiment a clinical trial. Note #2: A clinical trial includes hundreds, if not thousands of patients. This was a little mistake, but could misrepresent the process of evaluating safety and efficacy to the millions of people in the theater this weekend. By the way, this flaw was my infectious disease researcher wife's biggest beef with the film.

Speaking of infectious disease, we need to talk about immunity. If 1% or the world's population was immune to the film's virus, Manhattan should have been left with 15,000 people. It took 70 minutes or so for an explanation of why Will Smith's character was the only human remaining. It turns out that 30% of those who survived turned into zombies. These (poorly animated) zombies ended up killing the rest of the people. How likely is it that a virus could cause a devolution (or evolution) of humans into zombies? Greg Bear offers a pretty believable mechanism in Darwin's Radio. If this little viral beastie was a certain type of retrovirus, aggressive zombies could be the next step in evolution, and this could even occur in one generation. I am guessing that this is the part of the film that the audience is supposed to suspend its belief about...

What about the basement laboratory? Smith's character used a fancy eyeglass-mounted video camera to record his experiments on various compounds to reverse the virus's symptoms in sewer rats. The writers got some things right here. Only "compound #6" worked; this was one of twenty he tried in this series, in what we assume was a long string of trials. This brings us to Note #3: Only a small fraction of science experiments 'work.' Of note is that only one rat was tested with #6 before moving to human trials! I guess this paucity of pre-clinical data can be excused when civilization is at stake. While we are on the topic of animal experiments, the presentation of animal research in this film was well done. The rabid rats were clearly animated, so no beef could be made about living conditions for real rats (and the fact that they were injuring themselves on the cages). The cages, by the way, were appropriate for animal size and were not overcrowded. Smith's character didn't need to get IACUC approval for his work, but he was mostly in compliance for many rules about animal care. Some notable lapses: no dedicated facility, interventions that were terminal, minimal personal protective equipment.

The treatment of the bench science was appropriate. There were no unneeded CSI-styled eye-candy closeups of pipetting or tube shaking. (You know the shot: when one of the attractive lab techs flicks an Eppendorf tube up in front of his/her face instead of using the vortexer.) This workshop looked like a well stocked lab crossed with an intensive care unit. There were QPCR machines, vital signs monitors (just like those at the UW hospital!), and med supply carts along with an appropriate amount of clutter. Conveniently for the plot, there were also bullet-proof glass doors. Except for the dim lighting, this looked like a great place to do science.

In my opinion, the ethical land mine in this film was not the fact that some crazy scientist unleashed a deadly virus - that occurred off screen. I worried about the ethical use of human subjects. Smith's character has a wall packed with photos of zombies that he unsuccessfully cured of their zombieism. The viewer is asked to overlook the fact that these zombies have the potential to be fully human. At one point in the film, Smith's character reports that these creatures have lost all semblance of human nature. This is a fine trick to make it okay for experimenting on them. (That is how some scientists justify animal research.) However, the observant audience member will note that the zombies have clear emotional responses to stimuli, exhibit abstract planning and operate in a social manner. One (the chief zombie) even seems to show an attachment to the zombie subject Smith's character is trying to cure. Note #4: If a cure occurs only after sacrificing hundreds of zombie-humans, is the research ethical? Is exterminating the zombie way of life genocide?

Finally, over the course of the film, the protagonist shifts from a Christian to an atheist to an agnostic. First, he prays with his family before all Hell breaks loose. Later, he reasons that God would never permit such a catastrophe, therefore does not exist. The final resolution depends on a near-death and perhaps spiritual experience in which Smith's character adopts a perspective that things 'happen for a reason.' I did not appreciate (nor would my atheist readers) how his suicidal ideation occurred in the post-religion period, while the noble savior surfaced after reconsidering a religious perspective. Apart from that flaw, I was pleased that this portrayal of a scientist encompassed religious, agnostic and atheist perspectives, therefore illuminating Note #5: Science can be done by individuals from diverse belief spectra.

In the end, my wife and I agreed that this was an entertaining movie and worth the $8 after a day of studying. The plot was creative enough to get me thinking about some interesting research ethics and science in society issues. Hopefully it got some others thinking as well.

A Very Test Tube Christmas

Seattle's Colors have transformed into something a little more festive than their previous incarnation. This is a living installation, in that each tube may be cleaned and refilled with specimens found near my home. These items were all collected from Magnuson Park on a Saturday stroll with my wife. 'Tis the season for red and white berries. The previous incarnation grew a variety of mold in the months between Seattle Colors V1 and V2, further emphasizing the living nature of this piece.

Here are the same berries - red, orange, yellow, green, blue, and violet - after growing mold and being submerged in dilute bleach. I wonder what the next phase of Seattle's Colors will be? If you have any ideas for me, here's a fun craft: Download the image below, color it in and emailit to me. (Or just post a comment below.)

Merry Christmas! And please don't go out and buy stuff just for the sake of it. Consider crafting something personal, giving a gift of an experience or assembling a creative alternative to a store-bought item.

So Blue

(or why I'm a Democrat)

The world is globalizing, nuclear weapons are proliferating, the Middle East is seething, but Republicans are still arguing the Scopes trial.

-Maureen Dowd

Keeping Track

What a Day. Today in the ER, I diagnosed the following:

• New onset temporomandibular joint (TMJ) syndrome in a 29 year old woman.
• Phimosis and otitis externa in a 10 month old boy.
• Hip bursitis in a 72 year old man.

I participated in the care of:

• Man vs. table saw: the loser was a finger (unless the hand surgeons at Harborview can work a miracle).
• A young man with periodic familial hypokalemic paralysis.
• 51 year old man with suicide ideation and a plan. (See photo below.)

The currents are deadly enough without having to deal with the impact. I have first hand experience (with the current, not the impact). Let me tell you: going through at slack tide is a much better idea than trying any other time. The current gets up to 8+ knots at flood and ebb. My wife once diagnosed me with suicidal ideation for trying to take this tidal rapid in my now deceased aluminum Grumman canoe.

We admitted the the man with severe depression. Things are looking good for him. I am glad he came in today and decided to stay; he's also been an excellent teacher so far.

R(eee)view

It's been a month since I first unpacked my ASUS Eee laptop computer, and folks are clamoring for my review. I did promise you a breakdown of my experiences.

If you are thinking of buying an Eee, I would recommend NewEgg.com. They now have several models in addition to the white 4G model I purchased. Either they or UPS screwed up my shipping, but they were quick to admit their error and refunded my shipping costs. Here's me on the airplane last month writing my epic entry about evolution and creationism in Kentucky.

I'll spare you (and me) the specifications. If you are serious about buying one, you probably already know these details. I'm not in the business of sales.

• Size Matters: I love that it is less than 2 pounds! It can go anywhere. The keyboard is small, but my size 9 1/2 hands do just fine. I do have trouble using the touchpad, so I bought a mini-USB mouse with a retractable cord (no RF devices on airplanes) that does the trick.

• Battery Life: Don't expect the batt to last more than your other laptop. The longest I had it run was 4 hours, but the wireless card was disabled. The mini-mouse drains the power faster, too. On average, I'd say the battery lasts 3 hours between charges.

• Screen: For espn.com, the narrow screen makes navigation tough. But for authoring and reading blogs, word processing, and general web use, it's just fine.

• Start-Up: It's more like 25 seconds to start. And if you connect to wireless networks, it will be about 90 seconds.

• Connectivity: I've had some frustration with connecting to my current wireless network, but have had trouble with my PC on the same network. I use the hardwire cord to avoid that problem. I've been able to connect to every (other) wireless access point I've encountered in the hospital, the local library and the pub.
  

• Social Aspects: I get soooo many comments about how cute my computer is. The Eee has serious potential as a nerd/chick magnet. Seriously. No, really. I mean, I don't (ab)use the Eee that way, but maybe you could...

• Disk Space: It's pretty amazing to use a compy that has the operating system, all the needed programs and space for your files in 4 GB. I keep everything on an 8 GB thumb anyway, and have interfaced with my 1 TB mother drive. Anything I do on this little guy is small potatoes anyway.

• Operating System: I can hardly tell it's LINUX. Except that it's faster, doesn't have stupid update messages and has yet to crash. There are some things I wish I could customize, but I am a little afraid of that. Now that medicine is beating the engineer out of me.

• Name: Eee is hard to explain to people. The name is pretty lame.

• Role: For my life, this little machine can do almost everything I need in a computer. Honestly, this is not much. I have yet to try and print from it (no printer at my current residence). When my HP PC crashes for good, I will probably buy a desktop and use the Eee as my mobile terminal. Whether that terminal runs LINUX or not, I am not sure. I guess it depends how much of a geek I will need to be to install & maintain it. Because I am getting less geeky by the month.

• Applications: All OpenOffice applications are installed along with other programs like LTris, pdf Reader, Firefox and a sundry of others I haven't yet used.

Here I am a month later. These pics were taken using the built in webcam. (The direct connect via Skype might come in handy sometime.) For now, it simply offers evidence that I really like this hoody sweater. FYI, the words out of frame say "the unthinkable."

FAMILY Medicine

This is family medicine:

In the ER on Monday night, I injected a steroid/marcaine cocktail into a man's biceps tendon and referred him to an orthopedic surgeon. On Thursday, I saw his wife to renew her Vicodin prescriptions for rheumatoid arthritis. This afternoon, we deliver their 4th grandchild by C-section.

Socialized Mormons

So, Mitt Romney's a Mormon... This we knew. And he “will serve no one religion, no one group, no one cause, and no one interest. A president must serve only the common cause of the people of the United States.” Okay... That's inclusive (patronizing?) enough for me. And he does "not insist on a single strain of religion—rather, he welcomes our nation’s symphony of faith." Wait a minute... does this assume that all have faith? What about my atheist friends and colleagues? Will they have chairs in Mitt Romney's orchestra?

In the end, I think it is really too bad that Romney is not interested in being a spokesman for his faith. After all, the current President of the Mormon Church, Gordon B. Hinckley "hates war with all its mocking panoply... War is Earth’s greatest cause of human misery. It is the destroyer of life, the promoter of hate, the waster of treasure. It is man’s costliest folly, his most tragic misadventure.” The candidate willing to say this whose name is not Ron Paul, will get my vote. Even if he's from Ohio.

A look at Mitt Romney’s vision for America’s foreign policy reveals little, however, that resembles any of these most basic and central Mormon values. In contrast to Gordon Hinckley’s hatred of war, Romney’s central foreign policy concern, in fact, is a deepening of American militarism and war making. Specifically, Romney advocates drastically increasing American military expenditures, escalating the Iraq war, continuing operations against transnational Islamic militant groups, and preparing for a military assault on Iran.

That's the analysis offered by a little publication a friend recently alerted me of called The Mormon Worker. This was penned a few months ago; perhaps Romney will soon change his mind about Iran.

The Mormon Worker is a strange collection of ideas conflating anarchism, Mormonism, and socialism that highlights some central disparities between the teachings of Mormonism and the way most Mormons vote. Many of the arguments are the same made by Dorothy Day and the Catholic Worker movement. See also the Christians who in the voting booth or policy forum seem to always forget the teachings from the Sermon on the Mount.

Due to the agreements forged by church fathers and the state in the wake of the controversies surrounding polygamy,

Mormons find themselves supporting capitalism and government, and therefore exploitation, imperialism, jingoism, and militarism, considering these things inherent to their religion, despite the many resources within Mormon scripture advocating the contrary. One significant reason Mormons should seek to abolish government and capitalism is the fact that States continually wage war in foreign lands for the sake of economic gain.

To William Van Wagenen (the man behind the Worker) and the other Mormon workers (I wonder if all Mormon workers are stock brokers like Van Wagenan...) out there, I tip my hat. I challenge you to vote your conscience in 2008, even if there's no chance of Utah being a blue state.

Peds Grand Rounds is Coming to Town

This edition (Volume 2, Edition 12) of Pediatric Grand Rounds is presented in the context of that familiar ode to the jolly fat man. Some readers may bristle at the extent to which I conformed to the hegemony that Christmas has over the month of December, but the truth is that kids love Christmas. What I didn’t realize before compiling these entries is the extent that Santa Claus prescribes prevention in this instructive carol.

Before we strike up the band, Pediatrics Grand Rounds needs a new home. Clark Bartram did a great job initiating the tradition of collecting interesting pediatrics articles, but PGR is now in search of a new administrator. Please consider whether you could host or coordinate future editions. If you are interested, please comment on this post or send an email to Clark or me. Do the same if you would like to host January’s issue. With thanks to Thomas Nast and without further ado...


You better watch out for the greatest threat to kids’ health. Steven Parker brings home a topic that is close to my heart and flies under the radar too often in this country.

You better not cry, or is it actually okay to cry sometimes? Kristen Heinan at The Differential offers a connection between the difficult experiences in the PICU and the world outside.

You better not pout, I'm telling you why: the person responsible for your care, protection and nutrition might forsake you.

Santa Claus is coming to town and he’s bringing a new puppy. Curious about whether new puppies and new babies combine to produce pediatric allergies? Med Journal Watch digests the answer for you...

He's making a list of effective parenting techniques; or at least Dave Munger and his readers at Cognitive Daily are. Scientific studies of parenting are common, but studies linking parenting to morality are scarce. That’s why you should check this post out.

Checking it twice, just like you need to do with those pediatric liquid medicines. Mexico Medical Student helps you out with the not-so-simple math.

Gonna find out who's naughty - I bet you thought internet trolls were just bad for your blog. Sandy at Junkfood Science explains how trolls can turn into killers.

or nice. The Thinking Mother knows who is naughty and nice at home and in the classroom. She also offers ideas about how to facilitate more nice behavior.

Santa Claus is coming to town, and he’s got great gifts for kids of all ages. And Dr. Gwenn compiled them all into this handy compendium for your holiday shopping.

He knows you when you are sleeping, and Michael Breus thinks we all should be paying more attention to how much our teenagers sleep.

He knows when you're awake, and if you’re in between being awake and asleep, chances are you have yawned recently. Now is that because you’re tired? Dr. Deb thinks not.

He knows if you've been bad or good, but can dear old Santa resolve the dilemma about the 14-year-old Jehovah’s Witness who refused blood transfusion in Seattle and as a result died last month? Several bloggers have offered their perspectives critical of this situation including Beast at Atheist Haven and Orac at Respectful Insolence. Not happy with unbalanced perspectives, I offer my own assessment.

So be good for goodness sake! Sometimes, however a 3-year-old’s conception of good is a little different than yours or mine.

Santa Claus is coming to town! Be sure to email him before it’s too late. That's it for this month. Keep track of the next PGR at this site.

Witnessing Evil?

On November 28 a young man named Dennis Lindberg died in Seattle's Children's hospital. He died because he refused treatment for leukemia. I have personally met many individuals close to this case. I work in Skagit County, WA - the same county where Judge John Meyer made his well publicized ruling. Last week, A Jehovah's Witness who happened to have a deep vein thrombosis taught me about the Winesses' perspectives about blood. His wife shared that she was in the same congregation as this young man. The attending hematologist for this procedure gave lectures about leukemia when I was a medical student at Children's Hospital in Seattle. My wife worked with him for a new diagnosis of leukemia that presented in a kid that came to the Children's ER. I have taken courses with and from some of the professional ethicists on staff at Children's. I would not choose the same path for myself of a child in the same situation, but when you see the story from so many angles, it's harder to be so critical of the outcome.

On top of the complexity already inherent in this case, there are a few distortions, inaccuracies and partial truths about this story gaining traction in the blogosphere - particularly in the atheist community. This post is meant to bring to light some of those lapses in intellectual honesty. We all complain about how science is too-often misused by politicians; when dealing with an issue as controversial at this one, the least we can do is present all of the facts.

Here are some points that if you rely on blogger news, you may not have encountered:

(1) Jehovah's Witnesses were founded in 1872. Any reference to the faith being founded on Bronze Age or Dark Ages thinking is inaccurate hyperbole. The religion is based on 19th Century pre-modern medical thinking.

(2) The treatment denied by the judge was not the stem cell transplant. It was a blood transfusion. Why is this distinction important? Stem cell transplants are the single most expensive procedure in medicine (hundreds of thousands of dollars just to do the procedure). We do them (and many health insurers cover them) because they work, but not all patients facing leukemia choose to be transplanted. Some cannot afford it. Some do not want to go through the pain of the procedure. Others (like this patient) have different reasons. If after providing all of the information, the patient does not consent to a procedure, the medical establishment usually respects this decision. Keep in mind that the legal decision here was related to the blood transfusion which could keep the patient alive for several days, not the stem cell transplant, which has 70% survival at 5 years as reported in the media. It's not as simple as a 750 word article would have you believe. (The Seattle PI printed a good story overall.) The Cheerful Oncologist offers a refreshing perspective on this issue.

(3) There has been some criticism of the words "mature minor." Some say it is a contradiction. The terminology comes directly from Washington State law. Health care providers are very familiar with the term; mature minor is most often applied to pregnant teenagers and to teens who need psychiatric services. The right to make autonomous, confidential (parent-free) medical decisions about reproduction (including abortion) and mental health issues is routinely conferred to 14-year-olds. It has not been previously applied to patients with blood diseases. Joana Ramos outlines some of the issues in a white paper she authored:

Doctrine of the Mature Minor
In most states of the US, 16 is the minimum age for donating blood with parental consent. In a variety of instances, teens are able to consent to, or refuse, medical treatments including surgery. It is customary that 14 is the age of consent for confidential reproductive health services, including elective abortions; substance abuse treatment and counseling; and for consent or refusal of mental health services, even when parents feel that a child’s life may be in danger(1).

The legal concept of the mature minor is well established in case law nationwide(2). It governs such topics the age of consent to engage in sexual activity, to marry, and to make independent and confidential decisions about medical care. The following list of rights extended to teens serves as a good illustration of this concept. Many of these rights involve activities that carry varying amounts of risk, may have both psychological and physical health consequences, and may be neither beneficial nor life-saving. While the laws vary in each state, teens commonly have the right to:

• make decisions as to one’s own guardian or custodial parent at 12
• travel and to purchase a ticket to travel by public conveyance anywhere in the US at age 13 without parental permission
• be employed at 16, but to engage in agricultural work at age 12, in other occupations at 14, with certain jobs being exempt from any age limits
• obtain a license and drive a motor vehicle at age 16
• have one’s body pierced at age 16 without parental consent
• enlist in the military at age 17, with parental consent
• petition the court to become an emancipated minor with cause
• make decisions on behalf of a child parented by one’s self at any age

References:
1. Stenger, RL. ( 1999-2001) “Exclusive or Concurrent Competence to Make Medical Decisions for Adolescents in the United States and United Kingdom”, Journal of Law and Health, 14(2):209-41.
2. Forman, DL. (1998) Every Parent’s Guide to the Law. (pp. 87-154) New York: Harcourt Brace.

The legal precedent in this case is that the 14-year-old was conferred mature minor status for a condition that was not reproductive or psychiatric. In his criticisms of this case, Orac makes the right concession to adult Jehovah's Witnesses regarding decisions about transfusion. He believes a grey area to apply between age 15 and 17. Based on the above examples, I think the range should be 14-17.

(4) Some have written this to be an ignorant backwards, if not abusive decision. To those who think this, I would invite you to seek out a Jehovah's Witness. Ask him about blood. If you don't learn from that individual, every congregation has several experts and health advisers. I bet you will learn things about bloodless surgeries (a few of which are at least as successful as traditional approaches) and artificial blood that you had know idea about.

(5) The newspapers included a fact about this case that most bloggers have left out. The patient's biological parents (who filed the injunction to force the blood transfusion) had a long history of drug abuse. They were in and out of jail, but had been in recovery only recently. They flew to Seattle days before the court hearing and the patient's death. If their son was dying of leukemia, why were they not in Seattle in the weeks and months before this incident?

The bottom line here is that this case is complex. At its center is a 14-year-old's autonomy. Closely related to that is the freedom of religion. The same individuals who value the separation of church and state have called for that wall's dismantling via a court of law. In the end, the judge looked at this young man's ability to make life and death decisions. My suspicion is that Dennis Lindberg was better prepared to make this decision than you or I.

Continuity

Today is the midpoint of my family medicine clerkship. For the past three weeks, I have seen kids with coughs, guys who want Cialis, dislocated joints, pregnant mommies, runny noses, depressed senior citizens, strep throats, Caesarian sections, annual physicals, lots of funny skin spots, uncontrolled diabetes... the list could go on.

You know what I have liked the most out of my experiences so far?

Continuity. It is rewarding to see a women who formerly had oxygen saturations of 85% on O2 nasal cannula walk into clinic (from her home) and have no problem finishing a sentence. It is nice to be able to pick up a skin color change from mild jaundice to something to be concerned about. It is heart-wrenching to see an 80 year old man deteriorate from a compassionate caretaker for his demented wife and palsied son to a fetal position writhing in pain from a pelvic bone infection. (I hope and pray he recovers.)

These are all aspects of medical care I would miss out on by pursuing the top two specialties I've been considering recently: emergency medicine and hospitalist.

We shall see about this!