Americans invented the idea of  “McDonaldization” in which consumer services are standardized to be efficient, predictable, and controllable.  When we want something, we want it now!  We want to be able to understand it, predict it, and control it.  However, healthcare isn’t a service that’s amendable to McDonaldization.  Cooking and serving up fast food has a relative small number of variables that can easily be controlled and predicted such as the size of the hamburger patty and the heat and time required to cook it. The diagnosis and treatment of human illness has literally hundreds of millions of variables to deal with. This is why medical care is not anywhere near as “convenient” as fast food.

But the folks at X-prize want to change this.  Their solution is to open a competition for inventors to develop a Star Trek style “tricorder” to detect and diagnose disease just as the fictional medical tricorder was used in the science fiction series. What is the specific problem to their tricorder solution? According to their promotional video, consumers are faced with a paradox.  From the video;

You want to know what’s wrong. Is this normal?  Is this urgent?  Do I need to see a doctor? But, today, the only way to know if you need to see a doctor is . . . to see a doctor. And that’s not fast, not convenient, not easy. So you wait . . .

The average time to get an appointment is 21 days. The average visit to the doctor takes nearly 2 hours.  Cause you’ve got nothing better to do, right? And then you only receive the right diagnosis or treatment 55% of the time.

Correct. Medical care is nether efficient, convenient, predictable, or controllable and this drives Americans crazy. Part of the reason is the massive complexity of human disease. Part of the reason is how our health care system is organized with way too much emphasis on advanced medical care and procedures and too little emphasis on health care access, primary care, and prevention.

The X-prize foundation’s approach to this problem is to empower consumers and patients with a quick and easy home or outpatient mobile  device to provide real time data on critical health metrics such as vital signs to accurately diagnose disease.  The requirements appear to be only that the device is mobile and be able to accurately diagnose a set of 15 diseases. There is no information on what these “diseases” would be.  The device should also be able to give information to the patient as to whether everything is “OK” or not.

The push to develop a more patient friendly health monitoring device is certainly laudable.  However, it’s not likely that such a device will work in the way that they intend it to. The problem won’t necessarily be with limitations in technology. The problem will be in how we interpret and act on information. The limitations and complexities of the diagnostic and treatment process is something that doctors have to deal with every day. Doctors take a limited set of data and formulate what they believe is the best diagnostic and therapeutic course of action that is uniquely tailored to each patient and each  situation.  They take into account not only the data but their training, experiences, statistical probabilities, and “educated guessing”. This is why medicine is still an art.

And data is not the end point of the diagnostic process. Each abnormal data point could have multiple meanings depending on what you are looking for (the pre-test probability) and the statistical likelihood of disease in your particular population. For example, an elevated blood pressure could mean that you have hypertension or it could mean that you are anxious or because of medications or because of renal artery stenosis. A high heart rate could mean anxiety or a pulmonary embolism. Abnormal laboratory results have the same problem. A low sodium level could be caused by anxiety or a brain tumor. Anemia could be caused by a poor diet or colon cancer. Even imaging is tricky. A mass seen on an XRay or CAT scan could be benign or malignant. There is even the fixed and known possibility of false positives and false negatives for each test that has nothing to do with error or technical variability. Detecting abnormalities is easy. It’s the interpretation that is hard. To say with confidence that your device will be able to diagnose a specific disease with “accuracy” is dangerous thinking.

And who or what will interpret the data for the tricorder user? A computer algorithm can be used but is likely to come up with a diagnostic differential list that may not be accurate and will certainly not be exhaustive. This is because the initial evaluation of a patient is often followed up by more advanced evaluation and it is currently not possible to put every diagnostic modality (Xray, CT scan, PET scan, nuclear imaging, EKG, EEG, biopsy, stress testing, and exploratory surgery) into a mobile phone. Maybe in the far future we will develop a “universal” diagnostic device that includes everything but this is not one of the stated goals of this X-prize.

Even worse than diagnostic uncertainty is the false sense of security that could be provided by normal data in the setting or real disease (i.e. a false negative). The FAQ page from the X-prize foundation states that the tricorder should be able to “give confirmation that everything is ok with a consumer and notify that something is not ok (a “check engine light”)“. This approach is simplistic and absurd to the extreme. Show me a person with completely normal vital signs and blood tests and I’ll show you a patient who is has undiagnosed HIV or a smoker who has a malignant growth in their lung. The danger is that whatever limited data this device does provide will, if normal, give consumers a false sense of security and lead them to cancel that trip to the doctor.

The biggest problem is that such a device is either not required for it’s intended purpose or won’t make any difference in outcomes. Will it really be able to help people make a decision on whether or not to see a doctor or go to an ER? True medical emergencies almost never present subtlety. Ironically, PAIN is one of the biggest indicators that something is seriously wrong and the measurement of pain is not something that can currently be directly done by a tricorder or any other device.  Bleeding, passing out, shortness of breath, vomiting, decreased consciousness; patients rarely have a problem knowing when something is seriously wrong because their bodies do a much better job than any tricorder could do in letting them know. And when should you go to see a doctor in an non-emergent setting? The best way is to use a simple rule of thumb. If you have to consider it then likely you should go. And as far as prevention, do we really need a device to tell us to stop smoking, loose weight, and get some exercise?

There yet may be some uses for such a device. More frequent monitoring of metrics like blood pressure and blood glucose levels in the outpatient setting may, if accurate, help doctors to better control such chronic conditions as hypertension and diabetes and better control can lead to better outcomes. Cheaper and mobile medical devices would help health care workers enormously in areas of the world that are remote and/or lack access to modern medical care.

But to develop a device with the stated goal of “empowering” consumers in their health care decisions by helping them know when they can avoid the inconvenience of having to see a doctor is amazingly shortsighted and ridiculous. And it’s potentially dangerous by giving people a false sense of security that they do not need to see a doctor.

I foresee one main outcome of the development of this tricorder. The typical civilian users of such a device are likely to be suburban, middle aged, relatively healthy and health obsessed. These are the types of patients that doctors in affluent areas dread. These patients Google the differential diagnosis for every single symptom or strange noise coming from their bodies and make frequent trips to their doctor with pages of printouts about their “condition”.  Congratulations X-prize! You’ve begun the process to develop the most important enabler for hypochondriacs that the world has ever known.

Once upon a time, video pirates were limited to taping movies off cable and selling the tapes to their friends. But this didn’t put a dent in Hollywood’s ability to make and profit enormously from crappy movies. Then came the internet (or the internets for those of you in Texas) and people could easily share digitized copies of music and more crappy movies. Then came the Digital Millennium Copyright Act of 1998 (DMCA) that brought copyright protection into the digital domain to outlaw the intentional sharing of copyrighted material.  But the problem with the DMCA was that it was ineffective outside of US court jurisdiction.  Other than war, how does a greedy media mogul prevent foreign internet sites from providing illegal downloads to Americans? Answer; make US internet service providers (ISPs) liable and responsible for blocking access to these illegal sites. Enter the Stop Online Piracy Act.

The SOPA would allow media companies (or any owner of copyrighted material) to ask the US Attorney General to demand that American ISPs directly block access to any foreign web site that is believed to be violating US copyright law. But that’s not all! The bill allows the Justice Department to seek to prevent internet search engines (Google, Bing) from listing the offending site and stop US internet advertizing companies and internet pay services like PayPal from doing business with the offending site. Additionally, internet companies  that take the initiative and block access to a foreign web site that they believe violates US copyright law would be immune from litigation. Much has been written about this pile of dung pending legislation but I would like to add a few NON-lawyer observations.

1. SOPA appears to circumvent the 5th and 14th Amendment guarantees of Due Process. All it takes for the US AG to order a web site blocked is to obtain a court order. The order remains in effect indefinitely. There does not appear to be any provisions in the act to  allow for a hearing or trial to give the offending site and/or the ISP a chance to present their case even if the “foreign” site is owned by a US company.
2. The lack of Due Process makes it more likely that SOPA could be used to restrict free speech by a person or organization seeking to abuse the law.
3. Lack of Due Process misplaces the burden of proof. Any involved party can  petition the court to overturn the order but since the initial order remains in effect indefinitely the burden of proof is placed on the accused (the ISP or other domestic internet company).  This is exactly the opposite of our innocent until proven (by the government)  guilty legal traditions.
4. SOPA is a huge departure from current law that limits the liability of  Internet Service Providers for the activities of their customers. Under DMCA, providers are liable for copyright law violations only if they directly participate  in or directly benefit from illegal activity.  Simply providing internet access that MIGHT be used to download pirated music is not in itself illegal. This is consistent with existing law that does not require telecommunication companies to verify that their products are being used only for legal purposes.
5. SOPA places the burden of monitoring and preventing international digital copyright violations on the internet service providers instead of with law enforcement and foreign governments.  Cell phone companies are not required to monitor nor guarantee that pre-paid cell phone are being used for family friendly activities.  Lawmakers need to learn to differentiate between the illegal act and the medium that made such an act possible.
6. Immunity from litigation for blocking web sites is a legal mess waiting to happen.  What is to prevent a US internet service provider from blocking a “foreign” web site that is actually owned by a US company and direct competitor of the ISP in question? Does Congress really want to dole out liability protection and the power to block web sites to ISPs?
7. SOPA does not make any exceptions for non-profit sites, archives, educational sites, etc.
8. SOPA will not be effective if utilized as intended. Piracy sites and services are notorious for finding technical ways around censorship. The technology neophytes who wrote this legislation seem to be blissfully unaware of the dynamic nature of the internet. Pirate web sites are not like illegal bordellos that can be raided and shut down.  New DNS addresses and servers can be set up and the new address disseminated online via social networks in a fraction of the time it takes for a court to issue an order.  A more likely scenario is for a game of “cat and mouse” to be played out over weeks to months as pirate sites stay several steps ahead of the Justice Department.
9. A SOPA that does not work as intended could lead to an actual American firewall. If trying to block access to individual addresses only leads a futile cat and mouse chase across the internet, the Justice Department may decide to broaden its court order to the blocking of entire foreign ISPs, networks, or even entire countries. This is not a slippery slope. This is a realistic technical solution and logical end-point for a law that aims to prevent the illegal sharing of copyrighted material. There is nothing in SOPA to prevent this from happening.
10. Is SOPA really needed? There is no hard evidence that illegal file sharing has had any large or lasting impact on the legal sales of nor the production of  intellectual material. If the Justice Department were able to successfully block every single global illegal file sharing site, would it really result in any significant additional revenue for the entertainment industry? Is it worth the potential chaos, abuse, and damage to the freedom of the internet just to secure a few million more in income for an entertainment industry that is in no danger of becoming extinct anytime soon?

Congresses’ repeated attempts to focus more attention on preventing illegal downloads of such American classics as Freddy Got Fingered than they do in passing laws to prevent internet censorship and guarantee internet access is more than a clear indication that our representatives are by-and-large older white men who don’t known how to use a computer, think that the internet is literally a system of tubes, believe that freedom and commerce can be protected by restricting it, and frequently get calls and visits from a nice gentleman who works for the MPAA or the RIAA and would like to treat them to a little lunch or a round of golf in Tahiti.

Please write your Congress-person or Senator. Also, let the sponsor of SOPA, Rep. Lamar Smith (R-TX), know what you think of him and his bill.

It’s stunning to think about the national debt in these terms.  What’s even more stunning is how brazenly both parties, liberals, and conservatives are willing to risk long term economic security to feed their own ideological interests.  A case in point is the NYT’s Paul Krugman who dismisses any short or long term concerns about the US debt with a fanciful wave of his a priori wand. What is Dr. Krugman’s calming tonic in the face of a 15 Trillion dollar IOU? Basically, he implies that the debt doesn’t matter as long as you can raise taxes and interest rates remain low.

Deficit-worriers portray a future in which we’re impoverished by the need to pay back money we’ve been borrowing. They see America as being like a family that took out too large a mortgage, and will have a hard time making the monthly payments . .

First, families have to pay back their debt. Governments don’t — all they need to do is ensure that debt grows more slowly than their tax base. The debt from World War II was never repaid; it just became increasingly irrelevant as the U.S. economy grew, and with it the income subject to taxation.

So as long as we have rich Americans from which the US government can feed from then we will be OK. After all, the top 5% of income earners pay 60% of the US income tax even though their income is 35% of all personal income. For liberals, as long as we can raise taxes, we can continue deficit spending ad nauseum.  For conservatives, it’s even worse. The mantra appears to be deficit spending with low taxes now (trickle down) and to hell with the future.

Of course, Krugman is correct . . . .  about the present. The enormous US debt does not pose a serious short term threat to the stability of the US economy or economic recovery.  Given the sheer size of the US economy, there is no credible risk that the US government would default on it’s debt nor is there any reason to believe that the market for US Treasury bonds would dry up or become unstable. And interest rates are at an all time low, thanks mostly to the severity of the recent recession and the efforts of the Federal Reserve to stimulate the economy through borrowing and investment.

But, like the sky diver falling without a parachute, the danger for the US economy lies not in the present while tumbling through space but at some point in the future when the ground makes its presence known. It’s inevitable that the economy will pick up steam and with growth will come a rise in interest rates. Even small increases in rates can have a profound impact on the interest we pay on the debt.  Right now the interest payment on the national debt is about $242 billion a year.  Interest rate increases over the next decade have the capability of causing the interest on the national debt to exceed $1 TRILLION a year! Chew on this number for a while. This amount represents mandatory spending that does not go towards any social program, military asset, or regulatory agency. These billions pay investors in the US debt of which almost 50% are now foreigners (mostly the central banks of China, Japan, the United Kingdom and Brazil).

There is a very real possibility of a spiraling and out of control situation to develop as the interest on the national debt becomes bigger. Growing entitlement programs (Social Security, Medicare, Medicaid) combined with the increased interest payments could cause mandatory spending to exceed total government revenue. At this point the government’s ability to manage the debt would become even more difficult from a budgetary and political standpoint. The remaining choices, massive cuts in discretionary spending (including defense), massive cuts in entitlement benefits, and/or massive tax increases would become ever more drastic and unpopular.  Just like today there would be government gridlock, indecision, and political pettiness all resulting in  action that will be too little, too late. Meanwhile, the spiral continues, with increased budget deficits creating an ever larger national debt with increased interest payments

What happens then? The problem is that nobody really knows, not even Dr. Krugman. There is a great amount of debate among economists about how big the national debt burden could become and when the economy would become negatively affected. There is evidence that among industrialized countries, those with national debt below 60% of GDP had better annual economic growth (3-4%) than those with debts of 90% or more of GDP (1.6%). Though it’s unclear whether the larger debts were due to a slower economy and a decrease in tax revenues, the possibility remains for a negative impact on economic growth. Krugman further tries to differentiate debt held by households from the national debt.

This is the point almost nobody seems to get — an over-borrowed family owes money to someone else; U.S. debt is, to a large extent, money we owe to ourselves.

No it’s not.  As mentioned, almost 50% of our debt is held by foreign banks. And we can’t just stop paying interest on the debt because it’s “money that we owe ourselves.”  A US default on its debt or even a perceived inability of the US government to pay interest on the debt would result in volatility in the bond market causing falling bond prices and increased interest rates which would worsen the budget crunch as previously stated.  The US government is very much like a household that is very overextended on its credit. It’s like a family taking advantage of a credit card with no limit and ridiculously low interest rates.  A default would wreck the world wide economy and impair the government’s ability to borrow more money at low interest rates.

But lets assume that Krugman is correct and we can go on borrowing forever because it’s money that we owe ourselves that we don’t have to pay back. The problem with this “all is well” approach is it does not take into account the possibility of a “perfect storm” of different economic factors combining with our debt burden to result in economic catastrophe. Greece is a good example. They were forced by the Economic Union to adopt the Euro at inflated exchange rates for the old drachma that severely impaired their ability to borrow and service their national debt.  Though the US does not face the same type of monetary problems, the recent collapse of the sub-prime lending market is a good example of an entirely new economic variable that was unforeseen by almost every economist.  Hence, like earthquakes, economic disasters are very hard to predict but inevitable. The US national debt is like the proverbial sword of Damocles hanging over our heads. It has the potential to dramatically worsen and complicate what would normally be a survivable economic crisis.

Above all, however, Krugman and everybody else want job growth combined with economic growth. The problem is that the current massive amount of government spending is poorly designed to deliver this.   John Maynard Keynes famously called for the government to “prime the pump” with government spending for goods and services to stimulate the economy but the 2011 Federal budget included over $2 Trillion in mandatory spending and most of it was spent -quite literally – on people who are NOT WORKING. Social security for retirees and people with disabilities. Medicare for people older than the traditional retirement age of 65. Medicaid much of which is for children and those on disability. Unemployment benefits for . . . . people who are unemployed! And the recent bank bailouts designed to keep bank employees who already have jobs from becoming unemployed.  Even recent massive spending on two wars was primarily spent overseas during the occupations to employ Iraqis, Afghanis, and other foreigners. In theory and except for Federal employees, US government spending does not result in the creation of a single new American job.  It helps to maintain the status quo. No wonder the recovery has been jobless and sluggish.

During World War II the US government spent several hundred billion dollars to directly employ Americans to provide goods and services for the war effort. The economy responded with the biggest peacetime expansion in history. But today we have a multi-Trillion dollar economy and a few hundred billion dollars in domestic spending here and there is not going to cut it. What is needed is a multi-Trillion dollar domestic spending bill for the direct employment of Americans for nationwide infrastructure improvements. Unfortunately, we’ve already used up our political capital with year after year of massive deficit spending regardless of crisis. At least World War II had an end. By 1946 we no longer needed thousands of tanks, planes, and ships to fight the fascist threat and so spending decreased dramatically to prewar levels. This fiscal rationality no longer applies. For three decades, nearly every Federal budget has been followed by an even bigger budget. We no longer have either the political foresight or will to constrain spending so that we can reserve massive spending increases for times of true emergencies.  We have been spending our “rainy day money” on sunny days and now we have nothing left.

In reality, many hospitalist services are overwhelmed with patients  who would never be considered for a hospital admission 90% of the time in the rest of the world (a 90 year old with 15 mins of mild chest pain? really? Seriously?). Having to manage dozens of complex patients with multiple medical problems is itself not a manageable situation so certain . . um . . shortcuts are needed.

Behold! The standardized, modern, hospitalist admission order set (with helpful comments added);

____________________________________

BY AND LARGE GENERAL HOSPITAL (B&LGH)

Date:

Admit to Medicine Dr. ______________ (The actual name does not matter as there is only a 40% chance that the patient  will be seen by this doctor and not 3 or 4 different covering docs while in the hospital).

Diagnosis ________________________(Not important since this often comes from the ER doc and should be considered for novelty purposes only).

Condition ________________________(Only important if this case gets presented as part of a TV medical show).

Diet ____________________________(Other then pain meds, the only order most patients care about).

Activity__________________________(Usually much more than the patient will ever regularly get at home).

Home Medications to continue _____________________   (Only a few patients have a complete and accurate list. Besides, the nursing staff will make these determinations for you).

Protonix 40 mg IV q 24 hours (regardless of admission diagnosis)

Demerol 25 to 50 mg IV every 6 hours as needed for pain  (Morphine is far superior for pain control  but patients keep asking for it and the name sounds so “cool”).

Laxatives: None until day 4+ in the hospital without a BM (hospitalists are too important to order laxatives from the get-go).

Antibiotic: __ Zosyn 3.375 gms IV q 6 hours. __ Levoquin 500 mg IV q 24 hours. ___ Rocephin 1 gm IV q 24 hours (pick one regardless of admission diagnosis).

• Is the patient on antibiotics? Consult an infectious disease specialist.
• Is serum  creatinine more than 1.4? Consult nephrology (points awarded if the patient never needs any treatment other than IV fluids).
• Is the patient nauseated? Consult gastoenterology (extra points are awarded if the patient undergoes an endoscopic exam that could have otherwise been done as an outpatient).
• Is the patient depressed about being sick and in the hospital? Consult psychiatry (extra points if patient to be given supportive psycotherapy while in the hospital).
• Is the patient confused about being in the hospital? Consult neurology (extra points if patient gets a complete stroke work up + an EEG).
• Does the patient have a history of cancer that went into remission 15 years ago and was admitted for an acute MI? Consult oncology.
• Does the patient have anemia after loosing several pints of blood from a bleeding ulcer? Consult hematology.
• Is the patient morbidly obese? Consult pulmonology because they MIGHT have obstructive sleep apnea.

If  you have consulted less than 3 specialists then return to above orders and reconsider or randomly pick an organ system to undergo intense scrutiny.

Is the D-dimer level more than 0.4? Order CAT scan angiogram of the chest.

Discharge the patient when seen and cleared by all specialists (i.e do not call me as I will have left the hospital hours ago).

That would be OK if Mr. Sheen actually had some talent to showcase, like, say, playing the tuba with his toes or being able to take out his own spleen using nothing but a pair of chopsticks and a Mr. Potato-head. That I would pay to see. But, no. His “act” appears to be an abuse related hypomanic tirade into persecution delusions and ego inflation.

Mr. Sheen had been making several million per episode of Two and a Half Men. That is, he got paid millions of dollars to memorize a few lines and then repeat them in front of a camera. Yet he still felt massively betrayed and taken advantage of.

Speaking of, I get paid $38 to perform an invasive procedure that could save a patient’s life (according to Medicare reimbursement calculations). I get paid even less by the Federal government to see a hospital patient and make complex medical management decisions. Like Mr. Sheen, I could have done massive amounts of drugs and alcohol and displayed my resulting psychiatric condition on national television. But, I don’t have enough Tiger Blood (TM) in my system.

A traditional or legendary story . . esp. one that is concerned with deities or demigods and explains some practice, rite, or phenomenon of nature . . any invented story, idea, or concept . . an unproved or false collective belief that is used to justify a social institution.

This is ironic since it sounds like the biblical version of creation and the term “myth” fit perfectly. In the very least, evolutionary theory provides a logical explanation for the existence of fossils, something that is never mentioned in nor should even exist according to Genesis.

O’Donnell appears to be a creationist supporter who claims that there is “as much, if not more, evidence” for creationism than there is for evolutionary theory. The problem that O’Donnell and other creationists dismiss is that creationism is based on a literary and religious myth and evolution is  based on empirical evidence. There is no getting around this fact nor the fact that O’Donnell and creationists are incapable of determining the difference between theology (myth) and science (evidence).

Like other creationists, O’Donnell is also incapable of understanding that the pedestrian definition  of the term “theory” (guess, conjecture, or speculation) is not the same as the use of “theory” in scientific
parlance (a coherent group of general propositions used as principles of explanation for a class of phenomena).

What is not at all clear is whether O’Donnell is really a moron who’s intellectual development stopped prior to her formative years or whether she is a “victim” of circumstance held captive by her beliefs or given better opportunities to advance politically by being a moron within the moron party. But I have a hard time believing that a reality could exist where O’Donnell has a respectable career as an evolutionary biologist. As they say, the cream always rises to the top. Or in O’Donnell’s case, the opposite.

The vuvuzela is like a straightened trumpet and is played by blowing a raspberry into the mouthpiece. The player’s lips open and close about 235 times a second, sending puffs of air down the tube, which excite resonance of the air in the conical bore. A single vuvuzela played by a decent trumpeter is reminiscent of a hunting horn.

Americans wear their team colors and cheer . . at specific exciting times during the game. Soccer fans wear their team colors and blow vuvuzelas . . . continuously during the match. Oddly, the only time the drone appears to abate is right after a goal.

First there is Iron Man aka Tony Stark who’s life is dependent upon an “arc reactor” implanted in his chest that is made, in part, out of the metallic element palladium which, along with rhodium, ruthenium, iridium and osmium, is a platinum group metal with widespread uses as a catalyst, in electronics, and even as jewelry.

I have no idea how the arc reactor is supposed to generate such a massive amount of power coming from such a small device without an obvious fuel source. And what does this have to do with Palladium? Actually, there has been theoretical work done in the field of “cold fusion” (i.e. generating energy from the fusion of two hydrogen atoms at room temperatures and one atmospheric pressure) utilizing palladium as the catalyst. But no actual device has ever been created or proven to work.

However, Mr. Stark is stuck with this palladium arc reactor in his chest and it is causing toxicity from the palladium manifesting as great looking engorged veins that coarse up his chest to his neck and make really interesting 90 degree turns giving one the impression that this is . . not natural. Which is just as well since the vast majority of branching patterns in nature do not form at 90 degrees like a microchip. If anything, this should have looked like a fractal.

And what is palladium toxicity? It’s not uncommon that direct contact with palladium as with other metals can cause dermatitis which is a localized inflammatory skin reaction. There are no known systemic effects of palladium in the literature even though there have been studies showing palladium’s toxic effects on cells in vitro. If anything, Mr. Stark would have had a raging case of contact dermatitis involving the skin around the implantation site. I suppose the itching from this skin reaction alone would be enough to make him get drunk, put on the iron man suit, and go skeet shooting watermellons at his birthday party. But I digress.

And what about the “treatment” of “lithium dioxide” given to Mr. Stark for his palladium toxicity? Lithium is an element with a valence of one meaning that it can only form a single chemical bond. Two lithium atoms can bind to a single oxygen atom to from lithium oxide (Li-O-Li with two lithium atoms in place of the two hydrogen atoms in water H2O). Or two lithium atoms can combine with two oxygen atoms to form lithium peroxide (Li-O-O-Li). But there is no chemical way to get lithium DIoxide O-Li-O. Evidently, Tony Stark was the victim of medical quackery (and bad script writing) although there was quite a placebo effect on the a fore-mentioned microchip venous dilatation pattern on his skin which disappeared within seconds of being injected with . . something that was not “lithium dioxide”.

So Mr. Stark makes an arc reactor out of a new element that he synthesized himself using a do-it-yourself room sized laser. Don’t you need a particle accelerator the size of a small country to create a new element and that this element would be extremely radioactive and unstable and have a half-life measured in seconds? Ok, I’m not going there.

Probably the most realistic aspect of Iron Man 2 was when Tony Stark promoted his personal assistant, a woman with no formal business training, to be CEO of a multi-billion dollar company. This I could see happening.

The Pentagon statistics show the nuclear stockpile was reduced by 75 percent between the fall of the Berlin Wall in 1989 and September 30, 2009, and 84 percent since its peak of more than 31,255 in 1967.

Other than deterrence, I’m sure that there was some rational reason why we had over 31 thousand nuclear weapons in 1967. It must have been based on the number of Soviet and other strategic targets rather then just an attempt to keep up with the Ivans who, at the time, had far fewer nuclear weapons.

The logic of nuclear stockpiling is confusing. On one hand, it’s understandable to think in terms of destructive yield and targets and how many kilotons of explosives are needed to destroy the enemy. But on the other hand, there is this huge fudge factor – the great unknown – about the effects of radiation, electromagnetic pulse (EMP), and sheer massive destructive potential that are all unique to nuclear weapons.

The great unknown is how many nuclear weapons would need to be used before the enemy’s ability to fight completely collapsed. EMP waves would disable most electronics and lay waste to any modern economy that keeps its records on computers and digital storage. Large swaths of radiation would extend the fatal yield from acute radiation poisoning for days to weeks and hundreds of miles beyond the initial blast zone of any single bomb. The targeting of civilian centers (or military targets near civilian centers) would overwhelm the nation’s ability to deal with millions of injured and displaced people clogging roads and relief sites.

Our military likely knows this number to within a very specific range and I suspect that the total number of nuclear detonations of a certain yield needed to completely disable an enemy’s ability to conduct offensive operations – which is not the same thing as complete destruction – is only dozens to a few hundred, depending on the country. This is likely why there has been a gradual reduction in the numbers of nuclear weapons since this peak in 1967 while the USSR continued its escalation in the numbers of these very expensive devices during the 1970s and 1980s.

But since that peak in 1967 and continuing to today, we continue to have far more nuclear devices then we would ever need OR be able to use in wartime. In the event of a nuclear war with another nuclear power – mostly the USSR/Russia – we would be getting hit with nuclear weapons at the same time thus diminishing our ability to fight. It’s massively unlikely that we would be able to use more than a few hundred weapons before our ability to fight collapsed as well, assuming that both sides continued to fight despite such massive destruction. All of this makes the need to have more than several hundred nuclear weapons a huge waste of money and resources. The inability to understand this minimal strategic gain at an enormous economic cost is what significantly contributed to the collapse of the USSR in the 1980s.

What about a limited nuclear war? The only way we would ever use nukes against another country is if we had evidence (obvious or via investigation) that the country in question was directly responsible for a mass causality weapon of mass destruction (WMD) attack on American interests. In this case, the retaliation would not simply be retribution but an attempt at instant removal of a regime and destruction of their military capacity because of that regime’s proven intentions and ability to use WMDs.

In this scenario and in almost all cases (Iran, North Korea, Pakistan, Yemen) it is highly unlikely that more than a few weapons would be needed to obliterate the regime including any civilian strongholds of the regime and devastate their military ability to fight. Because this initial strike would need to be followed immediately by an invasion to secure the country and round up remaining forces, the fewer nukes we use the less radiation we expose our forces (and neighboring countries) to.

It is for this reason that the right wing criticism of Obama’s signing of the latest nuclear arms reduction treaty with Russia is laughingly absurd. If ratified, the new treaty would limit each side to about 1,550 nuclear weapons. Obviously the Pentagon feels that this number is more than adequate as both a deterrent and the ability to destroy Russia and have enough left over to go after one or more smaller countries in a worst case scenario. This treaty is more of a clean up policy for both nations to eliminate the extra costs of several thousand nuclear weapons that are strategically irrelevant.

The Pentagon would not have signed off on such a deal as negotiated by the US if this could compromise our security. In the very least, the military would have leaked their protests to the media about their concerns that this number would be too low, thus compromising our security. This didn’t happen.

Instead, it was non-military right wingers including non foreign policy specialist and resignation expert S. Palin who claimed that the treaty would leave the US vulnerable or send the wrong message to terrorists and aggressive foreign regimes. And they based this claim on nothing more than their own ignorance (or a willingness to play this off the ignorance of their supporters for political points).

In 2006 (the latest data available), the 40% highest earning American Households paid 86% of Total Federal Tax Liabilities. The 60% lowest earning households paid just 14%.

And although Americans are not taxed at the higher total rates seen in many European and Scandinavian countries, the average US tax payer certainly does not see as many benefits as most European tax payers. Where is my month long August vacation with pay?

Then there is the absurd way that doctors who accept Medicare and Medicaid are taxed. That’s right. Our Medicare/Medicaid income is taxed in the same lunatic way that social security benefits are taxed even though these benefits were already derived from income taxes.

Given how little the average Medicare beneficiary has already contributed from their income over several years to decades  vs how much the average Medicare beneficiary actually consumes in modern expensive health care, a large percentage of Medicare funding comes from fresh tax sources and as you have already read above, most of the fresh tax sources are the 40% highest earning Americans.

In other words, a large percentage of a physician’s taxes get recycled into public insurance reimbursements for Medicare and Medicaid and then that income is itself taxed and so on and so forth. That money doesn’t get injected into the economy, it just cycles around and around the Federal bureaucracy generating administrative processing costs. Crazy, no?

Today also happens to be yet another deadline for when the 21% cut in Medicare reimbursement kicks in. I have a proposition for Congress. Let the 21% pay cut become permanent and introduce a bill to exempt income generated from caring for Medicare and Medicaid patients from Federal income taxes. I think it’s more than a fair trade off. And maybe Congress can begin to slow the decline in providers who accept government health insurance.