Monday, January 31, 2011
Your Birthday, Your Tree and their meanings (wowzone.com) WOW Poetry,... - StumbleUpon
Your Birthday, Your Tree and their meanings (wowzone.com) WOW Poetry,... - StumbleUpon
CHESTNUT TREE (the Honesty) - of unusual beauty, does not want to impress, well-developed sense of justice, vivacious, interested, a born diplomat, but irritates easily and sensitive in company, often due to a lack of self confidence, acts sometimes superior, feels not understood loves only once, has difficulties in finding a partner.
Sunday, January 30, 2011
Undercover police cleared 'to have sex with activists' | UK news | guardian.co.uk
Undercover police cleared 'to have sex with activists' | UK news | guardian.co.uk
The best way of stopping any liaison getting too heavy was to shag somebody else. It's amazing how women don't like you going to bed with someone else," said the officer, whose undercover deployment infiltrating anti-racist groups lasted from 1993 to 1997.
The best way of stopping any liaison getting too heavy was to shag somebody else. It's amazing how women don't like you going to bed with someone else," said the officer, whose undercover deployment infiltrating anti-racist groups lasted from 1993 to 1997.
Renesys - The Internet Intelligence Authority
Renesys - The Internet Intelligence Authority
Dr. Andy T. Ogielski
President and Chief Scientest, Co-founder
Andy Ogielski, President and Chief Scientist, is responsible for leading the company’s growth initiatives and assessing new business development opportunities.
Andy has more than 25 years experience in the disciplines of data networking and telecommunications, Internet protocols, wireless systems, software systems, and scientific computing. Prior to founding Renesys, he was a research professor at Rutgers University where he led multimillion-dollar government funded projects such as scalable Internet modeling and simulation software (SSFNet) that pioneered analysis of large networks exceeding 100,000 multiprotocol hosts and routers. At Bell Communications Research (now Telcordia), Andy built pioneering high-speed network packet traffic recording and analysis systems, fraud detection software, streaming distributed video servers, and network operations software systems. As a research scientist (MTS) at AT&T Bell Laboratories Andy was involved in very large scale scientific computing, including designing and building a special-purpose supercomputer. Andy holds a Ph.D. in theoretical physics from the University of Wroclaw, Poland.
The Vertical Slice - Collaborative Agile Contracts
The Vertical Slice - Collaborative Agile Contracts
Recently peterstev reported on, 10 Contracts for your next Agile Software Project.
In BestBrains we now have experience from two commercial projects using a new kind of agile contract.
We want to create contracts where risk is shared fairly between customer and supplier and where likewise benefit is shared fairly. Based on our experiences we have arrived at a contract model that has proven to achieve this result. We call this the collaborative agile contract.
The main mechanism of the contract is to delay some of the payment until a certain criteria has been reached. We do not use a date as this criteria which otherwise seems to be common. Rather we want a criteria that tells when we have a situation where the customer is getting value from the software. There is generally a mutual interest of arriving at this situation as quickly as possible. Effectiveness and creativity from the supplier will be rewarded. And the customer will be careful when deciding what features are needed in order to reach that goal.
The contract defines the following elements:
We are going to report on our experiences at Agile 2009, but don't hestitate to comment on this blog entry or contact Lars Thorup to learn more about agile contracting.
agile kontrakter
Collaborative Agile Contracts
Wednesday, June 03, 2009 10:15:49 AM (Romance Standard Time, UTC+01:00)Recently peterstev reported on, 10 Contracts for your next Agile Software Project.
In BestBrains we now have experience from two commercial projects using a new kind of agile contract.
We want to create contracts where risk is shared fairly between customer and supplier and where likewise benefit is shared fairly. Based on our experiences we have arrived at a contract model that has proven to achieve this result. We call this the collaborative agile contract.
The main mechanism of the contract is to delay some of the payment until a certain criteria has been reached. We do not use a date as this criteria which otherwise seems to be common. Rather we want a criteria that tells when we have a situation where the customer is getting value from the software. There is generally a mutual interest of arriving at this situation as quickly as possible. Effectiveness and creativity from the supplier will be rewarded. And the customer will be careful when deciding what features are needed in order to reach that goal.
The contract defines the following elements:
- Scope described loosely in a few paragraphs, a kind of vision statement
- An hourly price, that is 10-50% below what is normal for pure time-and-material
- A set of milestones, which will lead to payment of a fixed amount. The simple criteria that tells that a given milestone has been reached, is whether the software is deployed in production.
- A development process following agile practices
- A suggested time frame for the overall project and for each milestone
We are going to report on our experiences at Agile 2009, but don't hestitate to comment on this blog entry or contact Lars Thorup to learn more about agile contracting.
agile kontrakter
Creating a portable development environment : orestis.gr
Creating a portable development environment : orestis.gr
Here is what it includes:
- Portable Python (python + django)
- Subversion - standalone binaries
- Notepad2
- μTorrent
- Mac-on-a-stick
- Portable apps suite that includes:
- Putty
- Firefox
- OpenOffice
- 7-Zip
- Gaim
- Clamwin
- Sudoku
- VLC player
Saturday, January 29, 2011
Friday, January 28, 2011
Tuesday, January 25, 2011
Monday, January 24, 2011
Sunday, January 23, 2011
Huffington Post: David Eyre's Pancake
Sent from my iPad
Saturday, January 22, 2011
Economist Defends Photoshopping Obama Cover (PHOTOS)
Economist Defends Photoshopping Obama Cover (PHOTOS)
If you look how The Economist edited their cover photo of the President, in the original he is bending his head down to listen carefully to a much shorter local parish president Charlotte Randolph, standing with her and Coast Guard Admiral Thad Allen on a Louisiana beach.
The edited photo use on The Economist's cover zapped the other two, and appears to show Prez O bending is head due to the weight of his fight against BP "Obama v BP."
If you look how The Economist edited their cover photo of the President, in the original he is bending his head down to listen carefully to a much shorter local parish president Charlotte Randolph, standing with her and Coast Guard Admiral Thad Allen on a Louisiana beach.
The edited photo use on The Economist's cover zapped the other two, and appears to show Prez O bending is head due to the weight of his fight against BP "Obama v BP."
Article: How Billionaires Rule Our Schools
How Billionaires Rule Our Schools
http://dissentmagazine.org/article/?article=3781
How Billionaires Rule Our Schools
The cost of K–12 public schooling in the United States comes to well over $500 billion per year. So, how much influence could anyone in the private sector exert by controlling just a few billion dollars of that immense sum? Decisive influence, it turns out. A few billion dollars in private foundation money, strategically invested every year for a decade, has sufficed to define the national debate on education; sustain a crusade for a set of mostly ill-conceived reforms; and determine public policy at the local, state, and national levels. In the domain of venture philanthropy—where donors decide what social transformation they want to engineer and then design and fund projects to implement their vision—investing in education yields great bang for the buck.Hundreds of private philanthropies together spend almost $4 billion annually to support or transform K–12 education, most of it directed to schools that serve low-income children (only religious organizations receive more money). But three funders—the Bill and Melinda Gates Foundation, the Eli and Edythe Broad (rhymes with road) Foundation, and the Walton Family Foundation—working in sync, command the field. Whatever nuances differentiate the motivations of the Big Three, their market-based goals for overhauling public education coincide: choice, competition, deregulation, accountability, and data-based decision-making. And they fund the same vehicles to achieve their goals: charter schools, high-stakes standardized testing for students, merit pay for teachers whose students improve their test scores, firing teachers and closing schools when scores don't rise adequately, and longitudinal data collection on the performance of every student and teacher. Other foundations—Ford, Hewlett, Annenberg, Milken, to name just a few—often join in funding one project or another, but the education reform movement's success so far has depended on the size and clout of the Gates-Broad-Walton triumvirate.
Every day, dozens of reporters and bloggers cover the Big Three's reform campaign, but critical in-depth investigations have been scarce (for reasons I'll explain further on). Meanwhile, evidence is mounting that the reforms are not working. Stanford University's 2009 study of charter schools—the most comprehensive ever done—concluded that 83 percent of them perform either worse or no better than traditional public schools; a 2010 Vanderbilt University study showed definitively that merit pay for teachers does not produce higher test scores for students; a National Research Council report confirmed multiple studies that show standardized test scores do not measure student learning adequately. Gates and Broad helped to shape and fund two of the nation's most extensive and aggressive school reform programs—in Chicago and New York City—but neither has produced credible improvement in student performance after years of experimentation.
To justify their campaign, ed reformers repeat, mantra-like, that U.S. students are trailing far behind their peers in other nations, that U.S. public schools are failing. The claims are specious. Two of the three major international tests—the Progress in International Reading Literacy Study and the Trends in International Math and Science Study—break down student scores according to the poverty rate in each school. The tests are given every five years. The most recent results (2006) showed the following: students in U.S. schools where the poverty rate was less than 10 percent ranked first in reading, first in science, and third in math. When the poverty rate was 10 percent to 25 percent, U.S. students still ranked first in reading and science. But as the poverty rate rose still higher, students ranked lower and lower. Twenty percent of all U.S. schools have poverty rates over 75 percent. The average ranking of American students reflects this. The problem is not public schools; it is poverty. And as dozens of studies have shown, the gap in cognitive, physical, and social development between children in poverty and middle-class children is set by age three.
Drilling students on sample questions for weeks before a state test will not improve their education. The truly excellent charter schools depend on foundation money and their prerogative to send low-performing students back to traditional public schools. They cannot be replicated to serve millions of low-income children. Yet the reform movement, led by Gates, Broad, and Walton, has convinced most Americans who have an opinion about education (including most liberals) that their agenda deserves support.
Given all this, I want to explore three questions: How do these foundations operate on the ground? How do they leverage their money into control over public policy? And how do they construct consensus? We know the array of tools used by the foundations for education reform: they fund programs to close down schools, set up charters, and experiment with data-collection software, testing regimes, and teacher evaluation plans; they give grants to research groups and think tanks to study all the programs, to evaluate all the studies, and to conduct surveys; they give grants to TV networks for programming and to news organizations for reporting; they spend hundreds of millions on advocacy outreach to the media, to government at every level, and to voters. Yet we don't know much at all until we get down to specifics.
Pipelines or Programs
The smallest of the Big Three,* the Broad Foundation, gets its largest return on education investments from its two training projects. The mission of both is to move professionals from their current careers in business, the military, law, government, and so on into jobs as superintendents and upper-level managers of urban public school districts. In their new jobs, they can implement the foundation's agenda. One project, the Broad Superintendents Academy, pays all tuition and travel costs for top executives in their fields to go through a course of six extended weekend sessions, assignments, and site visits. Broad then helps to place them in superintendent jobs. The academy is thriving. According to the Web site, "graduates of the program currently work as superintendents or school district executives in fifty-three cities across twenty-eight states. In 2009, 43 percent of all large urban superintendent openings were filled by Broad Academy graduates."
The second project, the Broad Residency, places professionals with master's degrees and several years of work experience into full-time managerial jobs in school districts, charter school management organizations, and federal and state education departments. While they're working, residents get two years of "professional development" from Broad, all costs covered, including travel. The foundation also subsidizes their salaries (50 percent the first year, 25 percent the second year). It's another success story for Broad, which has placed more than two hundred residents in more than fifty education institutions.
In reform-speak, both the Broad Academy and Residency are not mere programs: they are "pipelines." Frederick Hess, director of Education Policy Studies at the conservative American Enterprise Institute, described the difference in With the Best of Intentions: How Philanthropy Is Reshaping K–12 Education (2005):
Donors have a continual choice between supporting "programs" or supporting "pipelines." Programs, which are far more common, are ventures that directly involve a limited population of children and educators. Pipelines, on the other hand, primarily seek to attract new talent to education, keep those individuals engaged, or create new opportunities for talented practitioners to advance and influence the profession.…By seeking to alter the composition of the educational workforce, pipelines offer foundations a way to pursue a high-leverage strategy without seeking to directly alter public policy.
Once Broad alumni are working inside the education system, they naturally favor hiring other Broadies, which ups the leverage. A clear picture of this comes from Los Angeles. The foundation is based there and exerts formidable influence over the LA Unified School District (LA Unified), the second largest in the nation. At the start of 2010, Broad Residency alums working at LA Unified included Matt Hill, who oversees the district's Public School Choice project that turns schools over to independent managers (Broad pays Hill's $160,000 salary); Parker Hudnut, executive director of the district's innovation and charter division (Kathi Littmann, his predecessor, was also a Broad resident); Yumi Takahashi, the budget director; Marshall Tuck, chief executive of the nonprofit that manages schools for Mayor Antonio Villaraigosa; Mark Kieger-Heine, chief operating officer of the same nonprofit; and Angela Bass, its superintendent of instruction. In June 2010, the Board of Education hired Broad Academy alumnus John Deasy as deputy superintendent of LA Unified (he's a likely candidate for the superintendent's job). At the time of hiring, Deasy was deputy director of education at the Gates Foundation.
Broad casts a long shadow over LA Unified, but other foundations also invest. A $4.4 million grant from the LA-based Wasserman Foundation, $1.2 million from Walton, and smaller grants from Ford and Hewlett are paying the salaries of more than a dozen key senior staffers in the district. They work on projects favored by the foundations.
Philanthropists Are Royalty
On September 8, 2010, the Broad Foundation announced a twist on the usual funding scenario: the Broad Residency had received a $3.6 million grant from the Bill and Melinda Gates Foundation. According to Broad's press release, the money would go "to recruit and train as many as eighteen Broad Residents over the next four years to provide management support to school districts and charter management organizations addressing the issue of teacher effectiveness." Apparently Broad needs Gates in order to expand one of its core projects. The truth is that the Gates Foundation could fully subsidize all of Broad's grant-giving in education, as well as that of the Walton Family Foundation. Easily—it's that outsized. Since Warren Buffett gave his assets to Gates, the latter is more than six times bigger than the next largest foundation in the United States, Ford, with $10.2 billion in assets.
Now is the moment for me to address the inevitable objection. Many people, including leftists, consider it unseemly, even churlish, to criticize the Gates Foundation. Time and again, I've heard, "They do good work on health care in Africa. Leave them alone." But the Gates Foundation has created much the same problem in health funding as in education reform. Take, for example, the Gates project to eradicate malaria.
On February 16, 2008, the New York Times reported on a memo that it had obtained, written by Dr. Arata Kochi, head of the World Health Organization's malaria programs, to WHO's director general. Because the Gates Foundation was funding almost everyone studying malaria, Dr. Arata complained, the cornerstone of scientific research—independent review—was falling apart.
Many of the world's leading malaria scientists are now "locked up in a 'cartel' with their own research funding being linked to those of others within the group," Dr. Kochi wrote. Because "each has a vested interest to safeguard the work of the others," he wrote, getting independent reviews of research proposals "is becoming increasingly difficult."
The director of global health at Gates responded predictably: "We encourage a lot of external review." But a lot of external review does not solve the problem, which is structural. It warps the work of most philanthropies to some degree but is exponentially dangerous in the case of the Gates Foundation. Again, Frederick Hess in With the Best of Intentions:
…[A]cademics, activists, and the policy community live in a world where philanthropists are royalty—where philanthropic support is often the ticket to tackling big projects, making a difference, and maintaining one's livelihood.…[E]ven if scholars themselves are insulated enough to risk being impolitic, they routinely collaborate with school districts, policy makers, and colleagues who desire philanthropic support.
…The groups convened by foundations [to advise them] tend to include, naturally enough, their friends, allies, and grantees. Such groups are less likely than outsiders to offer a radically different take on strategy or thinking.
…Researchers themselves compete fiercely for the right to evaluate high-profile reform initiatives. Almost without exception, the evaluators are hired by funders or grantees….Most evaluators are selected, at least in part, because they are perceived as being sympathetic to the reform in question.
Hess found that the press, too, handles philanthropies with kid gloves. One study reviewed how national media outlets (the New York Times, Los Angeles Times, Washington Post, Chicago Tribune, Newsweek, and Associated Press) portrayed the educational activities of major foundations (Gates, Broad, Walton, Annenberg, and Milken) from 1995 to 2005. The study revealed "thirteen positive articles for every critical account." Hess had three explanations for the obliging attitude of the supposedly disinterested press: a natural inclination to write positively about "generous gifts," the routine tendency to affirm "professionally endorsed school reforms," and the difficulty of finding experts who will publicly criticize the foundations.
The cozy environment undermines all players—grantees, media, the public, and the foundations themselves. Without honest assessments, funders are less likely to reach their goals. According to Phil Buchanan, executive director of the Center for Effective Philanthropy, "If you want to achieve the greatest possible positive impact, you've got to figure out how to hear things from people on the ground who might know more than you about some pretty important things" (Seattle Times, August 3, 2008).
No Silver Bullet
The sorry tale of the Gates Foundation's first major project in education reform has been told often, but it's key to understanding how Gates functions. I'll run through it briefly. In 2000 the foundation began pouring money into breaking up large public high schools where test scores and graduation rates were low. The foundation insisted that more individual attention in closer "learning communities" would—presto!—boost achievement. The foundation didn't base its decision on scientific studies showing school size mattered; such studies didn't exist. As reported in Bloomberg Businessweek (July 15, 2010), Wharton School statistician Howard Wainer believes Gates probably "misread the numbers" and simply "seized on data showing small schools are overrepresented among the country's highest achievers…." Gates spent $2 billion between 2000 and 2008 to set up 2,602 schools in 45 states and the District of Columbia, "directly reaching at least 781,000 students," according to a foundation brochure. Michael Klonsky, professor at DePaul University and national director of the Small Schools Workshop, describes the Gates effect this way:
Gates funding was so large and so widespread, it seemed for a time as if every initiative in the small-schools and charter world was being underwritten by the foundation. If you wanted to start a school, hold a meeting, organize a conference, or write an article in an education journal, you first had to consider Gates ("Power Philanthropy" in The Gates Foundation and the Future of Public Schools, 2010).
In November 2008, Bill and Melinda gathered about one hundred prominent figures in education at their home outside Seattle to announce that the small schools project hadn't produced strong results. They didn't mention that, instead, it had produced many gut-wrenching sagas of school disruption, conflict, students and teachers jumping ship en masse, and plummeting attendance, test scores, and graduation rates. No matter, the power couple had a new plan: performance-based teacher pay, data collection, national standards and tests, and school "turnaround" (the term of art for firing the staff of a low-performing school and hiring a new one, replacing the school with a charter, or shutting down the school and sending the kids elsewhere).
To support the new initiatives, the Gates Foundation had already invested almost $2.2 million to create The Turnaround Challenge, the authoritative how-to guide on turnaround. Secretary of Education Arne Duncan has called it "the bible" for school restructuring. He's incorporated it into federal policy, and reformers around the country use it. Mass Insight Education, the consulting company that produced it, claims the document has been downloaded 200,000 times since 2007. Meanwhile, Gates also invested $90 million in one of the largest implementations of the turnaround strategy—Chicago's Renaissance 2010. Ren10 gave Chicago public schools CEO Arne Duncan a national name and ticket to Washington; he took along the reform strategy. Shortly after he arrived, studies showing weak results for Ren10 began circulating, but the Chicago Tribune still caused a stir on January 17, 2010, with an article entitled "Daley School Plan Fails to Make Grade."
Six years after Mayor Richard Daley launched a bold initiative to close down and remake failing schools, Renaissance 2010 has done little to improve the educational performance of the city's school system, according to a Tribune analysis of 2009 state test data.…The moribund test scores follow other less than enthusiastic findings about Renaissance 2010—that displaced students ended up mostly in other low performing schools and that mass closings led to youth violence as rival gang members ended up in the same classrooms. Together, they suggest the initiative hasn't lived up to its promise by this, its target year.
Last fall, Daley announced that he wouldn't run again for mayor; Ron Huberman, who replaced Duncan as schools CEO, announced that he would leave before Daley; and Rahm Emanuel, preparing to run for Daley's job, announced that he would promote another privately funded reform campaign for Chicago's schools. "Let's raise a ton of money," he told the Chicago Tribune (October 18, 2010). Eminently doable.
Investing for Political Leverage
The day before the first Democratic presidential candidates' debate in 2007, Gates and Broad announced they were jointly funding a $60 million campaign to get both political parties to address the foundations' version of education reform. It was one of the most expensive single issue efforts ever; it dwarfed the $22.4 million offensive that Swift Boat Veterans for Truth mounted against John Kerry in 2004 or the $7.8 million that AARP spent on advocacy for older citizens that same year (New York Times, April 25, 2007). The Gates-Broad money paid off: the major candidates took stands on specific reforms, including merit pay for teachers. But nothing the foundations did in that election cycle (or could have done) advanced their agenda as much as Barack Obama's choice of Arne Duncan to head the Department of Education (DOE). Eli and Edythe Broad described the import in The Broad Foundations 2009/10 Report:
The election of President Barack Obama and his appointment of Arne Duncan, former CEO of Chicago Public Schools, as the U.S. Secretary of Education, marked the pinnacle of hope for our work in education reform. In many ways, we feel the stars have finally aligned.With an agenda that echoes our decade of investments—charter schools, performance pay for teachers, accountability, expanded learning time, and national standards—the Obama administration is poised to cultivate and bring to fruition the seeds we and other reformers have planted.
Arne Duncan did not disappoint. He quickly made the partnership with private foundations the defining feature of his DOE stewardship. His staff touted the commitment in an article for the department's newsletter, The Education Innovator (October 29, 2009):
…The Department has truly embraced the foundation community by creating a position within the Office of the Secretary for the Director of Philanthropic Engagement. This dedicated role within the Secretary's Office signals to the philanthropic world that the Department is "open for business."
Within weeks, Duncan had integrated the DOE into the network of revolving-door job placement that includes the staffs of Gates, Broad, and all the thinks tanks, advocacy groups, school management organizations, training programs, and school districts that they fund. Here's a quick look at top executives in the DOE: Duncan's first chief of staff, Margot Rogers, came from Gates; her replacement as of June 2010, Joanne Weiss, came from a major Gates grantee, the New Schools Venture Fund; Assistant Secretary for Civil Rights Russlynn Ali has worked at Broad, LA Unified School District and the Gates-funded Education Trust; general counsel Charles P. Rose was a founding board member of another major Gates grantee, Advance Illinois; and Assistant Deputy Secretary for Innovation and Improvement James Shelton has worked at both Gates and the New Schools Venture Fund. Duncan himself served on the board of directors of Broad's education division until February 2009 (as did former treasury secretary Larry Summers).
How to Set Government Policy
Nothing illustrates the operation of Duncan's "open for business" policy better than the administration's signature education initiative, Race to the Top (RTTT). The "stimulus package" included $4.3 billion for education, but for the first time, states didn't simply receive grants; they had to compete for RTTT money with a comprehensive, statewide proposal for education reform. It is no exaggeration to say that the criteria for selecting the winners came straight from the foundations' playbook (which is, after all, Duncan's playbook). To start, any state that didn't allow student test scores to determine (at least in part) teacher and principal evaluations was not eligible to compete. After clarifying this, the 103-page application form laid out a list of detailed criteria and then additional priorities for each criterion ("The Secretary is particularly interested in applications that…"). Key criteria included
(C)(1) Fully implementing a statewide longitudinal data system(D)(2) Improving teacher and principal effectiveness based on performance [this is followed by criteria for evaluating performance based on student test scores]
(E) Turning around the lowest-achieving schools
(F)(2) Ensuring successful conditions for high-performing charter schools and other innovative schools
States were desperate for funds (in the end, thirty-four applied in the two rounds of the contest). When necessary, some rewrote their laws to qualify: they loosened or repealed limits on the number of charter schools allowed; they permitted teacher and principal evaluations based on test scores. But they still faced the immense tasks of designing a proposal that touched on all aspects of K–12 education and then writing an application, which the DOE requested (but did not require) be limited to 350 pages. What state has resources to gamble on such a venture? Enter the Gates Foundation. It reviewed the prospects for reform in every state, picked fifteen favorites, and, in July 2009, offered each up to $250,000 to hire consultants to write the application. Gates even prepared a list of recommended consulting firms. Understandably, the other states cried foul; so did the National Conference of State Legislatures: Gates was giving some states an unfair advantage; it was, in effect, picking winners and losers for a government program. After some weeks of reflection, Gates offered the application money to any state that met the foundation's eight criteria. Here, for example, is number five: "Does the state grant teacher tenure in fewer than three years? (Answer must be "no" or the state should be able to demonstrate a plan to set a higher bar for tenure)."
Who says the foundations (and Gates, in particular) don't set government policy?
On October 9, 2009, Edward Haertel, chair of the National Research Council's Board on Testing and Assessment (BOTA) sent a letter-report to Arne Duncan to express BOTA's concern about the use of testing in RTTT's requirements.
Tests often play an important role in evaluating educational innovations, but an evaluation requires much more than tests alone. A rigorous evaluation plan typically involves implementation and outcome data that need to be collected throughout the course of a project.
REFLECTING "A consensus of the Board," the nineteen-page letter went on to review the many scientific studies that demonstrate the pitfalls of using standardized test scores as a measure of student learning, teacher performance, or school improvement. BOTA recommended that the DOE use these studies to revise the RTTT plan. Unfortunately, as Haertel explained in his cover note, "Under National Academies procedures, any letter report must be reviewed by an independent group of experts before it can be publicly released, which made it impossible to complete the letter within the public comment period of the Federal Register notice [for RTTT's proposed regulations]." The scientists needed a peer review of their work, so they missed the Federal Register deadline, and that meant Duncan could ignore their recommendations—which he did. Haertel's letter (www.nap.edu/catalog/12780.html) makes for poignant reading in the twenty-first century: science imploring at the feet of ideology.
Other Ways to Invest for Political Influence
Private foundations are not allowed to lobby government directly, but they can, and all do, "share the lessons of their work" with lawmakers and their staffs. As the RTTT story shows, the Big Three also intervene more directly in policy and politics in ways available only to the mega-rich.
Consider the case of school reform in Washington, D.C. Former schools chancellor Michelle Rhee battled the teachers' union in acrimonious contract negotiations for more than two years; she wanted greater control over evaluating and firing teachers. Her breakthrough move was to get $64.5 million from the Broad, Walton, Robertson, and Arnold foundations to finance a five-year, 21.6 percent increase in teachers' base salary. The union took the money in exchange for giving Rhee some of the changes she wanted. The money came with a political restriction: the foundations could withdraw their pledges if there was a "material change" in the school system's leadership. When critics challenged the legality of the arrangement (Hadn't Rhee negotiated a deal that served her personal financial interests?), the chancellor found a way to shuffle funds and spend on a schedule that made the leadership clause irrelevant. The foundations' attempt to dictate who would be D.C. schools chancellor failed, but their investment paid off with highly publicized (and, the foundations hoped, precedent setting) concessions in a union contract.
On the question of who controls public schools, the Big Three much prefer mayoral control to independent school boards: a mayor with full powers can push through a reform agenda faster, often with less concern about the opposition. On August 18, 2009, the New York Post quoted Bill Gates on mayoral control: "The cities where our foundation has put the most money is where there is a single person responsible." In the same article, the Post broke the news that Bill Gates had "secretly bankrolled" Learn-NY, a group campaigning to overturn a term-limit law so that Michael Bloomberg could run for a third term as New York City mayor. Bloomberg's main argument for deserving another term was that his education reform agenda (identical to the Gates-Broad agenda) was transforming city schools for the better. Gates put $4 million of his personal money into Learn-NY. "The donation helped pay for Learn-NY's extensive public-relations, media, and lobbying efforts in Albany and the city." The Post also reported that Eli Broad had donated "millions" to Learn-NY. Since Bloomberg's reelection, however, the results of one study after another have shown that his reform endeavors are not producing the positive results he repeatedly claims.
In its "advocacy and public policy" work, the Gates Foundation also funnels money to elected officials through their national associations. The foundation has given grants to the National Governors Association Center for Best Practices, National Conference of State Legislatures, United States Conference of Mayors, National Association of Latino Elected Officials Education Fund, and National Association of State Boards of Education. They've also funded associations of high nonelected officials, such as the Council of Chief State School Officers (see gatesfoundation.org).
Ventures in Media
On October 7 and 8, 2010, the Columbia Journalism Review ran a two-part investigation by Robert Fortner into "the implications of the Bill and Melinda Gates Foundation's increasingly large and complex web of media partnerships." The report focused on the foundation's grants to the PBS Newshour, ABC News, and the British newspaper the Guardian for reporting on global health. Of course, all three grantees claim to have "complete editorial independence," but the ubiquity of Gates funding makes the claim disingenuous. As Fortner observes, "It is the largest charitable foundation in the world, and its influence in the media is growing so vast there is reason to worry about the media's ability to do its job." The Chronicle of Philanthropy, too, questioned the foundation's bankrolling of for-profit news organizations and its "growing involvement with journalism" (October 11, 2010). Neither publication mentioned that Gates is also developing partnerships with news and entertainment media to promote its education agenda.
Both Gates and Broad funded "NBC News Education Nation," a week of public events and programming on education reform that began on September 27, 2010. The programs aired on NBC News shows such as "Nightly News" and "Today" and on the MSNBC, CNBC, and Telemundo TV networks. During the planning stages, the producers of Education Nation dismissed persistent criticism that the programming was being heavily weighted in favor of the Duncan-foundation reform agenda. Judging by the schedule of panels and interviews, Education Nation certainly looked like a foundation project. The one panel I watched—"Good Apples: How do we keep good teachers, throw out bad ones, and put a new shine on the profession?"—was "moderated" by Steven Brill, a hardline opponent of teachers' unions and promoter of charter schools. The panel did not belong on a news show.
Gates and Broad also sponsored the documentary film Waiting for Superman, which is by far the ed reform movement's greatest media coup. With few exceptions, film critics loved it ("a powerful and alarming documentary about America's failing public school system," New York Times, September 23, 2010). Critics of the reform agenda found the film one-sided, heavy-handed, and superficial.
In 2009 the Gates Foundation and Viacom (the world's fourth largest media conglomerate, which includes MTV Networks, BET Networks, Paramount Pictures, Nickelodeon, Comedy Central, and hundreds of other media properties) made a groundbreaking deal for entertainment programming. For the first time, a foundation wouldn't merely advise or prod a media company about an issue; Gates would be directly involved in writing and producing programs. As a vehicle for their partnership, the foundation and Viacom (with some additional funds from the AT&T Foundation) set up a tax-exempt 501(c)(3) organization called the Get Schooled Foundation. The interpenetration of foundations and the spawning of new ones is endless. In July 2010, Get Schooled hired Marie Groark, then senior education program officer at Gates, as its executive director. Among its initiatives, Get Schooled lists Waiting for Superman, which is produced by Paramount Pictures, a subsidiary of Viacom. This is how the New York Times (April 2, 2009) described the Gates-Viacom deal:
Now the Gates Foundation is set to expand its involvement and spend more money on influencing popular culture through a deal with Viacom….It could be called "message placement": the social or philanthropic corollary to product placement deals in which marketers pay to feature products in shows and movies. Instead of selling Coca-Cola or G.M. cars, they promote education and healthy living….Their goal is to weave education-theme story lines into existing shows or to create new shows centered on education.
The Hubris That Comes from Power
On June 15, 2010, Gates Foundation CEO Jeff Raikes announced the results of the "Grantee Perception Report," which the foundation had commissioned from the Center for Effective Philanthropy. The center, a nonprofit research group, has rattled the foundation world with surveys that show how grantees evaluate a funder and also how that evaluation compares to the evaluations of other funders. Some 1,020 Gates grantees, active between June 1, 2008, and May 31, 2009, responded to the survey. On questions relating to the experience of working with Gates, the foundation got bad grades. "Lower than typical ratings," Raikes wrote.
Many of our grantee partners said we are not clear about our goals and strategies, and they think we don't understand their goals and strategies.They are confused by our decision-making and grant-making processes.
Because of staff turnovers, many of our grantee partners have had to manage multiple Program Officer transitions during the course of their grant, which creates more work.
Finally, they say we are inconsistent in our communications, and often unresponsive.
The report intrigued me because it shows another aspect of how Gates operates on the ground. More important, it helps explain why the Big Three can keep marketing and selling reforms that don't work. Certainly ideology—in this case, faith in the superiority of the private business model—drives them. But so does the blinding hubris that comes from power. You don't have to listen or see because you know you are right. One study after another sends up a red flag, but no one in the ed reform movement blinks. Insanity, defined as doing the same thing over and over and expecting different results, applies here.
Can anything stop the foundation enablers? After five or ten more years, the mess they're making in public schooling might be so undeniable that they'll say, "Oops, that didn't work" and step aside. But the damage might be irreparable: thousands of closed schools, worse conditions in those left open, an extreme degree of "teaching to the test," demoralized teachers, rampant corruption by private management companies, thousands of failed charter schools, and more low-income kids without a good education. Who could possibly clean up the mess?
All children should have access to a good public school. And public schools should be run by officials who answer to the voters. Gates, Broad, and Walton answer to no one. Tax payers still fund more than 99 percent of the cost of K–12 education. Private foundations should not be setting public policy for them. Private money should not be producing what amounts to false advertising for a faulty product. The imperious overreaching of the Big Three undermines democracy just as surely as it damages public education.
Joanne Barkan, who graduated from public schools in Chicago, lives and writes in Manhattan and on Cape Cod. Her next article on education will focus on teachers and their unions.*The Broad and Walton foundations had endowments of about $1.4 billion and $2 billion, respectively, in 2008 (the latest available figures, according to the Foundation Center). The Gates Foundation had an endowment of $33 billion as of June 2010, with an additional $30 billion from Warren Buffett, spread out over multiple years in annual contributions (from gatesfoundation.org). The Broad endowment comes primarily from the sale of SunAmerica to AIG in 1999; the Walton endowment from Wal-Mart Stores, Inc.; and the Gates endowment from Microsoft.
[Ed: due to a production error, this article first appeared online with the subtitle "Public School Reform in the Age of Venture Philanthropy."]
(via Instapaper)
Sent from my iPad
Friday, January 21, 2011
Wednesday, January 19, 2011
Tuesday, January 18, 2011
Clijsters apologizes after handing Safina historic loss - Busted Racquet - Tennis� - Yahoo! Sports
Clijsters apologizes after handing Safina historic loss - Busted Racquet - Tennis� - Yahoo! Sports
Clijsters apologizes after handing Safina historic loss
One year ago, Dinara Safina was the No. 2 seed at the Australian Open. The year before that, she made it all the way to the finals before losing to Serena Williams. On Tuesday, Safina suffered the worst loss ever by a former No. 1 player, a 6-0, 6-0 "double bagel" drubbing at the hands of Kim Clijsters. It's the first time a woman who was once the top-ranked player in the world had ever lost by that score.
After the match, the ever-congenial Clijsters felt the need to apologize for beating Safina so badly:
"I do feel bad, I even caught myself at 5-0 in the second set, she hit a couple of backhands down the line, I was like 'Yeah, that's it!'
"When she doesn't play against me, I'm rooting for her because I want her to get back into it and build confidence. But I wouldn't give her a (sympathy) game."
Before the match, some television analysts were playing up the fact that it could be a tough match for Clijsters and that Safina was a dangerous first-round opponent for the woman many (including myself) picked to win the entire tournament. But all those expectations are simply a reflex to seeing the name "Safina" on the draw sheet. There had been no recent signs she'd be making a return to form. The 24-year-old came into Melbourne on a five-match losing streak. She had almost lost 0-0 to Marion Bartoli in Hobart. She hasn't won a Grand Slam match since last year's Australian. She's lost.
Safina seems to realize this better than anyone. "I didn't know how to win a point," Safina told reporters while biting her lip. "There was nothing I could do to hurt her. I'm scratching my head thinking what the hell I am doing."
There's a chance Safina could drop out of top 100 in the rankings after the tournament. From No. 2 to No. 100 in one year. It's been a long, quick fall for Dinara Safina.
Monday, January 17, 2011
jordanmechner.com � Blog Archive � Ammo for Luddites
jordanmechner.com � Blog Archive � Ammo for Luddites
Having just read three Ian Fleming novels, one Henry James and one Jonathan Franzen on my new Kindle over the holidays, I found myself vaguely troubled by the feeling that I hadn’t really read them… that their plots and characters might slip out of my memory as easily as they slipped into the Kindle’s.
Having just read three Ian Fleming novels, one Henry James and one Jonathan Franzen on my new Kindle over the holidays, I found myself vaguely troubled by the feeling that I hadn’t really read them… that their plots and characters might slip out of my memory as easily as they slipped into the Kindle’s.
I told myself this was old-style thinking, that just because I don’t have the actual physical, dog-eared, tea-stained books to shove onto a bookshelf as souvenirs doesn’t mean their contents have engraved themselves any less deeply into my brain.
Now along comes this post by my scarily intelligent friend Jonah Lehrer (and his previous post foreshadowing it), citing a new Princeton study hinting that, maybe, the inchoate unease we bibliophiles have been feeling is more than just sentimental:
This study demonstrated that student retention of material across a wide range of subjects and difficulty levels can be significantly improved in naturalistic settings by presenting reading material in a format that is slightly harder to read.
It reminds me of another study I read a while back, suggesting that elementary school kids who squirm and fidget in their seats actually retain and process information better than if they sat still like they’re supposed to.
I just wish I could remember where I read it.
21st Century Insurance News - Its Unstable Year
21st Century Insurance News - Its Unstable Year
In what insurance analysts are declaring as an additional hard hit to the economy and to a business with a distinguished history, the Woodland Hills branches of 21st Century Insurance may drop up to 750 jobs in the next 16 months as its latest forerunner, Farmers Insurance Group, amasses affairs.
Farmers Insurance, a subsidiary of Zurich Financial Services Group, bought 21st Century from the distressed insurance titan, American International Group, last July 1, 2010 for $1.9 billion.
Since June 2010, Farmers Group has been searching for capabilities and methods to modernize operations.
There were a number of areas where they caught sight of a need to reduce the labor force because there were a few redundancies.
Fifty-six office workers out of 979, who hold a job at the two buildings 21st Century Insurance rents out in Woodland Hills, were informed August 27 that the company will no longer need their services. Three more positions will be slashed on September 4, another position is planned to be removed on September 30, and 52 more employees will be scratched off before October ends.
The work reduction would be made gradually, more or less on a monthly basis.
Farmers Insurance will as well cut its employments in Georgia.
On the whole, some 1,200 appointments are marked to be carved off before the end of the year, corresponding to 20 percent of the 21st Century personnel.
However, 21st Century Insurance will not be going somewhere else.
Its acquirement helped Farmers Insurance move toward the direct-to-consumer marketplace, which Farmers dreams will assist them in competing with alternative multi-channel businesses like Progressive and Allstate.
Visit Insurance.Us. Your online source for insurance news and insurance products.
Article Source: http://EzineArticles.com/?expert=Cheryl_G._Anderson
Peter Pronovost : The New Yorker
Peter Pronovost : The New Yorker
Annals of Medicine
The Checklist
If something so simple can transform intensive care, what else can it do?
by Atul Gawande December 10, 2007
If a new drug were as effective at saving lives as Peter Pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.
The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal. Now survival is commonplace, and a large part of the credit goes to the irreplaceable component of medicine known as intensive care.
It’s an opaque term. Specialists in the field prefer to call what they do “critical care,” but that doesn’t exactly clarify matters. The non-medical term “life support” gets us closer. Intensive-care units take artificial control of failing bodies. Typically, this involves a panoply of technology—a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. When you are unconscious and can’t eat, silicone tubing can be surgically inserted into the stomach or intestines for formula feeding. If the intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into the bloodstream.
The difficulties of life support are considerable. Reviving a drowning victim, for example, is rarely as easy as it looks on television, where a few chest compressions and some mouth-to-mouth resuscitation always seem to bring someone with waterlogged lungs and a stilled heart coughing and sputtering back to life. Consider a case report in The Annals of Thoracic Surgery of a three-year-old girl who fell into an icy fishpond in a small Austrian town in the Alps. She was lost beneath the surface for thirty minutes before her parents found her on the pond bottom and pulled her up. Following instructions from an emergency physician on the phone, they began cardiopulmonary resuscitation. A rescue team arrived eight minutes later. The girl had a body temperature of sixty-six degrees, and no pulse. Her pupils were dilated and did not react to light, indicating that her brain was no longer working.
But the emergency technicians continued CPR anyway. A helicopter took her to a nearby hospital, where she was wheeled directly to an operating room. A surgical team put her on a heart-lung bypass machine. Between the transport time and the time it took to plug the inflow and outflow lines into the femoral vessels of her right leg, she had been lifeless for an hour and a half. By the two-hour mark, however, her body temperature had risen almost ten degrees, and her heart began to beat. It was her first organ to come back.
After six hours, her core temperature reached 98.6 degrees. The team tried to put her on a breathing machine, but the pond water had damaged her lungs too severely for oxygen to reach her blood. So they switched her to an artificial-lung system known as ECMO—extracorporeal membrane oxygenation. The surgeons opened her chest down the middle with a power saw and sewed lines to and from the ECMO unit into her aorta and her beating heart. The team moved the girl into intensive care, with her chest still open and covered with plastic foil. A day later, her lungs had recovered sufficiently for the team to switch her from ECMO to a mechanical ventilator and close her chest. Over the next two days, all her organs recovered except her brain. A CT scan showed global brain swelling, which is a sign of diffuse damage, but no actual dead zones. So the team drilled a hole into the girl’s skull, threaded in a probe to monitor her cerebral pressure, and kept that pressure tightly controlled by constantly adjusting her fluids and medications. For more than a week, she lay comatose. Then, slowly, she came back to life.
First, her pupils started to react to light. Next, she began to breathe on her own. And, one day, she simply awoke. Two weeks after her accident, she went home. Her right leg and left arm were partially paralyzed. Her speech was thick and slurry. But by age five, after extensive outpatient therapy, she had recovered her faculties completely. She was like any little girl again.
What makes her recovery astounding isn’t just the idea that someone could come back from two hours in a state that would once have been considered death. It’s also the idea that a group of people in an ordinary hospital could do something so enormously complex. To save this one child, scores of people had to carry out thousands of steps correctly: placing the heart-pump tubing into her without letting in air bubbles; maintaining the sterility of her lines, her open chest, the burr hole in her skull; keeping a temperamental battery of machines up and running. The degree of difficulty in any one of these steps is substantial. Then you must add the difficulties of orchestrating them in the right sequence, with nothing dropped, leaving some room for improvisation, but not too much.
For every drowned and pulseless child rescued by intensive care, there are many more who don’t make it—and not just because their bodies are too far gone. Machines break down; a team can’t get moving fast enough; a simple step is forgotten. Such cases don’t get written up in The Annals of Thoracic Surgery, but they are the norm. Intensive-care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.
On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside. Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels. Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today, in my hospital, a hundred and fifty-five of our almost seven hundred patients are, as I write this, in intensive care. The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.
A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail. This is hard. There are dangers simply in lying unconscious in bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers form. Veins begin to clot off. You have to stretch and exercise patients’ flaccid limbs daily to avoid contractures, give subcutaneous injections of blood thinners at least twice a day, turn patients in bed every few hours, bathe them and change their sheets without knocking out a tube or a line, brush their teeth twice a day to avoid pneumonia from bacterial buildup in their mouths. Add a ventilator, dialysis, and open wounds to care for, and the difficulties only accumulate.
The story of one of my patients makes the point. Anthony DeFilippo was a forty-eight-year-old limousine driver from Everett, Massachusetts, who started to hemorrhage at a community hospital during surgery for a hernia and gallstones. The bleeding was finally stopped but his liver was severely damaged, and over the next few days he became too sick for the hospital’s facilities. When he arrived in our I.C.U., at 1:30 A.M. on a Sunday, his ragged black hair was plastered to his sweaty forehead, his body was shaking, and his heart was racing at a hundred and fourteen beats a minute. He was delirious from fever, shock, and low oxygen levels.
“I need to get out!” he cried. “I need to get out!” He clawed at his gown, his oxygen mask, the dressings covering his abdominal wound.
“Tony, it’s all right,” a nurse said to him. “We’re going to help you. You’re in a hospital.”
He shoved her—he was a big man—and tried to swing his legs out of the bed. We turned up his oxygen flow, put his wrists in cloth restraints, and tried to reason with him. He eventually let us draw blood from him and give him antibiotics.
The laboratory results came back showing liver failure, and a wildly elevated white-blood-cell count indicating infection. It soon became evident from his empty urine bag that his kidneys had failed, too. In the next few hours, his blood pressure fell, his breathing worsened, and he drifted from agitation to near-unconsciousness. Each of his organ systems, including his brain, was shutting down.
I called his sister, who was his next of kin, and told her of the situation. “Do everything you can,” she said.
So we did. We gave him a syringeful of anesthetic, and a resident slid a breathing tube into his throat. Another resident “lined him up.” She inserted a thin, two-inch-long needle and catheter through his upturned right wrist and into his radial artery, and then sewed the line to his skin with a silk suture. Next, she put in a central line—a twelve-inch catheter pushed into the jugular vein in his left neck. After she sewed that in place, and an X-ray showed its tip floating just where it was supposed to—inside his vena cava at the entrance to his heart—she put a third, slightly thicker line, for dialysis, through his right upper chest and into the subclavian vein, deep under the collarbone.
We hooked a breathing tube up to a hose from a ventilator and set it to give him fourteen forced breaths of a hundred-per-cent oxygen every minute. We dialled the ventilator pressures and gas flow up and down, like engineers at a control panel, until we got the blood levels of oxygen and carbon dioxide where we wanted them. The arterial line gave us continuous arterial blood-pressure measurements, and we tweaked his medications to get the pressures we liked. We regulated his intravenous fluids according to venous-pressure measurements from his jugular line. We plugged his subclavian line into tubing from a dialysis machine, and every few minutes his entire blood volume washed through this artificial kidney and back into his body; a little adjustment here and there, and we could alter the levels of potassium and bicarbonate and salt in his body as well. He was, we liked to imagine, a simple machine in our hands.
But he wasn’t, of course. It was as if we had gained a steering wheel and a few gauges and controls, but on a runaway eighteen-wheeler hurtling down a mountain. Keeping his blood pressure normal was requiring gallons of intravenous fluid and a pharmacy shelf of drugs. He was on near-maximal ventilator support. His temperature climbed to a hundred and four degrees. Less than five per cent of patients with his degree of organ failure make it home. And a single misstep could easily erase those slender chances.
For ten days, though, all went well. His chief problem had been liver damage from the operation he’d had. The main duct from his liver was severed and was leaking bile, which is caustic—it digests the fat in one’s diet and was essentially eating him alive from the inside. He had become too sick to survive an operation to repair the leak. So we tried a temporary solution—we had radiologists place a plastic drain, using X-ray guidance, through his abdominal wall and into the severed duct in order to draw the leaking bile out of him. They found so much that they had to place three drains—one inside the duct and two around it. But, as the bile drained out, his fevers subsided. His requirements for oxygen and fluids diminished. His blood pressure returned to normal. He was on the mend. Then, on the eleventh day, just as we were getting ready to take him off the mechanical ventilator, he developed high, spiking fevers, his blood pressure sank, and his blood-oxygen levels plummeted again. His skin became clammy. He got shaking chills.
We didn’t understand what had happened. He seemed to have developed an infection, but our X-rays and CT scans failed to turn up a source. Even after we put him on four antibiotics, he continued to spike fevers. During one fever, his heart went into fibrillation. A Code Blue was called. A dozen nurses and doctors raced to his bedside, slapped electric paddles onto his chest, and shocked him. His heart responded, fortunately, and went back into rhythm. It took two more days for us to figure out what had gone wrong. We considered the possibility that one of his lines had become infected, so we put in new lines and sent the old ones to the lab for culturing. Forty-eight hours later, the results returned: all of them were infected. The infection had probably started in one line, perhaps contaminated during insertion, and spread through his bloodstream to the others. Then they all began spilling bacteria into him, producing his fevers and steep decline.
This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, four per cent of American I.C.U. patients develop a bladder infection. After ten days on a ventilator, six per cent develop bacterial pneumonia, resulting in death forty to fifty-five per cent of the time. All in all, about half of I.C.U. patients end up experiencing a serious complication, and, once a complication occurs, the chances of survival drop sharply.
It was a week before DeFilippo recovered sufficiently from his infections to come off the ventilator, and it was two months before he left the hospital. Weak and debilitated, he lost his limousine business and his home, and he had to move in with his sister. The tube draining bile still dangled from his abdomen; when he was stronger, I was going to have to do surgery to reconstruct the main bile duct from his liver. But he survived. Most people in his situation do not.
Here, then, is the puzzle of I.C.U. care: you have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” So how do you actually manage all this complexity? The solution that the medical profession has favored is specialization.
I tell DeFilippo’s story, for instance, as if I were the one tending to him hour by hour. But that was actually Max Weinmann, an intensivist (as intensive-care specialists like to be called). I want to think that, as a general surgeon, I can handle most clinical situations. But, as the intricacies involved in intensive care have mounted, responsibility has increasingly shifted to super-specialists like him. In the past decade, training programs focussed on critical care have opened in every major American city, and half of I.C.U.s now rely on super-specialists.
Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high-school diploma and a one-year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice—pediatrics, surgery, neurology, or the like. Already, though, this level of preparation has seemed inadequate to the new complexity of medicine. After their residencies, most young doctors today are going on to do fellowships, adding one to three further years of training in, say, laparoscopic surgery, or pediatric metabolic disorders, or breast radiology—or critical care. A young doctor is not so young nowadays; you typically don’t start in independent practice until your mid-thirties.
We now live in the era of the super-specialist—of clinicians who have taken the time to practice at one narrow thing until they can do it better than anyone who hasn’t. Super-specialists have two advantages over ordinary specialists: greater knowledge of the details that matter and an ability to handle the complexities of the job. There are degrees of complexity, though, and intensive-care medicine has grown so far beyond ordinary complexity that avoiding daily mistakes is proving impossible even for our super-specialists. The I.C.U., with its spectacular successes and frequent failures, therefore poses a distinctive challenge: what do you do when expertise is not enough?
On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build its next-generation long-range bomber. It wasn’t supposed to be much of a competition. In early evaluations, the Boeing Corporation’s gleaming aluminum-alloy Model 299 had trounced the designs of Martin and Douglas. Boeing’s plane could carry five times as many bombs as the Army had requested; it could fly faster than previous bombers, and almost twice as far. A Seattle newspaperman who had glimpsed the plane called it the “flying fortress,” and the name stuck. The flight “competition,” according to the military historian Phillip Meilinger, was regarded as a mere formality. The Army planned to order at least sixty-five of the aircraft.
A small crowd of Army brass and manufacturing executives watched as the Model 299 test plane taxied onto the runway. It was sleek and impressive, with a hundred-and-three-foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill.
An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs that needed adjustment to maintain control at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The Army Air Corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.
Still, the Army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do.
They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking, but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But this new plane was too complicated to be left to the memory of any pilot, however expert.
With the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The Army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the Army gained a decisive air advantage in the Second World War which enabled its devastating bombing campaign across Nazi Germany.
Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.
Yet it’s far from obvious that something as simple as a checklist could be of much help in medical care. Sick people are phenomenally more various than airplanes. A study of forty-one thousand trauma patients—just trauma patients—found that they had 1,224 different injury-related diagnoses in 32,261 unique combinations for teams to attend to. That’s like having 32,261 kinds of airplane to land. Mapping out the proper steps for each is not possible, and physicians have been skeptical that a piece of paper with a bunch of little boxes would improve matters much.
In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.
The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.
Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.
Pronovost recruited some more colleagues, and they made some more checklists. One aimed to insure that nurses observe patients for pain at least once every four hours and provide timely pain medication. This reduced the likelihood of a patient’s experiencing untreated pain from forty-one per cent to three per cent. They tested a checklist for patients on mechanical ventilation, making sure that, for instance, the head of each patient’s bed was propped up at least thirty degrees so that oral secretions couldn’t go into the windpipe, and antacid medication was given to prevent stomach ulcers. The proportion of patients who didn’t receive the recommended care dropped from seventy per cent to four per cent; the occurrence of pneumonias fell by a quarter; and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the I.C.U. make their own checklists for what they thought should be done each day improved the consistency of care to the point that, within a few weeks, the average length of patient stay in intensive care dropped by half.
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.
These are, of course, ridiculously primitive insights. Pronovost is routinely described by colleagues as “brilliant,” “inspiring,” a “genius.” He has an M.D. and a Ph.D. in public health from Johns Hopkins, and is trained in emergency medicine, anesthesiology, and critical-care medicine. But, really, does it take all that to figure out what house movers, wedding planners, and tax accountants figured out ages ago?
Pronovost is hardly the first person in medicine to use a checklist. But he is among the first to recognize its power to save lives and take advantage of the breadth of its possibilities. Forty-two years old, with cropped light-brown hair, tenth-grader looks, and a fluttering, finchlike energy, he is an odd mixture of the nerdy and the messianic. He grew up in Waterbury, Connecticut, the son of an elementary-school teacher and a math professor, went to nearby Fairfield University, and, like many good students, decided that he would go into medicine. Unlike many students, though, he found that he actually liked caring for sick people. He hated the laboratory—with all those micropipettes and cell cultures, and no patients around—but he had that scientific “How can I solve this unsolved problem?” turn of mind. So after his residency in anesthesiology and his fellowship in critical care, he studied clinical-research methods.
For his doctoral thesis, he examined intensive-care units in Maryland, and he discovered that putting an intensivist on staff reduced death rates by a third. It was the first time that someone had demonstrated the public-health value of using intensivists. He wasn’t satisfied with having proved his case, though; he wanted hospitals to change accordingly. After his study was published, in 1999, he met with a coalition of large employers known as the Leapfrog Group. It included companies like General Motors and Verizon, which were seeking to improve the standards of hospitals where their employees obtain care. Within weeks, the coalition announced that its members expected the hospitals they contracted with to staff their I.C.U.s with intensivists. These employers pay for health care for thirty-seven million employees, retirees, and dependents nationwide. So although hospitals protested that there weren’t enough intensivists to go around, and that the cost could be prohibitive, Pronovost’s idea effectively became an instant national standard.
The scientist in him has always made room for the campaigner. People say he is the kind of guy who, even as a trainee, could make you feel you’d saved the world every time you washed your hands properly. “I’ve never seen anybody inspire as he does,” Marty Makary, a Johns Hopkins surgeon, told me. “Partly, he has this contagious, excitable nature. He has a smile that’s tough to match. But he also has a way of making people feel heard. People will come to him with the dumbest ideas, and he’ll endorse them anyway. ‘Oh, I like that, I like that, I like that!’ he’ll say. I’ve watched him, and I still have no idea how deliberate this is. Maybe he really does like every idea. But wait, and you realize: he only acts on the ones he truly believes in.”
After the checklist results, the idea Pronovost truly believed in was that checklists could save enormous numbers of lives. He took his findings on the road, showing his checklists to doctors, nurses, insurers, employers—anyone who would listen. He spoke in an average of seven cities a month while continuing to work full time in Johns Hopkins’s I.C.U.s. But this time he found few takers.
There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost’s evidence. So far, he’d shown only that checklists worked in one hospital, Johns Hopkins, where the I.C.U.s have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the checklists are being used properly. How about in the real world—where I.C.U. nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the idea of filling out yet another piece of paper?
In 2003, however, the Michigan Health and Hospital Association asked Pronovost to try out three of his checklists in Michigan’s I.C.U.s. It would be a huge undertaking. Not only would he have to get the state’s hospitals to use the checklists; he would also have to measure whether doing so made a genuine difference. But at last Pronovost had a chance to establish whether his checklist idea really worked.
This past summer, I visited Sinai-Grace Hospital, in inner-city Detroit, and saw what Pronovost was up against. Occupying a campus of red brick buildings amid abandoned houses, check-cashing stores, and wig shops on the city’s West Side, just south of 8 Mile Road, Sinai-Grace is a classic urban hospital. It has eight hundred physicians, seven hundred nurses, and two thousand other medical personnel to care for a population with the lowest median income of any city in the country. More than a quarter of a million residents are uninsured; three hundred thousand are on state assistance. That has meant chronic financial problems. Sinai-Grace is not the most cash-strapped hospital in the city—that would be Detroit Receiving Hospital, where a fifth of the patients have no means of payment. But between 2000 and 2003 Sinai-Grace and eight other Detroit hospitals were forced to cut a third of their staff, and the state had to come forward with a fifty-million-dollar bailout to avert their bankruptcy.
Sinai-Grace has five I.C.U.s for adult patients and one for infants. Hassan Makki, the director of intensive care, told me what it was like there in 2004, when Pronovost and the hospital association started a series of mailings and conference calls with hospitals to introduce checklists for central lines and ventilator patients. “Morale was low,” he said. “We had lost lots of staff, and the nurses who remained weren’t sure if they were staying.” Many doctors were thinking about leaving, too. Meanwhile, the teams faced an even heavier workload because of new rules limiting how long the residents could work at a stretch. Now Pronovost was telling them to find the time to fill out some daily checklists?
Tom Piskorowski, one of the I.C.U. physicians, told me his reaction: “Forget the paperwork. Take care of the patient.”
I accompanied a team on 7 A.M. rounds through one of the surgical I.C.U.s. It had eleven patients. Four had gunshot wounds (one had been shot in the chest; one had been shot through the bowel, kidney, and liver; two had been shot through the neck, and left quadriplegic). Five patients had cerebral hemorrhaging (three were seventy-nine years and older and had been injured falling down stairs; one was a middle-aged man whose skull and left temporal lobe had been damaged by an assault with a blunt weapon; and one was a worker who had become paralyzed from the neck down after falling twenty-five feet off a ladder onto his head). There was a cancer patient recovering from surgery to remove part of his lung, and a patient who had had surgery to repair a cerebral aneurysm.
The doctors and nurses on rounds tried to proceed methodically from one room to the next but were constantly interrupted: a patient they thought they’d stabilized began hemorrhaging again; another who had been taken off the ventilator developed trouble breathing and had to be put back on the machine. It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.
Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morning, a senior nurse walked through the unit, clipboard in hand, making sure that every patient on a ventilator had the bed propped at the right angle, and had been given the right medicines and the right tests. Whenever doctors put in a central line, a nurse made sure that the central-line checklist had been filled out and placed in the patient’s chart. Looking back through their files, I found that they had been doing this faithfully for more than three years.
Pronovost had been canny when he started. In his first conversations with hospital administrators, he didn’t order them to use the checklists. Instead, he asked them simply to gather data on their own infection rates. In early 2004, they found, the infection rates for I.C.U. patients in Michigan hospitals were higher than the national average, and in some hospitals dramatically so. Sinai-Grace experienced more line infections than seventy-five per cent of American hospitals. Meanwhile, Blue Cross Blue Shield of Michigan agreed to give hospitals small bonus payments for participating in Pronovost’s program. A checklist suddenly seemed an easy and logical thing to try.
In what became known as the Keystone Initiative, each hospital assigned a project manager to roll out the checklists and participate in a twice-monthly conference call with Pronovost for trouble-shooting. Pronovost also insisted that each participating hospital assign to each unit a senior hospital executive, who would visit the unit at least once a month, hear people’s complaints, and help them solve problems.
The executives were reluctant. They normally lived in meetings worrying about strategy and budgets. They weren’t used to venturing into patient territory and didn’t feel that they belonged there. In some places, they encountered hostility. But their involvement proved crucial. In the first month, according to Christine Goeschel, at the time the Keystone Initiative’s director, the executives discovered that the chlorhexidine soap, shown to reduce line infections, was available in fewer than a third of the I.C.U.s. This was a problem only an executive could solve. Within weeks, every I.C.U. in Michigan had a supply of the soap. Teams also complained to the hospital officials that the checklist required that patients be fully covered with a sterile drape when lines were being put in, but full-size barrier drapes were often unavailable. So the officials made sure that the drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new central-line kit that had both the drape and chlorhexidine in it.
In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.
Pronovost’s results have not been ignored. He has since had requests to help Rhode Island, New Jersey, and the country of Spain do what Michigan did. Back in the Wolverine State, he and the Keystone Initiative have begun testing half a dozen additional checklists to improve care for I.C.U. patients. He has also been asked to develop a program for surgery patients. It has all become more than he and his small group of researchers can keep up with.
But consider: there are hundreds, perhaps thousands, of things doctors do that are at least as dangerous and prone to human failure as putting central lines into I.C.U. patients. It’s true of cardiac care, stroke treatment, H.I.V. treatment, and surgery of all kinds. It’s also true of diagnosis, whether one is trying to identify cancer or infection or a heart attack. All have steps that are worth putting on a checklist and testing in routine care. The question—still unanswered—is whether medical culture will embrace the opportunity.
Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise—the right stuff. But as knowledge of how to control the risks of flying accumulated—as checklists and flight simulators became more prevalent and sophisticated—the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do—in surgery, emergency care, and I.C.U. medicine—more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation.
The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost’s lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That’s what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly—and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.
Pronovost remains, in a way, an odd bird in medical research. He does not have the multimillion-dollar grants that his colleagues in bench science have. He has no swarm of doctoral students and lab animals. He’s focussed on work that is not normally considered a significant contribution in academic medicine. As a result, few other researchers are venturing to extend his achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade.
I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).
“At the current rate, it will never happen,” he said, as monitors beeped in the background. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.
I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and coördinating a database to track the results. He’s already devised a plan to do it in all of Spain for less.
“We could get I.C.U. checklists in use throughout the United States within two years, if the country wanted it,” he said.
So far, it seems, we don’t. The United States could have been the first to adopt medical checklists nationwide, but, instead, Spain will beat us. “I at least hope we’re not the last,” Pronovost said.
Recently, I spoke to Markus Thalmann, the cardiac surgeon on the team that saved the little Austrian girl who had drowned, and learned that a checklist had been crucial to her survival. Thalmann had worked for six years at the city hospital in Klagenfurt, the small provincial capital in south Austria where the girl was resuscitated. She was not the first person whom he and his colleagues had tried to revive from cardiac arrest after hypothermia and suffocation. They received between three and five such patients a year, he estimated, mostly avalanche victims (Klagenfurt is surrounded by the Alps), some of them drowning victims, and a few of them people attempting suicide by taking a drug overdose and then wandering out into the snowy forests to fall unconscious.
For a long time, he said, no matter how hard the medical team tried, it had no survivors. Most of the victims had gone without a pulse and oxygen for too long by the time they were found. But some, he felt, still had a flicker of viability in them, and each time the team failed to sustain it.
Speed was the chief difficulty. Success required having an array of equipment and people at the ready—helicopter-rescue personnel, trauma surgeons, an experienced cardiac anesthesiologist and surgeon, bioengineering support staff, operating and critical-care nurses, intensivists. Too often, someone or something was missing. So he and a couple of colleagues made and distributed a checklist. In cases like these, the checklist said, rescue teams were to tell the hospital to prepare for possible cardiac bypass and rewarming. They were to call, when possible, even before they arrived on the scene, as the preparation time could be significant. The hospital would then work down a list of people to be notified. They would have an operating room set up and standing by.
The team had its first success with the checklist in place—the rescue of the three-year-old girl. Not long afterward, Thalmann left to take a job at a hospital in Vienna. The team, however, was able to make at least two other such rescues, he said. In one case, a man was found frozen and pulseless after a suicide attempt. In another, a mother and her sixteen-year-old daughter were in an accident that sent them and their car through a guardrail, over a cliff, and into a mountain river. The mother died on impact; the daughter was trapped as the car rapidly filled with icy water. She had been in cardiac and respiratory arrest for a prolonged period of time when the rescue team arrived.
From that point onward, though, the system went like clockwork. By the time the rescue team got to her and began CPR, the hospital had been notified. The transport team got her there in minutes. The surgical team took her straight to the operating room and crashed her onto heart-lung bypass. One step went right after another. And, because of the speed with which they did, she had a chance.
As the girl’s body slowly rewarmed, her heart came back. In the I.C.U., a mechanical ventilator, fluids, and intravenous drugs kept her going while the rest of her body recovered. The next day, the doctors were able to remove her lines and tubes. The day after that, she was sitting up in bed, ready to go home. ♦
ILLUSTRATION: YAN NASCIMBENE
To get more of The New Yorker's signature mix of politics, culture and the arts: Subscribe now
Subscribe to:
Posts (Atom)