Central Line

I came across an interesting long-form article in Vox. Written by Sarah Kliff and published in last July, it is subtitled There’s an infection hospitals can nearly always prevent. Why don’t they? I paused before getting to the meat to ask myself what it might be: C.diff? Kaposi's sarcocoma? Staph aureus? But the infection isn't about an infective species but an infective practice. Or rather, poor practice - with the administration of drugs by central line - that results in avoidable infection and all too often, death. As it happens, the bacteria involved is often Staphylococcus aureus or S. epidermidis, so I was partly right.

Wot's a central line, then? It is a central venous catheter CVC: a tube with a sharp end that is inserted into a large vein with quite direct access to the heart - usually femoral, jugular or sub-clavian vein. Once this is inserted, the nursing staff can connect ampoules of medication for delivery direct to the circulatory system and they can do it multiple times. Intra-muscular or sub-cutaneous injection is more appropriate for once-off administration and takes time to disperse or deliver to where it is needed. Trouble occurs where / when outside meets inside. A nurse who doesn't wash her hands, or washes her hands, gloves up and then touches the bed-stead; a dressing applied crooked, or not at all . . . and suddenly you have an infected catheter. Infected with MRSA and your sick patient is in significantly deeper doo-doo than before. Between 1990 and 2010, US hospitals logged 25,000 central line infections CLI every year. Half a million events is data, and the Center for Disease Control CDC in Atlanta compiled a list of 90 interventions that they believed to reduce the likelihood of CLIs. Dr Peter Pronovost, working in the ICU at Johns Hopkins U. in Baltimore was determined to get to the bottom of the epidemic, at least on his watch, in his hospital. For him, a raw list of 90 possible things to avoid was far too long for busy doctors and nurses to read with attention: surely some were more useful than others? surely some were essentially the same as others? So he dug a little, thought a little, consulted a little, researched a little and came up with a shorter list:

• wash hands
• cover staff and patient in sterile clothing
• swab chlorhexidine locally
• avoid groin-area [eeeuw] catheters [so no femoral vein, pls]
• remove unused catheters 

and empowered and trained the nurses to own CVCs and keep them clean; even if that meant calling out doctors who didn't follow the short-list. But he also created CVC carts that had all the necessary supplies at hand - to make it easier to do the right thing. CLIs fell by 50% within 90 days and by 70% within six months. Other ICU staff in other hospitals read the literature, implemented similar check-lists and saw their infection rates plummet as well.

The article also points out the virtue of hospitals being prepared to admit error and engaging with the relatives of those mistakes. Doing this

• shows compassion 
• helps prevent further similar cases
• and reduces the likelihood of a costly legal case against the hospital. 

What we've seen in Ireland, again and again, is that the parents of dead children don't want money, they want an assurance that no other family will suffer as they have.

Bob's yer oyster

One of the rites of passage that I flunked happened when I was a spotty youth newly enrolled as an undergraduate student in TCD. A friend of mine invited me to spend Hallowe'en weekend at her family's dacha on the Kerry coast. On the Saturday lunchtime a dozen+ of us went off to a minute bar/grocery some distance away. Someone asked if what I was dhinking and I said Guinness because that's what all the men were at and a couple of minutes later a pint of plain was on the wooden counter in front of me. I sipped this delicately - it was different size and colour from Campari & soda but had some of the same repellent properties. I was making progress when another pint was put beside the first, and before I'd started that another pint appeared. In the end there were four pints of the black stuff with my name on it. Naive as I was I knew enough not to feel obliged to slug them all down. At one point (things were getting a little hazy, I wasn't used to drink) a car pulled up outside and a chap brought in a wet sack of oysters weighing perhaps 5kg and presented them to the party as a gift of the sea. I bottled out of the oysters as well although they seemed to go down other throats with easy familiarity if lubricated with Guinness.

Point is, we didn't grow up with eating invertebrates. Fish we did eat but it was usually covered in ‘breadcrumbs’ the bright orange&yellow wholly artificial coarse sand that was/is sold in a cardboard packet. I loved plaice’n’chips and fish fingers which in those days were little oblong fillets of cod. Now, of course, fish fingers are made from the bits that can’t be sold in recognisable cuts: fins, skins, offcuts and sweepings turned into a paste and held together with fish-bone glue. I was (and am) really unadventurous when eating out – plaice & chips & peas if it was on the menu, which was almost always. Years later, when I was briefly a European apparatchik and often in Brussels, I’d always order mussels (and frites/friet!) out of respect to the Belgian national dish. I wouldn’t buy mussels to eat at home, but I’ll scarf them down if they are put in front of me. I’m not ready for oysters yet, though.

I guess we should eat fish when / while we can get it because we have collectively f**ked over the oceans in a rapacious and wasteful looting of the sea’s riches. It amazes me that you can buy cod and haddock for less than €10/kg and I’ll eat it at that price. I feel guilty rather than delighted at these bargains because it tells me that someone in the food chain is being exploited. A good friend and good blogger grew up in Cheekpoint, County Waterford thinking he’d be a fisherman all his life. But his whole community was washed up on the beach as surplus to requirements in 2003 when the few remaining salmon were declared off-limits.

I was reflecting on all this because of an article sent to me by The Boy about Bren Smith a Canadian fellow who thought he was destined to hunt fish all his living days. But as he grew from boy to man, the fish were harder to find and the boats had to go further to catch enough to make a living. And they dumped tons and tons of ‘by-catch’ because their market value was too low. Their nutritional value was omega-3 super but to the fishermen and the fishing industry it was just clutter. He left Canada for The Warm(er) South and started an oyster farm in Long Island Sound [L oysters growing in 500x1000mm plastic mesh bags on raised stands to ensure full water circulation at high tide]. Oyster farming, like all sea-labour, is brutal hard work: the bags need turning and shaking, they are salty and covered with sharp barnacles which cut the hands open. Successive Hurricanes Irene and Sandy dumped tons of stirred silt over his horizontal salt-water farm destroying or burying his hardware and suffocating the stock - he was bust . . . but not broken.

Smith learned that hugging the sea-bottom was vulnerable and took uop a lot of space while an oyster monoculture put all his eggs in the one basket. His next venture went vertical and diverse [R growing scallops, and clams as well as seaweeds and hanging the whole thing from floats - the cages on the bottom are full of oysters and crabs]. He is thus making a product out of the intrusive sea weed; the watch word is kelp is the new kale. Seems that kelp is highly efficient a sequestering carbon [mitigating the old carbon footprint], but also locks up nitrogen [turning agri-nitrate run-off into an asset for his farm rather than an ecological disaster]. He is trying hard to persuade super-trendy NYC chefs to incorporate his seaweeds into their Nouvelle Cuisine assiettes presque vides. But the fall-back plan is to ship kelp ashore as a nitrogen-, phosphate- and mineral-rich fertiliser for suburban truck-farms and market gardens. If the fertiliser demand dries up, the kelp's carbon can be fermented into biofuel to heat homes and drive cars. He's recently won a $100,000 sustainablity prize for is 3D farm vision.

The statistics are impressive: on an up-and-running inshore 3D farm they can grow 25 tonnes of greens and 250,000 mixed shellfish to the acre [=0.4 ha.]. That scales up to calculate that an area the size of Washington State - 185,000sq.km - has the capacity to feed all 7.5 billion of us. You'd be hard put to get 20 tonnes of anything edible out of an acre of soil, and that would only be made possible by lurrying on tons of NPK fertiliser at vast expanse. You can't in any sensible way add fertiliser to these 3D farms: it will just wash away on the next tide, but the ocean is wide and rich and seaweeds and shellfish are the most efficient things we know to concentrate the good things the ocean brings. Smith's philosophy is that his 3D farm at Thimble Island Oyster Co. is not exclusive. He welcomes 150 species of fish; seals; recreational visitors and all the nitrate running off the land.

Explanatory propaganda vimeo. Longform article in Medium. Bren Smith at TedX Bermuda 2013.

Colour supplement 140816

Aggie:
Scything clover: wish I could do this
Scything and stooking wheat it's a different stroke
Running the distance:
Mr and Mrs Regan, pensioners of standing, run marathons
Music:
Pekka Kuusisto fiddles and sings at The Proms
Iron & Wine - Cinder and Smoke
Kodaline sing All I want, at Glastonbury
Food-horror:
The Egg Master at the Grauniad
Architectural education:
McMansion 101
Literature:
I tribbed Henry Marsh's book Do No Harm last year. Now you can read a longform chapter.
We were clearing out one of the sheds this weekend and came across a couple of yard-sale books which I'd acquired for the hilarious titles;

Lesbia's Little Blunder by Bessie Marchant. 1st edn Frederick Warne 1934. [cost me 30p] This was Beatrix Potter's [prev] publisher. I don't think it is subconsciously 'gay' the way the Biggles books and supposed to be. But there is plenty of scope for Viz magazine fnarr snk snk leers: There's a Mounty, for instance, and lady called Miss Boosey and "Strange Doings at Spruce Bottom"
"I came on such a queer place," she burst out breathlessly . . . etc. etc.
Almost as exciting is Bully, Fag and Hero by Charles J. Mansford. Publ. Jarrolds 1897. [also cost 30p] Which from the picture on the cover is about schoolboy bondage.

Wheelchair access

As a society, we're well engaged with wheelchair access. In designing lecture-theatres, you can't tick that box by imagining the wheelchairs perched at the very top of the tier right next to the door: many of the wheelchair-bound have sight-problems as well and so architects (and lecturers, students) have to get them access - if they need it - near the front. As part of the wall-to-wall coverage of the Rio Olympics, someone wheeled out Margaret Maugham to remember the very first Paralympic Games in 1960. It was called the 9th "Stoke Mandeville Games for the Paralysed" and was the first time when the lads had gotten away from Buckinghamshire. Only later did it get rebranded as the 1st Paralympic Games - it's a bit like King James of the Bible being James I of England and James VI of Scotland. Margaret Maugham won the gold medal for archery [see R] in 1960 and gave and gave to the paralympic movement for years afterwards. She was reflecting that those first games were held immediately after the reg'lar 1960 Rome Olympiad and the competitors were housed in the recently vacated Olympic Village. Each athlete was assigned two squaddies from the Italian Army to bring them up and down the several flights of stairs between beds and buses. That was the pragmatic solution to wheelchair access in the years when the occupants of wheelchairs were bluntly called The Paralysed. The paras were delighted with the care and attention they received from the Italians "We had packed lunches delivered. We thought they were lovely - they each had a bottle of wine."

About 40 years later, just as the Celtic Tiger was starting to flex its muscles, I used to walk past the offices of the Irish Wheelchair Association in Fenian St, Dublin 2. Every morning someone used to put out a little plywood ramp, so that it was accessible by people in wheelchairs. I spend a few weeks pointing out the irony of the situation to anyone who'd listen and asking rhetorically if Ireland Inc. could not afford £250 of ready-mix concrete and some shuttering to do that properly. At about the same time there was an event at a public building in Dublin when the President was going to honour a citizen in a wheelchair. The Office of Public Works were on to it: they got in some scaffolding and planks and rigged up a system that made it possible for the honoured guest to attend her own gig. But the honoured guest refused to accept such a temporary and undignified delivery system - she was not a barrow of blocks and a bag of cement. She thought that things should have moved on since Jesse Owens had to use the service entrance of the Waldorf-Astoria Hotel. And just how wheelchair-accessible would that building be the following week after the celebrities had gone home?

That made the news and help shift the public perception towards a more fully inclusive system of integration. Students should be able to sit with their mates regardless of their mobility status; same with going to a concert or having a cup of coffee or taking the bus. Irish legislation eventually caught up so that, by 1st Jan 2010, every new building that required a fire-certificate also required a Disability Access Certificate. My Alma Mater, for example, retro-fitted entry to the mid 19thC houses of New Square, so that nobody had to negotiate 3 moderately uneven granite steps to the front door. Now everyone can get inside up a swish architect-designed ramp [L] which nods to the existing building but does pretend to be mid-19thC itself.

At some point we'll have to put a cap on making everything [The top of Croagh Patrick [prev]? The Camino de Santiago? Mt Everest? Thoor Ballylee? Every bus and train? Every car? Every toilet? Every house?] wheelchair accessible in the same way that we'll have to put a cap on the amount the state is prepared to spend on minority medications. But I don't think we're there yet. The VP of Paralympics Ireland, for example, couldn't get access to her polling station in the Spring 2016 elections for example.

Badgers and TB, all wrong

Two days ago, I was telling a sorry story about my contribution to the killing of badgers Meles meles to protect small babies from contracting tuberculosis, a disease caused by the bacterium Mycobacterium tuberculosis: it's a argument that requires several 'logical' steps:

• badgers bump into cows in the dark
• transferring the bacteria as they touch noses
• cow develops a case of TB between regular testing for the disease
• bacilli infest the milk
• and are not killed by pasteurisation
• baby's innate immune system doesn't work quick enough
• off to the consumption ward for invasive antibiotic treatment

Fast forward to last week when Dau.I sent me a link to an article in the Grauniad about badgers and cattle and tuberculosis. It's the kind of thing that the Guardian [city boys, Arts block educated] loves to publish: exposing boffins, farmers and the government as culpably inept, destructive and wasteful. We had a brief skype about it later and she asked with devastating rhetorical flourish "How could the badgers on our fields infect the cattle on the other side of the county borrrder if that boundary was defined by the Aughnabrisky River? Would they snuffle 600m down river to cross the 19thC hump-back road bridge?"

Now the Aughnabrisky isn't deep or wide except after a spill of rain across its mountainy catchment area. But if you-the-badger want only worms, insects and a bit of bonking in the Spring would you choose to get wet all over to achieve these desiderata?

But enough of me and my anecdotal [sample size N=1] badger and get down with some data from Cornwall. [R sample N=4 of super-cute badgers from Pinterest]. When I hung out with ecologists in the early 80s, a key piece of tech was the radio-collar. You couldn't hope to see what meadow voles Microtus pennsylvanicus were doing under the long grass but you could track their whereabouts by putting a teeny-tiny radio-transmitter round their necks and triangulating their position with a couple [or better, three] of receivers. Very crude, but sufficiently techy to smell like science if you were applying for grant money. The radio-collars didn't last very long: several of them seemed to finish up inside locally marauding cats Felis catus. Technology has moved on - bring on the GPS, lads! - and researchers from The Institute of Zoology in London have popped GPS tracking collars on 400 cattle and 100 badgers which shared the same space on 20 farms in Cornwall. In all more than 8,000 collar-nights were recorded for cattle and at no time did any cow come within coughing distance = 1.5m range of any badger. The fond imaginings of nose to nose contact in the dark between members of the two different species can now be dumped in the dustbin of fantasy.

One of the authors of the paper Prof Rosie Woodruffe asserts that culling badgers will "make no meaningful contribution to cattle TB control in Britain" despite costing millions. A key problem with TB is that test for carriers is far from being 100% accurate and reliable. The scientists suggest that the culling be stopped and the money devoted to more research for better immunological or DNA sequencing tests for the presence of M. tuberculosis. And who is going to develop these new tests? Scientists! One of the reasons for the continuation of culling is the investment - emotional, psychological, logistical - in culling. Thus pilot studies become full-blown programmes almost regardless of the results.

Back in my ecological days we used to refer to study animals as bigger than a breadbox [cows, badgers, easy] or smaller [voles, Mycobacterium tuberculosis, hard/invisible]. Current policy is to slaughter cattle if they are infested with TB and dispose of the carcasses in quicklime and by incineration. At the same time, the Mycobacterium-rich slurry from these cows [inhumanedoor model] and/or the fields where they have defecated [free-range] are classed as entirely fit for fertilising the grass which subsequent cattle will eat. I hadn't thought of that way of spreading tuberculosis: the bacteria can survive for many  Because they are small, the TB bacteria have been invisible in the equation.  It's easier to blame the black-and-white bread-boxes than blame the farming "industry" for self-destructive practices that have served to keep vets in their practice by government-mandated testing for a disease which is decisively encouraged by the way cattle are intensively raised and maintained inside.

A case could be made that the monstrous way we raise cattle in intensive systems have not only encouraged the spread of tuberculosis within that species but have also adversely affected the badgers as innocent bystanders who happen to hunt grubs on the same pasture. Eat more lentils: that will reduce the incidence of tuberculosis too.

Perseid urticaria

Obeying my own orders, I woke up at 0100hrs in the night screaming "Perseids!" and flung out of bed to see if they were flying as predicted. Conditions less than ideal. The Eastern horizon was glowing with the lights of the metropolis of Enniscorthy (pop 11,000) 20km distant. More than half of the sky was cloud-covered and the rest was somewhat of hazy - might have been the absence of my spectacles. Nevertheless I caught 6 meteors, all travelling out of the NE but across the whole visible portion of the sky; one much brighter than the others. I caught rather more than 6 nettle-stings from sitting down briefly on a pair of concrete blocks. I brushed my hand across these to ensure than they weren't soaking wet and was already sitting down before I registered that my hand had been stung. And inevitably, I sat on the same nettle Urtica dioica. Yaroo! but not enough to bring enough tears to further prevent meteor-watching. So this years Perseid-count was a pain in the arse but not a total pain in the arse. Chekkitout Photo by Wilson Lam from Flickr.

Perseids

Three years ago I was lying out in a field on the night of the 12th of August waiting for meteors. I saw lots because that's when the Perseids peak, but I also saw the International Space Station boopling across the sky in its stately fashion. This year we are being exhorted to get out and look up unless the weather is completely overcast and/or raining. That's Thursday/Friday night! But any day this week will do also if the weather is predicted to be better then. Apparently, this year's shower will be super bright and abundant despite the moon being a week off full. The later in the night you leave your session, the more likely that the moon will have set and the brighter the meteors will seem. It's easier for me than you city-dwellers because where we live you can't get further from a bus stop and still be in the province of Leinster. Distance from bus-stop also means that there are damned few street-lights and spot-lit mansions to pollute the skies with their light.

The Perseids are the trail of fragments that have broken off from 109P/Swift-Tuttle a comet that was named/ discovered in 1862 but has been precovered at various dates going back to the Chinese sightings more than 2000 years ago. Swift-Tuttle is trying to go on its immensely long assymmetric orbit round the sun but is locked in orbital resonance with Jupiter. For every 11 times Jupiter goes round, Swift-Tuttle completes exactly 1 orbit; so it reappears every 130.4 years, most recently in 1992. The comets, however, appear every year, sometimes with more activity than others. It depends if we are travelling through a material dense part of the comet's trail. The viewing density differences are due to the gravitational pull of Jupiter sweeping the fragments into clumps. At 26km, Swift-Tuttle is the largest known object whose orbit comes close to Earth but the regularity of its orbit allows astronomers to calculate that the thing itself won't come remotely close until at least 2000 years into the future. We just eat its dust.

Astronomy Ireland advises you that constellation Perseus is in the NE at this time of year and is asking you to count the number of meteorites you can count in 15 minutes. Only those that appear to radiate from Perseus, however: the rest are sporadics. According to them Thursday 11th is the peak viewing for the show. That's tonight: good hunting/counting.