it's called organ "donation" for a reason... it's also called an anatomical "gift." You're giving somebody else life, with something you no longer need; it's strictly voluntary...nobody's going to force you.
So You're going to die and bury that organ... yet you're going to try to scratch and scrabble for that last thin dime, even as you die? You refuse to take part in a process that benefits others, simply because you cannot benefit yourself? No streak of altruism? Not one iota of selflessness in you? You were given life... yet you insist on being paid for giving others life, via something you were just going to throw away to rot?
Hmmmm... I'm guessing I won't be seeing you volunteering down at the homeless shelter much... suit yourself.
Then how about getting an account and posting under it? There aren't even a dozen physicians I know of that regularly participate in this forum: a couple of internists, one radiologist, one orthopod, one ER doc (me)... some of the posters here would no doubt appreciate the additional input.
BTW, I'm afraid I'm going to have to ask for a literature reference to your "more bacteremic from teeth brushing then from a dental cleaning" statement. About 20 years on Medline shows that virtually all the studies on bacteremia involve extractions, dental probing, and manipulation of the teeth... I didn't see a single study regarding the tooth-brushing claim. I'm not saying you're wrong... just asking for the reference.
Your doctor has a valid point; there's little case data to back it up. It's a recommendation, nothing more.
The incidence of Endocarditis is fortunately very low in the normal population... there may not even be enough non-IV-drug-user-cases per year such that you could really design a study of sufficient statistical power to prove/disprove the benefit of antibiotics. The benefit of antibiotics must be weighed the risks (ie. you might have an allergic reaction). A patient fully appraised of the risks is a wonderful thing... I absolutely support such a person deciding for themselves what to do.
Consider this, however. Endocarditis is bad news... it's not a minor illness, and may be preventable by a couple of doses of antibiotics. Minimal risk... but potentially great benefit... or not.
It all depends on how you like your odds. You've clearly thought about it, and made an educated decision; may the odds be with you.
it's not terribly different in the US, particularly in a large, urban ER.
If you come to the ER for a minor complaint, you can end up waiting 7 or 8 hours before you see a doctor (you'll be triaged long before that). It's not a first-come-first-served deal... anyone who's sicker than you gets seen before you, even if they come in after... it's just the way it is.
And that's just the beginning... lots of ERs end up holding sick and critical patients for days while waiting for an ICU or Telemetry bed to open up. JCAHO is trying to address the ER-holding issue, but hospitals are not responding quickly, for a couple of reasons.
Money. It costs money to keep and open additional units. Money for nurses, techs, beds, equipment, etc. In cash-strapped urban medical centers, that money's just not there, particularly with medicare and 3rd party payers ratcheting down reimbursements. As reimbursements get tighter and tighter, it gets harder and harder to cost-shift for all the non-paying trauma, etc. That's going to get worse, BTW, as our population ages and gets sicker. Buckle your seatbelt, Dorothy.
Staff. There's a nursing shortage, in case nobody was aware. I can see patients pretty quickly, but there's often no nursing staff to take care of them upstairs (nurses can only take care of so many patients per nurse... once they top out, they can't safely take more, regardless of how many empty beds are on the unit). Ergo, the patients get held in the ER. Then, when I run out of ER beds, I end up putting people in the hallway. Once I run out of hallway space, the whole process grinds to a halt. All the while, the patients in the waiting room are rioting because they're been waiting for so many hours... I've actually lined up and seen patients in the waiting room once I ran out of space in the department proper... it's certainly not by-the-book medicine, but we do what we can.
Facilities. Lots of ERs are just not big enough. I've worked in ERs with volumes from 15,000 patients per year to over 90,000, level-1 urban trauma centers to small community hospitals, and I've yet to work in one that had enough space. ER volumes are going up every year, all over the country... hospitals can't build fast enough to keep up with demand.
It's amazing to me that some ERs do as well as they do... longer wait times are just a symptom of several larger problems.
I've had all kinds of injured patients come directly from the bar, many with pretty severe preexisting medical problems.
Had a guy come in from a barfight, with his cervical-spine external fixation frame still on (titanium ring around the head, screws that go into the skull, and carbon fiber rods down to padded shoulder harnesses). Yep... one of these. Placed, I might add, from his previous DUI accident.
Patients with end-stage emphysema (still smoking) who carry around oxygen tanks everywhere they go... picked up by the paramedics from the smoky bar (smoky bingo halls are another favorite).
Liver-failure cirrhosis patients who are picked up from the bar after they start vomiting blood...
You'd be amazed where you can find sick people making themselves sicker (you current and Ex-EMS guys know what I'm talking about).
No. Your dentist is actually doing the right thing.
Your dad has a valve problem in his heart, and dental work does cause a transient bacteremia (bacteria being released into the bloodstream). Most of the time your immune system will clear out those bacteria, no problem... most of the time.
If you have a damaged heart valve, those bacteria can infect the valve, leading to a condition called Bacterial Endocarditis. The bacteria grow on the valve, and can destroy that valve, as well as throwing infected bits downstream in your circulation, leading to brain abscesses, kidney and lung infections, and general sepsis.
Endocarditis is a nasty, nasty condition... probably most of the cases I've seen were IV drug users. It's a hell of a life; some of those folks will shoot up anything they can find, regardless of what's in it (ie. foreign material loaded with bacteria). Also, when they are re-using needles, the needles will eventually dull, and sometimes barb (painful!). To detect a barb, addicts will sometimes lick the needle tip, then shoot up if no barb is felt with the tongue... you can see where I'm going with this. The human mouth is only slightly less dirty than the human anus... they end up injecting tons of bacteria, and develop Endocarditis. To make matters worse, they never go to the doctor, except when they try to scam more narcotics, or inadvertantly overdose. By the time they do show up, their valves are shot, and they're almost dead. If they survive, they end up needed open-heart surgery and valve replacement.
Anyway, that's probably more than you wanted to know... but as far as dental procedures go, the antibiotics your dad takes are effective in preventing Endocarditis. He'd be well-advised to keep taking them as prescribed.
I don't think the original poster was referring to Endocarditis though... I'm fairly sure he was referring generally to Atherosclerotic Disease.
in some countries... I believe China still harvests organs from prisoners.
In the US there's so much oversight that I can't see it even being possible. Many transplants aren't even done in-house... the organ gets flown to where it needs to go (I've flown on a couple of those... you get to jump to the front of the line on the taxiway, even if there are 30 planes waiting to take off).
Seriously, there are so many ethical questions, paperwork to be filled out, different physicians involved... declaring someone brain-dead and pulling the plug is a big deal, even more so if it's an equivocal case; it requires multiple physicians to sign off, consultation with the family (and their physician), appropriate consultations and diagnostic testing, and often a review from the hospital ethics committee. Hell, half of the doctors that sit on those committees don't even like one another... they just tolerate each other. There's NO WAY they'd all agree, in some nepotistic star-chamber fashion, to something as evil as wrongfully terminating someone's life and harvesting their organs. No way.
I can't see that caper ever being pulled off and not coming to light.
It can induce asystole for a few seconds... I've never seen it last for 30 seconds.
Patient reports of the adenosine experience vary greatly. Some don't mind it... others would rather have you cut their heart out than get adenosine. I'll never forget a biker guy I saw a couple of times for recurrent SVT (SuperVentricular Tachycardia). He hated adenosine (though it always worked); said it made him feel like he was dying. He was a great big muscular tattoo-covered man, and would cry like a little baby when you brought out the drug, literally weeping in terror.
To see a grown man reduced to that... my heart really went out to the poor guy.
I'd appreciate a link to that... I've been doing this for a long time, and I've never thought that belief was widely held. I've heard of theoretical links between C. pneumoniae, but that's about it (of course, C. pneumoniae has been theoretically linked to all kinds of things, including Chronic Fatigue Syndrome, among others).
I'd say the classical risk factors for heart disease still hold; smoking, hypertension, diabetes, the bad gene (usually a triglyceride or cholesterol metabolism problem), etc. This really isn't a flat-earth-round-earth debate... Any new theory had better be pretty compelling, particularly with the mountain of research backing up the standard risk factors.
The "bacterial infection" guys may turn out to be right... but they're going to have to prove it.
You are correct... cap refill can be a useful tool in the field, but it's hard to quantify based on its numbers; 2 secs, 3 secs, 4 secs? The sensitivity and specificity of cap refill isn't really what it should be to be considered a reliable test by itself (don't misunderstand; cap refill is clinically useful, and I use it all the time... but only as part of the bigger picture).
Cyanosis (or even methemoglobinemia) won't necessarily decrease your cap refill. It may make your nailbeds blue, but they will probably pink-up (or blue-up) at the same rate, provided you're not hypoperfusing. Dehydration, low BP, cold, Reynauds phenomenon, peripheral vasoconstriction of whatever cause, etc will all affect cap refill.
In its heyday, cap refill was actually part of the Trauma Score during most of the 1980s (put out by the American College of Surgeons to help stratify trauma patients). Interestingly, it was given significantly less clinical importance about ten years later when the Revised Trauma Score was developed (there had been some studies that seriously questioned its reliability).
Getting back to the main point: I find standard blood pressure measurements to be very useful. There are so many nuances involved between the systolic and diastolic measurements for various disease processes, like the narrowing of the pulse pressure in hemorrhagic shock... loss of pulsatile flow, and a single pressure measurement could seriously affect clinicians' ability to interpret normal/abnormal physiologic parameters.
It might not make a big practical difference, but still...
They expand on the acronym in a couple of scenarios.
ATLS (Advanced Trauma Life Support, a program by the American College of Surgeons) expands that to ABCDE: Airway, Breathing, Circulation, Deficits in neurologic function, and Exposure (remove/cut off all clothing... easier to find injuries and wounds that way).
Also, the "C" in the old "ABC" acronym is also supposed to stand for Cerebral protection in addition to circulation. I've also heard CPR termed "cerebral pulmonary resuscitation." That's probably a fair substitution, since your main goal in CPR is to protect the brain by creating a low-flow rather than a zero-flow state (contrary to what some folks think, CPR doesn't restart the heart from a V-fib/V-tach arrest... generally only electricity can do that).
Once your brain's dead, you're dead... even if your heart, lungs, kidneys, etc are all working normally. Those folks become organ donors, or should...
Let me put in a plug here... PLEASE CONSIDER DONATING YOUR ORGANS. Please... talk to your family about it, get it on your driver's license or living will. Lots of people need organs, and if you don't need yours anymore (and you have no deep religious/philosophical objection), why not donate them? Just a thought...
Exactly what I was thinking. The law of unintended consequences may come into effect here.
The lack of a pulse may not seem like a big deal, but the physiology of human blood pressure is based on pulsatile flow. The loss of that "pulse" may cause real problems... would small emboli or damaged red cells will get stuck in the microcirculation without that pulsatile flow to dislodge them?.
Where it would cause problems for me clinically is when placing arterial lines, drawing blood gasses, or assessing for arterial insufficiency. For example, every elderly patient who comes in with a broken hip gets a pulse check in their leg... if it's not present, they have a much more urgent problem than simply getting their hip fixed with a gamma nail... the same would apply if they were in an accident and broke their femoral shaft. Also, anatomic variations are common... how do you find the artery if there's no pulse?
The ability to assess for a pulse is very important in clinical medicine... I'm sure there are many more examples.
the procedure is actually to assess them first... something along the line of shaking them and asking "Annie! Annie! Are you OK?"
If they answer "yes," you're done.
I realize you were only joking, but the entire clinical picture needs to be taken into account.
My favorite EMS call is the patient with a minor head injury who is rushed in with a "blown pupil." When you go see the patient, they're awake and alert, not vomiting, not somnolent, etc. It's usually someone who's new, and doesn't understand the pathophysiology behind Uncal Herniation and 3rd nerve compression.
Back to the topic at hand... I wonder if the lack (or blunting) of the systolic peak and diastolic trough in the blood pressure would lead to any physiologic problems? According to the article, the device is actually a Left Ventricular Assist Device (the ole' intra-aortic balloon pump is the classic example of such a device). It steals blood from the left ventricle and steadily pumps it into the aorta... but I wonder if it has any effect on the coronary arteries?
The coronary arteries mainly fill during diastole, when the aortic valve closes and blood floods the coronary sinuses on the aortic side of said valve... since this device essentially "steals" blood from the left ventricle and injects it somewhere downstream, I wonder if the coronaries get the same filling? (I suppose it's a question of where you place the downstream catheter.) It might not make a difference if you have clean coronaries, but if you've got a Left-main stenosis, it could be bad to drop that filling pressure...
In a perfect hydraulic system, it wouldn't matter, since pressure injected in one location would increase pressure in all locations... but arteries have compliance, and they can flex.
Interesting device... it'd be nice to know some more details.
Whatever the origins of the drug war, some drugs are absolutely harmful in untrained hands (Note: I specifically said untrained hands... cocaine, opiates, and amphetamine derivatives do have legitimate medical uses, provided they're prescribed by someone with the proper expertise). I'm speaking particularly about hard drugs. Anyone who denies this either has a political agenda, or is not connected to reality. In a perfectly Libertarian world, it wouldn't matter, because society wouldn't be liable for the costs of people drowning their bodies in illicit drugs. However, fortunately or not, society does end up paying.
I don't have many problems with marijuana in my clinical practice... but cocaine? Meth? Heroin? Oh hell yes... I could curl your hair with the stories of some of my overdoses and trauma patients, many related directly to those drugs.
Admittedly, other common drugs can also cause mortality and morbidity (eg. angioedema from ACE inhibitors is an absolute nightmare), but those drugs are typically treating an actual medical condition... they're not simply being used by those individuals who seem to spend their days seeking the ultimate buzz.
I don't necessarily feel people should be prevented from making their personal choices... but when they're sucking up the resources of others in the process of exploring the depths of their addiction, I understand society wanting to have some say in the matter.
As an aside, depending on the receptor specificity of the vaccine involved, it might be possible to block some of the euphoria without blocking the analgesia. If they could engineer a drug to be that specific, I'd be inclined to use it... I don't see where blocking the buzz (and other side effects) could be anything but beneficial. After all, when I'm straightening someone's broken arm or leg, I could care less if they're high as a kite; my primary goal is that they're spared the exquisite agony that comes from bone grinding/crunching on bone...
It's a shame that a man with such a talent should also be such a vicious anti-semite. Just goes to show that genius in one area can be accompanied by pig-ignorance in other areas. I knew he was an odd sort of man... but his anti-semitism is news to me.
Also, to suggest that 3000 innocents slaughtered by terrorists is a good thing puts him in the same category as those palestinians who danced in the streets when the towers fell. He's probably not going to get much sympathy from most americans.
Cancer occurs as a consequence of genetic damage that hits certain critical genes within in a cell, usually those that control cell growth/death. Many genes control cell growth... if one of these genes gets overexpressed, or a suppressor gene or modulator region for one of the aforementioned genes gets damaged or otherwise turned off, you can get cancer... but not always.
If your own body's immune system recognizes the cancer cell as abnormal and kills it, you dodge the bullet. There's absolutely no way to quantify how often it happens, but it's probably more often than we know.
Ionizing radiation affects DNA by damaging it. However, your body can often use the matching DNA strand from the other side of the double-helix to repair the damaged region... you have enzymes in your cell nuclei that are specifically for this. You should thank your lucky stars for those enzymes too... there are a few syndromes where those enzymes are deficient or dysfunctional: those poor patients grow cancers like it's their job.
I found the grammar and spelling to be rather better than what I've come to expect from the average 419'r. It's usually quite clear that these scammers either uneducated, or don't speak/write english natively; the poor command of the language is a huge red flag.
I have to give the guy credit for trying... it's the first 419 scam I've read that correctly used the word "aberrational" in a sentence.
let's all be honest and transparent here... there is very little in common between how the prisoners are Gitmo are treated, and how the residents of Siberian Gulags were treated. Let's not lose sight of reality amidst the hyperbole. Also, this is not comparable to rounding up Japanese-Americans during WWII... troops aren't raiding every mosque in the US and carting the worshipers off to internment camps.
The US miltary has plenty of space to detain people of interest: Iraq alone has had tens of thousands of prisoners (insurgents/terrorists/whatever) processed through its jails just since the end of the war. Consider the possibility that there may be a good reason why people end up at Gitmo instead of a more geographically-convenient location. It's no small expense to move a person from Afghanistan to Cuba (one of my military buddies has flown that mission multiple times, and it's a pain in the ass).
People have raised the issue regarding lack of due process, and they probably have a valid point. The SCOTUS has now stepped in to ask that due process, in some form, be followed. I don't think most people have a problem with that; Checks and Balances are good.
That said, if you're holding someone against their will for whatever reason, they probably should have some sort of representation (a military JAG officer is probably safer than some Hamas agent cum lawyer) and you should have to justify that detention to someone. The sticking point, of course, is who represents, and who judges. There are enormous national security and foreign/domestic intelligence assets at stake, so an OJ-Simpson-style public hearing is probably inappropriate... I'm frankly not sure what form this process will eventually take.
In fairness to the current administration, the entire "unlawful combatant" issue has never been a problem of this magnitude (there were a few german spies caught and executed during WWII... IIRC, they represent some of the only applicable case law). Unlawful combatants certainly haven't been a problem in such volume... remember, Afghanistan's terror camps operated under the Taliban for years and trained thousands of terrorists. Some of them are in the US... wouldn't it be great to catch and/or kill the next Mohammed Atta before he completes his mission?
The US is not Israel. A lot of this is uncharted territory for the US judicial system. This process will work itself out, and it's perfectly OK to argue about it, but I also don't think it's unreasonable to expect it to take a little time.
Play on a well-admined server, and you'll find your CS experience much more enjoyable. I play on a server where there is NO profanity (spoken or written), no racist or pornographic nicknames, no cheating, etc... they have a ton of admins and it's rigorously enforced. What's more, if you feel you've been unfairly kicked/banned, you can lodge a protest on the group's website... bans have been overturned for unsubstantiated accusations of cheating (no demo recorded, etc).
A server run by adults, for adults, is a wonderful thing... playing with mature, responsible players... it brought enjoyment back to my CounterStrike experience.
I'd advise you to explore some more servers. Don't dismiss a great game mod because you happen to play on servers with hormonally-poisoned 13yo adolescents.
I suspect he doesn't have a CDROM... many older laptops lack them.
As an example, I just built a mobile internet station for my aging parents to take on vacation with them... salvaged an old Thinkpad 600 to do it. The laptop didn't have a CDROM, though they did have an old Xircom 10Mb network card...so I did a network install of Mandrake 9.2.
Now, they couldn't be happier... reading their email on the road, instant messaging me when we're online at the same time, online banking...
I'm sure scads of people are going to go on and on about how worthless old laptops are, or how they can't do anything without that CDROM. It just takes a little imagination.
You almost sound like an NRA member (that's not an insult... I have no problem with the NRA, but your slippery slope arugment is a common one for that organization). And it's not an invalid argument... creative prosecutors have already tried to use sections of the Patriot Act against non-terror crimes (though I'm only aware of one case).
What I'm interested in is not tying the hands of the people whose job it is to do the dirty work. Like you, I have a problem with brutal torture... but what about creative interrogation (harkening back to my original question)? Also, I have a problem with advertising our capabilities and limitations to the terrorists we might capture. The more you know about your enemy, including his strengths and weaknesses, interrogation methods, procedures, etc, the better you can train against them. The US military SERE school used to run soldiers through several types of interrogation camps, based on intel we've gathered from our enemies. There were Russians camps, Central-American camps... we are able to train our soldiers effectively against capture by those folks partially because we know their methods. I would deny that advantage to the terrorists by leaving a bit of ambiguity... publishing lengthy legal brief on exactly what we can and cannot do gives the terrorists too much info.
I understand your point about the government becoming a threat... but fixing that is only one election away. Don't believe it? Look at the changes in the last four years; those could be mostly undone with a single swing in an election.
And even if it came to violence... the US is one of the most-heavily armed nations in the world (in terms of the general populace). Think the US is having problems in Iraq? What army is going to occupy a country the size of the US? Certainly not the US Army, totally drawn from the regular US populace, and not at all interested in imposing martial law on its own citizens. Again, look at Iraq, and the problems the US is having getting iraqis to fight their own... that would be even more magnified in the US.
Thanks for the interesting discussion... I appreciate you being vigilant about freedom.
Sun-Tzu was wise... his works are still required reading for various three-letter agencies, and the US Army War College, among others.
For my own part, I agree: never give the enemy the initiative... action always beats reaction. Keep your enemy reacting to you; it allows you to choose the time, place, and tempo of the battle.
2. Point granted on the street situation... but I still maintain that preemptive strikes are justifiable in some circumstances (though the benefits may not be seen for decades). Israel's strike on Saddam's nuclear reactor is an excellent example... without it, we'd be facing a nuclear-armed Iraq, and a MUCH different middle east today. If Iran develops nukes, it gets nastier still.
3. Heheh... again, point granted, though stupidity being more common than evil, I would defend my reference. However, your corollary is equally valid, and has the additional benefit of being more specific (as a bonus, it incorporates my unstated assumption).
4. Jury is still out on this one... "preparing" prisoners for interrogation could cover a lot of territory. Not to be legalistic, but that's where this will be debated, and lawyers live for details.
Someone already made a comment about acting like Clinton... but we can't really have a debate without defining terms... so what do you define as torture? Don't regurgitate some UN definition... I'm talking about you, yourself.
Yes... if you inflict enough pain, someone will tell you anything they think you want to hear, just to stop the agony. If you want to emulate the North Vietnamese, and get US POWs to sign bogus "confessions" (even John McCain signed a statement saying he was an "air pirate", IIRC), that kind of torture works quite nicely. Anyone who's been through SERE school in the US military will tell you: everyone breaks eventually... it's what you give up when you break that counts.
If you're a dimwitted thug who's simply after bogus confessions to wave around on your state-run television propaganda channel, fine... ask all the leading questions you want. Eventually, you'll get what you're looking for... but that's not what I'm talking about. (Echos of the "The Prisoner." We want information... information... information...)
How about questioning a person under conscious sedation, which disinhibits them, but causes them no physical harm? How about simple isolation? How about the chinese "water torture" (a psychological stressor that's physically harmless)?
I don't mean to single you out, but you've been so vehement in your posts... would you be willing to sacrifice to save the life of an innocent? Nobody's asking you to give your life... just do an unpleasant task. We're not talking about scooping out eyeballs... it doesn't even have to physically harm the terrorist. Could you do it? Now instead of saving one life, how about an entire platoon of young soldiers? How about a third-grade class? One-hundred innocents? A thousand? You can see what I'm getting at here... I'm always fascinated with where the sliding scale of competing harms balances out for people.
I honestly don't know myself, and I'm thankful that I don't have to make that decision. But I try to be mindful of the fact that even if I am not making that decision, somebody, somewhere, probably has to... Think about that. I don't envy that person. I can only hope they've considered all the options, and whether they'll be able to live with the results. I try to never underestimate the power of human rationalization... but would it be strong enough? I don't know.
I sometimes wonder how well Tomas de Torquemada slept.
2. "Innocent until the situation is fully ascertained" can't really exist on the street... things happen too quickly (unless you want to sacrifice a lot more police officers than already die each year). When a cop sees a guy coming with a knife or a gun, he has to choose in a split second. Maybe the person was simply bringing the gun to the police officer, (or it was a toy gun, or they were just joking, or, or, or...) but that's just the way it goes. Innocent until proven guilty is great... but there's no time for a jury when you see somebody raising the muzzle of a weapon. Incidently, by the time SWAT gets called, we're pretty sure who we're after (but even so, 99% of all SWAT call-outs are ended with no shots fired by SWAT).
3. Heh...I feel your pain... but to be argumentative in return, Hanlon's razor could be considered a derivative or corollary of Occam's razor
4. I wouldn't say torture was the rule rather than the exception... though I'm not sure that's even reliably measurable. Torture for its own sake is simple sadism, and those who got their rocks off torturing prisoners will get their due, as well they should. It was particularly nice of them to take pictures for posterity's sake. Sick and stupid is quite a combo...
Nobody is liked by everyone... the diversity of ideas and viewpoints on a planet with multi-billions of people will absolutely ENSURE that someone, somewhere, hates you. Besides, does being unpopular justify violent action?
Just a couple of comments.
1. Fair point... I'll grant you this one.
2. In the right circumstances, I fully support preemptive war, just as I endorse police officers not waiting until they're shot at to shoot back (as a former SWAT officer, I've personal experience with this one). Giving your enemies the first punch is stupid; I can't see sacrificing lives on the basis of either indecision or moral cowardice.
3. Intelligence is often nothing more than a best guess. Occam's razor may be appropriate here... don't attribute to malice that which is explained by simple incompetence.
4. Avoid torturing? Good advice, and probably followed by the vast, overwhelming majority. But defining torture... and whether it's ever permissible is a great debate. Rhetorically, a case can be made for torture in some circumstances (if a terrorist knew where a nuke was, and refused to divulge that info, is torture justifiable? Does the tiny private moral victory of "I'm a good person... I don't torture others" drown out the screams of the millions you might be sacrificing by staying within your own moral comfort zone?) I honestly don't know the answer to that one. As technology progresses, and the technological bar to enter the nuclear-club gets lower and lower (and as nukes proliferate, ala AQ. Khan), that scenario becomes plausible... Seriously... what would you do?
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it's called organ "donation" for a reason... it's also called an anatomical "gift." You're giving somebody else life, with something you no longer need; it's strictly voluntary...nobody's going to force you.
So You're going to die and bury that organ... yet you're going to try to scratch and scrabble for that last thin dime, even as you die? You refuse to take part in a process that benefits others, simply because you cannot benefit yourself? No streak of altruism? Not one iota of selflessness in you? You were given life... yet you insist on being paid for giving others life, via something you were just going to throw away to rot?
Hmmmm... I'm guessing I won't be seeing you volunteering down at the homeless shelter much... suit yourself.
I am an Infectious Disease specialist
Then how about getting an account and posting under it? There aren't even a dozen physicians I know of that regularly participate in this forum: a couple of internists, one radiologist, one orthopod, one ER doc (me)... some of the posters here would no doubt appreciate the additional input.
BTW, I'm afraid I'm going to have to ask for a literature reference to your "more bacteremic from teeth brushing then from a dental cleaning" statement. About 20 years on Medline shows that virtually all the studies on bacteremia involve extractions, dental probing, and manipulation of the teeth... I didn't see a single study regarding the tooth-brushing claim. I'm not saying you're wrong... just asking for the reference.
Your doctor has a valid point; there's little case data to back it up. It's a recommendation, nothing more.
The incidence of Endocarditis is fortunately very low in the normal population... there may not even be enough non-IV-drug-user-cases per year such that you could really design a study of sufficient statistical power to prove/disprove the benefit of antibiotics. The benefit of antibiotics must be weighed the risks (ie. you might have an allergic reaction). A patient fully appraised of the risks is a wonderful thing... I absolutely support such a person deciding for themselves what to do.
Consider this, however. Endocarditis is bad news... it's not a minor illness, and may be preventable by a couple of doses of antibiotics. Minimal risk... but potentially great benefit... or not.
It all depends on how you like your odds. You've clearly thought about it, and made an educated decision; may the odds be with you.
it's not terribly different in the US, particularly in a large, urban ER.
If you come to the ER for a minor complaint, you can end up waiting 7 or 8 hours before you see a doctor (you'll be triaged long before that). It's not a first-come-first-served deal... anyone who's sicker than you gets seen before you, even if they come in after... it's just the way it is.
And that's just the beginning... lots of ERs end up holding sick and critical patients for days while waiting for an ICU or Telemetry bed to open up. JCAHO is trying to address the ER-holding issue, but hospitals are not responding quickly, for a couple of reasons.
Money. It costs money to keep and open additional units. Money for nurses, techs, beds, equipment, etc. In cash-strapped urban medical centers, that money's just not there, particularly with medicare and 3rd party payers ratcheting down reimbursements. As reimbursements get tighter and tighter, it gets harder and harder to cost-shift for all the non-paying trauma, etc. That's going to get worse, BTW, as our population ages and gets sicker. Buckle your seatbelt, Dorothy.
Staff. There's a nursing shortage, in case nobody was aware. I can see patients pretty quickly, but there's often no nursing staff to take care of them upstairs (nurses can only take care of so many patients per nurse... once they top out, they can't safely take more, regardless of how many empty beds are on the unit). Ergo, the patients get held in the ER. Then, when I run out of ER beds, I end up putting people in the hallway. Once I run out of hallway space, the whole process grinds to a halt. All the while, the patients in the waiting room are rioting because they're been waiting for so many hours... I've actually lined up and seen patients in the waiting room once I ran out of space in the department proper... it's certainly not by-the-book medicine, but we do what we can.
Facilities. Lots of ERs are just not big enough. I've worked in ERs with volumes from 15,000 patients per year to over 90,000, level-1 urban trauma centers to small community hospitals, and I've yet to work in one that had enough space. ER volumes are going up every year, all over the country... hospitals can't build fast enough to keep up with demand.
It's amazing to me that some ERs do as well as they do... longer wait times are just a symptom of several larger problems.
I've had all kinds of injured patients come directly from the bar, many with pretty severe preexisting medical problems.
Had a guy come in from a barfight, with his cervical-spine external fixation frame still on (titanium ring around the head, screws that go into the skull, and carbon fiber rods down to padded shoulder harnesses). Yep... one of these. Placed, I might add, from his previous DUI accident.
Patients with end-stage emphysema (still smoking) who carry around oxygen tanks everywhere they go... picked up by the paramedics from the smoky bar (smoky bingo halls are another favorite).
Liver-failure cirrhosis patients who are picked up from the bar after they start vomiting blood...
You'd be amazed where you can find sick people making themselves sicker (you current and Ex-EMS guys know what I'm talking about).
No. Your dentist is actually doing the right thing.
Your dad has a valve problem in his heart, and dental work does cause a transient bacteremia (bacteria being released into the bloodstream). Most of the time your immune system will clear out those bacteria, no problem... most of the time.
If you have a damaged heart valve, those bacteria can infect the valve, leading to a condition called Bacterial Endocarditis. The bacteria grow on the valve, and can destroy that valve, as well as throwing infected bits downstream in your circulation, leading to brain abscesses, kidney and lung infections, and general sepsis.
Endocarditis is a nasty, nasty condition... probably most of the cases I've seen were IV drug users. It's a hell of a life; some of those folks will shoot up anything they can find, regardless of what's in it (ie. foreign material loaded with bacteria). Also, when they are re-using needles, the needles will eventually dull, and sometimes barb (painful!). To detect a barb, addicts will sometimes lick the needle tip, then shoot up if no barb is felt with the tongue... you can see where I'm going with this. The human mouth is only slightly less dirty than the human anus... they end up injecting tons of bacteria, and develop Endocarditis. To make matters worse, they never go to the doctor, except when they try to scam more narcotics, or inadvertantly overdose. By the time they do show up, their valves are shot, and they're almost dead. If they survive, they end up needed open-heart surgery and valve replacement.
Anyway, that's probably more than you wanted to know... but as far as dental procedures go, the antibiotics your dad takes are effective in preventing Endocarditis. He'd be well-advised to keep taking them as prescribed.
I don't think the original poster was referring to Endocarditis though... I'm fairly sure he was referring generally to Atherosclerotic Disease.
in some countries... I believe China still harvests organs from prisoners.
In the US there's so much oversight that I can't see it even being possible. Many transplants aren't even done in-house... the organ gets flown to where it needs to go (I've flown on a couple of those... you get to jump to the front of the line on the taxiway, even if there are 30 planes waiting to take off).
Seriously, there are so many ethical questions, paperwork to be filled out, different physicians involved... declaring someone brain-dead and pulling the plug is a big deal, even more so if it's an equivocal case; it requires multiple physicians to sign off, consultation with the family (and their physician), appropriate consultations and diagnostic testing, and often a review from the hospital ethics committee. Hell, half of the doctors that sit on those committees don't even like one another... they just tolerate each other. There's NO WAY they'd all agree, in some nepotistic star-chamber fashion, to something as evil as wrongfully terminating someone's life and harvesting their organs. No way.
I can't see that caper ever being pulled off and not coming to light.
or Adenocard (trade name in the US).
It can induce asystole for a few seconds... I've never seen it last for 30 seconds.
Patient reports of the adenosine experience vary greatly. Some don't mind it... others would rather have you cut their heart out than get adenosine. I'll never forget a biker guy I saw a couple of times for recurrent SVT (SuperVentricular Tachycardia). He hated adenosine (though it always worked); said it made him feel like he was dying. He was a great big muscular tattoo-covered man, and would cry like a little baby when you brought out the drug, literally weeping in terror.
To see a grown man reduced to that... my heart really went out to the poor guy.
I'd appreciate a link to that... I've been doing this for a long time, and I've never thought that belief was widely held. I've heard of theoretical links between C. pneumoniae, but that's about it (of course, C. pneumoniae has been theoretically linked to all kinds of things, including Chronic Fatigue Syndrome, among others).
I'd say the classical risk factors for heart disease still hold; smoking, hypertension, diabetes, the bad gene (usually a triglyceride or cholesterol metabolism problem), etc. This really isn't a flat-earth-round-earth debate... Any new theory had better be pretty compelling, particularly with the mountain of research backing up the standard risk factors.
The "bacterial infection" guys may turn out to be right... but they're going to have to prove it.
You are correct... cap refill can be a useful tool in the field, but it's hard to quantify based on its numbers; 2 secs, 3 secs, 4 secs? The sensitivity and specificity of cap refill isn't really what it should be to be considered a reliable test by itself (don't misunderstand; cap refill is clinically useful, and I use it all the time... but only as part of the bigger picture).
Cyanosis (or even methemoglobinemia) won't necessarily decrease your cap refill. It may make your nailbeds blue, but they will probably pink-up (or blue-up) at the same rate, provided you're not hypoperfusing. Dehydration, low BP, cold, Reynauds phenomenon, peripheral vasoconstriction of whatever cause, etc will all affect cap refill.
In its heyday, cap refill was actually part of the Trauma Score during most of the 1980s (put out by the American College of Surgeons to help stratify trauma patients). Interestingly, it was given significantly less clinical importance about ten years later when the Revised Trauma Score was developed (there had been some studies that seriously questioned its reliability).
Getting back to the main point: I find standard blood pressure measurements to be very useful. There are so many nuances involved between the systolic and diastolic measurements for various disease processes, like the narrowing of the pulse pressure in hemorrhagic shock... loss of pulsatile flow, and a single pressure measurement could seriously affect clinicians' ability to interpret normal/abnormal physiologic parameters.
It might not make a big practical difference, but still...
They expand on the acronym in a couple of scenarios.
ATLS (Advanced Trauma Life Support, a program by the American College of Surgeons) expands that to ABCDE: Airway, Breathing, Circulation, Deficits in neurologic function, and Exposure (remove/cut off all clothing... easier to find injuries and wounds that way).
Also, the "C" in the old "ABC" acronym is also supposed to stand for Cerebral protection in addition to circulation. I've also heard CPR termed "cerebral pulmonary resuscitation." That's probably a fair substitution, since your main goal in CPR is to protect the brain by creating a low-flow rather than a zero-flow state (contrary to what some folks think, CPR doesn't restart the heart from a V-fib/V-tach arrest... generally only electricity can do that).
Once your brain's dead, you're dead... even if your heart, lungs, kidneys, etc are all working normally. Those folks become organ donors, or should...
Let me put in a plug here... PLEASE CONSIDER DONATING YOUR ORGANS. Please... talk to your family about it, get it on your driver's license or living will. Lots of people need organs, and if you don't need yours anymore (and you have no deep religious/philosophical objection), why not donate them? Just a thought...
Exactly what I was thinking. The law of unintended consequences may come into effect here.
The lack of a pulse may not seem like a big deal, but the physiology of human blood pressure is based on pulsatile flow. The loss of that "pulse" may cause real problems... would small emboli or damaged red cells will get stuck in the microcirculation without that pulsatile flow to dislodge them?.
Where it would cause problems for me clinically is when placing arterial lines, drawing blood gasses, or assessing for arterial insufficiency. For example, every elderly patient who comes in with a broken hip gets a pulse check in their leg... if it's not present, they have a much more urgent problem than simply getting their hip fixed with a gamma nail... the same would apply if they were in an accident and broke their femoral shaft. Also, anatomic variations are common... how do you find the artery if there's no pulse?
The ability to assess for a pulse is very important in clinical medicine... I'm sure there are many more examples.
the procedure is actually to assess them first... something along the line of shaking them and asking "Annie! Annie! Are you OK?"
If they answer "yes," you're done.
I realize you were only joking, but the entire clinical picture needs to be taken into account.
My favorite EMS call is the patient with a minor head injury who is rushed in with a "blown pupil." When you go see the patient, they're awake and alert, not vomiting, not somnolent, etc. It's usually someone who's new, and doesn't understand the pathophysiology behind Uncal Herniation and 3rd nerve compression.
Back to the topic at hand... I wonder if the lack (or blunting) of the systolic peak and diastolic trough in the blood pressure would lead to any physiologic problems? According to the article, the device is actually a Left Ventricular Assist Device (the ole' intra-aortic balloon pump is the classic example of such a device). It steals blood from the left ventricle and steadily pumps it into the aorta... but I wonder if it has any effect on the coronary arteries?
The coronary arteries mainly fill during diastole, when the aortic valve closes and blood floods the coronary sinuses on the aortic side of said valve... since this device essentially "steals" blood from the left ventricle and injects it somewhere downstream, I wonder if the coronaries get the same filling? (I suppose it's a question of where you place the downstream catheter.) It might not make a difference if you have clean coronaries, but if you've got a Left-main stenosis, it could be bad to drop that filling pressure...
In a perfect hydraulic system, it wouldn't matter, since pressure injected in one location would increase pressure in all locations... but arteries have compliance, and they can flex.
Interesting device... it'd be nice to know some more details.
Whatever the origins of the drug war, some drugs are absolutely harmful in untrained hands (Note: I specifically said untrained hands... cocaine, opiates, and amphetamine derivatives do have legitimate medical uses, provided they're prescribed by someone with the proper expertise). I'm speaking particularly about hard drugs. Anyone who denies this either has a political agenda, or is not connected to reality. In a perfectly Libertarian world, it wouldn't matter, because society wouldn't be liable for the costs of people drowning their bodies in illicit drugs. However, fortunately or not, society does end up paying.
I don't have many problems with marijuana in my clinical practice... but cocaine? Meth? Heroin? Oh hell yes... I could curl your hair with the stories of some of my overdoses and trauma patients, many related directly to those drugs.
Admittedly, other common drugs can also cause mortality and morbidity (eg. angioedema from ACE inhibitors is an absolute nightmare), but those drugs are typically treating an actual medical condition... they're not simply being used by those individuals who seem to spend their days seeking the ultimate buzz.
I don't necessarily feel people should be prevented from making their personal choices... but when they're sucking up the resources of others in the process of exploring the depths of their addiction, I understand society wanting to have some say in the matter.
As an aside, depending on the receptor specificity of the vaccine involved, it might be possible to block some of the euphoria without blocking the analgesia. If they could engineer a drug to be that specific, I'd be inclined to use it... I don't see where blocking the buzz (and other side effects) could be anything but beneficial. After all, when I'm straightening someone's broken arm or leg, I could care less if they're high as a kite; my primary goal is that they're spared the exquisite agony that comes from bone grinding/crunching on bone...
It's a shame that a man with such a talent should also be such a vicious anti-semite. Just goes to show that genius in one area can be accompanied by pig-ignorance in other areas. I knew he was an odd sort of man... but his anti-semitism is news to me.
Also, to suggest that 3000 innocents slaughtered by terrorists is a good thing puts him in the same category as those palestinians who danced in the streets when the towers fell. He's probably not going to get much sympathy from most americans.
The theory goes something like this:
Cancer occurs as a consequence of genetic damage that hits certain critical genes within in a cell, usually those that control cell growth/death. Many genes control cell growth... if one of these genes gets overexpressed, or a suppressor gene or modulator region for one of the aforementioned genes gets damaged or otherwise turned off, you can get cancer... but not always.
If your own body's immune system recognizes the cancer cell as abnormal and kills it, you dodge the bullet. There's absolutely no way to quantify how often it happens, but it's probably more often than we know.
Ionizing radiation affects DNA by damaging it. However, your body can often use the matching DNA strand from the other side of the double-helix to repair the damaged region... you have enzymes in your cell nuclei that are specifically for this. You should thank your lucky stars for those enzymes too... there are a few syndromes where those enzymes are deficient or dysfunctional: those poor patients grow cancers like it's their job.
I found the grammar and spelling to be rather better than what I've come to expect from the average 419'r. It's usually quite clear that these scammers either uneducated, or don't speak/write english natively; the poor command of the language is a huge red flag.
I have to give the guy credit for trying... it's the first 419 scam I've read that correctly used the word "aberrational" in a sentence.
let's all be honest and transparent here... there is very little in common between how the prisoners are Gitmo are treated, and how the residents of Siberian Gulags were treated. Let's not lose sight of reality amidst the hyperbole. Also, this is not comparable to rounding up Japanese-Americans during WWII... troops aren't raiding every mosque in the US and carting the worshipers off to internment camps.
.. I'm frankly not sure what form this process will eventually take.
The US miltary has plenty of space to detain people of interest: Iraq alone has had tens of thousands of prisoners (insurgents/terrorists/whatever) processed through its jails just since the end of the war. Consider the possibility that there may be a good reason why people end up at Gitmo instead of a more geographically-convenient location. It's no small expense to move a person from Afghanistan to Cuba (one of my military buddies has flown that mission multiple times, and it's a pain in the ass).
People have raised the issue regarding lack of due process, and they probably have a valid point. The SCOTUS has now stepped in to ask that due process, in some form, be followed. I don't think most people have a problem with that; Checks and Balances are good.
That said, if you're holding someone against their will for whatever reason, they probably should have some sort of representation (a military JAG officer is probably safer than some Hamas agent cum lawyer) and you should have to justify that detention to someone. The sticking point, of course, is who represents, and who judges. There are enormous national security and foreign/domestic intelligence assets at stake, so an OJ-Simpson-style public hearing is probably inappropriate.
In fairness to the current administration, the entire "unlawful combatant" issue has never been a problem of this magnitude (there were a few german spies caught and executed during WWII... IIRC, they represent some of the only applicable case law). Unlawful combatants certainly haven't been a problem in such volume... remember, Afghanistan's terror camps operated under the Taliban for years and trained thousands of terrorists. Some of them are in the US... wouldn't it be great to catch and/or kill the next Mohammed Atta before he completes his mission?
The US is not Israel. A lot of this is uncharted territory for the US judicial system. This process will work itself out, and it's perfectly OK to argue about it, but I also don't think it's unreasonable to expect it to take a little time.
Play on a well-admined server, and you'll find your CS experience much more enjoyable. I play on a server where there is NO profanity (spoken or written), no racist or pornographic nicknames, no cheating, etc... they have a ton of admins and it's rigorously enforced. What's more, if you feel you've been unfairly kicked/banned, you can lodge a protest on the group's website... bans have been overturned for unsubstantiated accusations of cheating (no demo recorded, etc).
A server run by adults, for adults, is a wonderful thing... playing with mature, responsible players... it brought enjoyment back to my CounterStrike experience.
I'd advise you to explore some more servers. Don't dismiss a great game mod because you happen to play on servers with hormonally-poisoned 13yo adolescents.
I suspect he doesn't have a CDROM... many older laptops lack them.
As an example, I just built a mobile internet station for my aging parents to take on vacation with them... salvaged an old Thinkpad 600 to do it. The laptop didn't have a CDROM, though they did have an old Xircom 10Mb network card...so I did a network install of Mandrake 9.2.
Now, they couldn't be happier... reading their email on the road, instant messaging me when we're online at the same time, online banking...
I'm sure scads of people are going to go on and on about how worthless old laptops are, or how they can't do anything without that CDROM. It just takes a little imagination.
You almost sound like an NRA member (that's not an insult... I have no problem with the NRA, but your slippery slope arugment is a common one for that organization). And it's not an invalid argument... creative prosecutors have already tried to use sections of the Patriot Act against non-terror crimes (though I'm only aware of one case).
What I'm interested in is not tying the hands of the people whose job it is to do the dirty work. Like you, I have a problem with brutal torture... but what about creative interrogation (harkening back to my original question)? Also, I have a problem with advertising our capabilities and limitations to the terrorists we might capture. The more you know about your enemy, including his strengths and weaknesses, interrogation methods, procedures, etc, the better you can train against them. The US military SERE school used to run soldiers through several types of interrogation camps, based on intel we've gathered from our enemies. There were Russians camps, Central-American camps... we are able to train our soldiers effectively against capture by those folks partially because we know their methods. I would deny that advantage to the terrorists by leaving a bit of ambiguity... publishing lengthy legal brief on exactly what we can and cannot do gives the terrorists too much info.
I understand your point about the government becoming a threat... but fixing that is only one election away. Don't believe it? Look at the changes in the last four years; those could be mostly undone with a single swing in an election.
And even if it came to violence... the US is one of the most-heavily armed nations in the world (in terms of the general populace). Think the US is having problems in Iraq? What army is going to occupy a country the size of the US? Certainly not the US Army, totally drawn from the regular US populace, and not at all interested in imposing martial law on its own citizens. Again, look at Iraq, and the problems the US is having getting iraqis to fight their own... that would be even more magnified in the US.
Thanks for the interesting discussion... I appreciate you being vigilant about freedom.
Sun-Tzu was wise... his works are still required reading for various three-letter agencies, and the US Army War College, among others.
For my own part, I agree: never give the enemy the initiative... action always beats reaction. Keep your enemy reacting to you; it allows you to choose the time, place, and tempo of the battle.
2. Point granted on the street situation... but I still maintain that preemptive strikes are justifiable in some circumstances (though the benefits may not be seen for decades). Israel's strike on Saddam's nuclear reactor is an excellent example... without it, we'd be facing a nuclear-armed Iraq, and a MUCH different middle east today. If Iran develops nukes, it gets nastier still.
3. Heheh... again, point granted, though stupidity being more common than evil, I would defend my reference. However, your corollary is equally valid, and has the additional benefit of being more specific (as a bonus, it incorporates my unstated assumption).
4. Jury is still out on this one... "preparing" prisoners for interrogation could cover a lot of territory. Not to be legalistic, but that's where this will be debated, and lawyers live for details.
I must confess, I've enjoyed this exchange.
Someone already made a comment about acting like Clinton... but we can't really have a debate without defining terms... so what do you define as torture? Don't regurgitate some UN definition... I'm talking about you, yourself.
Yes... if you inflict enough pain, someone will tell you anything they think you want to hear, just to stop the agony. If you want to emulate the North Vietnamese, and get US POWs to sign bogus "confessions" (even John McCain signed a statement saying he was an "air pirate", IIRC), that kind of torture works quite nicely. Anyone who's been through SERE school in the US military will tell you: everyone breaks eventually... it's what you give up when you break that counts.
If you're a dimwitted thug who's simply after bogus confessions to wave around on your state-run television propaganda channel, fine... ask all the leading questions you want. Eventually, you'll get what you're looking for... but that's not what I'm talking about. (Echos of the "The Prisoner." We want information... information... information...)
How about questioning a person under conscious sedation, which disinhibits them, but causes them no physical harm? How about simple isolation? How about the chinese "water torture" (a psychological stressor that's physically harmless)?
I don't mean to single you out, but you've been so vehement in your posts... would you be willing to sacrifice to save the life of an innocent? Nobody's asking you to give your life... just do an unpleasant task. We're not talking about scooping out eyeballs... it doesn't even have to physically harm the terrorist. Could you do it? Now instead of saving one life, how about an entire platoon of young soldiers? How about a third-grade class? One-hundred innocents? A thousand? You can see what I'm getting at here... I'm always fascinated with where the sliding scale of competing harms balances out for people.
I honestly don't know myself, and I'm thankful that I don't have to make that decision. But I try to be mindful of the fact that even if I am not making that decision, somebody, somewhere, probably has to... Think about that. I don't envy that person. I can only hope they've considered all the options, and whether they'll be able to live with the results. I try to never underestimate the power of human rationalization... but would it be strong enough? I don't know.
I sometimes wonder how well Tomas de Torquemada slept.
I love a good preemptive flamewar.
2. "Innocent until the situation is fully ascertained" can't really exist on the street... things happen too quickly (unless you want to sacrifice a lot more police officers than already die each year). When a cop sees a guy coming with a knife or a gun, he has to choose in a split second. Maybe the person was simply bringing the gun to the police officer, (or it was a toy gun, or they were just joking, or, or, or...) but that's just the way it goes. Innocent until proven guilty is great... but there's no time for a jury when you see somebody raising the muzzle of a weapon. Incidently, by the time SWAT gets called, we're pretty sure who we're after (but even so, 99% of all SWAT call-outs are ended with no shots fired by SWAT).
3. Heh...I feel your pain... but to be argumentative in return, Hanlon's razor could be considered a derivative or corollary of Occam's razor
4. I wouldn't say torture was the rule rather than the exception... though I'm not sure that's even reliably measurable. Torture for its own sake is simple sadism, and those who got their rocks off torturing prisoners will get their due, as well they should. It was particularly nice of them to take pictures for posterity's sake. Sick and stupid is quite a combo...
Nobody is liked by everyone... the diversity of ideas and viewpoints on a planet with multi-billions of people will absolutely ENSURE that someone, somewhere, hates you. Besides, does being unpopular justify violent action?
Just a couple of comments.
1. Fair point... I'll grant you this one.
2. In the right circumstances, I fully support preemptive war, just as I endorse police officers not waiting until they're shot at to shoot back (as a former SWAT officer, I've personal experience with this one). Giving your enemies the first punch is stupid; I can't see sacrificing lives on the basis of either indecision or moral cowardice.
3. Intelligence is often nothing more than a best guess. Occam's razor may be appropriate here... don't attribute to malice that which is explained by simple incompetence.
4. Avoid torturing? Good advice, and probably followed by the vast, overwhelming majority. But defining torture... and whether it's ever permissible is a great debate. Rhetorically, a case can be made for torture in some circumstances (if a terrorist knew where a nuke was, and refused to divulge that info, is torture justifiable? Does the tiny private moral victory of "I'm a good person... I don't torture others" drown out the screams of the millions you might be sacrificing by staying within your own moral comfort zone?) I honestly don't know the answer to that one. As technology progresses, and the technological bar to enter the nuclear-club gets lower and lower (and as nukes proliferate, ala AQ. Khan), that scenario becomes plausible... Seriously... what would you do?