Nobody’s birthday comes immediately to mind today, but what does come to mind is the so-called Birthday Problem.

   How many people in a room does it take for two of them to have the same birthday?  First blush would lead you to think that it would take about 183 people (365/2) to give you a 50% chance (an even bet).   Actually, you have a 50-50 chance if there are only 22 people in the room.  So the next time you’re with 23 or more people make the bet, you’ll wind up a money maker.  The reason why it takes so few is that it’s not just the chance that you have the same birthday as any of the 21 others, but the next guy also might match with anyone else in the room, and so on down the line.  Trivial problems such as this have great meaning when you start talking about things like bone marrow matching.

Status: 8.5/10.   Just a little tired today despite getting my first full night’s sleep in a while.  Have a rash over part of shoulders and back and the medial sides of arms and legs (“medial” is medical for towards the middle, while “lateral” means towards the outside), so the rash on my arms and legs is on the inside of them not the outside.  Doctors would not say “outside” or “inside” since they would use that in referring to things that were really outside or inside something (actually they’d use terms like external and internal).  My team doesn’t know what the rash is (as most honest doctors would admit about any rash they saw), but they’ll watch it.    

Events:   Had my bone marrow today (for those of you keeping score that’s 3 now in 3 weeks).  They’ll have a preliminary look tomorrow, but one of the more experienced docs said he’s loathe even to comment on that first look.  He’s told people before that it looked good only to find out when the real confirmatory bone marrow was done 3 ½ weeks from now that he was wrong and vice-versa.
   Probably the reason is the infamous “it depends.”  While they adhere to a consistent notion of individuality, their protocol is to do a bone marrow on everyone at Day 14.  Individual patients will look different on that snapshot day.  So I think we’ll wait to make any judgments until it counts (when they do the next bone marrow as an outpatient after I’m actually out of here and at home).

   Tomorrow I’m scheduled for a lumbar puncture (spinal tap) to exam the central nervous system for any involvement.

Comments:  I was told yesterday that in addition to the lumbar puncture for diagnostic purposes they would instill some chemotherapy into the spinal fluid as a protective measure.  Now, that was not mentioned in the protocol documents I read over carefully, nor in the detailed chemotherapeutic calendar they give you, nor in any conversations I’ve had to date.  I expressed my dismay, and of course told them of the anxiety of any patient who now wonders, “Is there anything else you haven’t told me?”   And who among us likes surprises, right?

  They apologized on rounds this morning and said that everyone else had thought someone else had covered it.  And that when they changed attending physicians it slipped through the cracks.

   Although my major at MIT was Aeronautics and Astronautics, it was in the area of Space Systems Engineering.  You can’t launch a major Apollo mission to the moon or a Space Shuttle mission to the International Space Station without an array of checklists, redundancies, and an eye toward how every little issue relates to every other.  One little glitch and you’ve botched years and years of work.

    What they lacked here was a simple checklist – “the patient has been informed of and understands the following…”  The boxes are checked off, signed off, and dated.  Everyone has access to them in the chart, and there’s no confusion.  Every pilot understands the invaluable nature of a checklist for takeoff, landing, and cruising in between.  Capt. “Sully” Sullenberger has written about the critical nature of having a checklist as he was in the time-compressed throes of trying to land his USAir flight in the Hudson River.

   Dr. Atul Gawande, who writes for the New Yorker, and who has published several books on the medical scene has written of the importance of them in his latest book called The Checklist Manifesto.  I would venture that most of the medical errors that occur in the hospital (medication errors, transfusion errors, operating on the wrong limb or wrong patient) stem from the simplest of human frailties, that we are not infallible computers.

   But it doesn’t take a computer to solve most of those problems, a simple pencil and slip of paper most of the time does the trick.  Yet, imagine what you could do with a computerized patient information system.  It’s not that complex (as they say, it’s not rocket science), and some hospitals have systems that look at many of the areas of importance, but far too few.  The issues are obviously cost and the leadership to make it happen.  But the cost savings in the long term would far outweigh the upfront outlays, and the real cost of human lives cannot be measured.

   A lot of my thoughts of late have been on the precious nature of human life, the preciousness of friendship, and the enduring power of love.

 I send mine to you,



10 Responses to “”

  1. wendy Says:

    B-Oh my… the infamous we thought you knew… seems so weird at such a prestigious hospital… so I’m expecting that after you’re completed healed and grateful for all that they did for you..that a discharge report of things that they need to improve on will be forthcoming..and probably greatly appreciated… who doesn’t want to have an expert come to assess their medical practices and advise, for free mind you,of what they need to get an A++ rating. Wasn’t it a hospital in Boston that has been doing that and has improved their rating to magnificient.. Looking forward to a report that says… all I had to do today was eat and sleep and read and play

  2. Donna Hill Howes Says:

    Life, friendship and love…..that wraps up the “Big Three” in a nutshell.
    Sending love right back at ya!

  3. Marsha Says:

    Hi Bruce,

    I never cease to be amazed at your fund of knowledge and many talents. I think Lizst only is appreciated by good healthy cells, so your piano playing was therapeutic as well as entertaining.

    I enjoyed your birthday story – maybe I should play the lottery with the numbers in my birthdate – in my group of 4, two of us share the same birthday. Makes for a good office celebration every April 20th! Not so proud to admit that Adolf Hitler also shared the day – but he didn’t work with my group, so he doesn’t count anyway.

    Looking forward to having you back home soon. Hoping for good news this week. Here’s to a good night’s sleep! Sweet dreams —


  4. Judy and Larry Says:

    As always, a very insightful posting tonight, Bruce. I have found myself looking forward to receiving them each day. When I was at the Mayo Clinic in Rochester, they had a piano in their lobby. They even had volunteer pianists come and play for the patients. I am sure that your rendition of Lizst was beautiful and that everyone who heard it enjoyed it. Keep your spirits and strength up and we will all pray for a great report.
    Love, Judy

  5. Judie Davidson Says:

    I’m reading Malcolm Gladwell’s book, What the Dog Saw. Just finished the chapter in which he writes of implicit and explicit learning. Your ability to play Lizst surely had moved from explicitly to implicitly learned; what I’m getting at is that you were the first person to tell me about Malcolm Gladwell…Thanks. I have enjoyed all of his books. I can only imagine you will be glad to play the piano somewhere other than the hospital. Take care, Judie

  6. Warren Says:

    The medical school at Dartmouth has been touting the benefits of lists. As a result, I raised the issue with the CEO of Scripps Hospital Encinitas at one of our board meetings. It seems so simple a concept yet so effective. Your point is well taken.

    I think the computerized medical records problem is more complex than meets the eye. It seems that every specialty needs unique capabilities. The lack of excellent voice recognition software is still a problem for doctors entering data during patient encounters.

    Your situation is a reminder of how precious every moment is and how one’s life can change in an instant. We look forward to seeing you in perfect health in June.


  7. sheldan (Sheldon Dan) Says:


    That is a famous math problem. Being a professor of developmental math at Southwest, I am always fascinated by any math problems.

    Your cousin,


  8. Bill Israel Says:

    Give ’em hell, Bruce. It’s not as if they don’t teach checklists in med school; it’s that they only get real when you’re handed the responsibility and need to devise and use them, daily. I don’t think I’d care to be an M.D., looking you in the eye, and saying: gosh, that fell between the cracks. Go get ’em — and good luck on the lumbar puncture.

    Bill (and Eileen)

  9. joel steinberg Says:

    The brain and CSF are “privileged” sites. They are not easily penetrated by chemotherapeutic agents; hence the intrathecal administration of drugs (usually methotrexate) to get around the blood-brain barrier. I couldn’t begin to count all the Ommaya Resevoirs I inserted for that very purpose. And if you haven’t already had a diagnostic L.P., they should send some fluid for cytology. Just as I was retiring, Kaiser Permanente went to an all-computerized medical record, with just the sort of checklists you speak about. Now, nobody gets an incision without two observers agreeing on the side, site, and level– to say nothing of getting the patient right! Now when Margaret gets her treatments, two nurses (and she herself) have to identify her and the drugs she is getting–the drugs are scanned into the record via bar codes, and she also gets scanned in via the barcode on her wrist band with a hand-held scanner, just like the product scanners at Costco. Joel

  10. Sharon McDonnell Says:

    Love…..Its your SOCO Bruce!

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