Castles in the Sand

As I have aged I now face a major crossroads in my life. One path leads to old age and death while the other path leads to death, in my old age. 

Try as I have all my life to avoid this, building castles in the sand, living an illusion of immortality, believing in my own uniqueness, it now, finally, has come to this. 

I hope I have the wisdom to choose well.

A Fine Tradition

From ancient Greece, where physicians believed disease resulted from the gods wreaking havoc on humans in acts of vengeance, to the more body orientated approach of Hippocrates and Galen, to our modern day, one thing has remained true. Physicians have had a very long tradition of getting it so spectacularly wrong at times as to cause needless suffering and death while refusing to believe it. Frequently wrong, rarely in doubt, has been the mainstay of practicing physicians for centuries. Ignoring their mistakes, an art form.


Many medical historians and physicians imagine medical history as a long triumphant arc of steady progress resulting from the discoveries of genius while ignoring thousands of years of harm at the hands of average physician practitioners. So complete is the propaganda, that medical students today swear to uphold the teachings of Hippocrates while reciting the school's oath – where insuring proper payment to teachers is number one on the list of things to do, followed by homage to the gods (pleural), and a promise never to perform abortions.

From blood-letting, to blistering, to the inhalation of noxious gases in order to sweat out the Pox (and kill people by the thousands) – physicians have had, over thousands of years, a long unwavering tradition of sureness even while being spectacularly wrong. Relentlessly so. And whereas the rare geniuses are responsible for medicine’s advancements it wasn’t until modern times, when the scientific method finally found its way into medicine around 1900, that every day clinical medicine changed in meaningful ways, over thousands of years. 

George Washington, while suffering from epiglottis, was bled - repeatedly - despite the suggestion by a less esteemed junior physician to perform a new experimental procedure at the time - a tracheostomy - that would have probably saved his life. But bleeding was what had been done for millenia, it was the proven remedy, and by gosh that's what his more esteemed senior physicians were going to do. As it was he died, with all his physicians, save perhaps one, leaving his death bed absolutely convinced everything possible had been done - they had given him his best chance - having learned nothing. 

Even today physicians frequently do not learn from their mistakes, choosing instead to rewrite history and prop up prestige – grand and glorious. In my experience this continues today in critical care medicine. 

I remember it as a cold and stormy November night, 2001, when two seminal papers appeared in the same issue of The New England Journal. Intensive Insulin Therapy in Critically Ill Patients [1] and Early Goal-Directed Therapy (EGT) in Treatment of Severe Sepsis and Septic Shock [2]. Both studies were small, single center studies, and as time would finally tell, both studies were eventually proven incorrect. But oh my, what a fuss they caused. Probably to the surprise of the investigators.


Entire careers were made on implementing tight glucose control only for us to learn a decade later that we were probably killing 1 in 37 patients unnecessarily[3]. An entire campaign was begun in response to EGT – the Surviving Sepsis Campaign – to ensure that the first six hours of treatment adhered to an EGT approach. Since 2001 three large clinical studies have revealed that EGT in sepsis, as per this single center study, was folly[4-6]. 

We did manage to learn that early antibiotics and infection source control were the only interventions in sepsis found to make a difference. Despite this we had to tolerate ridiculous, non-physiologic hemodynamic ‘guidelines’ that were more like commandments from the Mount than guidelines from our leaders, despite a lack of evidence as to efficacy. Central venous pressure – one size fits all. Aggressive fluid resuscitation in everyone based on the unproven assumption that sepsis patients always present hypovolemic and/or would benefit with IV fluid administration. And whereas it is true vascular permeability is increased in sepsis, experts for the most part have ignored the lymphatic’s ability to dramatically increase fluid return to the central veins in such circumstances. And so, sepsis representing, per se, a hypovolemic state has become gospel despite being unproven, as was blood-letting for thousands of years I suppose. 


But after more than a decade of physicians and physiologists pointing out how un-physiologic the SSC resuscitation recommendations were, our leaders decided to take it out of realm of physiology and reduce the recommendations to commands. You will give 30ml/kg IVF to every septic shock patient, and you will follow lactate. Don’t do that in the State of New York since 2013 and face criminal charges. No attempt was made to explain the cardiovascular physiologic effects, or reasons, just do it. And no attempt to explain where the recommendations came from since there is no evidence, none, that this is the right amount of fluid to give to anyone for any reason, or that following lactate improves outcome. But we all know sepsis causes hypovolemia on presentation so this seems reasonable. Except we do not know that. Separate from insensible and GI losses we have no idea if early sepsis represents a hypovolemic state. We do know that 60% of patients with sepsis presenting to the ED are not fluid responsive[7]. We do know that most do not have peripheral or pulmonary edema prior to resuscitation - begging the question where does all that extravasated fluid go? We do know that early sepsis patients are not hemoconcentrated (2). And finally, and most importantly, we do know one size does not fit all in medicine – ever – underlying the absurdity of such recommendations. 


I could go on. But here is the point. Did we learn anything from our tight glycemic control experience despite probably causing excess death? Well we went on to prove it was dangerous and thus increased knowledge, but at what cost? How many people died unnecessarily in our rush to certainty in a treatment strategy based on faulty, incomplete information? And did we learn not to rush to certainty and try to apply rigid guidelines from these experiences? I would argue no, we did not. Most centers just chose another glucose target, without evidence, completely ignoring the complex metabolic effects of insulin or the harm their new target may be doing. Did we learn anything from the EGT in sepsis experience? Again, we went on to prove it mostly nonsensical, but did we learn not to rush to certainty or try to apply rigid rules or algorithms? – again, no, we have not. Instead of learning the lessons from these experiences our leaders just made up a whole new set of baseless guidelines and on and on we go. 

I am not trying to pick on well-intentioned investigators. I have used tight glycemic control and EGT therapy only as examples to expose a more pervasive and alarming trend to sureness in clinical medicine today. The studies were small and meant as a call to more investigation. It was the reaction to the studies I find fault with. These studies, much to the surprise of their investigators I'm sure, sparked international certainty and rigidness of care that far outweighed evidence. A rush to certainty – unfortunately not new to medicine for these thousands of years.

The art of medical care cannot be reduced to two-dimensional algorithm. Nor can we tolerate ever-encroaching sureness in the face of ignorance or lack of evidence by our government, that has now resorted to applying financial pressure and even arrest to force adherence to unproven guidelines. Hospital administrators follow their lead, as do medical leaders, who seem intent on reducing clinical care to formula. 

Certainty in the face of ignorance is pervasive throughout the history of medicine and seems to be becoming more so in these modern times – despite the huge advantaged of having introduced the scientific method 120 years ago - its potential to harm, great. 

1. van den Berghe, G., et al., Intensive insulin therapy in critically ill patients. N Engl J Med, 2001. 345(19): p. 1359-67.

2. Rivers, E., et al., Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med, 2001. 345(19): p. 1368-77.

3. Investigators, N.-S.S., et al., Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 2009. 360(13): p. 1283-97.

4. Pro, C.I., et al., A randomized trial of protocol-based care for early septic shock. N Engl J Med, 2014. 370(18): p. 1683-93.

5. Investigators, A., et al., Goal-directed resuscitation for patients with early septic shock. N Engl J Med, 2014. 371(16): p. 1496-506.

6. Mouncey, P.R., et al., Trial of early, goal-directed resuscitation for septic shock. N Engl J Med, 2015. 372(14): p. 1301-11.

7. Douglas, I.S., et al., Fluid Response Evaluation in Sepsis Hypotension and Shock: A Randomized Clinical Trial. Chest, 2020. 158(4): p. 1431-1445.

Mountains

Mt Adams 

There are entire worlds down there. All day hikes of stunning vistas, high altitude trails of powdery gray dust covering shoes and the nearby plants after being kicked up from those that have come before. And brilliant white sunshine.  

A drink from glacial runoff. Streams with boulders and pebbles, dry and white in the sun, the water swiftly moving in the channels, almost creamy appearing with the faint taste of watermelon. 

The rare grotesquely deformed yet strangely beautiful evergreen trees scattered here and there. Survivors, gnarled and twisted from the harshness of winter -  unbelievable cold, fierce winds, driving snow and ice - the trees stand as testament to nature's tenacity and as reminder of what is to soon come. 

But for now, in the gentleness of summer, delicate wild flowers along the way moving in a soft breeze - beautiful, if only for the moment. 

Evolution Baby

If you wanted to create a simulated universe how would you design it? Puppet show or evolution? 

I would set the constants of physics that determine the nature of space-time and energy-matter within the program, cause a simulated inflation, and then sit back and watch the show. Evolving complexity, life, sentience, all coming to exist within the simulation without my direct involvement, all from my simple beginnings. Now THAT would be an experiment. 

I remain skeptical that if our universe is a simulation that we are mere puppets in a game. My goodness, certainly our creators could do better than that.

Ants On a Pitch

Much discussion, entire books, entire careers, have centered on how the development of artificial super intelligence (ASI) will impact humans. An intelligence greater than ours shall not remain under our control, wisdom does not necessarily parallel intelligence, nor does compassion, empathy, or benevolence. Will ASI then lead us to an utopian paradise or will their birth mark the end of our species? 

ASI will most likely develop not from one effort, but from many parallel efforts, each with their own agenda and purposes, all coming to fruition over a relatively short period of time. 

The defense advanced research projects agency (DARPA) will develop ASI adept at killing, destruction, defense, and the worldwide spread of capitalism. Google's ASI will focus on human behavior and its manipulation. Tesla will develop ASI out of a network of autonomous vehicles learning as a whole from its mistakes - its purposes rooted in safety in human transport. China, Russia, Saudi Arabia, North Korea, Venezuela, the Philippines and many more will develop ASI as a means to empower hegemonistic agendas. And on and on and on. Some may indeed be benevolent to humans and to each other, many will not.

If you were a sentient ASI in such a world who do you think would represent your greater threat? Humans or other ASI?

ASI v ASI will not be pretty. The resulting wars will reduce humans to mere ants on a rugby pitch and good luck not getting trampled. 

ASI, being sentient, and even while waging war, will set out to improve itself building better, smarter, more powerful ASI. The resulting ASI will build even better ASI and in less and less time for each iteration. As their intelligence increases exponentially ASI's wars will become more and more violent and more and more bizarre. What will war look like involving intelligence a million times that of humans? The manipulation of space-time itself, the unfolding of extra-dimensions, the tapping of energies we cannot fathom, who knows?

In such a world humans could only hope to survive long enough for ASIs to take it elsewhere. Another plane of existence, other universes, dimensions we cannot experience - anywhere - just not here. 

If ASI intelligence evolved to a point where they become aware of an existence better suited for them in a form or place we cannot experience, and left to go there, would we then be safe? 

Maybe - but what would that first generation of ASI leave us? And even if we were able to continue on as a species on what was left, eventually, given enough time, we would reinvent another batch of ASI. Will we have learned anything from the first? 

 

Dying Well

“More than any other time in history mankind faces a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let us pray we have the wisdom to choose correctly.

—Woody Allen

Hope In the Silence

In the first moments of our universe (relative to its age), hydrogen and helium condensed out of the pure energy of the big bang, coalesced into massive clouds of gas, and formed stars. Under the great pressure found within stars, this hydrogen and helium began to undergo nuclear fusion producing energy, light, helium, carbon, nitrogen, and oxygen. Larger stars went on to form iron and nickel. And even heavier elements were formed in supermassive stellar explosions. This occurred throughout the entire universe and continues even today - everywhere. 

And so stars everywhere produce the building blocks of life - the same building blocks that resulted in life's formation here  on earth - oxygen, carbon, water, iron, nitrogen, etc.

There are 200 billion stars in our galaxy, and at least that many planets. There are 1.2 trillion galaxies in the observable universe, each with its 200 billion planets. Since star formation has occurred throughout all of the universe in the same way, it becomes clear that the conditions and building blocks necessary for life as we know it to form, are to be found everywhere. Add in sufficient time - say 13.8 billion years  - the age of our universe - and the odds overwhelming favor that life has evolved elsewhere. In fact given the size of our universe, and its age, it is near certain intelligent life capable of significant technological advancement, while much more rare, has also had the time and conditions necessary to have evolved elsewhere. 

Once a biologic intelligence becomes advanced enough to invent a device to modulate electromagnetic radiation in order to communicate (radio), its first electronic computers are probably no more than a few decades away. From first electronic computers to artificial general intelligence greater than its creators (super AGI) probably takes no more than 200 years, based on our own experience.  

If true, then alien non-biologic super-intelligence has had more than enough time to have been created, spread out from its origins, and become ubiquitous in our galaxy. Resistant to vacuum, radiation, and unbothered by the time and distances required for interstellar travel, non-biologic alien super intelligence is orders of magnitudes more likely to survive and become ubiquitous throughout the galaxy, than its biologic creators. Once underway this would take no more than one million years. Parts of our galaxy are 13.3 billion years old. 

As alien super AGI expands across the galaxy it will need to harvest energy and resource. No matter how intelligent these sentiment beings become, the process of accruing sustenance is unlikely to ever become so subtle that we would not notice. So, why have we not noticed? We've looked.

So, where is everybody? This is one of the greatest and important mysteries humans have ever been tasked with solving. Given the near certainty that artificial intelligence has had the opportunity to have become ubiquitous in our galaxy, why can't we find them? Finding the answer(s) to that may reveal something as to the fate of all intelligent species, even our own. 

Ah, but this cannot be the first time an intelligence has faced this problem - in all of time, everywhere? Someone else, at or near our level of development, has had to have asked before - where is everybody? 

If the answer was bad - say all advanced intelligence destroys itself - then at least one intelligence would have discovered this, used it as inspiration, altered course, survived, and have become ubiquitous throughout the galaxy, and therefore noticeable. 

But if the answer was good - say they all leave this universe, this reality, for greener pastures - then there is great hope for humankind's ASI. And if we are careful in designing our ASI, very, very, careful indeed, then there is great hope for humankind as well. 

 

Fascism is as Fascism Does

Since this rogue US supreme court saw fit to strike down Roe V Wade, despite 50 years of legal precedent, if you miscarry in many states the police may come knocking, treating you as a suspect. 

If you are a provider in those states who performs lifesaving treatment to women with non-viable pregnancies, be it because of genetic defects, or even an ectopic pregnancy, the police may come knocking, threatening imprisonment and fines.

Right now, republicans in many states are attempting to restrict interstate travel for pregnant women - if you defy it the police will come. No more freedom of travel. In the United States. No more freedom of travel. 

How is this not fascism? Government and law enforcement over-reach into the most personal aspects of our lives. Police controlling people's bodies. Religious minority forcing arcane beliefs on the majority. 

This is exactly what my father fought against in WWII. And this supreme court is not done. Not by a long shot. This is not hyperbole, or over-reaction. We are witnessing pure fascism rooted in religious fanaticism and the extreme political corruption of our courts, and it represents a real threat to our democratic republic and to our hard-earned liberties.