The Mornin' Mail is published every weekday except major holidays
Friday, September 25, 2009 Volume XVIII, Number 69

did ya know?

Did Ya Know?...The New Life United Methodist Church, 1/2 mile north of Leggett corporate office, will hold a a Parents Night Out Sat. Sept 26 from 6 p.m. to 10 p.m. New born to 12 yr. For info call 417-438-2961

Did ya know?....Steadley Elementary School in Carthage, Missouri is having a Fun Fair, September 26th from 4:00-7:00. Bracelets are available for purchase for $10 in advance or $12 at the fair. All proceeds will benefit the students of Steadley.

today's laugh

I couldn’t find my luggage at the airport baggage area.

So I went to the lost luggage office and told thewoman there that my bags never showed up.She smiled and told me not to worry because she wasa trained professional and I was in good hands.

"Now," she asked me,

"Has your plane arrived yet?"...

While working at a pizza parlor I observed a man ordering a small pizza to go. He appeared to be alone and the cook asked him if he would like it cut into 4 pieces or 6.

He thought about it for some time before responding.

"Just cut it into 4 pieces; I don’t think I’m hungry enough to eat 6 pieces.

A Chronological Record of Events as they have Transpired in the City and County since our last Issue.


Prof. Gray Presented a Valuable German Library of Several Hundred Volumes.

Mrs. O. Trenkler, who left last Saturday to spend her remaining years in Germany, presented to Principal Gray of the High School a very fine German library of several hundred volumes.

Several of the scientific and philosophical works are first editions and bear dates as far back as 1783 and 1789. The editions de lux of Goethe and Shiller are masterpieces of the bookbinder’s art. Included in the collection are Nehrling’s treatise on the birds of North America which is a classic in its field and copiously illustrated with colored plates of the birds of this continent and Meyer’s Universum of 20 volumes which is at present under the ban in Germany because of the enlightened republican opinions which its author lets forth.

Besides the library, the aged lady left with Mr. Gray an excellent microscope of 500 diameters, made in Germany and used by Dr. Trenkler in his university work at Jena, together with a large collection of bacteriological slides and the scientific instruments used by the doctor in his long practice.

The microscope and other suitable instruments will be used by Mr. Gray in his science work in the High School and a number of the books in the school library.

  Today's Feature

Clarified Trash Pick-up Regulations.

The City Council heard the first reading of an ordinance that will modify the rules for storing and disposing of trash and garbage during its meeting last Tuesday evening. Most of the changes are due to the new automated system that is scheduled to go into effect October 1.

The ordinance provides that all city residents "shall be provided by the city or its contractor, sufficient and adequate containers for the storage of all solid waste ...and shall maintain such solid waste containers at all time in good repair." It also requires that no other containers except the provided poly-carts can be used to store solid waste.

"Solid waste containers which are not approved may be collected together with their contents and disposed of by the collectors," the proposed ordinance reads.

Containers are to be stored so as to not be seen from the street behind the front line of a residence, except that "Containers may be placed at the curb side after 5:00 p.m. the day before the regularly scheduled pickup day but no later than 6:30 a.m. the pickup day. Containers shall be removed from the curb by 7 p.m. on the pickup day."

Flu Nightmare: In Severe Pandemic, Officials Ponder Disconnecting Ventilators From Some Patients

by Sheri Fink, ProPublica

With scant public input, state and federal officials are pushing ahead with plans that -- during a severe flu outbreak -- would deny use of scarce ventilators by some patients to assure they would be available for patients judged to benefit the most from them.

The plans have been drawn up to give doctors specific guidelines for extreme circumstances, and they include procedures under which patients who weren’t improving would be removed from life support with or without permission of their families.

The plans are designed to go into effect if the U.S. were struck by a severe flu pandemic comparable to the 1918 outbreak that killed an estimated 50 million people worldwide. State and federal health officials have concluded that such a pandemic would sicken far more people needing ventilators than could be treated by the available supplies.

Many of the draft guidelines, including those drawn up by the Veterans Health Administration, are based in part on a draft plan New York officials posted on a state Web site two years ago and subsequently published in an academic journal. The New York protocol, which is still being finalized, also calls for hospitals to withhold ventilators from patients with serious chronic conditions such as kidney failure, cancers that have spread and have a poor prognosis, or "severe, irreversible neurological" conditions that are likely to be deadly.

New York officials are studying possible legal grounds under which the governor could suspend a state law that bars doctors from removing patients from life support without the express consent of the patient or his or her authorized health agent.

State and federal officials involved with drafting the plans say they have been disquieted by this summer’s uproar over whether Medicare should pay for end-of-life consultations with families. They acknowledged that the measures under discussion go far beyond anything the public understands about how hospitals might handle a severe pandemic.

By every indication, state and federal officials expect to weather this year’s flu season without having to ration ventilators. That assumes that the H1N1 virus will not mutate into a more serious killer, that the vaccines against it and the other seasonal flus will continue to prove effective, and that any dramatic surges in the number of patients in need of ventilators will occur in different parts of the U.S. at different times.

In recent months, New York officials have met three times with physicians, respiratory therapists and administrators to rehearse how their plan might play out in hospitals in a severe epidemic. In one of those "tabletop exercises," participants suggested that the names of triage officers charged with making life and death choices among patients at each hospital should be kept secret. The secrecy would be needed, participants said in interviews, to avoid pressure and blame from colleagues caring for patients who were selected to be taken off life support.

When they posted their plan on the Web in coordination with a video conference in 2007, New York officials promised to solicit public input. Since then, they have consulted with medical and legal professionals and other experts, but few members of the general public, and the plan has remained unchanged. They declined to make the comments they have gathered immediately available for review, and those comments are not published on the Health Department’s Web site.

In the initial proposal, officials called public review "an important component in fulfilling the ethical obligation to promote transparency and just guidelines."

The academic publication of the plan envisaged the use of focus groups to solicit comment from "a range of community members, including parents, older adults, people with disabilities, and communities of color." Those have not been held.

Beth Roxland, the current executive director of the New York State Task Force on Life and the Law, said the ethicists included in the state’s planning process focused largely on vulnerable populations. "Even if we didn’t have direct input from vulnerable populations," she said, "their interests have been well accounted for." Roxland said that public comment solicited when the ventilator plan was posted on the Health Department Web site was "sparse."

Dr. Guthrie Birkhead, Deputy Commissioner of the Office of Public Health for New York state, said he wondered whether it was possible to get the public to accept the plans. "In the absence of an extreme emergency, I don’t know. How do you even engage them to explain it to them?"

Even so, other states, hospital systems and the Veterans Health Administration—which has 153 medical centers across all states -- have drafted protocols that are based in part on New York’s plan. The inclusion and exclusion criteria for access to ventilators, however, are different. For example, under the current drafts, a patient on dialysis would be considered for a ventilator in a VA hospital in New York during a severe pandemic, but not in another New York hospital that followed the state’s plan, which excludes dialysis patients. The VA’s exclusion criteria are looser because the patient population it is charged with serving is typically older and sicker than in other acute care hospitals. Different states, reflecting different values, have also established different criteria for who gets access to lifesaving resources.

The Institute of Medicine, an independent national advisory body, is expected to release a report on Thursday morning, at the request of the U.S. Department of Health and Human Services, that will recommend broad guidelines to help guide planners crafting altered standards of care in emergencies. At an open meeting held to inform the report on Sept. 1, participants described successful public exercises related to allocating scarce resources in Utah and in a Centers for Disease Control and Prevention study conducted in Seattle.

Questions about how hospitals would handle massive demand for life support equipment arose when New York state health department officials ran exercises based on a scenarios involving H5N1 influenza.

"They kept running out of ventilators," said Dr. Tia Powell, director of the Montefiore-Einstein Center for Bioethics and former executive director of the New York State Task Force on Life and the Law, which was asked to address the problem. "They immediately recognized this is the worst thing we’ve ever imagined. What on earth are we going to do?"

Officials calculated that 18,000 additional New Yorkers would require ventilators in the peak week of a flu outbreak as deadly as the 1918 pandemic. Only a thousand machines would be available, the officials estimated. The state’s acute care hospitals in 2005 had about 6,000 ventilators, 85 percent of which were normally in use. A moderately severe pandemic would have resulted in a shortfall of 1,256 ventilators, health officials found.

In 2006, New York planners convened a group of experts in disaster medicine, bioethics and public policy to come up with a response. After months of discussion, the group produced the system for allocating ventilators. They first recommended a number of ways that hospitals could stretch supply, for example by cancelling all elective surgeries during a severe pandemic. The state has also since purchased and stockpiled 1,700 Pulmonetic Systems LTV 1200 ventilators (Cardinal Health Inc., NYSE) -- enough to deal with a moderate pandemic but not one of 1918 scale.

Officials realized those two measures alone would not be enough to meet demand in a worst-case scenario. Ventilators were costly, required highly trained operators, and used oxygen, which could be limited in a disaster.

The group then drew up plans for rationing of ventilators. The goal, participants said, was to save as many lives as possible while adhering to an ethical framework. This represented a departure from the usual medical standard of care, which focuses on doing everything possible to save each individual life. Setting out guidelines in advance of a crisis was a way to avoid putting exhausted, stressed front-line health professionals in the position of having to come up with criteria for making excruciating life and death decisions in the midst of a crisis, as many New Orleans health professionals had to do after Hurricane Katrina [2].

The group based its plans, in part, on a 2006 protocol developed by health officials in Ontario, Canada, which relied on quantitative assessments of organ function to decide which patients would have preference for an intensive care unit bed. The tool, known as the Sequential Organ Failure Assessment (SOFA) score, is not designed to predict survival, and not validated for use in children, but the experts adopted it in light of the lack of an appropriate alternative triage system.

This summer, New York officials brought the state’s plan to groups from several New York hospitals for the tabletop exercises. They met behind closed doors to assess how hospitals might implement the proposed measures if the H1N1 pandemic turned unexpectedly severe this fall. In the fictional scenario, paramedics were ordered not to place breathing tubes into patients until physicians "can assess whether they meet the criteria to be placed on a ventilator.’’

Problems were immediately apparent. Dr. Kenneth Prager, a professor of medicine and director of clinical ethics at Columbia University Medical Center, was concerned about the lack of awareness of the plan among the larger public and the majority of the medical community. Societal input "is totally absent," he said and called for more outreach to the public. "Maybe society will say: ‘We don’t agree with your plan. You may think it’s ethically OK; we don’t.’ "

The protocol, he said, would also place a great burden on clinicians charged with selecting which patients would be removed from life support. Physicians were concerned doctors involved in the legitimate and painful selection processes might be inappropriately construed as "death squads." "We facetiously dubbed them the ‘death squad’ or the ‘guys in the back room,’ " Prager said. He envisioned family members breaking down and screaming when they found out their loved ones would be disconnected from ventilators. "It really is a nightmare."

Even so, he felt that the plan – and its effort to save the greatest number of patients – was ethically appropriate. "If we don’t use triage, people will die who would have otherwise been saved," he said, because a number of ventilators are "being used to prolong the dying process of patients with virtually no chance of surviving."

Doctors at the exercises feared that they would be sued by angry patients if they followed the draft guidelines. "There’s absolutely no legal backing for physicians," said Lauren Ferrante, a medical resident at Columbia University Medical Center. "Who’s to say we’re not going to get sued for malpractice?"

New York officials said they were currently working out legal options for implementing the plans, such as gubernatorial emergency declarations or emergency legislation.

"You can take something today that’s not necessarily active and overnight flip the switch and make it into something that has those teeth in it," said Dr. Powell, who served on the committee that drafted the plan.

Just Jake Talkin'

I’ve always liked gadgets. Shucks, I just like the word gadget. Sounds kinda off the wall and fun. Most gadgets are based on some real great idea, but most just don’t seem ta be that practical.

I’m sure that little fishin’ rod you carry around in your pocket makes a lota sense to some folks. I don’t spend a lota time at the fishin’ hole, but I’ve never actually seen anyone usin’ one a the things.

Now a fly swatter, that’s a real practical gadget cause most anyone can use one effectively. If ya run into someone who can’t operate a fly swatter, keep your distance.

As a kid I put together a series of pulleys and cord to make my bed. ‘Sides nearly gettin’ nearly strangled one night, it really didn’t save any time. It was just a fun gadget like most ya see.

This is some fact, but mostly,

Just Jake Talkin’.


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ART NOTES from Hyde House

by Sally Armstrong, Director of artCentral



A perfect night, a wonderful crowd, great sales, and beautiful ceramic artwork. These things greeted patrons and guests last Friday evening, and thanks to those who came out for a great evening with us at Hyde House Gallery to view the art work of Joplin artist Jed Schlegel and Pittsburg artist Gregory Krepps. Both artists were present to visit with the viewers, to share about their work telling folks a bit about each of their creative process. I had a nice group of visitors on Saturday and Sunday afternoon as well, and hope to see additional folks this Friday through Sunday at this very nice exhibition of these exceptional pieces. As we complete the property work on the new parking lot this week, several can say that they have already parked in one of the new 12 spaces while we are still in gravel! I had my board present Monday night for a special called planning meeting to begin putting together a number of ideas that we have tossed around all summer in honor of artCentral’s 25th Anniversary to be celebrated in 2010! A lot was accomplished in the two hours we met Monday, and discussion continued today during our regular scheduled noon meeting of the board. I have a great board, and they come up with great ideas. We had so many, that we decided to work out the details on our favorite four, and so we will be bringing information soon on four special events we will be presenting to both our membership as well as the general public very soon. These events will be in addition to our regularly planned exhibitions next year, and that’s not even mentioning at least four artist workshops that we hope to also present to our adults, with a special children’s event near the holidays next December of 2010. I hope you will remain attentive to this space as I bring further details of what we hope to be a fun and enjoyable year in 2010, but not to forget that we still have two exciting show coming up in the remainder of 2009. We next welcome Dan McWilliams of Jasper and his beautiful oil paintings in the Main Gallery, along with Mary Lou Reed from Sarcoxie in the Member Gallery and Rachel Wilson, winner of the first award in this year’s Membership Show will be back with a whole herd of found-wood horses for exhibition on the lawn, all to be presented in October. Stay tuned!

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