Pirates of Space

Ed note: I wrote this post to provide some back story/rationale for my forthcoming (maybe) starship simulator app based on the Lensman series of Edward E. “Doc” Smith. I wanted to provide some exposition updating Smith’s pioneering use of the concept of “inertialess drive” in light of current physics. This opening parallels the opening of the original 1934 version of Triplanetary, though Smith of course gets the action going much quicker and more adroitly than I do. My title is also the same as the first chapter of Smith’s work — a work which he later retrofitted into the Lensman Universe as a prequel.  To those unfamiliar with the Lensman series, it is a classic that defined the genre of space opera, introduced concepts such as defensive screens and tractor beams that are familiar through their use in Star Trek and elsewhere, and was runner-up for the Hugo award for Best All-Time Science Fiction Series (Asimov’s Foundation took the prize).   This post is just a pastiche.  It is not allegorical and has nothing to do with medicine.  Tellus is a Latin name for Earth and is the terminology used in the Lensman Universe.  And, finally,  MICRO-AGGRESSION ALERT: 1930s sexism is present, but is integral to the storyline.


The Tethys II bored though interstellar space (modified from Charles Schneeman, Astounding, Jan, 1940).
The luxury liner Tethys II bored though interstellar space… (modified from Charles Schneeman, Astounding, Jan, 1940)


Chapter I

Pirates of Space

The luxury liner Tethys II bored through interstellar space at supraluminal speed, halfway between its Tellurian embarkation point and its first port of call — Centralia, the star system closest to the Galactic Core. Despite the several days required to reach it from Tellus, Centralia with its extraordinarily brilliant night sky was a popular cruise destination. The brilliance of its sky was due not only to the density of stars at the galaxy’s core but also to the presence of the Sagittarius A black hole.  This supermassive black hole emitted tremendous radiation in all visible and non-visible electromagnetic spectra as doomed star systems near the event horizon were accelerated and compressed to unimaginable degrees — generating a spectacle unique in the galaxy!

On the ship’s bridge, junior officers tensely scanned status screens, watching for any disturbance in the subether that might indicate the presence of unwanted visitors approaching. Second Officer Mullen, the officer of the watch, strode between the various command stations and peered at the glowing screens searching for any anomalies. Everything appeared nominal, but he was nervous nevertheless. He stopped before the security officer’s station.

“Picking up anything, Jenkins?” he asked.

“Everything clean, inside and out, sir,” the security man responded.

“Fine. But don’t let up on the spy ray sweeps. Right now we’re about as far from any Galactic Patrol outpost as we will be on this transit.” Mullen examined the read-outs carefully. “But you’re right, nothing suspicious that I can see.”

The security officer chuckled nervously. “Maybe we’ll get lucky.”

Mullen hoped so. Space piracy and lawlessness had been increasing. Ships, both freight and passenger, had disappeared without a trace. No one knew if this was the result of external attacks or internal sabotage or both. But there had been too many ships lost recently and both crew and passengers were nervous. Tonight (it was night by ship’s time, though the concepts of day and night had little bearing other than on the comfort of the ship’s occupants) was the Captain’s Dinner, and the ship’s senior officers were engaged with the passengers, helping them (with the aid of liberal amounts of free mixed drinks) allay their anxiety.

In the first class luxury lounge, First Officer John Crittenden escorted one of the V.I.P.s of the voyage, Tellurian Senator Jacob Mendez’s daughter, Julia. They had just finished the final course of Baked Alaska, coffee and aperitifs. Captain Vandersteen had assigned Crittenden the task of entertaining Miss Mendez for the evening, and, despite his initial reluctance (related to his dislike of her father’s politics), he grudgingly had to admit that the daughter seemed to have none of her father’s political interests and was certainly more of a pleasure to escort than her father would have been.

They left the lounge and entered the Promenade Deck which circled the midsection of the ellipsoidal ship. Along the outside of the deck the visi-panels displayed stark visions of the interstellar void. As they walked side by side, Crittenden found himself momentarily distracted by the young woman’s charms, so much so that he had to ask her to repeat the question she had evidently just asked.

Used to her facility for distraction and the frequent awkwardness of men around her, she cheerfully repeated her question. “The stars we are seeing out the observation panels — certainly we are not seeing actual visual light at the speed we are going?”

Crittenden noted the stunning starfields that appeared in the viewports.  He launched into an explanation.

“Although they look like windows, these panels are video screens that function differently depending on our speed. At sub-light velocities they show actual light, though filtered as necessary to prevent retinal overload. Cruising as we are at about 90 parsecs per hour, there is no possibility of recording any vibrations in the ether. We are outrunning light by an order of magnitude of …” he paused, did some quick and rough calculations. It wasn’t often that he thought in terms of velocities as slow as light. “Well, we are travelling almost 3 million times as fast as light. So what we are seeing isn’t light. The detectors on the outer shell of the ship are tuned to record radiation in the subether. It is a simple matter to translate these images to visible light, which makes for pretty images.”

She studied the star patterns for a moment, which visibly shifted as she watched, reflecting the tremendous velocity of the star-liner. She seemed lost in thought.

“Commander Crittenden…,” she began.

“Please, just John,” he interrupted.

“Okay,” she continued, but then avoided either mode of address. “I have to admit that I have not studied the subject much, but I am interested in space travel and its apparent paradoxes, especially in light of some of the early theories of physics, such as those originated by Einstein in the 21st century.”

He resisted the temptation to correct her history.

“I’m not a theoretical physicist,” he admitted. “It’s true I have some practical knowledge of how this ship works, but…” He hesitated, unsure how to finish his thought without repeating himself.

She swooped into the breach in the conversation, not allowing the pause to become awkward.

“Oh, my,” she exclaimed. “Perhaps you are overdue to be back at your watch. You hardly have time to waste with me, giving me an astrophysics lesson.”

“Not at all. I am happy to answer your questions.” He wasn’t lying. Talking to Miss Julia Mendez beat manning his watch any day.

A worried look creased her brow. “I know how important it is to have competent officers helming the ship. Especially given the risk of space piracy. I always worry that if there is ever a good time for the pirates to attack, it is during the Captain’s Dinner, when the captain and so many of the officers are away from the bridge.”

“There hasn’t been a ship lost to piracy since,” he paused, thinking back. “Since the Oberon, a good 15 months ago.”

“But that’s not that long ago, and the ship and its passengers were never found.” She shuddered, and with her arm linked with his, pulled herself closer to him, so that their hips touched.

With the pleasant contact Crittenden, who was single and as susceptible as any male space officer to female charms, rather hoped that this young woman had lots of questions about space travel. In addition he felt he should try to distract her mind from the remote, but non-zero, probability of the Tethys II suffering the same fate as the Oberon.

“I think we should just get back to your questions about how space travel works,” he transitioned awkwardly. “What do you want to know?”

“As I said, I have read some popular articles about space flight, but I don’t really understand it. How can we travel without inertia? If I am inertialess right now, why doesn’t my blood move so fast it would kill me? Or maybe it shouldn’t move at all. Either way I would be dead. And why does removing or neutralizing inertia allow us to go so fast? I thought the speed of light was the fastest possible speed for anything.”

“Well…,” he began.

She wasn’t done. “And why do we still use terms like the ‘ether?’ I read somewhere that way back in the 19th century they proved there was no such thing as an all-pervasive ether in space. And…”

“Whoa!” he laughed. “I’ll give you answers, but I don’t want to have so many questions that I lose track of them. Let me tackle that bunch, and you can ask some more after that.”

“Sorry, but I’m just curious,” she said.

“Right. Well, maybe I’ll start with the last question because it is related to the others. You are referring to the Michelson-Morley experiments, which set out to show that the speed of light varied depending on the motion of the observer relative to the supposedly fixed ether. The experiments ended up showing no variations at all in the speed of light, despite the motion of the earth. As Einstein proved, I believe in the beginning of the 20th century, not the 21st, the speed of light is constant regardless of the motion of the observer. The implication was that there is no fixed frame of reference in space and time; rather everything is relative to the observer.”

She looked puzzled. “I’m kind of lost as to what that has to do with the ether existing or not.”


“That’s not clearing up my confusion.”

He smiled. “No, I meant you are right to be confused. Michelson and Morley thought if there was an all-pervasive medium in space then light would act a certain way, and it didn’t. This was because light doesn’t behave the way they thought it did. But it didn’t mean that was no such thing as an all-pervasive medium underlying space and time.”

“No?” she asked.

“Negative. Skip forward about a 100 years. Scientists began to realize that mass — and as it turns out inertia — was not an intrinsic property of matter, but instead was due to an extrinsic field, the so-called Higgs field. Atoms, protons, neutrons, electrons and so forth floated in a sea of particles that imparted the properties of mass and inertia to matter. Much like a person entering the ocean suddenly meets with resistance and drag and what-not.”

“You said some kind of energy field, and then said a sea of particles. Which is it?”

“What does it matter?”

“Huh?  Oh, are you making a pun?”

He thought for a second, then responded. “If I were joking I’d come up with something better than that.”

They had made the circuit around the Promenade Deck and had come to a dimly lit bar and lounge, where other passengers seated in plush chairs were having drinks and conversing.

“Could I buy you a drink?” he asked.

“I don’t suppose you really have to buy it, as a ship’s officer, do you?”

“Of course not,” he said, not entirely truthfully. Actually it did come out of his expense account, but in age-old male fashion, he decided not to let his companion, who could probably have bought the whole ship, know this.

“Only if you join me,” she said.

He ordered a non-alcoholic beer for himself. Miss Mendez ordered a complicated cocktail with which he wasn’t familiar.

Settling in with their drinks, she urged him to continue.

“Ok. I think you know particles, fields, vibrations, and waves are all ways to describe something we can’t really understand properly without using terms that we are used to in the macro-world. The truth is the micro-world doesn’t really act like the world we see. Why would it? If atoms were just like little solar systems then we wouldn’t have learned very much about what makes up solar systems, would we?”

She looked confused, and he realized this wasn’t his best expository effort. He envied the great science popularizers who could explain complex science principles to lay persons without any trouble.

She made an attempt to paraphrase him. “So I guess you’re saying that this pervasive field made out of whatever that gives particles mass and inertia is what we in modern times call the ‘ether.'”

He sighed. “I wish I could have summarized it that succinctly.”

She waved a hand. “Being a senator’s daughter, I have an ability to cut through the malarkey and get to the actual message. Not that you are telling me malarkey!” She seemed concerned that she had inadvertently insulted him.

Malarkey was not the term he would have used, he thought. He reflected on the difference between the daughter of a politician and a rough and tumble space jockey. In many ways, this was a contact between alien worlds.

She laughed. “Oh please go on. I’m sorry.”

“I’ll try to be clearer. The inertialess drive, as originally developed by Rodebush and Cleveland, and then enhanced by Dr. Bergenholm, is a field generator, much like the generators for our defensive screens, except the Bergenholm generates an anti-Higgs field. Matter within such a field loses its inertial properties, so that velocities are constrained only by the power of the driving projectors and the density of mass through which the ship moves. Removal of a driving force results in instantaneous cessation of movement. Moreover when an inertialess, or as we say ‘free,’ vessel reverts to its inert state, there is conservation of momentum in that the relative motion of the vehicle prior to its going free is preserved. It’s counter-intuitive, but so is most of quantum mechanics. In a sense we are seeing the bizarreness of the quantum world on a macro-level, and our intuitions about the behavior of matter under these circumstances are just wrong.”

“I think I got all that, though I’m a bit unsure about the conservation of momentum property you mentioned. But never mind that. I don’t understand the paradoxes I have read about. How can we exceed light-speed, inertialess or not? Why doesn’t time slow down or stop or reverse? Why does there seem to be inertia inside the ship?”

“All good questions,” he began. He had neglected his beer, so he took a few sips. He beckoned for the waiter. It seemed they had given him an alcoholic drink by mistake. He went on talking.

“The free state of matter is an unprecedented state of matter. It doesn’t exist naturally in the Universe. It is only through the enormous generation of energy that occurs with total mass-energy conversion, a technology that was unthinkable in the 21st century, that inertia can be neutralized. As an analogy, think of how surprising and unexpected it would be to discover the properties of liquids and gases if the only experience you had with matter was in a solid state.”

She gazed at him closely. “I think you are dodging the question. I grew up in a political family. That’s something I can recognize.”

The waiter had taken away his drink to get another. He had been apologetic and couldn’t understand how the mixup had occurred. Crittenden felt a little fuzzy brained, perhaps from the alcohol, perhaps from the perfume of the lovely woman sitting across from him.

“You’re right. It’s tempting to oversimplify this stuff. I think Einstein himself said to make explanations as simple as possible, but no simpler. Photons and accelerated inert matter cannot exceed the speed of light. Free matter can. It was probably as surprising to Rodebush and Cleveland when they took that first trip on the Boise as it still is to you and me.” He sensed the need to wrap things up and get back on the bridge. He felt uneasy for some reason.  And woozier than he would have expected from a few sips of a beer.  Perhaps he was falling too much under the spell of this young beauty who, honestly, would never show anything more than polite interest to an overworked and underpaid space officer. John, you are gullible, he thought. Always have been. Always will be.

He continued. “As far as time dilation, uh, time slowing goes, it happens maximally at plus or minus 10 percent of the speed of light. At speeds that are thousands of times faster than the speed of light, like our present velocity, or at slow speeds, like normal inert velocities, time effects are negligible. So the passage of time shipboard and outside the ship is similar.”

“Ok. And the problem with the ship being inertialess but us inside not?”

“Well, thanks to the pseudo-inertial and pseudo-gravity generators, the ship has it’s own localized gravitational and Higg’s fields, otherwise we would be in serious trouble.”

His words were cut off by the loud ringing of the claxon. Warning lights flashed.  He snapped on his communicator.

“Bridge, Crittenden here. What’s going on?” he demanded.

The voice of Second Officer Mullen from the bridge was stressed. “We’re under attack. Defensive screens have been tripped. Something, someone has snagged us with a tractor beam and we’re screen-to-screen. We need you and the captain up here pronto.”

There was panic in his voice, and Crittenden knew he needed to get up to the bridge as soon as possible. Suddenly there was a jolt. A jolt! Given that they were still inertialess and under the influence of the pseudo-inertial and pseudo-gravitation fields, that could only be a structural hit. Shields penetrated! Counter-attack was crucial or the ship would be lost!

He jumped up, stumbling a bit.  What was in that drink? he wondered.  He turned to make brief apologies to his companion, and found himself staring into the barrel of a blaster that was leveled steadily at him.

“You’re far too trusting, John. Too bad for you.”

He stood motionless, too shocked for words.

“Oh don’t worry.” The senator’s daughter smiled as she kept the blaster trained on him. “The ship will be taken but it won’t be destroyed. After all, I’m on board, and I am too valuable a prize to be wasted.”

Chapter II, Space Hostage, will be available on newsstands next month.  Don’t miss it!

Why Electronic Health Records Will Not Get Better

Today I read an article in Politico entitled “Doctors barred from discussing safety glitches in U.S.-funded software.”  The article states that, despite massive public funding of Electronic Health Records (EHR), the EHR corporations (including Epic Systems, Cerner, Siemens, Allscripts, eClinicalWorks and Meditech) routinely attach gag clauses to contracts with the hospitals and medical groups who purchase their systems. We are talking about gag clauses that prevent criticism by health care workers of EHR software, gag clauses that prevent disclosure of technical flaws or software bugs that could be potentially lethal to patients, and even gag clauses that prevent posting of EHR software screenshots. All this is under the guise of protection of intellectual property — as if the public has no right to information about systems that were largely publicly funded, either via taxpayers through the stimulus package, or through payment of hospital bills or insurance premiums. This is outrageous!

But it’s also old news to those of us who have had to deal with the byzantine software behemoths that these companies produce. A couple of years ago I got beaten up by Epic and my hospital administration for publishing a tongue-in-cheek satirical review of the Epic EHR as a video game, complete with screenshots. Epic didn’t like the screenshots and ordered them removed. As it turns out, Epic has a squad of workers (some have referred to them as the “Epic Police”) whose sole job is to scour the internet, looking for Epic screenshots, and then bullying the poster until they are removed. The whole sordid tale is told here.  I am not the only one who has had this experience. Several of my colleagues have had run-ins with the Epic Police, with similar results.

A lega Epic EHR screenshot
A legal Epic EHR screenshot?

Those of us who are critical of the lack of transparency of EHR software are not trying to embarass the EHR companies by publishing flaws in their systems. This is a public health issue. Dr. Bob Wachther published a case in which a flaw in EHR software resulted in a patient getting a massive overdose of the drug Septra. Tellingly, the reaction of the EHR company (Epic again — not to pick on them, but they are the largest EHR company and thus may be disproportionately represented in these stories) was not horror that their software may have led to a life-threatening medical error, but rather that Dr. Wachter had dared to publish screenshots that showed how the error occurred. Again, this is simply outrageous.

Doctors have been accused of failing to police themselves, but in truth there is a long history of transparency in Medicine. In Grand Rounds, Cath Conference, or Morning Report, doctors show cases to their peers that do not always present themselves in the best light. Complications are presented to a critical but sympathetic audience, for we have all been there and want to improve. Constructive criticism is offered and accepted. This transparency extends beyond one’s own group of colleagues. Case reports of complications are routinely published in the medical literature, with the hope that the lessons learned can be passed on to other doctors who can then avoid the same mistakes.

This kind of transparency only works if every component of a case is open for discussion and review. This is not compatible with the gag clauses in current EHR contracts. Having such gag clauses is comparable to having a manufacturer of electrocardiography machines state that the electrocardiograms produced by their machines can’t be posted on the internet. It is equivalent to a drug company refusing to disclose the mechanism of action of a new drug even though they know how it works. It is equivalent to publishing the results of a research study, but refusing to publish the methodology, claiming that information is “proprietary.”

Current EHR systems are not state-of-the-art software. They basically consist of a backend database on a server, and a client user interface that provides data entry. There has been little to no effort made to interface between different EHR systems or provide for a standardized data format. There is very little artificial intelligence built into these systems, other than attempts to force compliance with clinical guidelines and billing criteria.  The user interface is bloated and clumsy. It does not conform to a doctor’s workflow. Instead doctors have had to adjust their workflows to accomodate the EHR systems. I believe major advances could be made in the usability of these systems if, as is the case with most of the non-medical software we use, bugs and other flaws could be openly reported without fear of reprisal from the EHR companies.

Until that happens, EHR systems will continue to suck.

You Can’t Tell the Batters Without a Scorecard

If you want to know who the best surgeon in the hospital is, ask the surgical nursing staff. If you want to know who does the best job opening up coronary arteries using catheters, balloons, and stents, ask the cardiac catheterization lab nurses and technicians.

Unfortunately these approaches to comparing physicians’ skills are only available to hospital personnel. They are the only people who are in a position to compare the technical performance of many different doctors. This is not information the average patient can easily obtain.

The average patient has to rely on intangibles when trying to select a doctor. Fuzzy data such as bedside manner, self-confidence, board certification, waiting time for office visits and procedures, and word of mouth. Or, worse still, patients are told which doctor they have to see by their insurance company.  None of these methods of choosing a doctor is likely to have a high correlation with a doctor’s technical skill. There’s got to be a better way…

Along comes the Surgeon Scorecard, a web application published by ProPublica.

With the scorecard it is possible to see raw complication rates of any surgeon (I’m sure the same data for cardiologists and other specialities is coming soon) in the United States who operates on Medicare patients. Pick any hospital and the individual complication percentages are displayed on a colored spectrum (green, yellow and pink on my screen) indicative of low, medium and high complication rates. An ominous red explanation point appears if one or more surgeons have complication rates in the pink zone. Click on individual surgeons and their data is shown in more detail, including numbers of procedures and 95% confidence limits (which frequently overlap more than one complication zone). Curiously, some surgeons with zero complications still have an adjusted complication rate in the medium range.

Going to be hard to get these complication rates down because...statistics!
Going to be hard to get these complication rates down because…statistics!

The publication of this database has unleashed somewhat of a twitter-and-media-storm, to the point that I’m not sure why I’m chiming in at all. Smarter people than I have complained about the methodology or have bemoaned the impact of all this on the practice of medicine. We are living in the era of “Big Data,” and “Data” is only going to get “Bigger” as it continues to accumulate in the ultimate garbage-in-garbage-out receptacle: electronic health records (EHR).

Unfortunately the subtleties of statistics are lost on the average patient, who just looks at whether a surgeon falls into the green, yellow or pink zone on the complication rate spectrum. Given the negative PR potential of this data, it is likely that some surgeons will refuse to operate on high risk patients, for fear of tainting their outcome data. So, as with quantum physics, the Heisenberg Uncertainly Principal holds in the field of medicine, in that the attempt to measure outcomes may result in changing outcomes. Certainly the numbers will look better if high-risk patients are avoided. But will healthcare actually be better?  As was seen with EHR systems, the field of medicine’s square peg continues to be a difficult fit for computer technology’s round hole.

It is hard to argue against transparency, which seems axiomatically to be a good thing. There is no way to put the database genie back into the bottle. The only way to go forward is to make sure data collected is accurate and includes medical and demographic information about the population operated upon.  This will allow the data to be normalized as best as possible. All that data collection is a pain and a distraction. But patients want to know how good their doctor is, and right now the Surgeon Scorecard is the only game in town — unless you can corner a surgical nurse and get his or her honest opinion.

What If My CHA2DS2-VASc Score Is One?

There is nothing simple about atrial fibrillation; it is a complicated, often overwhelming disease, both for patient and physician. One question that invariably comes up early on is the question of prophylactic anticoagulation for prevention of stroke. Who should receive anticoagulation? Which anticoagulant? How should anticoagulation be handled around the time of surgical procedures, or before and after ablation or cardioversion? How should anticoagulation be monitored? How should it be modified in patients with kidney or liver disease? Should anticoagulation be used in patients who have increased bleeding risks? Just the topic of anticoagulation in atrial fibrillation is overwhelming!  Too much for a short blog post. We’ll have to narrow this down further. Let’s talk about using risk scores to decide who should be placed on anticoagulation therapy.

chadsvascAtrial fibrillation risk scores were designed to assess stroke risk in patient populations with atrial fibrillation “without valvular heart disease.” I quoted that because “without valvular heart disease” is not well defined for this purpose. Certainly these risk scores don’t apply to patients with prosthetic heart valves, or with rheumatic mitral stenosis, but beyond that in practice these scores seem to be used even in patients with mild to moderate non-rheumatic valvular disease. The CHADS2 score is very simple, but has become passé in recent years. It is too gross a measure; people with low scores can still be at significant risk for stroke. It has been replaced by the CHA2DS2-VASc score in recently published guidelines. This score makes it much harder to achieve a score of 0 and escape anticoagulation. Using this risk score, both the 2012 European Society of Cardiology (ESC) and 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) atrial fibrillation guidelines recommend no anticoagulation if the score is zero, and full anticoagulation if it is 2 or greater. Where there is some hesitation, if not disagreement, is when the CHA2DS2-VASc score is 1.  Anticoagulate or not? The previous iteration of the guidelines leaned strongly toward anticoagulation for a CHA2DS2-VASc score of 1. The latest sets of guidelines are more equivocal. How to handle a score of 1 is particularly important when one realizes that female sex, on its own, is a risk factor in CHA2DS2-VASc with a point value of 1. Yes, half the people on the planet are born with a CHA2DS2-VASc score of 1 and by the old guidelines would require anticoagulation just on the basis of their sex.

A Swedish study published in 2012 sheds some light on this issue. The study concluded that, while female sex is a risk factor for stroke in atrial fibrillation if other risk factors are present, by itself, in women less than 65 years old without other risk factors, female sex does not confer a significant risk of stroke. The implication is that a CHA2DS2-VASc score of 1 that is only due to female sex does not warrant anticoagulation.

The results of this study were directly incorporated into the 2012 ESC guidelines (I note that Dr. Gregory Lip is a coauthor of both these guidelines and the Swedish study). Thus the recommendation by the ESC is full anticoagulation (aspirin and aspirin + clopidogrel are relegated to remote second-line therapy) for CHA2DS2-VASc score of 1 or higher, after excluding females with no other risk factors and age < 65 years, who (as with men with the same criteria) do not need anticoagulation.

The AHA/ACC/HRS 2014 atrial fibrillation guidelines are more vague than the ESC guidelines when the CHA2DS2-VASc score precisely equals 1. Cardiology guidelines are presented using a sort of quantified equivocation, with recommendations classified as I (should do it), IIa (reasonable to do it), IIb (you can consider doing it) or III (don’t do it). Not quite orthogonal, there are 3 levels of certainty as well: A (data derived from multiple randomized clinical trials), B (data from one randomized clinical trial), or C (“expert” opinion). Given this, it is interesting that anticoagulation for a CHA2DS2-VASc score of 2 or more is a class I, A level of evidence recommendation, and no anticoagulation for a score of 0 is a class IIa, B level of evidence recommendation. For a CHA2DS2-VASc score of 1 there is complete equivocation, with the following class IIb recommendation:

For patients with nonvalvular AF and a CHA2DS2-VASc score of 1, no antithrombotic therapy or treatment with an oral anticoagulant or aspirin may be considered. (Level of Evidence: C)

Addressing the possibility of a exclusion for females with a CHA2DS2-VASc score of 1, the guidelines state (again equivocating):

"In a study of Swedish patients with nonvalvular AF, women again had a moderately increased stroke risk compared with men; however, women younger than 65 years of age and without other AF risk factors had a low risk for stroke, and it was concluded that anticoagulant treatment was not required. However, the continued evolution of AF-related thromboembolic risk evaluation is needed."

This all creates a problem for physicians, patients (females especially), and also for the physician-programmer writing an app such as EP Mobile that calculates these risk scores and attempts to make recommendations. At present EP Mobile simply uses the old recommendations, as do most of the web-based online risk score calculators I surveyed (e.g. here and here). A user of EP Mobile pointed out to me that its recommendations are out of date.  Trying to fit such complexity into a small dialog box on a smartphone screen is challenging.  Nevertheless I will be updating the app so that its anticoagulation recommendations more precisely match current guidelines — at least until the next set of guidelines comes out.

After Life

Jonathan closed his eyes, died, and immediately woke up in a place that was, he assumed, Heaven. He could hardly contain his astonishment. A lifelong rationalist (a physicist to boot!), he was fully prepared for the eventuality that death was the end. But here he was — moments before occupied with the mechanics of dying (it wasn’t as bad as I expected, he thought) — and now in what he hoped might be “a better place.”

As a place it leaned more towards his idea of heaven than hell, though in truth it did not fit his conception of either well. He stood in a grassy field with rolling hills which he realized oddly resembled the default wallpaper of Microsoft Windows XP. His rational mind tried to convince him that this was some sort of dying-related-asphyxia-induced hallucination, or that he had not even died at all, despite all evidence to the contrary. Perhaps the life that he had up until this moment presumed he had actually lived was the illusion, and this bland yet cheery landscape the reality. Certainly the green grass rippling in the mild breeze and the fluffy white clouds in the blue sky seemed real enough. But his life before death had seemed equally real as well. It was all truly puzzling.

Engrossed as he was in these philosophical musings, he did not notice until the last minute that someone was approaching him from over the top of one of the rolling hills. The fellow was almost on top of him when he noticed him, and indeed was close enough by then to determine that he was not a “he” after all, but rather a woman. And a rather comely woman at that.

Being a physicist, Jonathan lacked the poetic vocabulary that really would have been helpful to describe this woman adequately. That she was of an indefinitely young age, was about 5 feet 8 inches tall, had light brown hair and dark brown eyes, was slender of build and so forth really failed to do justice to her. Given the context, he might have used the term “angel” to describe her, though only in an earthly sense, as she appeared to lack a set of wings.

The woman stopped in front of him and looked him up and down. He greeted her with a cheery “Hello,” and paused as one normally would to allow her time to respond. As no response was forthcoming, he continued.

“What is this place?” he asked. He felt this question was a little less silly than starting with “Where am I?”

The woman appeared puzzled. She spoke.

“K’aire. Onoma soi ti estin. Podapos ei?”

Jonathan had assumed that she would speak English, though come to think of it he wasn’t sure why. He didn’t recognize her language at all. It wouldn’t have mattered much if he had, as he didn’t speak any languages other than English.

He attempted to indicate to the woman that he was friendly and had no weapons, using hand signs. It was at this point belatedly that he became aware that his clothes had not made the transition to the afterlife, which put him in an awkward situation to say the least.

The woman (who, if you are curious to know, was clothed in a flowing white robe) turned and with a hand gesture beckoned him to follow her.

So they set off over the rolling grassy knolls, Jonathan rather desperately looking for something with which he could cover his nakedness and the woman in white leading the way in silence. As there wasn’t much else to do on this journey, Jonathan’s mind again became preoccupied with theories of what this place was that he had found himself in, post-mortem.

If it was some kind of biblical afterlife, it was somewhat disappointing: certainly nice scenery — and a beautiful woman! — but somehow he had expected more. Also, his naked condition could not hide the fact that he had been resurrected not in some idealized youthful Statue of David-like body, but in the same 50ish, flawed, somewhat pot-bellied body that he had departed the mortal plane in. Oh well.

The two topped a grassy rise. A small valley lay beneath, split by a sparkling blue stream. A white marble columnated structure rested adjacent to the stream. The design was that of a small temple of the sort found in ancient Greece. The woman (whose garment he now recognized to be what one would find on a Greek goddess) led the way down the side of the hill towards the small temple.

Jonathan smiled. It appeared the Greeks had gotten it right after all. There were probably hundreds or even thousands of afterlife stories among the world’s religions.  They couldn’t all be true.  Frankly he was surprised that any of them were true.  Of course nobody believed in Zeus or Athena or Apollo or any of those old Greek gods anymore. Nevertheless all evidence at this point indicated that they were real, as was their afterlife. He was a little cloudy on his Greek mythology though. He remembered something about Elysium Fields, but also some awful Underworld with a dark lord named Hades and a ferry piloted by Charon who steered the dead across the river Styx.  Well maybe he was jumping to conclusions. He needed more data, more information before setting up his hypothesis, he said to himself in good scientific fashion.

By this time they had reached the white temple. Inside was a statue of a goddess seated on a throne. The woman in white bore an uncanny resemblance to the marble goddess. At the base of the statue were some words carved into the marble — words which were unmistakably written in the Greek alphabet.

Well that nails it, Jonathan thought. I’ve died and gone to heaven, though clearly this is a more pragmatic and concrete heaven than the biblical one. I am clearly in the presence of a goddess. I’m a little hungry and am beginning to get the urge to use the bathroom, but all told, this is much better than I had any right to expect.

He wished he could communicate with his goddess/companion, for he had many questions, not the least of which was where he could get some clothes. She seemed oblivious to his nakedness, which was somewhat reassuring, but he couldn’t envision spending eternity in this state.

The goddess (he wished he could read the Greek script to ascertain which one she was — Athena? Hera?) laid her hand on the corner of the base of the statue and suddenly a secret door swung open. Jonathan could see a set of marble stairs leading down into darkness.

A secret door activated by a secret button would not be surprising in a bad B movie, but such things are indeed rare in real life, he thought. Of course this isn’t real life, but still…

The goddess (if that was what she was) motioned for him to descend and reluctantly he did so. She did not follow him. Instead she activated whatever secret switch closed the secret door. Now Jonathan found himself walking down stairs in pitch blackness. This was disconcerting to say the least. The word “underworld” popped back into his head.

I’m not sure what I will find at the bottom of these stairs, but I think it won’t be nice, he thought.

The stairs went on for longer than he expected. He had to place his feet carefully to avoid slipping and falling down into the darkness. Such a fall would be fatal in the world of the living. He was not sure what the consequences would be if he was already dead.

Might be an interesting experiment, if circumstances were different, he told himself, again using that scientific mind that had gotten him so far in life. He continued to focus on the task at hand, namely getting to the bottom of the endless subterranean stairs.

After a couple of hours (he judged) the stairs began to get more uneven, the atmosphere became dank and humid, and the temperature had dropped several degrees. In his clothesless state, he began to shiver. But he seemed to have no other option other than to go on.

Eventually he reached the last step and almost fell when his feet tried to descend another. He was in a tunnel with damp stone walls. Far at the end there appeared to be a faint glow of light.

The light was farther away than he realized. But, as with all journeys, he finally reached the end of the long corridor and passed into a dimly lit cavern. The lighting came from phosphorescent material on the walls which glowed a ghoulish pale violet. The cavern was enormous, stretching into the distance, its nether wall lost in mists. A continuous moaning sound came to his ear, faint, but becoming louder and more pitiful as he walked to the small boat moored on the shore of the underground river, where the monstrous ferryman waited.

Reading About Steve Jobs

The iconic Jobs and Wozniak Apple II photo
Wozniak, Jobs, and the Apple II

I am interested in the history of computer technology and over the last couple months have read a lot about Steve Jobs. To be specific I read Walter Isaacson’s Steve Jobs, Brent Schlender’s Becoming Steve Jobs, and a book published back in 2001, Alan Deutschman’s The Second Coming of Steve Jobs. To get the point of view of the other “Steve” I read Steve Wozniak’s autobiography, iWoz, How I Invented the Personal Computer, Co-Founded Apple, and Had Fun Doing It.  I watched the two biographical movies, Pirates of Silicon Valley from 1999 and the one from 2013 with Ashton Kutcher, Jobs. The first movie is a lot of fun, exploring the initial rivalry between Jobs and Bill Gates.  The second has been criticized but I like it also, and Kutcher’s resemblance to Jobs is uncanny.  I am looking forward to seeing Aaron Sorkin’s version when it comes out. I also read Fire in the Valley by Michael Swaine and Paul Freiberger, which is a free-ranging and entertaining history of the PC era and on which the first movie mentioned above was based.  Finally there are a number of documentaries on YouTube that address the early personal computer era.  One of the best is the 3-part Triumph of the Nerds.  There are numerous videos on YouTube of Jobs in action, from the earliest days of Apple until shortly before his death.

Reading and watching this stuff makes me nostalgic. I bought an Apple II+ in 1981 shortly after moving to Houston, Texas and starting my fellowship in electrophysiology. It was my reintroduction to computers after my brief fling back in my college days in the early 1970s. As underwhelming as its capacities were judged by today’s standards (base configuration had 48 KB RAM, 40 column all caps text display, 128 KB floppy drives and a MOS Technology 6502 CPU running at 1 MHz), I loved that little machine and was amazed by it. Using its 8 open expansions slots (something Woz insisted on and surprisingly prevailed in getting over Jobs’s objections) I had that thing decked out with an 80 column lowercase text display card, a 1 MB RAM-disk, memory expansion to 64 KB, and a CP/M card — all at considerable cost on a fellow’s salary.  For software I had WordStar for word processing, Turbo Pascal for programming, VisiCalc (the first spreadsheet program), dBase II (a database program) and lots of games, including the very first version of Flight Simulator. It worked well and was fun to use but over the years it was replaced by more powerful systems and eventually I threw it all out. Now I kind of wish I had kept it (or at least sold it on eBay). I kept all my old Byte magazines though, and paging through them is a trip down memory lane.  It’s fun to revisit those days when Microsoft with its software that could run on anything (as long as it was compatible with an IBM PC) appeared to be heading towards  victory over poor  Apple, despite the coolness of their Macintosh computers. As we all know, a lot has happened between then and now.

Isaacson’s book is very well written and, being the authorized biography, has a lot of material that the other books don’t. Nevertheless, the one period that Isaacson skimps a bit on, the time when Jobs was at NeXT and starting Pixar, is well fleshed out in the other two biographies, particularly Schlendler’s. His thesis is that the struggles at NeXT and Pixar were crucial for Jobs to become a better manager and thus be in a position to return to Apple and turn it around starting in 1997. Schlender also seems a bit more sympathetic to Jobs, though it is hard to paper over some of his worst characteristics.  For example, Jobs denied he was the father of his daughter Lisa, and he abandoned her when she was young. Later he acknowledged being her father and reconciled with her. This behavior seems particularly reprehensible given that Jobs himself was “abandoned” by his biological parents and was raised by foster parents. He eventually met his biological mother and his biological sister, the writer Mona Simpson. He discovered his biological father (who was a Syrian graduate student when Jobs was born) and actually had met him once by chance at a restaurant which his biological father owned, but neither realized the father-son relationship at the time. Jobs chose never to meet with his father again.

Jobs is a complex figure. He was self-centered and lacked empathy towards others. He could turn on the charm, but often in a calculating manner. His biographers point out his black and white approach to everything. To Jobs, other people and even things like food or computers or software programs were either perfect or they sucked. There was no middle ground. He may have mellowed somewhat as he grew older, but not much. Jobs’s genius appears to be that he was able to utilize both his strengths and his flaws together to inspire others to do their best (or get out of his way) and thus design and bring to market products that have certainly changed our world. In the process Apple became the wealthiest company on the planet.  But Jobs’s driving force was not wealth.  He aimed for perfection.

No Greek tragic hero is without his blind spot, and Jobs had his: his quirky views on health and diet. A child of the 60s growing up in California, he maintained a distrust of “western medicine” so that when diagnosed with a potentially surgically curable pancreatic cancer found incidentally on a routine CAT scan (he had a history of kidney stones, thus the CAT scan), he delayed surgery for 9 months. He tried various diets, alternative medicines, and acupuncture first. When he finally yielded to the surgery liver metastases were found, and after that, despite a liver transplant and aggressive chemotherapy it was only a matter of time before he succumbed.

Jobs’s genius was that he foresaw what most others didn’t: apart from the computer geeks like Steve Wozniak and the members of the Homebrew Computing Club back in the 1970s, most people don’t care about computer technology per se. They want to use these devices to listen to music, to read books and articles, to look up stuff, to keep in touch with friends, to watch movies, and to get their work done. For most, computer technology is just a means to an end. Steve Jobs realized this better than anyone else in the industry and had the overwhelming personality to find the best people and motivate them to do perform at levels they didn’t realize they were capable of.

One wonders what symphonies a 60 year old Mozart would have written. What songs were denied to the world when George Gershwin died of a brain tumor at age 38? What would Emily Brontë have written beyond Wuthering Heights if she had not died at age 30?  What other “insanely great” products were denied to the world when Jobs died at age 56?  Life at Apple goes on without Jobs. The hand-picked people he surrounded himself with continue without him. But his will be a tough legacy to uphold.

Index Verborum Prohibitorum

Index_Clemente_VIII_1596The Catholic Church for centuries maintained a list of banned books, the Index Librorum Prohibitorum,  only abolishing it in 1966.  Governments, particularly fascist ones, also have had a pronounced tendency to ban books for moral, religious, or political reasons.   Such censorship is a repugnant form of thought control.  It is no surprise that the fascist dystopias of George Orwell’s 1984 and Ray Bradbury’s Fahrenheit 451 center around the destruction or mutilation of the printed word.

While banning books may no longer be in vogue, it appears that banning individual words is fashionable if not de rigueur on today’s college campuses.  The justification is that some words are too hurtful to use.  Some words carry so much historical and racial baggage that their use is always off-limits.  Certain racial epithets can’t be used in any context, not even in a discussion of how bad it is to use racial epithets, because the very act of speaking these epithets is an act of violence.  Thus words are imbued with almost magical powers, and some words are so evil that they can never be spoken out loud.  The “N-word” is akin to “He-Who-Shall-Not-Be-Named” in the Harry Potter books.  People generally will avoid these forbidden words (as I will do here) partly out of a genuine desire to avoid hurting others’ feelings, but also, to be honest, out of fear — the fear of backlash, much like the fear of the media to publish cartoons of the Prophet Mohammed, though this is less a fear of outright violence than a fear of being ostracized and called racist.

This is what happened to the writer Wendy Kaminer when she used one of the proscribed words at a forum on free speech at Smith College in reference to teaching Huckleberry Finn, which, if anyone nowadays is allowed to read an unedited version, has a major character whose name contains that proscribed word.  Read her article in the Washington Post.  It is amazing that in this context (a free speech forum, in a discussion about a classic book that contains that word) she has been deemed a racist merely for using the actual word instead of its baby-talk equivalent.  This reminds me of the scene in Mel Brooks’ film, High Anxiety, when, at a convention of psychiatrists, the word “woo-woo” is used instead of “vagina” because one of the psychiatrists brought his young children with him.  Political correctness is childish.  Political correctness and freedom of speech don’t mix.  The United States Bill of Rights makes a big deal out of freedom of speech.  It does not mention politically correct speech.

I have been living in Paris, France the past 6 months.  Despite being the home of Voltaire and Charlie Hebdo, freedom of speech is more limited here than in the United States.   For example, shortly after the Charlie Hebdo massacre, comedian Dieudonne M’bala M’bala was arrested in Paris for anti-semitism and hate-speech.   Broadly defined hate-speech and holocaust-denial are crimes here in France and in Germany.  As reprehensible as this kind of speech is, it is not a crime in America.  In America we put up with the Westboro Baptist Church and their God Hates Fags signs at military funerals.  We allowed the American Nazi Party to march in Skokie, Illinois (though ultimately their march took place in Chicago).   We allow hate-speech because we allow all speech short of yelling “Fire” in a crowded theater.  We don’t want the government to decide what we are allowed to say, write, read, or hear.

It is unfortunate that in the name of political correctness some people think nothing of placing limits on such a wonderful and powerful freedom — the one freedom that really sets us apart from the rest of the world.  Americans seem all too willing to trade our hard-won freedoms for short-term comfort.  The Patriot Act is a case in point, with which we gave the government carte-blanche to spy on us in exchange for — what?  Is it so comforting that Big Brother is watching us all the time?  Personally I would rather apply the word “patriot” to Edward Snowden than to the act.

It is disappointing that after the Charlie Hebdo murders, despite the wide-spread Je suis Charlie signs, there was a tendency among some in the media to blame the cartoonists and writers, though stopping short of saying that they deserved to die for their “hate speech” (see here, for example).  And college campuses predictably went back to business as usual, promoting suppression rather than freedom of speech, denying (or attempting to deny) commencement speeches to figures such as Bill Maher, Ayaan Hirsi Ali, and Condoleezza Rice.   The Ivory Tower has never been so heavily defended against the onslaught of reality.

Words are powerful.   Words allow humans to download the contents of their brains in a format suitable for upload to other brains.  Words express ideas that can be disruptive and disconcerting to the status quo.  It is no wonder that others want to control our words.  The best weapon against bad ideas is unfettered freedom of expression.  Bad ideas need to be exposed to the light of day.  In the marketplace of ideas, good ideas will drive out the bad.  It is not necessary and indeed counterproductive to ban bad ideas, bad words, or bad books.  The most effective way to destroy the Westboro Baptist Church is not to ban their demonstrations, but rather to allow them to display their hateful ignorance in public.  In their own way, the Westboro Baptist Church has probably done more to advance the cause of the LGBT community than most pro-LGBT activist groups.

I find it sad that left-wing groups on college campuses, who in past years were at the forefront of freedom of expression are now the ones who are most willing to shut it down in the name of political correctness.


Introducing EP Calipers

epcalipersicon-180x180Ever since the 1990s, when computer-based electrophysiology (EP) systems were introduced, HV intervals and ventricular tachycardia cycle lengths have been measured in the EP lab by electronic calipers — simple but accurate measurements accomplished on-screen using a track ball or a mouse. Despite this, physicians still often carry a physical pair of calipers, perhaps preserved from the pre-Sunshine Act days when they were provided for free by drug companies. They use these calipers to measure heart rates and QT intervals on printed electrocardiograms (ECGs). But more and more, ECGs are viewed electronically. All physicians now use smart phones and frequently send and receive photos of ECGs or rhythm strips for analysis. For example, when I was on-call there would often be a patient who went into atrial fibrillation in the middle of the night, or a patient who would be due a dose of dofetilide (a potentially dangerous QT interval prolonging drug). The nurse would have a rhythm strip or ECG that needed analyzing and the easiest way to do that in the post-fax machine era was for them to take a photo with a smart phone and text or email it to me for analysis. Measuring heart rates or corrected QT intervals requires the use of calipers, but physical calipers don’t work well with smart phones — maybe even scratching the glass screen! Electronic calipers akin to those used in the EP lab would be useful to make accurate measurements on ECG and rhythm strip images.

I did not realize that there weren’t any apps (as far as I can tell) providing electronic calipers until this was pointed out to me by one of my Twitter buddies, Dr. Michael Katz. So I wrote an app, EP Calipers, that provides these calipers.

Making EP measurements on an iPad
Making EP measurements on an iPad
Measuring RR interval, iPhone 6 Plus
Measuring RR interval, iPhone 6 Plus
Amplitude measurement
Amplitude measurement
QT measurement with QTc calculation
QT measurement with QTc calculation
Multiple calipers, showing heart rate
Multiple calipers, showing heart rate

As the screen shots show, these calipers look just like those provided by EP recording systems, such as the GE (formerly Prucka) Cardiolab system. Multiple calipers can be used at the same time. Both time and amplitude calipers are available.  Unlike real calipers, it is possible to zoom images and make much more accurate measurements. Also unlike real calipers, it is easy to measure mean heart rates and calculate QTc intervals automatically.  The app makes the necessary calculations.

I am hoping these electronic calipers will be easy to use and helpful to anyone who has to deal with ECG recordings. This is the first iteration of the app and I am open to suggestions to improve it. Right now the app is available for Apple iOS (version 8.1 or higher required), but the Android version will be available Real Soon Now. Have fun measuring intervals electronically to your heart’s content!

EP Mobile Update Version 3.6 for Apple Devices

The reviewers at the Apple iTunes App Store have approved the revised version of the EP Mobile app.  For information on why the app needed to be revised, see my earlier posts on the subject.  I removed the drug dose calculators (note though that the Warfarin Clinic module was not removed), but added detailed drug dosing information and a creatinine clearance calculator that can be used while viewing the dosing information.  Other improvements to the app have been made as well.  The changelog is as follows:

Changes from version 3.5
* Removed drug dose calculators as requested by Apple (see developers guide section 22.9)
* Added new drug reference section with creatinine clearance toolbar
* Added creatinine clearance calculator
* Added right ventricular hypertrophy criteria
* Added D'Avila WPW accessory pathway location algorithm

I will release the new version in 2 days (March 22).  If for some reason you can’t live without the drug dose calculators, then don’t update the app.  Turn autoupdate off if it is on to prevent inadvertently updating the app.  Regardless of the lack of drug dose calculators, I encourage most people to update the app, because I think that using the new drug reference information in the app is a better way to determine drug dosages, and because I will continue to add new features to the app, which will not be available to those who do not update.

Note that Android users of EP Mobile still have access to the drug dose calculators, as well as the new features noted above.

I hope that at some point Apple changes its policy and adds physicians to the groups permitted to write apps that calculate drug doses.  After all, it’s what we do.

Countdown to version 3.6 release — Done! Released Mar 22, 2015!


Update on EP Mobile and Apple #2

As some of you are aware, the Apple App Store rejected an update to the EP Mobile app based on the presence of drug dose calculators in the app. The App Store guidelines state:

22.9 - Apps that calculate medicinal dosages must be submitted by the manufacturer of those medications or recognized institutions such as hospitals, insurance companies, and universities

For those who want more background on this issue, see these two previous posts (here and here).

I have decided to go ahead and remove the drug calculators from the app. All the drug calculator code remains in the app and, should Apple ever change their mind(s) on this policy, it will only require changing this single line of code to get them back.

// Sigh!

I toyed with putting a backdoor into the app to activate the drug calculators, but I realize if I do something like that it would be my last Apple app. I have modified the app to make up for the loss of the drug calculators, and I think that with these changes you will continue to be satisfied by the app.

Here are the changes.

The creatinine clearance calculator had been embedded in the drug calculators, so it has been promoted to its own discrete module (which is something I should have done anyway a long time ago.

EP Mobile Main Menu Drug calculators gone, creatinine clearance calculator added
EP Mobile Main Menu
drug calculators gone, creatinine clearance calculator added

Instead of the drug calculators, there is a drug reference section. Each of the drugs that formerly had calculators now has detailed dosing information, as well as other useful information, akin to what you find in the Medscape app. (An aside: I think drug dosage information as opposed to drug dose calculators is acceptable to Apple, as it is present in Medscape and other medical apps. Medscape does not meet the Apple criteria mentioned above any more than EP Studios does: it is not “the manufacturer of those medications or [a] recognized institution […] such as hospitals, insurance companies, and universities.”).

Two new modules: Right Ventricular Hypertrophy and Drug Reference
Two new modules: Right Ventricular Hypertrophy and Drug Reference

What makes the drug reference section more useful than the similar information in Medscape is that there is a toolbar at the bottom of the screen that allows you to calculate a creatinine clearance on the fly, and then retains that information while you are trying to figure out the appropriate drug dose. Thus the only calculation done is the creatinine clearance; the physician and not the app decides of the dose. In many ways this is superior than having a drug dose calculator, because more information is presented that may be useful to help decide on the proper dose.  The drug reference section can also be expanded in the future to include information on other EP related drugs that don’t necessary require any calculations to dose, such as amiodarone or ibutilide.

A portion of the drug reference for dofetilide. Note the detailed dosing information and the Creatinine Clearance toolbar at the bottom showing the last calculated CrCl.


Finally the D’Avila WPW algorithm has been added, as well as a module on diagnosing right ventricular hypertrophy. I have left in the Warfarin Clinic module too. This module was not called out by Apple on the last review, so we shall leave it alone for now.

I will submit the update to Apple in the next 24 hours. Their review process usually takes about a week. If the approve it, I will not release the update right away, but will give some advance notice on Twitter. If you really can’t live without the drug calculators, then you should turn off auto-update and not update the app. I think though that the drug reference section with the built-in creatinine clearance calculator more than makes up for the loss of the drug calculators, and I encourage you to update the app when it is available.

If you happen to be best buds with Tim Cook, let him know that rule 22.9 is stupid and should be sacked.