X-Message-Number: 4661 Date: 23 Jul 95 03:16:29 EDT From: Mike Darwin <> Subject: CRYONICS Sweep of History Part 1 Bob Ettinger writes: I won't bother responding to most of Mike Darwin's spin doctoring in # 4642. Most readers are probably capable of interpreting it adequately. But I'll remark on a couple of specifics: >1. On Biotime's "pushing the envelope" I have only a brief indirect report, >and don't know to what extent it may be confidential. I suppose I shouldn't >have mentioned it at all, but it did sound somewhat encouraging. Well, let's hear about it. EMs, functional studies, even a short synopsis can be disclosed without giving away patentable material. I'd be the first to admit that I'm critical of such an approach, but if hard data exists and it is clearly superior to what we've been able to achieve, then there is always the possibility of signing nondisclosure and liscening agreements. Most people in the community are concerned with getting the problem solved, not with who solves it. >2. Mike suggests that Cryonics Institute's finances are shakier than those of >others. (In earlier years he accused us of "fraud" because of our low prices; >now he just says we are not "prudent".) Anyone who wants to compare histories >and recent financial statements can make his own decision, and I think most >will agree that CI's finances AND financial prospects are second to none. >Mike says CI has achieved what it has because of overfunding by some; he >knows very well that EVERY organization (of any substantial size and history) >has benefited from "windfalls," and Mike has his own financial angel. But >these "windfalls" have been EARNED (Mike's too, of course), and if anything, >on average, we have grown DESPITE a surplus of bad luck. Actually, I think CI has had very good luck: certainly no intense internal political conflicts, no battles with the state, no massive admisistrative and technical overhead associated with multiple standys, in-field bypass, and complex training of personnel. If Bob interpreted my remarks as an attack on CI, then he was mistaken. I fully agree with almost all he has to say above. All cryonics organizations have benefited from uncompensated help (volunteerism) or funding coming from from some paying for the care of others. And, as I said in my post, I HAVE NO PROBLEM WITH THIS as long as everybody understands that's the case and why and how such economies are possible -- as well as the associated potential for the long-term fragility of these approaches. >The FACT remains that Cryonics Institute is presently the ONLY service >organization with no debt, no landlords, no stockholders, no paid officers or >directors, and positive cash flow. It is also the only one (except recently >formed ones) that has never raised its prices. Mike's focus on FACTS, as >opposed to opinion, theory, and speculation, seems highly selective. No argument here, and I think most of these things were wise moves. However: Careful analysis of CI's minimums and current and past costs of delivering patient care indicates that a patient coming in at the 28K minimum will have either not quite enough money or just barely enough (at, in MY opinion) unrealistically high interest rates, to fund long-term care. Now, it can be arugued that the historical rate of return on invested capital of 2% is far too conservative for the future. And, this may be true, however many, if not most in the financial community, would point out that the cost of money has remained relatively constant for a very long period of time and that anticipating a change in this is highly speculative, much like cryonics itself. I don't like stacked and associated high speculative things. I prefer to count on as a few miracles as possible. There is nothing wrong with this approach, it simply needs to be clearly acknowledged. CI, like Alcor, and even CryoCare and Alcor UK has benefitted immensely from disproportionate contributions from a few. There is nothing wrong with this, but after years of experience in the trenches, I can also tell you that there is little right with it. for example: a) such disproportinate giving leads to unspoken and usually unacknowledged feeling of debt and ownership on the part of the giver. Often these problems do not surface until many years later and they become particularly pronounced when growth occurs and benefits begin to accrue -- benefits which are not distributed commensurate with the effort put in. In religion, businesses and in cryonics I have observed this to be a very corrosive problem. b) Having made the points I have in a) above, I would say that the same thing often happens in for-profit structures, but less frequently. Still it is a serious problem all around. c) One of the reasons I think CI has been lucky is that they have indeed had windfalls. But luck is not the sole reason for their good fortune and windfalls come more often to those who work hard for them. CI's conservative financial stance, their eschewing debt, and their general frugality are also major factors in their current financial picture, and this has nothing to do with luck and everything to do with good judgment and hard work. d) I would say that my major doubts about CI are twofold: First, I think they are doing a lot more injury to their patients than some other groups are and I suspect (but of course cannot prove) that some of this injury will either delay recovery or reduce the fidelity of recovery. (This is perhaps the most subjective criticism since we can all stand up and wave our hands about our Friends of Future, and what they will be able to do. My second concern is that the ratio of minimally funded patients to overfunded patients may change unfavorably over time. Certainly, Bob would concede (I believe) that the minimum funding requirements do not include large or even moderate safety margins or significant cash for contingencies. As long as the wealthy or overfunded provide such cushion for the benefit all, there will no problem. However, that this will continue remains far from clear. Part of the problem that causes Bob I and to raise each others hackles (usually, I believe, unintentionally) is a radical difference in outlook and approach -- ego has a little to do with it, but, in my opinion, not much. When I and others were structuring Alcor's cryopreservation funding, (and later when CryoCare structured its approach, which I had little to no input into - by choice) there was the working assumption that there needed to be safety factors built in: in other words significant amounts of capital earning interest over the marginal cost of care calculations/estimates in order to cover unforseen contingencies; costs of moving, perhaps emergently, costs of transferring capital during hyperinflation, adverse governmental rulings, natural disaster, and on and on. They key point here was that patients are in a sort of peculiar position having all of the disadvantages of being dead and few if any of the advantages of being alive. To put this into more concrete terms, patients can't run out and earn more money or rapidly and flexibly husband their resources. No matter how good the cryonics society management, there will necessarily be less flexibility, longerresponse time, and less choices using a committee to make decisions. Individual comittee members can argue persuasively and well for a "let's wait and see" (seemingly conservative approach). This can have its advantages in the day-to-day operation of a business while things are going well, but it has been my experience that it can be a real impediment to needed change and growth when crises occur. My working assumption has always been that crises will occur. One reason I put the 10% rule in place at Alcor when I was CEO (i.e., 10% of all cryopreservation revenue went into the patient care fund) was because I anticipated problems based on my understanding and knowledge of history, and because I felt that active provision should be made to deal with the issue of the costs of revival. I felt and feel that the cryonics organization is responsible in no small measure for insuring these costs are met: in the form of paying for research to achieve them, and in the form of having cash on hand to pay such costs should revival become available. Bob and CI, to my knowledge anyway, have looked at things very differently. And this too is OK. Much can be said for the fact that having multiples of the marginal costs socked away as protection does you little good if you don't get frozen at all because you can't afford such protection. But, to some extent finding yourself in that position is a little like finding yourself with $1.00 in your pocket and the need to have $250K for a liver transplant. The best way to spend your dollar under those circumstances IMHO is to go buy a lottery ticket or, if in Vegas, gamble it some other way with a better probability of increasing the odds of getting the needed capital. Certainly a dollar isn't going to go very far very fast in generating investment return to allow for a 250K liver transplant using conventional investment strategies.. What I am saying here is that Bob and I have a deeply divergent view of the universe and that our differing views probably cause irritation in the other. Bob says the real problem is too much pessimism and that more people should look at the sweep of history and look on the bright side and sign up. I say that one of the reasons people don't sign up is because they can't look on the bright side and/or have many reasons rooted in past experience for not doing so. Further, I would argue that MANY of the cryonicists I know are "doped up" by big "N" optimism and are paralyzed or diverted into mind games about the future and its marvels without working for them. In fairness to Bob I think this more a problem with ALL other groups than CI, perhaps in part because the composition and demographics of CI is very different than Alcor, CryoCare or ACS. (I base this observation about CI on casual observation, not rigorous data, and am willing to stand corrected) BOTH points of view probably have their place. But they rub each other badly when held as strongly and in as disparate a fashion as Bob and I hold them. >3. Mike acknowledges that he may find it necessary to "trim unnecessary >things." That's fine. And I have repeatedly said that CI will in due course >adopt any improvement that we find verified, either for everyone or as a >higher-priced option. Here we are perfectly agreed! I already know where I can trim certain things and will do so. I have been at work for over a year (in part due to Jim Yount's urgings) at offering a simpler protocol. >But Mike also says "we"--probably meaning Alcor when he was in >charge--started on the "high side" using approaches shown "in contemporary >clinical settings to radically affect outcome in a positive way." This is quite true, but Bob's following statement needs a lot of clarification. >Well, now. First off--and I admit this is dragging in stale fish--what is >important in a contemporary clinical setting may be totally irrelevant in a >cryonics setting. For example, Jerry Leaf and I had a long discussion by >correspondence as to whether it was necessary to use expensive commercial >water-for-injection, rather than much cheaper home made USP water for >injection; Jerry finally stopped responding. I still believe there would be >not even a CLINICAL difference, let alone a material difference for cryonics >use. I spoke with Jerry often on this matter and he *would not* I assure you be either happy with, or agree with your (IMHO implied) characterization that Jerry "stopped responding" (sic) to your correspondence because he was out of steam or felt he was not right.. We talked many times about this issue, alone and in the presence of others. Jerry was simply of the opinion that further effort spent trying to convince Bob and/or others at CI on this point was useless, becausehe had concluded that nothing he could say or do would change their minds. I don't often speak for people no longer around to state their position themselves, but on this matter Jerry was VERY clear and I think it unlikely that others around him at the time would not have known this well. Certainly, ALL those who knew Jerry well knew that he was not a man to have changed his mind on a publically help position without acknowledging it: he was too rigorous a scientist for that. As for the use of medical grade water: I use it for several reasons which I will shortly list. And no, I have no problem with in-house prepared water as long as there is some sort of evaluation of its quality. This is basic to any industry or craft that you at least *know* the quality of your materials. It is especially important in cryonics because the feedback loop is so long. Screwing up a patient today in some non-obvious way isn't going to show up until a long time in the future. Thus, and this is very important to me, baseline levels of quality or standards which are objectively verifiable should be set for every aspect of the program. Otherwise, there is a tendancy to find one's self descending the slippery slope: the bottom of which is not nonsterile equipment, but filthy equipment, not water which is pretty pure, but water which is heavily contaminated. When I buy tubing, water, or supplies from a medical manufacturer I have a reasonably good degree of assurance that serious breaches of quality are not present. My assurance stems not so much from in-house testing (although I do actually do some of this) as it does from the sure knowledge that the same product is being used on live people and will be recalled if there are problems or at least shortly found out!. Back in the early 70's we were using Ringer's Solution as a base perfusate. I had purchased 12 cases made by Cutter Labs from the Bay Area in CA (I was in indiana at the time). As it turned out, the Cutter product had massive heat-stable exo and endotoxin contamination in some bottles. Patients became actutely ill and sometimes died before the infusion of a single 500 cc bottle was completed. Why? Because some of these toxins are "pore forming" meaning that they sidle up to cells, attach themselves to the cell membrane, and make a big hole in it. This destroys the cell's ability to inionically regulate itself. This results in several things happening in short order: massive efflux of intracellular potassum and other ions, and massive influx of sodium, water and calcium. The sodium and water cause immediate cell swelling and the calcium triggers the inflammatory/immune cascade which incudes activation of cell membrane dismantling phospholipases. Other bacterial toxins directly activate phospholipases and other cell digesting enzymes making a nice feast of ready-to-ingest cell components. Both Jerry and I have had the unfortunate experience of actually witnessing this happening to living patients. I personally have given endo and exo toxins to dialysis patients (quite unintentionally) in the early days of dialyser reuse. The effects are rapid and devastating and the primary cause of death is shock due to degradation of the capillary membrane (both endothelial cells and basement membrane) resulting in plasma proteins and water accumulating between the cells: otherwise known as edema. This is not conducive to good subsequent cryoprotective perfusion or to preserving cell structure. Fortunately, such heavy contamination is rare. And DI/RO treated tap water which has been autoclaved is probably plenty good. But, you'd better have a way to test it and make sure it is good, because even a firm the size of Cutter with lots of quality control in place, ocassionally slips up. Neither Jerry nor I felt that such in house checking was worth our time or the cost, when we could buy medical grade water with a very long shelf life from established vendors. Further, I understand that CI premixes its 75% glycerol perfusate and stores it, nonsterile, under simple refrigeration. Is this true? If so, I guarantee you it is just (very shortly) a matter of time before you have a lovely collection of molds and similar organisms that can tolerate high osmolality solutions growing in it. We have stored 70% glycerol concenterate at -10C (non sterile) and within a few months commonly see 2-4 mm "cotton balls" of mold growing in it. We have cultured the "clean" (i.e., visibly mold free) bottles and found them to sewers of bacteria and mold: colony counts in the may K to millions! If there is doubt on Bob's part of this, I will send him a sterile culture vial (along with simple instructions and supplies on how to collect the sample and place it in the vial without adding contamination not already present) which he can send (directly) to an independant clinical lab, for either animals or people, and tell exactly where he stands. I'll even pay the costs: you can use our account number with Smith Kline Beecham or Professional Animal Laboratory. There are also several labs that deal with customers by Fed Ex. >There is also, for example, the question of details of sterilization >procedures for instruments. If I understand it correctly, Mike insisted on >the most expensive procedure, even though many hospitals and physicians' >offices used (and still use) much cheaper ones. This is nonsene!!!!! And totally untrue. The only thing we don't use steam sterilization for (which is very cheap and what Bob is probably referring to) is tubing packs, plastic items, and other heat sensitive items. These cannot be steam sterilized as they either melt, deform, behave unreliably, or change properties (such as becoming fogged or opaque). I do most of my ethylene oxide (EO) sterilization in Mexico (CA air quality laws make it prohibitively expensive to do it here) or have it done at a local hospital (which Alcor used to use). The cost in Mexico is cheaper than using steam here! And the cost here, even for a large batch (big 60 liter reservoirs, etc) is a box of See's chocolates for the hospital Central Service staff. Hardly the picture Bob paints. More to the point, other physicians DO NOT use cheaper methods of sterilization to sterilize these kinds of items. They use EO. Some manufactuers use gamma sterilization, but the problem here is degradation of the plastics from the radiation. Incidentally, I know this business very well, the head of one of the major disposable medical device companies and I knew each from Indiana days and I have frequent access to the plant, plus I have toured plants and talked at length to a variety of device manufacturers whose products I either was, or was seeking to evaluate. I DO admit to using EO to do most, though not all of my instruments (something normally done with steam). And this is because I have found it saves me thousands of dollars. How? By allowing me to use "junk" Pakistani stainless steel instruments which are corroed away or frozen-up by steam sterilzation. I do NOT use Pakistani cutting instruments or vascular instruments: there I use only the best German or American stainless. But I do use Pakistani Alice tissue forceps, hemostats, mosquitos, towel clamps, and Weitlander retractors, all of which I acquire after hospitals discard them after one use (they come packed as disposables!) . Properly lubicated and cared for, and above all NOT steam sterilized, these instruments will provide a hundred or more uses. While the "feel" is not as good as German stainless, and while some diligence is required to weed out defective instruments (cracks, misalinged clamping surfaces, etc) it is still very economical to use this equipmet. A major cardiovasdcular tray goes for 20-30K. By buying used quality instruments, German made "blanks" (=good stainless steel) finished in Pakistan (=les costly workmanship), and judicious use of full-Pakistani manufactured equipment, I can cut the cost of such a tray to 5K to 8K. >I would be REALLY astonished >if the difference between these procedures were important for a cryonics >patient. In fact, it would be astonishing if a little added infection (there >is always some infection present in every patient, even if subclinical) were >a significant danger to the patient at all, in comparison to the other >problems of revival and rejuvenation. True--we may need to go to clinical >criteria on that happy day when we achieve reversible-on-demand suspended >animation, but that day is not here and unfortunately may not be close. (We >are all selective in our optimism and pessimism.) I have repeatedly, and from the earliest days stated that I do not believe sterile technique during cryoprotective perfusion is of critical importance to the patient. My God, I've seen guys take shotgun wounds to their bellys, roll into the ER with a peritoneum full of feces, end up with so much tissue trauma and swelling that the wound can't be closed for days post-op and the surgeon has sutured one side of large, flexible irrigating IV solution bag to the edges of the wound so he can look into the guy's belly and see what's going on (this is called a Bogata bag). These guys survive routinely. Here, antibiotics and an intact immune system are all that is necessary. Certainly I think that bacterial contamination, within limits, is not going to be any kind of barrier to recovering patients. On the other hand, I think most people would be profoundly uncomfortable being perfused with feces laden water, or grossly bacterially contaminated or toxin laden water/perfusate. I AM more picky about in-field sterility. Here the rationale is simple and that is that the patient, especially if thumper supported and externally cooled, is going to be at above room temperature for many hours and in the range of 4C to 15C for many hours *in the absence of a functioning immune system. This makes the patient a culture dish for organisms, particularly cold anerobes or gram negative bugs (toxin producing ones like the so-called "flesh eating bacteria" there has been so much hype about). Indeed, in such patients it is not uncommon to see distension of the gut and high intra-abdomnial pressure due to distension of the bowel with gas from bacterial action on food and mucosa: even when the patient has been promptly packed in ice following cardiac arrest. That's one reason I give antiobiotics during transport: it slows or stops this. There is yet another added and very important reason for sterile technique. You don't walk into a mosque in Iraq with your shoes on and then go to a food stall and pick up food with your left hand. The latter will cause the food vendor to shy away from you in disgust and refuse to sell you food. This is so because Islamic culture considers the left hand unclean and dirty (it is used to wipe and wash the genitals and anus after urination and/or defecation) Islamalso considersthe wearing of shoes in mosque to be disrespectful and dirty.. There is a certain rational basis to the latter and to the former too (we (my lover and I) don't wear our shoes inside our house either: no one with a yard full of geese, ducks, chickens a pig and so on, with any concept of cleanliness, would). What's my point here? Simple: In-field operations are going to go on in front of medical personnel and family. THEY do not understand about nanotechnology, or even really about Bogata bags, survival of patients with fecal contamination of the abdomen etc., and what the implications of these things are for future (more advanced) medical technology. What they DO have deeply ingrained in them is the importance of sterile technique and the importance of Universal Precautions in avoiding the spread of very dangerous nosocomial (hospital bug) infections from patient to patient and to staff. Failure to use good sterile technique in the field radically reduces the medical staff's respect for the both the cryonics technicians giving cryonics care and for cryonics itself. Here we are dealing with DEEP emotional issues, and DEEP professional conditioning. I have enough problems selling the basics of cryonics to family and medical staff without taking on the shibbolith of abandoning sterile technique. Finally, and this is an example of something Bob does which really irritates me, I have not only stated the above arguments (in response to Bob and others) many times before, but I have also repeatedly pointed out the following one, which, once the patient is our hands, is the BEST argument for sterile technique in the world: Sterile technique cuts both ways. It not only protects a contemporary medical patient from contamination with infection (a matter of little consequence for cryonics patients) but it PROTECTS THE STAFF FROM INFECTION WITH THE PATIENT'S PATHOGENIC organisms. Most cryonics patients are in terrible shape when they die; by this I mean that they are profoundly immunosuppresed by diease, malnutrition, and often theraputic drugs. ( How many of you know that many (indeed most) antibiotics also are significantly immunosuppressive?!) In addition, such patients will frequently have nonsocomial infections consisting of highly antibiotic resistant bugs bred over the last 45 years or so in hospital environments. Such patients may well have bedsores or multiple other skin lesions from dressings (tape damage to skin), surgery, needle sticks, and so on, which are crawling with potentially infectious agents. Patients who have had ventilator support may well have really bad strains of Staph or Pseudomonas in the lungs, ET tubes and nasal/oral cavities or body secretions (saliva, lung edema fluid drainage, chest tube drainage, feces, urine, etc.). Many of these patients will have been treated with multiple antibiotics (and some will still have died of infection!) and many will have AIDS or chemotherapy making them colonies for CMV, EBV and other viruses (not to mention HIV!!!) as well as drug resistant bacteria. I have seen healthy people dead in 24-48 hours despite antibiotics from nosocomially transmitted, multi-drug resistant bugs. I have also seen hospital staff suffer serious morbidity and mortality from viral infection from ill patients. I myself spent 3 days in the ICU and about 6 weeks off work due to Hepatitis B infection. Nearly 1/3rd of our staff became infected and several died or were dying from chronic active Hepatitis B when I left my dialysis job in Indiana. Now, we have a vaccine against hepatitis B and ALL my staff gets it. (A new vaccine for hepatitis A, a food borne (fecal vehicle) and less serious form of hepatitis has just been released and we are in the process of vaccinating everyone for that). However, that does not cover staff for HIV. Nor for Hepatitis C which is highly infectious and has a far higher mortality and morbidity associated with it and which is on the rise (consider that many cryonics patients receive multiple infusions of blood products before legal death!). To give you an idea of what Hepatitis C does: Mickey Mantle and Larry Hagman both had/have liver cancer from this agent. In fact, it can be credibly argued that in both men the cirrotic changes and liver failure observed in them were more likely to due chronic active Hepatitis C than to alcohol intake. A lot more alcoholoics drink a lot harder than those two guys and didn't end up with liver failure. In the future, until newer antibiotics or other technology is deployed to deal with multi antibiotic resistant organisms, sterile technique or universal precautions are going to become increasing critical both in medicine and in cryonics. Any average Joe who reads TIME or NEWSWEEK will be aware of this problem. Since sterile products (particularly drapes, gloves and gowns) do not cost significantly more than the same quality of product which not sterile, and, since we can sterilize these items excepting gloves, in-house, we do so. Protecting the patient here is secondary to protecting the staff. Further, sterile technique, properly taught and rigidly enforced, is not just the use of sterile items on the patient. It includes: a) Not contaminating environmental surfaces with etiologic agents from the patient b) Handling sharps (anything that can cut or puncture skin) in a highly disciplined way designed to prevent puncture of other staff members. c)disposing of sharps in a highly disciplined way. d) Cleaning of instruments post operatively uising appropriate protective gear (face sheilds and nitrile rubber gloves) and disinfectants prior to sterilization. In BPI's operating room people can be assured that if they touch a door or cabinet handle they are not touching something that someone with sticky perfusate/blood contaminated hand (gloved or ungloved) touched a short while before. They can be confident that if they touch their eyes or lips or other body mucosa, or scratch a sore or scab after touching OR equipment door levers, or fixtures they are likely NOT infecting themselves with HIV, hepatiis, or antibiotic resistant bugs. Dr. Steve Harris used to yell me about laying #11 (very sharp and pointed) scalpel blades down on the instrument tray instead of tucking them under the towel in a consistent place on the tray. It is just too easy to get cut. Similarly, I think Steve revised his opionion of the importance of a scrub nurse in potentially HIV or infectious cases (i.e. ALL human cases) when he saw first hand how a an instrument tray gets jumbled up and can become a land-mine for someone rummaging around for the right instrument. A scrub nurse, which adds several hundred dollars to the cost of BPIs procedures, keeps the instrument tray in flawless (and truly awesome) order. S/he moves many "later used, or optional" instruments off the tray and on to the back-table to avoid overcrowding the tray, and, just as importantly, she anticipates the surgeon's needs and has the right instrument in her hands beforethe surgeon calls for it. This reduces frustration, reduces fatigue, increases the speed, smothness and skill of the surgeon, and greatly reduces the risk of a stick, cut and/or infection. While it could be aruged that sterile instruments need not be used, it could better be argued that if a staff members cuts him/her self on a nonsterile instrument (even one not used on a patient) the risk of infection is greater and the liklihood of a defensible position with OSHA, Worker's Comp and others is greatly diminished, if no tvaporized. My point in going to all this trouble and taking all this time is to point out that in human cases, giving up sterile technique, one of Bob's favorite criticisms, will not benefit the patient one whit. In fact, it can be argued that one lerthal, mutilating or even serious infection of a staff member will wipe out all the savings gained in dropping this option. Three times I have seen staff exposed to HIV+ fluid from cryonics patients. Leaving aside the anxiety there was the personal inconvience of using a condom, sexual abstinence or other unpleasant maneuvers with their spouses until seronegativity could be reasonably reliably established. And, while I've no doubt Bob and Ralph Merkle would be willing to take the stand to defend the cryonics organization facing litigation over this issue, I seriously doubt that their arguments about nanotechnology, more people getting frozen due to lower up front costs, etc. will impress a magistrate or jury who has just listened to a string of expert witnesses from the medical community with sterling credentials in infectious diseease control and epidemiology ( whose concern will also not be about the "patient" but about the staff member who BECAME a patient because the cryonics organization didn't practice a basic, well proven, deeply ingrained aspect of medicine). I think the above are plenty good reasons to continue sterile technique and to pay the relatively modest costs associated with it. In tubing packs which were single-wrapped and not sterilized in our lab both here and at Fullerton we have observed dead insects (hatched from eggs or crawled in through the one layer wrapper) and white sheets of "mildew?" partially occluding the tubing lumen. Sterilization thus ensures a "bottom" or "floor" level of quality which prevents the procedure slipping into something unacceptable. Look, its very simple really: if you have no specifications or parameters set out and enforced, then anything goes. Even in teaching kids to wash dishes certain inspection procedures are taught and enforced: as a child I got called back for hasty wash jobs to remove a stuck on fragment of egg, or other food remnants from crevices which I was in too muxch of a hurry to notice or to pecoccupied with other things to care about. This leaves out specs for things like amount of soap, water temperature, rinsing procedure, drying procedure etc. (for instance why not use somebody's bath towel from the shower rack to dry the dishes with; they only used it once, it's dry now and it smells OK, seems a shame to dirty another towel.... :) Funny? Yeah, but not so funny when it happens in medicine or you get sick from coliform bacteria or staph toxin. Finmally, I'll quote from recent post to one of the medical forums I participate in. This quote is TYPICAL and not unusual. It involves commentary on medication errors pccuring in a large hospital, but could just a Rate This Message: http://www.cryonet.org/cgi-bin/rate.cgi?msg=4661