CP Staff: Vigilante Justice!

From time to time, Camp Parsons staff are able to give back to the community, usually by assisting the Fire Department when extra manpower is needed.  However, yesterday, we were able to help the sheriff apprehend a serial maple tree thief.  

On Tuesday afternoon, I got a radio call that a tree fell down over the five-mile-hike trail.  Then, Thursday night, CIT outpost was cut short when chainsawing was heard in the northwest part of out property (used only for hiking and occasional outpost camping) for about two hours around midnight.  We went up on Friday afternoon to see where the tree had fallen and start clearing the trail.  It turned out, though, that the tree was actually cut down (sometime before Tuesday) and had been stripped of some bark and cut into seemingly random pieces.  A trail had been beaten down from the tree to the logging road just on the other side of the property line.

After a little research, I found that maple theft is a pretty common problem in the Olympic Forest and surrounding area.  Methamphetamine users have found that cutting down maple trees and selling certain parts of them for use in musical instruments.  They are usually not caught and are able to get a fair amount of money for small pieces of wood.  There's a pretty lengthy Seattle Weekly article from April that details this: http://www.seattleweekly.com/home/946487-129/wood-maple-says-timber-sisson-county.

So, the plot thickens on Saturday.  Four of us decided to go on a short hike to explore the area at the Northwest corner of the property.  As we walked up the trail, though, we heard chainsaws.  Suspecting that their operators were likely either armed, on drugs, or both, we stayed pretty far away.  When we were about 50 feet away, we saw three people just running over the crest of a hill.  We walked back down the hill and went around a different way to try to get at least a description of a vehicle.  Sure enough, right where I had seen the path beaten towards our trail there was a truck parked off the road.  We got into a position that we could see the truck but were well away and hidden.  

I called the Camp Director to let him know that the thieves were back and he called the sheriff.  We knew which road they likely came in on, so he parked off the highway to try and get a license plate.  We kept watching and called back when we heard the truck leave.  From that point, the timing was perfect.  The sheriff had just pulled in when the truck matching the description turned off the logging road and onto the highway.  The sheriff knew exactly who it was from the description of the truck.  Apparently they had been trying to catch him for a while, but hadn't been able to catch him in the act.  He tried to get away, but turned down a dead-end road and was quickly put in handcuffs and taken to jail.  He and one other man, as well as a woman (their lookout) were caught and are now without a truck, wood, and chainsaws.  This is this particular person's fourth or fifth time going to jail for the same crime over a 20-year period.  Hopefully this time, with multiple witnesses and his being caught red-handed, they can throw a heavier book at him. 

Crimes like this are frustrating because it's so hard to catch anyone.  We were all just tickled at the fact that the timing worked out so perfectly and that everything was in place for them to be caught quickly and without incident.  It's too bad that this 100+ year old tree had to die, but it's great that we could initiate the call that got the sheriff to catch their long-time target. 

Scouting Sashays Into the 21st Century

Last week, the Boy Scouts of America's National Council voted to change the organization's membership policy to lift restrictions based on sexual orientation. It reads as follows:

"Youth membership in the Boy Scouts of America is open to all youth who meet the specific membership requirements to join the Cub Scout, Boy Scout, Varsity Scout, Sea Scout, and Venturing programs. Membership in any program of the Boy Scouts of America requires the youth member to (a) subscribe to and abide by the values expressed in the Scout Oath and Scout Law, (b) subscribe to and abide by the precepts of the Declaration of Religious Principle (duty to God), and (c) demonstrate behavior that exemplifies the highest level of good conduct and respect for others and is consistent at all times with the values expressed in the Scout Oath and Scout Law. No youth may be denied membership in the Boy Scouts of America on the basis of sexual orientation or preference alone.  Additionally, the resolution maintained the Boy Scouts of America’s current membership policy for all adult leaders."

This is a huge step; I won't discount the fact that a change has been long overdue. However, it's important to realize that this change in policy is not yet a change in the organization's fundamental values; they still have a ways to go. At first glance this change seems like just what advocates wanted. However, when you consider the ramifications of this new policy, there's just as much ignorance and intolerance as ever. For their membership policy to be truly changed, it needs to apply to all members, not just youth.  

In their FAQs published along with the announcement of the policy, the BSA states "when members are no longer a youth participant, they must meet the requirements of our adult standards." The message they send with that statement is that they'll no longer exclude "out" youth from the start, but that they'll get the boot on their eighteenth birthday. The BSA is supposed to be an organization that builds character and develops hard-working, good citizens who contribute positively to society, so how, if the character built is intended to be sustainable for life, can they justify abandoning these youth at possibly one of the most difficult times of their life (realizing who they are and making the transition from childhood to adulthood). The BSA goes on to say "Scouting has always worked to ensure that it is a supportive and safe environment for young people, both physically and emotionally." That statement is obviously untrue from a historical stance, but as they move forward, how can they say they're actually supportive and safe when they throw you under the bus at age 18?

A big implication of this policy applies to Eagle Scouts. The "most attractive scenario" according to their survey was that "it would be unacceptable to deny an openly gay Scout an Eagle Scout Award solely because of his sexual orientation." Most people seem to push their requirements until the last minute, getting their award within a year of turning 18, so what's the message they send when saying they won't deny your award, yet they'll revoke your membership within a few months?  It's always been known that once you're an Eagle Scout, you're always an Eagle Scout. This policy gives scouts the false impression that they can be comfortable and supported as an out gay teen, yet if they do make their sexuality known, that dashes any chance of their being able to support their troop as an adult leader one day.

One thing that I completely agree with is their statement that "Scouting is a youth program, and any sexual conduct, whether homosexual or heterosexual, by youth of Scouting age is contrary to the virtues of Scouting." This has always been the case and I'm glad they included it. Any sort of inappropriate behavior in a scouting setting will (and should) have appropriate consequences, regardless of who it is. Two gay scouts getting physical or overly flirtatious on an outing should be thought of as just as inappropriate as a married couple (parents of a scout) doing the same thing or an older scout talking to his patrol about which "base" he and his girlfriend got to. 

The thing I am most disappointed in with this change is that it was a compromise from the original proposal (not differentiating between adults and youth).  The BSA says "As the National Executive Committee just completed a lengthy review process, there are no plans for further review on this matter."

That's what they think... 

I was reassured to hear an interview on KJR last week with Rob McKenna, who is part of the Seattle Council Executive Board subgroup that really pushed this issue to the forefront on the national level. He explained some of the reasoning behind the compromise. They felt that it was unlikely an all-inclusive policy would pass a vote. As the issue of youth is somewhat simpler than that of adults (not for logical reasons, but you do eliminate some of the 'gay=pedophile' believers' issues) and that the survey showed much more consensus in regards to gay youth, they were confident that this would have higher odds of success. Then, once some of the naysayers realize that the world isn't going to end on Jan 1, 2014, more people will be open about a policy that doesn't exclude gay leaders. Some are concerned that supportive organizations will pull out, which I'm sure will happen, but the financial support from the Fortune 500 companies holding back because of this issue alone will more than make up for it. It might just take some time to actually show the good in this change for the skeptics to do a little more batting for both teams (and for the social and financial best interests of the organization).  

So, National Council, you may have no plans for further consideration, but those working so hard recently aren't done yet. McKenna said that they aren't nearly done pushing for what's right and that this is only one step in the process. Those of us that disagree with the BSA's longstanding discrimination owe a lot to McKenna, Brad Tilden of Alaska Air Group, and the countless other Seattle Scouters who put a lot of effort in already and aren't giving up until the policy is fully changed. (Goes to show you that staying involved to do what's right can have a greater impact than a fleeting, dramatic gesture of turning in your Eagle award and quitting, like many have done.)

I've been surprised at the lack of religious group pushback. The Mormon Church (major population in scouting) released a new opinion on homosexuality a couple months ago, which isn't one of approval by a long shot, but did introduce some level of acceptance. A statement of the baptist church was recently brought to my attention as well; it's also not one of acceptance but is a sliver more open than before.  You can google these to read what they actually say, but my personal conclusion is that the opposing religious groups are seeing that the whole country (as well as the BSA, though at a much slower rate) is changing with or without 100% support and because they see the great value in scouting, they're starting to accept the new status quo, regardless of their disapproval. I've only heard of one case of complete disassociation, a Bremerton chartered organization (i.e. the church sponsoring the troop) that dropped their troop. I'm sure this is happening more, but the ones we lose will be replaced 100-fold by those we'll gain or get back.

There's a lot more to say, but I'll leave it at that for now. Scouting is the best youth organization to build character and develop boys into productive, valuable members of society. I'm glad that they have finally taken the first step towards non-discrimination so that all boys can benefit from all that scouting has to offer. It does really suck that they had to make this compromise for the time being, but one step is significant and it's reassuring to see that the driving force and support will not slow or stop until the job is done. When it comes down to the methods and ideals of scouting, sexuality shouldn't even be an issue whatsoever, but the fact that there are people being actively excluded means that the issue needs to be addressed. Any distraction from the program is unfortunate and I can't wait for the day we can say it's settled so all focus can be put on the program itself, but we're not yet there.

---------------------------

"Many...have commented that they are 'sick' of people talking about gay issues, or simply 'don't care' if someone is gay and would rather they would keep it to themselves. I find this disheartening.

There may come a day when we need not come out of the closet, and need not remind others of the terrible violence, inequity, and ostracism that LGBT people face daily because of who we are and who we love. But that day is not here, and more importantly will never get here, unless people continue to step forward and offer themselves as examples, often at great personal cost. I am called 'faggot,' 'degenerate,' 'queer,' and 'homo' by misguided people every day of my life...but this does not discourage me.  It only reminds me of how far we have to go. 

Once upon a time I was called a 'Jap' and put into a prison for four years with my entire family, for no other reason than who we were and who we looked like. It is my life's mission to fight against the dark forces of fear and intolerance that could ever lead again to such an injustice. 

Thank you for taking the time to listen. The next time you feel fatigue from hearing about LGBT issues, ask yourself this: Do we live yet in the kind of society where violence, hate and prejudice is not an issue? Until we do, be part of the solution, and stand always for justice and equality for all people." - George Takei

Message from the Inclusive Scouting Network

You may have heard about today's announcement from the BSA. I have a lot to say on this topic, as you might expect, but in the meantime (while I formulate thoughts into a readable form) this email went out this afternoon, which I found to be a very good explanation about the impact of this resolution if it is voted into policy:




The Inclusive Scouting Network


Dear Andrew Briggs,

We’re concerned and we hope you are too.

As you may have already heard, the Executive Council of the Boy Scouts of America released their proposed policy today, which keeps the gay ban in place for adult leaders but would prohibit kicking out openly gay Scout youth members “on the basis of sexual orientation or preference alone [emphasis added]”. The policy must be voted on at a national meeting of more than 1,400 Scout representatives in May and would not go into effect until 2014.

We believe the proposed policy is a small step forward, but does not go nearly far enough in addressing issues of discrimination against gay Boy Scout members and leaders. This policy maintains institutionalized discrimination, leaves open the possibility of harassment and bullying of gay youth, and continues to send the wrong message to youth members that discrimination is acceptable.

Under this policy, every gay Scout will eventually be kicked out -- it's only a question of when. Allowing a 16 year old to stay and complete his Eagle is a step forward, but why would he stay when the same policy will kick him out as soon as he turns 18? The message here is that LGBT people still aren't welcome in the BSA and have no future in Scouting.

We believe the proposed policy, though deeply flawed, is better than the current policy and therefore urge representatives to the national meeting in May to pass it. However, The Inclusive Scouting Network will continue working to ensure that the Boy Scouts of America will become a safe and affirming environment for all Scouts, regardless of sexual orientation, gender identity and religious belief. The only acceptable policy is a comprehensive national policy of non-discrimination that does not expire with age.

This is where you come in. We really need your help to continue working for change and providing Inclusive Scouting Awards for our allies within the BSA to wear and show their support for a more inclusive organization. Would you consider making a donation today to help us further our cause? Every dollar counts and is greatly appreciated as evidenced by the over 10,800 Inclusive Scouting Awards we have shipped in the past year alone!

Donate: http://www.inclusivescouting.net/about/donate/
Volunteer: http://www.inclusivescouting.net/volunteer/

Thank you for everything you do!

Chris, Mark, and Matt
Co-founders
The Inclusive Scouting Network
PO Box 2853, Malta, NY 12020

An ER over capacity, but still usually bored?

After tonight, I will be half way done with my Emergency Department rotation.  So far it has been a lot less exciting than I thought it would be.  That's not to say they haven't been busy, it just hasn't been with people who have any pharmacy-related needs.  I'll explain more in a bit, but here's a little bit about what I have done so far.  The only thing the ED pharmacist really does every day is following up on lab results for people who came and left, but results took a day or two to complete.  We'll evaluate the appropriateness of what drugs they did receive and, if necessary, consult one of the doctors for a decision that either they are okay untreated or they need a prescription.  We then have to call the patient and discuss the results, and sometimes call prescriptions in to their pharmacy.  Other than that, the day is spent answering the many (usually simple) questions that come up from nurses or doctors and participating in some of the more complicated procedures.  So if it's a slow day, there's not much to do.  But if there are a lot of sick patients, it can be a lot more interesting and fast-paced (which has been 2 of the 9 days so far).  

New things I've seen or helped with on this rotation (and they're fewer and farther between than for most students, since I had such a fantastic rotation last month) are chest tube placement with conscious sedation, an ankle reduction (using multiple people's brute force to pull a broken ankle into a splint-able position), and a little more experience with sedation/paralysis for intubation and post-cardiac-arrest management.  Also, since it has been slow most of the time, I have gotten to sit in on a few basic things not directly related to pharmacy but good general knowledge items if I am to work in that environment someday.  I helped transport a couple patients to CT and watched the scan, watched a couple central line placements, watched a PA drain an abscess, and observed the triage process for a couple hours.  Overall, though, it has been a pretty slow 2 weeks in terms of the percentage of my total time spent being something interesting.  Besides all that, I have gotten pretty good at interpreting and treating urine cultures, STD results, and common women's health complaints because of the daily labs I review (sometimes up to 50 or so).  I've also gotten to dose a few things, mix some IV drips, administer some medications, and set up infusions with smart pumps.  Not too glamorous or complicated, but I'm glad I'm getting the repetition and experience so I can confidently do those things when I'm out on my own, wherever that ends up being.

The biggest reason that my opportunity for experience has been slow in light of a sometimes overcrowded ED is because most of the people that come in don’t have any sort of emergency at all.  I knew that this was the case, but I had no idea how huge the difference was between the number of people that belong there and the number of people who could be more appropriately served at another, less emergent facility.  I realize that my personal threshold for thinking about seeking emergency care is higher than the average American, since I was raised in a healthcare-heavy family and also know a fair bit about first aid and diagnosis of simple conditions from scouts and school. But I still can't see how some people view certain things as grounds for going to the ED. 

A lot of people come in for something that has been bothering them for a week, two weeks, sometimes even a few months.  If it's been an issue for so long, why is it all of a sudden an emergency that needs to be evaluated right away?  Another common issue is people coming in if they need a test or imaging but their doctor can't schedule them for a week or two.  Sure, you may not want to wait 2 weeks for an STD test or an ultrasound to confirm a viable pregnancy, but those things are not emergent.  If your doctor isn't helpful, there are a number of walk-in clinics that do those things regularly.  There are also a lot of people that come in who don't need anything that couldn't be picked up at their local pharmacy.  And there are also a lot of people who were advised to do something (medications, follow-up, etc.) and didn't, so they just come back to the ED.

"My knee has been hurting for 6 months and I just played basketball and it hurts more."  Hmm… I wonder if you should have seen a doctor 4-5 months ago?

"I 'went out' with a woman and later she called me and said I should 'get myself checked out.'"  Ok, so go to a clinic, STD center, or even urgent care.  It's not an emergency room issue.

"I've been constipated for 2 days." 

Go to the store and get some Miralax.  If it's been a week and you're in pain, sure, come in, but 2 days is not a big deal. 

"I was just moving a bunch of furniture and my side hurts now." 

Ya think you could have pulled a muscle?  Heard of ice or heat packs? Tylenol? Ibuprofen?   

"I was here yesterday and diagnosed with the flu and I'm not better."  You were told to rest, take Tylenol for your fever, and drink plenty of fluids.  Do you really expect that just because you were in the ED yesterday, your flu will just *poof* go away overnight?

"I came in last month for this condition and was told to follow up with my doctor but I didn't and now it's worse."  Why should we treat you again if you're just going to ignore us anyway? It's your own fault for not following up!

Those are all real patient complaints I've heard over the last couple weeks.  Of course, you can't say those things to people.  Doctors will, and sometimes do, explain to patients that they really don't need to come to the ED for these non-emergent concerns and social workers will follow up with the frequent repeat customers discussing the concept of "primary care physicians," partially because Medicare and Medicaid are not paying for ED visits in certain cases (such as a man who came in 12 times in 15 months for the same non-emergent complaint).  It's hard to say what the reason is for people not making better decisions about the acuity of care they require (I think I'll write more about that in a separate post), but the outcome is often that people who really do need emergency care are left in the waiting room or in ambulances diverted to other hospitals because all the beds and nursing assignments are occupied by people who really shouldn't be in that setting.  There are urgent care clinics they can go to, and primary care doctors associated with public health or Medicaid for those who may not be able to afford private insurance.  It may be an insurance coverage issue, but also may be a lack of health knowledge in the population that creates this issue.

It's easy to get sarcastic and complain about the scads of people who don't have any business coming to the Emergency Department, but I don't want to gloss over the people that really do need that level of care and I'm glad there are so many great health care systems in the area that can provide that care.  Though my days are boring a lot of the time, when they are busier it is because there are patients that do have conditions that are either life-threatening or need care more urgently than making a doctor's appointment could guarantee.  At those times, I learn a lot and it is rewarding to see the pharmacists' and my knowledge put to use.  So I'll keep trudging through the boring parts and hope that the next interesting things comes up again soon, not wishing for people to be really sick, of course, but so I can learn more and get more exposure and comfort with the things pharmacists are asked about and the things we have to do.

Don't you have a job to do?

When did people start losing their work ethic?  Being an extern at so many places this year has given me the opportunity to see a lot of different work environments and I have, at times, been appalled at the lack of motivation that people have.  I just can't understand how someone can be content sitting and doing absolutely nothing during their paid shift at work.  For one, it is pretty darn boring; doing almost anything, tedious or unexciting as it may be, passes the time better than doing nothing.  And secondly, most employers don't pay you just to do nothing; even if your specific tasks are done, doing something to help someone else or doing a task that's not "your job" would be a better use of your time (and by association, your employer's money).

Here's a scenario I'm finding repeats itself almost anywhere you go: someone has a set list of responsibilities, which they do very well for the first part of their shift.  But after they've done those things that are "their job," they just stop working.  Sure, they do things here and there, but the majority of the latter part of their shift is spent just sitting/standing there, chatting with coworkers (thereby distracting them from doing their own job), browsing their phone/email/the internet, or the thing that surprises me the most: absolutely nothing!  If I even try to do that, I go bored out of my mind!  When these chatty Cathy's pull me into a conversation, I try to be polite by chatting for a brief moment, but I always have this feeling of needing to get back to some task or another.  Working nights at Ostroms, even when it was dead slow and everything was caught up, I had to be doing something productive in some way, even if I was talking to coworkers at the same time (making copies, cleaning something, restocking, etc.)  There are times to relax when I'm happy doing absolutely nothing but socializing, but when I'm doing a job, especially if it's paid, that isn't an option to me. 

The worst for me is when I am reporting to someone who just sits there for half of their shift because in some situations, if they don't give me a task, I can't really do anything either.  I try to find things to do (usually reading about topics I don't know) but there comes a point when I can't do anything more and it is excruciatingly boring to just sit in a chair, mindlessly clicking around at a computer for 6 hours of an 8 hour shift.  Maybe preceptors that don't really do much themselves shouldn't take students; their doing nothing means the student doesn't have much to do or learn, plus it just shows the student how lazy and unmotivated they are.  (I try not to think about the fact that people like this get hired over people with good work ethics just because they've been there longer or they know someone, or they have a better resume…)

What makes it worse is when "your" job is done but other people are running around like headless chickens.  This happens in the ER a lot.  It can be really busy in terms of patient numbers but not in terms of difficult or critical patients.  There will inevitably be one or two people doing nothing because their patients are taken care of.  It would be a better use of their time and a really helpful thing for their coworkers if they did something, anything at all, that was productive whether it be cleaning up a blood spill, running to get supplies, getting vitals, or answering call lights for someone else's patients.

Scenarios like that also make me wonder if costs of services would go down if people worked harder.  If there's someone who doesn't really do anything for the last 2 hours of their shift, do they really need to be scheduled that long?  If a nurse delegates her tasks to a technician and then sits and gossips for half an hour, do they really need to pay that many nurses at a time?  As an employer, I wouldn't expect people to work themselves ragged non-stop for their whole shift (because there are busier times and times that are more relaxed – that balance is necessary for sanity during the crazy times), but I would expect that if they have some down time they do something, insignificant or simple as it may be, as long as it is in some way productive.

I guess I'll never understand why people that don't have a work ethic are that way.  Though they might not have the technical skills, I can name a ton of 14-18 year olds (camp staff) that could do a much better job than people I see in the workforce.  At camp, it's just expected that you keep yourself busy from 7:30 am to 10 pm.  If your job is done, you find somewhere else to help out or something else productive to do.  It's really too bad that that attitude isn't common in the general work force.  Wasting their employers' money aside, I still just can't figure out how people can feel content (or not guilty in some way) doing absolutely nothing for periods of time at work.  It's frustrating for those that work hard (or want to but can't, because of the lazy-bums), but hopefully it is something that puts those hard workers ahead when it comes to hiring and consideration for leadership positions.  I guess that work ethic is one of the reasons that adults coming to Camp Parsons say they’ll hire any staff member in a heartbeat; it's not the norm and it's a desirable and valuable quality to have.

An Unwelcome Change of Pace

As I have mentioned, I LOVED my January rotation. I could go on and on about why I liked my preceptors, the facility, and the other staff I got to work with. But I'll refrain for now. There is something I noticed though. What didn't strike me as obvious at the time, but I'm quickly realizing, is that a big difference in these rotations is in the perspective from which you are taught/treated. I now realize that the difference between finding annoyance or reward in an experience has more to do with that perspective/attitude than the tasks you actually do (though that can have a big effect, too, if its a major deficit).

Two of my inpatient rotations were at places that don't do any formal teaching. There's no residents (for the most part) and there are traditionally fewer students, also in part due to their locations. I took it for granted at the time, but I was treated more as a colleague than a student. I had plenty of oversight and opportunity to get help when I needed it, but I got an attitude of more "we don't have as many students, I don't exactly know what to do with you, so you can do the things we do." That was, for me, much more enjoyable and educational. Of course, at first I got a lot more guidance and direct supervision but I was left more to do my assigned tasks and to check in with questions or approval before taking action.

The alternative is what I have experienced at a facility that DOES do formal teaching. There is a lot more hand-holding and I don't feel like I am viewed as someone who is at the level in education that I am. I don't like being asked if I have questions every ten minutes. I am an adult, almost a doctor (which I say with the highest level of humility...just making a point) it should be assumed that if I have questions, I'll ask them, which I frequently do.

Here's another difference: it is very common for preceptors to ask students questions ("grill" them). But there comes a point when that is overkill. Sure, for most things it is worthwhile to discuss the underlying basics as part of the topic, but I don't think it's necessary to explain EVERYthing. A specific example is asking me: are you familiar with dosing of alteplase for ischemic stroke? If I say yes, that I did a presentation on stroke protocols and dosing, I would expect that the pharmacist trust my response and confidence, and not make me regurgitate "0.9 mg/kg total up to 90 mg with 10% as an IV bolus followed by the rest as an infusion over an hour." I'm not saying it's not reasonable or useful to "grill" the student, but the manner in which you do it makes a huge difference. It probably sounds like I'm just whining about minor things, and its difficult to articulate what I mean, especially when non-verbal cues play a role, but the issue I have is when I feel like I'm answering things for the sole reason of proving I know them instead of as a piece in basing or facilitating a discussion on the topic.

While appropriate for a first experience too much of these things in a more advanced rotation make for a little bit of "arrested development" and feels like a huge slow-down in my development of the clinical skill-set I've been so excited about lately.

I can think of a couple possible reasons for these differences. One was immediately apparent when I compare these more formal-teaching rotations to school (you know, that three-year period I just hated for these exact reasons...?) and all those "educational methodologies" they beat to death. You can tell pretty quickly if someone is a newer graduate that bought into that stuff. The other reason I see is that the majority of students aren't like I am when it comes to interpersonal skills and confidence. I am a pretty independent and non-soft-spoken person, especially compared to some of my classmates. If you give me a task, I can do it on my own and wouldn't hesitate to ask for help if I need it, or speak up if I don't know something. I'm not afraid of talking to people (calling patients, discussing issues with physicians, etc). The fact that many students need this excessive hand-holding is probably why it happens. I guess teaching hospital preceptors are so used to doing it that it's become the standard.

(So am I implying that the school accepts a whole bunch of people who don't possess the confidence, independence, and communication skills that are necessary for a pharmacist to have? Hmm... )

Now I'm making this conclusion pretty early, so nothing says it won't change over time. My point, though, is that students at this level should be held to a high standard. If they are new to something, guide them through it and build trust in their skills and judgment as you get to know them and as they become more comfortable - that's part of teaching. But also realize when you can skip the hand-holding and treat the student as less of a child (a little harsh, but that's how it feels sometimes) when they prove their competency right away. Someone that asks questions a lot doesn't need to be asked if they have more. And someone quick to admit they don't know or remember something shouldn't be questioned every time they say they do (vs. if they dodge questions or try to pull answers from their backside). If you can bypass the more elementary concepts, there's way more time to go into things you wouldn't otherwise get to. It can be more educational for the student as well as less monotonous for the preceptor.

This realization in the difference in teaching styles of smaller vs. large/teaching hospitals is very valuable for my job searching as well as (and more importantly) my possible residency prospects. It's something I'll have to look at closely to determine if a particular residency would be a year of being like a CIT of pharmacy or, the way it should be, as a graduate who is almost a colleague and just gaining experience in a more structured setting than OTJ training. In situations like this, I just have to plug away, go along with their methods, and hope that enough of proving I can be treated like an adult will result in exactly that. If not, I'll still have learned something at the end, even if it was not as much as I could have and was through a process of baby steps and extra hoops to jump through.

When it comes down to it, I am still just a student. All responsibility lies on the preceptor when the student is gone or if/when something goes wrong, but tailoring the experience to each student's personal and clinical abilities and knowledge in order to find a point between holding their hand and totally throwing them off the deep end is important at this point in professional education. It can still be done with sufficient oversight, effective teaching, and appropriate guidance and, while it may be impossible for those students whose skills are lacking, will make a very meaningful difference for those who can handle it.

(If only everyone was as confident, responsible, and able to communicate as the Camp Parsons Staff...)

A Month Well-Spent

This past Thursday was the last day of my ICU clinical pharmacy rotation.  That means I am more than halfway through my academic year: five done and four to go.  Out of the five rotations I have done, though, this was by far the most educational, interesting, and potentially life-altering.  My previous rotations, even the best of them, played themselves out to the end which usually came at a point where I was ready to move on to the next one, even if the experience was very positive.  However, this rotation left me wanting more.  Other pharmacy schools use six-week rotations (instead of the four weeks at UW) and this is one month where I wish I had those two extra weeks.  The things I did, and the things my preceptors did as part of their regular day, were the things I can see myself doing, and enjoying doing, for years to come.  As an example, in school I would read things because they would be on the test and because they were a little interesting sometimes.  But in this last month (and the one previous, to some extent) I read those same types of things because I felt a drive to learn more.  When I came across something I didn't know or remember from school, I was actually excited to figure it out; find research papers, look up fundamental concepts (microbiology, biochemistry, etc.) to cement what I found, learn about any related issues, and (when the prompt came in the form of a "drug information" question from a pharmacist or doctor) tell other providers a little about something new or interesting I learned.  Clinical Pharmacy keeps me constantly thinking, by expanding and finding the newest changes regarding my knowledge, and ultimately using that knowledge to either support the medical team or directly improve a patient's stay in the hospital.

My recent post about clinical pharmacy ("My Career Revelation") was sort of left hanging.  As I eluded to, not having this revelation until January means that I have missed the cutoff for residencies.  A Pharmacy Practice Residency is a one-year program for pharmacists (almost exclusively new graduates) to gain experience in clinical pharmacy.  As with most professions, those doing the hiring are looking for candidates with experience.  This is especially important in pharmacy where, as a new graduate, you are often put in positions where you have little immediate support in making decisions quickly (e.g. working the night shift as the only pharmacist in the hospital when a decision must be made or a question answered that couldn't wait until morning).  Because of that (and probably some other factors), a pharmacy manager would find more difficulty in someone fresh out of school over someone with experience.  So by doing a residency, you have an intensive year as a paid (though at a lower rate), licensed pharmacist, but who has extra guidance and support during the time you further develop and become more comfortable with clinical skills.  A year of residency training is supposedly viewed as approximately equivalent to three years of regular work experience when it comes to hiring.  Beyond that first year, you can also do a second-year residency in a specific discipline (e.g. critical care) to even further hone and become more comfortable with your skills and knowledge.  Thus, residencies are beneficial to a new pharmacist by giving them more knowledge and confidence before being thrown into the deep end, as well as by providing them with a way to get the experience that is almost always needed to be considered for a job.

Applying for residencies is even more complicated than applying to college.  There are applications for each individual site but they all go through a central agency.  Once a site decides they are interested in you as a candidate, you are brought in for an interview.  You may interview at a few to a dozen different sites, and at the end of that process, you rank your preferences.  Each residency director does the same: ranks their preferences of which candidates they would most like to extend an offer to.  Once all those rankings and choices are submitted, a computer does some sort of algorithm that "matches" sites to candidates.  As you would expect, that process is pretty long which is why thinking about applying in January is far too late when the process started in September. 

So what do I do?  The first things I heard were that candidates are not considered for a clinical position without a residency under their belt.  I heard this from the school as well as managers at hospitals I've rotated at.  That being said, more of the young (more recently graduated and hired) pharmacists I've met hadn't done a residency than had.  I thought that a residency was a make-or-break part of your job application, when in fact, someone who hasn't done a residency but is a fast learner and relates well to other people could have a leg up on someone with a residency but who lacks interpersonal skills or a drive to succeed.  My plan, as of now, is to look for a job in a hospital that will hire me without a residency.  That may not, and likely won't be the clinical job I'm looking for.  As an entry-level pharmacist, it will likely be a weekend or evening job working hours that people with more tenure don't want to work.  But if I can find a door to get a foot into, it would be an opportunity to get on-the-job experience that may lead into that clinical position I want in the end.  And if it doesn't, it would be a way of making an income as well as keeping myself current on clinical topics (vs. spending nine months in a QFC counting pills and losing knowledge to a lack of its use) until next year's residency cycle begins and I can apply at that time.  That sounds like I have it pretty well figured out, right?  Fundamentally, I think I do, but what I need to figure out now it is who to talk to, where and how to apply, and where to put my name out so I will have somewhere to work come summer.  Graduation seemed so far away even a month ago, but now that I'm figuring out where I'd like to end up and how close June 14^th actually is, I'm realizing I have a lot to do in the upcoming months.

You've had your flu shot, what about your booze shot?

I heard on the radio this morning that there are animal trials underway for a new injectable drug they referred to as a "shot against alcoholism." What it actually is (and I haven't looked into the actual study) is not like a vaccination, but probably more similar to a "depot" drug, akin to something like DepoProvera for birth control: a drug you can take orally every day or get an injection (this new drug is 6 months, from what I understand) which maintains its effect for an extended period of time. It sounds like what they're working on (in Chilean mice, so far) is similar to Antabuse (disulfiram) which is a pill you take every day as a deterrent to drinking. If you drink while it's in your system, it produces horrible sickness (think "worst hangover you can imagine") including significant nausea and vomiting.

So why would something like that work? You don't have to take it if you don't want, then you'd be able to drink without consequence. It's a form of aversion therapy (akin to Schick-Shadel) which has a couple common uses. First is people who are self-motivated enough to quit but for whom other attempts have failed. They may realize, most of the time, that they shouldn't drink, but they do at times of stress, in the evening after a hard day, etc. They can reliably take their pill every morning, knowing that they shouldn't drink, then when an urge comes about they have a physical barrier to overcome the thoughts like "one drink will be okay" that lead to relapse. It doesn't always work, though; they interviewed one of these patients on the radio who actually planned to stop taking it a few days before an event (e.g. Super Bowl party) but always The other subset would be people who have legal factors involved such as DUI, probation, etc. and who can't be depended upon to stay compliant. They will be more closely followed by health care providers or probation officers, sometimes visiting daily to observe their dose.

Either of these types of people can be lost to follow up or fail to take their pill every day so they can have a drink. This new idea for a 6-month injection eliminates that day-to-day variability in compliance. You can't think "I'll just not take it today so I can drink tomorrow" because the drug is in your system for way longer than that. It also provides a solution to the huge costs and personnel requirements with daily check-ups in the cases of probation and the like. So it seems like a perfect solution! Though, as now with Antabuse, it would probably still be reserved for refractory cases of alcoholism, that is, those people who have tried and failed the more traditional treatments.

I can see one potential problem, though. It isn't unique to a long-acting version, but as with any addiction treatment, there is more than the physical-chemical process. I could easily see how courts might just mandate this drug's use as part of sentencing for certain cases (DUI, repeat intoxication offenders) and leave it at that. However, you aren't truly treating an addiction if you stop the physical behavior but don't address the psychological, emotional, and mental changes involved in any drug or alcohol addiction. You shouldn't give someone this shot and send then out the door the same way that you shouldn't give methadone treatment (substitute/replacement for heroin/opiate addiction recovery) without providing counseling, support groups, 12-step programs, and other resources. That said, though, as long as a holistic approach to alcoholism treatment isn't lost in the presence of a novel, convenient drug/delivery method, this could promise to be a beneficial solution, both financially (with no need for daily monitoring and fewer repeat offenses) and in terms of treatment success (resulting in fewer losses/injuries/deaths), for people who can't make those last steps to completely cutting out alcohol. It may also be a feasible alternative to repeat offenses or incarceration for those with DUI history as a contingency of driver's license reinstatement in certain cases. It isn't into human clinical trials yet, so it's at least 4-5 years down the road, but it will be interesting to see if this drug is successful and how it could potentially improve alcoholism treatment.

The worst day of their life, an average day for us.

As I mentioned in my previous blog, there are a lot of differences between what you do and see as a clinical pharmacist vs. a retail pharmacist. A lot of it just has to do with the nature of drugs and therapy used in inpatient vs. outpatient settings, but clinical pharmacists also participate in more "real" or tangible aspects of patient care. After spending only seven weeks in hospital settings, especially the last three in ICU and Emergency settings, I've seen more patients at the end of their life than any retail pharmacist ever would. It was an interesting experience to see and participate in my first few life-or-death "code" situations. When you see such situations depicted on TV, it's a very solemn and often hectic serious of events, but that's not usually how things go in real life.

There isn't this scrambling and shouting of orders that you see when they get the paddles and shock someone on TV. People work fast, but since these events are an everyday occurrence, especially at hospitals that treat more critically-ill patients, everyone is more used to what might happen and can act in a prompt but calm manner. Rushing around and yelling may make for good primetime drama, but it only adds more confusion and potential for error in real life. Doctors will urgently ask for drugs, shock, procedures, etc. but they do so in a methodical and calm way to ensure clarity and understanding for those administering treatment and the person recording what is done. Sometimes it even seems like they're teaching a class while treating a patient.

It's also not uncommon, except in the most difficult and complicated codes, for people to be smiling or even cracking jokes sometimes. That's not to say that they don't care about the patient; I have never seen a patient treated with less than the highest level of care and concern. But when you see these things every day, you quickly forget about the raw morbidity of the situation in the moment. This is a good thing, though. It's hard to stay focused on treatment and doing your job when emotion stands in the way, as it can be a very powerful factor. Critical conditions, terrible medical events, and death are just part of the job and some level of objectivity is important to keep focused on that one patient and all the patients after her.

Scrubs has been called the most accurate medical show on TV and I wholeheartedly agree. A lot of that is because of the more serious (non-comedic) situations like what Dr. Cox told Turk when he took a patient's death too hard: "You see Dr. Wen in there? He's explaining to that family that something went wrong and that the patient died. He's gonna tell them what happened, he's gonna say he's sorry, then he's gonna go back to work. Do you think anybody else in that room is going back to work today? That is why we distance ourselves, that is why we make jokes. We don't do it because it's fun, we do it so we can get by and sometimes because it's fun. But mostly it's the gettin' by thing."

Of course, that objectivity and ability to distance yourself is not always easy. Sometimes you have a "Jane Doe" patient brought in by ambulance who has so many tubes and lines in place that it's hard to see what she looks like. That's not as hard. But when it's someone who you recently saw up and talking who is now critically ill, or someone whose spouse is brought in crying to hold their hand, it's a lot harder to distance yourself. Or if it's a person who was otherwise healthy and suffered an unexpected sudden event, there's more emotion involved than in the case of someone who, through a long series of poor choices, put themselves into their condition (a "this could happen to me/someone I care about" factor).

I am always very vigilant for the presence of family. Usually the family is not present in the most serious/unstable part of code situations but are brought in once the patient has been somewhat stabilized. Those family members are usually not familiar with how situations like this are handled in a hospital and things you do or say that are common from a medical perspective and matter-of-fact can be taken as insensitive by someone who is experiencing a personal tragedy and one of the worst days of their life. Though I'm not religious myself, I really value the spiritual staff of a hospital because they don't have to worry about the patient's treatment at all but are there to provide a link between the family and the medical personnel. They do things like explain the condition of the patient in accurate but sensitive terms and explain why certain interventions have been taken in a way that someone with no medical training can understand. It is a better way to treat both the patient, medically, and their family, emotionally, to have separate people responsible for those very different but also very important things.

As I said in my last blog, clinical pharmacy is what I want to do. From reading all that I just wrote, you might be asking why I would want to be around death and illness every day. It's not about that, though, as much as it's about the rewarding things I would do to help people recover from illness or injury. People who are in a hospital, as either patients or visitors, are not happy to be there. Because of that, it's easy to think of reasons not to want to work there, but I believe that the rewards I can find in improving someone's care, either through direct interventions or indirect recommendations or support services would easily outweigh the surrounding sadness and tragedy.

I don't expect it to become any less heart-wrenching to see kids coming into an ICU to see their grandparent for the last time (and I could never see myself having a job where I was directly involved in breaking that news), and I hope I don't ever become numb to those situations, but it is an unfortunate reality of working in that setting. Sure, there will be more difficult situations to deal with throughout a career in a hospital vs. a retail store, but they won't overshadow the sense of accomplishment of improving patient care, as long as they are looked upon with just the right balance of objectivity in treatment and compassion for patients and their families.

My Career Revelation

If you asked me where I saw myself working after graduation any time throughout pharmacy school, I wouldn't hesitate in saying that a community/family/retail store was the place I wanted to be. Since I did my first hospital rotation last month, though, I see that as only a fall-back option. My only hospital exposure before last month was the introductory experience at UWMC a couple years ago. While I was there, I really only saw the factory-like dispensing/order entry pharmacist duties. Sure, there were questions from doctors and a couple times they would talk to a patient, but it seemed like the part of retail I'm not as fond of, just in a basement with almost no outside contact. After a month at a rural hospital and a couple weeks into a critical care rotation at a larger hospital, though, I have been exposed to and given the opportunity to do some of the many clinical things that pharmacists do in a hospital setting.

A clinical pharmacist plays an integral role in the healthcare team. Doctors have a lot of things to think about when treating a patient and it's simply not feasible to expect them to do or know everything; thus, the total care of the patient depends on people from many different healthcare disciplines. A few examples of things pharmacists do as part of this team are daily monitoring of end-organ function and re-dosing of drugs accordingly, management of drugs (antibiotics and anticoagulants mostly) that require very individualized dosing and need frequent monitoring, recommendation of anticoagulants to prevent clots while in the hospital, and regular evaluation of antibiotic choice for indications, susceptibility results from cultures, cost, toxicity, etc. Pharmacists are also heavily relied upon for drug dosing, recommendation, and preparation in situations like cardiac/respiratory arrest, blood pressure support, and intubation.

In today's hospitals, the pharmacist is part of the "team," not just a voice on the phone coming from the basement pharmacy. We can make recommendations to doctors about possible changes when we see something that can be changed or adjusted, and for many things there are protocols that allow pharmacists to make the changes themselves (e.g. changing an antibiotic dose when renal function changes). Most doctors are glad to have someone focused on the drugs specifically and we often get asked for input on decisions about drug choice or dosing. (Of course, there are pharmacists that take this too far and assume the position of telling the doctor what needs to happen or what was done wrong. They're shut down pretty quickly, though, and that's a whole different topic…)

What a lot of the difference between retail and hospital comes down to, from my perspective, is the need for professional/clinical judgment and decision-making. There are some aspects of retail where the pharmacist has to make these types of decisions, but unless a prescriber calls for advice or something is so out-of-whack that you call them to clarify, there often isn't enough information to form an opinion. All you have is the list of things they've had filled at your pharmacy, the prescription in front of you, and sometimes the patient's word (which can be variable, especially in elderly patients who didn't understand what their doctor told them). Sure, you catch big issues sometimes, but the little intricacies of drug therapy that a pharmacist is trained to evaluate usually slip by because you don't have the patient's history or lab results and you aren't physically there with the prescriber (and face-to-face interaction with doctors really does make a difference).

Don't get me wrong, I really do enjoy the "heart" of retail pharmacy. Talking to customers that have been coming in to your store for years, being a trusted person to come to with ailments that don't warrant a trip to the doctor, teaching people about their glucose meters and compression hose, and many other things are what drew me to pharmacy in the first place. However, with the amount of time you have to spend dealing with insurance companies, steadily declining reimbursement rates, and ever-expanding big box stores are crushing the small pharmacies, the only ones that provide these services. Sure, I could find a job at one of the few independent stores and be very happy for a while, but who know how long before that totally dies out and either factory/production-line or mail-order pharmacies take over completely. I think the monotony of filling and checking prescriptions would quickly take over the attractive aspects of customer service, too, especially with the need to process more prescriptions just to remain profitable. Being a clinical pharmacist will have its monotonous tasks too (entering orders, going through reports), but it is a growing field that I find much more mentally stimulating. And every pharmacist I've talked to so far has said that you can easily switch from hospital to retail at any point in your life, but it's rare and much more difficult to do the opposite. So if I want to have a clinical position, the time to act is now.

So how do I go about this? Unfortunately, it's not as easy as just applying to a hospital instead of a store. Inpatient pharmacy managers are looking, almost exclusively, for candidates with post-graduate training. Since I had this revelation within the last couple months and not a year ago, I've missed the whole application process for residencies starting after graduation. The plus side of that is I won't be starting a residency during the summer and can work at Camp Parsons. But that also means that I'll have to figure out some sort of plan for the upcoming year that I hadn't ever thought to consider until now. To be continued…

A Few Words on Guns

It's been quite a while since I've written one of these things.  It was a busy summer and it's been a busy year doing my last year rotations for pharmacy school.  I have thought of numerous blog topics, but haven't really ever sat down to write one of them.  The thing that prompted me to write this one was the three very heated conversations I've been around in the last 5 days on the topic and the fact that I am not one to interrupt such "discussions" so never really got to explain my take.  So here goes…

I could write for days about gun control and the different opinions of people all across the spectrum from complete pacifists to anarchists (and we're seeing all kinds come out of the woodwork right now).  I don't want to do that, though, I just want to address what I think the problem actually is and some reasonable solutions for improving our system and hopefully preventing some of the violence and tragedies we have seen.

MENTAL HEALTH

The first solution I think of every time I hear one of these stories on the news is not related to gun control, but to mental health.  Society has moved a long way from putting all of the people with mental disabilities in asylums, but there is still a stigma.  That and the fact that mental illness can't be visually seen and isn't as easily measured makes it difficult for people to get help.  It is just as important to evaluate our mental health options for children (especially those with broken homes or living in lower-income households) and for adults who can't afford it or don't have the support of family and friends that is often taken for granted.  I don't have any idea what a specific improvement would be, as I have little experience with or knowledge of  that system, but it needs attention and it is a shame that gun control pushes this very important medical factor out of the public's eye every time there's a similar tragedy.

GUN SAFETY AT HOME AND WITH YOUR KIDS

Now for gun control itself.  Before we go so far as to ban everything or start taking away guns from people who would never use them in a crime, there are numerous things that could be done to control gun violence and injuries.  The first is safety at home.  Gun owners have a HUGE responsibility with security.  Owning a gun means that you are responsible for where it is and whose hands it gets into.  For someone who lives alone, that may be as easy as keeping guns out of sight from outside, keeping your house locked,  and keeping reasonable measures in place to deter theft.  However, in homes with other people, especially children, there are more steps that need to be taken.  Gun locks and safes come in a huge variety of options.  You can get a big climate-controlled, Fort-Knox-like gun safe, but you can also get a sturdy lock for less than ten dollars.  There is no reason why someone in your house should be able to get to your gun if you don't intend them to.  Many of the tragic shootings are not committed by gun owners themselves, but by people who live in a house where guns have been left unsecured and/or accessible.  Another thing that should be done in households with guns is the education of kids at a young age.  What you let your child do at what age all depends on your comfort level, beliefs, and their maturity.  At minimum, though, you can't just keep guns hidden and not discuss safety.  Kids are curious and will find anything you try to hide.  So a better option is to teach them what a gun is, how they can be used for their intended purposes, but also dangerous and fatal if used improperly.  For older children, safe gun handling is vital.  The three basic rules, if followed, can prevent almost any accident: always keep the gun pointed in a safe direction, always keep the gun unloaded until ready to use, and always keep your finger off the trigger until ready to use.   In addition to those: don't ever touch a gun at home or at someone else's house without asking permission from your parents.  If you don't want to teach a kid to shoot or use the gun, fine.  But at least teach them how to be safe when there's a gun in the house.

GUN LICENSING?

Ok now here's my fix for the gun control issue that we're facing as a country.  Licensing.  When you turn 16 and wish to drive, you can get your driver's license.  When you turn an appropriate age and would like to buy, own, or use a gun, there should be a license for that.  Just like there are requirements for classes and exams (both written/knowledge and practical exams) for driving, there should be training and exam requirements for gun ownership.  When you get that license, they would do a criminal background check as well as a check for history of mental illness (which, if present, would be evaluated by a physician for relevance to gun safety concerns).  Just like you have to renew your driver's license, you would have to renew your gun license.  Those checks would be repeated upon each renewal.  When I buy a gun, I have absolutely no problem with background checks, and wouldn't even if they were required periodically after the initial purchase.  Neither should anyone else who owns a gun for non-criminal purposes.  Yes, it would be even more of a hassle than the process is now, but when it comes to the safety and security of schools and society, you should be willing to step through a couple of hoops for an elective purchase of something that has the potential to easily be lethal in the wrong hands.

OUR RIGHTS AND BETTER MANAGEMENT THAN OUTRIGHT BANS

With all I said about licensing, you'll notice I didn't say anything about the government telling you what you can and can't have.  Sure, high-capacity magazines aren't NECESSARY.  And there are a lot of situations where semi-automatic actions are more than you need.  But restrictions on those things shouldn't be made on a global level, they should be made for specific situations.  Pistols have the potential to be more dangerous and tricky to handle than long guns.  So don't ban them for everyone, implement an age requirement (which we have: 18 to buy a long gun, 21 for a pistol).  Having a gun where alcohol is consumed opens up more room for problems.  So don’t ban the gun, just restrict what you can have with you at various locations (bars, stadiums, schools, etc.).  I personally don't think there's any reason a regular citizen would  need an "assault rifle," but as Americans, we have rights to own what we choose to own, even if there are requirements to doing so. The answer isn't tightening down what you can and can't have, it's in ensuring that people who own guns are adequately knowledgeable in safety and have been background-checked and that special locations or circumstances are evaluated and mitigated individually.  (One exception is that I don't think there's any reason for anyone to have an automatic gun, but I'm not going to delve into detail there.)

IN CONCLUSION

So in summary (whew, that was a long blog), the answer to gun control shouldn't be to ban guns altogether but rather to enhance our current system in a way that better reviews criminal and mental history as well as evaluates a buyer's knowledge, skills, and attitude in regards to gun safety.  Gun-owning parents need to educate their children on firearm safety and all gun owners need to put sufficient measures in place to prevent unauthorized access to their guns.  I found a quotation from Thomas Jefferson (said to George Washington): "One loves to possess arms, though they hope never to have occasion for them."  That statement describes me pretty well.  I got interested in guns after running a rifle range and teaching various courses, and I enjoy the sport of target shooting, plinking, and trap/skeet.  I don't hunt, but only because I don't want to deal with the associated mess.  And having guns for home/personal defense gives some piece of mind, but I hope I'm never in a situation that they'd be necessary for that.  If we do ban guns, the criminals will still get them one way or another.  That ban would affect the law-abiding citizen and probably wouldn't reduce crime in the way gun-ban-advocates would hope.  I'll close with an interesting comparison and another quote from Jefferson.

Chicago has some of the most stringent gun control laws, yet is on the very high end of crime rates.  In contrast, a small city in Montana required  every adult to carry a gun for a certain period of time and the crime rate went down to zero.  (Just some food for thought).

"Laws that forbid the carrying of arms . . . disarm only those who are neither inclined nor determined to commit crimes . . . Such laws make things worse for the assaulted and better for the assailants; they serve rather to encourage than to prevent homicides, for an unarmed man may be attacked with greater confidence than an armed man." 
--Thomas Jefferson, quoting Cesare Beccaria in On Crimes and Punishment (1764).