On CRPS: Physiotherapist Holly v. Psychiatrist Bass

A wonderful response to what amounts to a poor opinion piece.  Here is the road map to the original "personal view":

VIEWS & REVIEWS
Personal View
Complex regional pain syndrome medicalises limb pain
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2631 (Published 28 April 2014)

The "Personal View" was proffered by:

Christopher Bass 

consultant liaison psychiatrist, 

John Radcliffe Hospital, 

Oxford OX3 9DU, UK

Christopher.bass@oxfordhealth.nhs.uk

Psychosocial factors may be more important than biomedical ones in type 1 disorder, writes Christopher Bass... 

I am a psychiatrist who has worked in general hospitals and pain clinics since the 1970s and have assessed many patients given a diagnosis of type 1 complex regional pain syndrome (CRPS). The syndrome is often diagnosed by inexperienced junior doctors when confronted by patients with unexplained symptoms, especially pain in the hands and feet. CRPS was once called algodystrophy, then reflex sympathetic dystrophy, but by 1994 the sympathetic component was abandoned and the current term was introduced.1 CRPS is part of a larger problem in chronic pain and reflects our lack of knowledge of causal mechanisms. 

It has been my impression that increasing numbers of patients are being diagnosed with this disorder, and that incidence rates are increasing (estimates in 2007 of 50 000 new cases annually in USA).2 In my opinion excessive reliance on this so called biomedical diagnosis for these patients is misguided. How has this occurred? 

Several new diagnostic criteria have been proposed,3 but they are not sufficiently objective or reliable.4 For example, criteria such as “continuing pain that is disproportionate to … 

 [This is where you have to fork over some bucks to continue reading... Entirely your call... Sign up for the temporary 14 day free trial to BMJ... But I bet Domino's has a hell of a special, maybe some sort of Kentucky Derby celebration... And for what it is worth, I have a current balance of $22,000 in credit card bills, most of at a very acceptable short term APR, so don't get too excited, youse true friends and relatives, especially given the rest of my medical debts, not subsidized by corrupt corporate banking, but by mine feeble monthly payments, designed to confound the best of creditors!]

This is where I insert more of my personal crap, because... because..?  Come on, you know why! Because:  Whose blog is it, anyway?

Because:  I've established my bona fides in these pages.

Because:  I'm in a shitload of pain right now, such that breathing in, so crucial to establishing one's shield against shitloads of pain, hurts so much that I am questioning the value of such a dull, repetitive bodily function.  Given that, you can just eat my grits should the rude insertion of my overblown opinions get your tidy whities in a discomfiting bunch.  If you're reading my erudite blog without the girding of underwear, perhaps you're looking for THIS (every blog post containing the word "porn").

My inserted personal crap amounts to this:  BMJ is worth the money.  Yes, more so than pizza.

Okay, returning to this exchange of opinions over several topics of common disagreement among health care professionals both interested in CRPS and interested as well as INFORMED about CRPS.

Sure, the response also is opinionated, but restrained by science, and supported by it, as well. It was written [well] by: 

 
Janet T Holly, Physiotherapist Clinical Specialist in Pain Sciences; 

Clinical Researcher at The Ottawa Hospital Rehabilitation Centre; 

Clinical Epidemiology Program, 

The Ottawa Hospital Research Institute, 

505 Smyth Road 

Ottawa, Ontario, Canada

If I could fit her "rapid response" on a tee shirt, my holiday shopping for the year would be complete.

Maybe a custom coffee mug?  Or a very large shot glass?  En tout cas, here it is, earning the text background color of light, healing green versus the hint at purple prose given the good psychiatrist who first opined above.

It was with great interest that I read Dr. Bass’s viewpoint in BMJ. I am a physiotherapist who is a Clinical Specialist in Pain Sciences working in Canada and long have been frustrated by the impact of clinician language and behaviour on many rehabilitation diagnoses. I have 23 years working with pain patients and 5 to 6 years working with Complex Regional Pain Patients as a critical mass. I too have felt at times labels can be harmful for patients receiving adequate comprehensive care. Unlike Dr Bass however, I find the label chronic pain or non-specific pain can be just as harmful as patients are frequently told, “there is nothing I can do” or “get over it”. Both responses are inappropriate but aid to highlight that changing the label does not change the problem that Dr. Bass is trying to address. Non-specific pain does not immediately lead to proper assessment and treatment of psychosocial flags.

He is correct that there is some cause for criticism of the Budapest Criteria and those involved in the world of research of complex regional pain are striving to improve upon these. However, The Budapest Criteria do have a specificity of 0.68 and a sensitivity of 0.99. In the world of clinical diagnostic testing, there are certainly worst tests for sensitivity and specificity. Continuing pain, which is disproportionate to the inciting event, is not the sole diagnostic criteria but rather they must report both one symptom in three or more categories and one sign in two or more categories at the time of the assessment. 1

The studies he alluded to re brief immobilisation and prolonged casting of a limb producing signs and symptoms mimicking CRPS drew no definitive conclusions re causation or potential future treatment. 2,3 Rather they were an insight as to where researchers may want to direct their efforts further. It is far too early in the game to be taking two studies and drawing conclusions re causation when the neurophysiology and immunology behind CRPS is complex and still being determined.

CRPS can cause profound disability in some but not all patients. The reference he used to support psychosocial factors being a potential causative factor is for general chronic pain.

Beerthuizen et al, 2011 actually did not find psychosocial factors pre-disposed individuals to CRPS. 4 This also is only one study and as such too early to make a judgment.

There are some distinct differences in those with chronic pain versus those with CRPS and the literature should not be intertwined. One of the main principles of applying best practice principles to a population is the literature has to match the context of the population. 5 Patients with chronic low back pain do not get spontaneous swelling, cooling or heating of a body area, loss of motor initiation, trophic changes, extensive loss of sensation etc…. the two groups cannot be compared. In addition, there is a subgroup of CRPS that have pain but the biggest disabling features are the temperature changes, trophic changes and swelling, not pain. As such, the term arm ache or leg ache or non-specific arm pain does not describe the population well at all. In addition, there are treatment techniques such as graded motor imagery that have some clinical level of success for CRPS but are not so useful for chronic non-specific low back and neck pain. 6 Lumping all pain diagnoses together will limit the usefulness of matching treatments that have positive effects on the subgroups where they are successful.

I agree screening for psychosocial factors is necessary to manage any condition, not just pain conditions. The tools he mentions are good ones for depression and pain and easy to use by all clinicians in busy practices. I would add screening for sleep dysfunction as this too has a large impact on healing and pain control. Screening for depression, anxiety and sleep dysfunction was recommended by Rakesh, 2012 at the International Association for the Study of Pain Congress in Milan based on published literature. 7,8

Dr Bass makes a good point in his title that CRPS should not be medicalised. However, this holds true for any condition in medicine from pain to cardiac issues. The key to health in any domain is self-reflection and self-management with occasional interventional procedures from physicians or allied health professionals. True health is a work in progress and takes time. If we add medicalization and the usual resultant fear to any diagnosis, we disempower patients from managing their own care. Iatrogenic harm happens in all medical diagnostic groups not just pain patients. We, the entire medical community, do not cure patients. We teach them to manage the changes that aging, trauma and exposure to illnesses cause. The problem Dr. Bass wants to tackle is not the label we put on our patients but rather the lack of evidenced based knowledge of health professionals and ability at identification of psychosocial flags early on (optimally before CRPS even occurs by their general practitioner) and management of these flags. We must practice holistically not just in our areas of specialization. We also must start and continue to train incoming practitioners about the power of language, excessive diagnostic procedures and the need to be truly present with all diagnostic groups of patients. We need to let patients tell their narrative so that belief systems/fears etc... can be expressed and addressed immediately in every day non-threatening language. No one is too busy for this as we spend the time later down the line managing beliefs once they are ingrained. We also need to teach our clinicians about knowledge translation to patients, styles of learning, readiness to change and barriers to learning. Without practicing with all these tools in place we cannot demedicalise any diagnosis nor empower our patients to manage it. Changing the label only pushes the problem to a new label.

1. Harden, R. N., Bruehl, S., Perez, R. S., Birklein, F., Marinus, J., Maihofner, C., Lubenow, T., Buvanendran, A., Mackey, S., Graciosa, J., Moqilevski, M., Ramsden, C., Chont, M., Vatine, J. (2010). Validation of proposed diagnositc criteria (the "Budapest Criteria") for complex regional pain syndrome. Pain ,Aug 150, 268-274. doi:10.1016/j.pain.2010.04.030

2. Schott Gd. Complex?Regional?Pain ?Syndrome? Pract Neurol 2007;7:145-57

3. Singh HP, Davis TR. The effects of short-term dependency and immobility on skin temperature and colour in the hand. J Hand Surg Br 2006;31:611-5

4. Beerthuizwn A, Stronks DL, Huygen FJ et al. The association between psychological factors and the development of complex regional pain syndrome type 1 – a prospective multicenter study. Eur J Pain 2011; 15:971-5

5. Dartnell J, Hemming M, Collier J, Ollenschlaeger G. Putting evidence into context: some advice for guideline writers. Evid Based Nurs 2008; 11:6-8 doi:10.1136ebn.11.1.6

6.. Moseley GL: Graded motor imagery is effective for long-standing complex regional pain syndrome. Pain 108:192-198.

7. Gupta A, Silman AJ, Ray D, Morriss R, et al. (2007). The role of psychosocial factors in predicting the onset of chronic widespread pain: results from a prospective population-based study. Rheumatology 46(4):666-71.

8. Meyer-rosberg K, Kvarnstrom A, Kinnman E, Gordh T, Nordfors L-O, Kristofferson A. Peripheral neuropathic pain – a multidimensional burden for patients. EJP 5(4):379-89 doi:10.1053/eujp.2001.0259

Competing interests: None declared

Write on, Janet T Holly, Physiotherapist Clinical Specialist in Pain Sciences and Clinical Researcher at The Ottawa Hospital Rehabilitation Centre, undoubted star of the Clinical Epidemiology Program... and, apparently, skier extraordinaire. 

Denizens and Mavens: Cultural Equity

A new YouTube channel, as yet having produced two videos, and promising but one new one every other week, called HelloDenizen -- owned by the advertising agency Denizen -- caught my eye. The Mad Men and Women of Denizen declare that:

Denizen develops wide reaching, highly engaging, strategically targeted social media campaigns that generate cultural equity and guarantee high levels of engagement for your brand. 

I cannot quite figure how an ad agency, no matter its dedication to things social, "generate[s] cultural equity." If you can quite figure it, please leave me a clue.

It's been a day of high pain, including a newbie, a pain in my upper left chest that radiates through the back, in the creepy manner of a letter opener turned shiv, and also throbs under my arm pit, making me and my complaint recipients think it's likely the infection trying new tricks.  That's after ruling out a heart attack because I lived through the night.  We a bunch o'Spocks here at Marlinspike Hall.

Hence, the seeking of relief via stupid videos. It hurts to breathe in, but not out.  (I -- lax -- left out a symptom.  What?  What's that?  "Stress?"  Umm, yes, a bit.  The quotidian worry set of a Planetary Citizen, for...  "So it goes.")

Unbeknownst to this ad agency with high production standards for its tiny hamsters and burritos, I have a *thing* about the word "denizen." It pairs, like a crisp, tart apple with the butter of a superb cold chardonnay, with the word "maven."

Never underestimate a maven.

maven (n.) 1965, from Yiddish meyvn, from Hebrew mebhin, literally "one who understands." Plural is mayvinim.

Another "unbeknownst" thing:  all mavens, all mayvinim, are women.

Betcha didn't see that coming.

Just remember, the next time you are tossing the term "denizen" about with an unbecoming nonchalance, that mavens merit a mention, too.  Even just as much.  Generate a little subversive cultural equity.

denizen (n.)early 15c., from Anglo-French deinzein, from deinz "within, inside," from Late Latin deintus, from de- "from" + intus "within" (see ento-). Historically, an alien admitted to certain rights of citizenship; a naturalized citizen.

The Genius Behind CALMARE and CTTC: Meet Giuseppe "The Vulture" Marineo

I've not mentioned CALMARE in quite some time.  First, I had one of its ardent supporters ask me to please "leave me alone," and the whine rang through the writing such that I felt guilty for the poor man. Then, my disgust having reached such an acidic state, it was either fork over another $100 for stomach medication or ignore the scam, ignore the scammers, including poor Joey and his "leave me alone" [sniff, sniff].

Actually, what came first was an extraordinarily prayerful woman badgering me on YouTube -- so well known for the quality of its commentary -- when I did not praise her Lord and sign up for Calmare treatments immediately.  They cured one of her offspring, you see.  She repeated a bunch of FDA rubbish, then some VA rubbish, then plain rubbish.  Then she got personal.  Anyway.

I conducted myself with my usual bendy, bendy politeness, and watched as she moved on to praise her Lord in the comment section of other people suffering with CRPS.  It was almost as if she were paid to do it, or something.  Anyway.

CTTC is the corporate entity that markets CALMARE / Scrambler Therapy as a cure for various neuropathies, including CRPS, post-herpetic neuralgias, and the nerve pain that can be engendered by chemotherapies.  It's crucial that the public understand that CTTC does nothing but coopt the patents for various products.  CTTC sells its soul to sell, it does not have any real investment in the product, and in this case, the patients -- just in the public perception of the product, and how cheaply they can buy up patents.

In their fertilization of the advertising world with CALMARE and CALMARE-related pellets of untruth, CTTC peppers social media, patient support groups, and advertisements dressed up as pain management newsletters or health-related articles decorated as actual research.  Videos have been widely distributed, starring cured patients who tearfully recall their prior suffering state, while never documenting that state in the recordings.  The Testimonial approach to CALMARE / Scrambler Therapy duplicates the get-rich-quick late night infomercial -- in methodology as in message (tremendous, too good to believe results with no effort beyond prying loose a credit card from a tight wallet).

I have many favorite lines among the testimonialists.  Right now it's I-am-so-thankful-for-Calmare because (prepare to weep):

"I have an allergic reaction to all medications. I cannot even have chemotherapy with stage 4 cancer."

I am not without a tender heart, as I ponder all the people I have known whose bodies relished the poisons of their chemotherapies and who never had any distressing reaction to the harsh chemicals coursing through their systems, at all.

The Straight Dope message board, my source for straight dope messages, once briefly contemplated how these remarkable testimonials come to life:

User ARCHETYPE, a naive sort, starts the conversation:

Infomercial testimonials
How do they get people to so convincingly testify in those infomercials?
Some (especially the latest ab gadget or those get-rich-quick products) are scams and the thing that gets me most is how they get these people to so convincingly testify. Some infomercials even state that their testifiers are not compensated.
It boggles me in three levels:
1) You KNOW the product can never work as advertised.
Home-based businesses. After researching some of the home-based business on the net and discovering how their scams actually work and reading unfortunate purchasers' stories you know it is not as simple as "making $12,000 for a few hours of work in my spare time in my underwear."
The latest ab gadget. Losing weight involves diet and much more significant exercise, cardio, etc. than just crunching the damn machine 5 minutes a day.
2) This applies more to products that are brand new in the market (I can't think of any specific ones at this moment!). But how do they find the people who have used a certain product it for X amount of months or years when you know that this is the first time it is being advertised?
Now, I'm aware of such things as test markets but how do they market to those test markets? And how do they find people who had success with their products when it clearly cannot work and convince these people to testify for their product?
3) What's in it for these testifiers? Is it a lot of money? Aren't they afraid their friends and family might see their testimony?

So how do they get these testimonies? Are they all lying and/or are paid actors despite the disclaimers that they are not?

ARCHTYPE receives many thoughtful responses, but I think the essence of them all is best encapsulated by user T-BONHAM:

They lie. LIE.
After all, if you are ripping people off by selling them a product that does not work, why would you hesitate to lie about testimonials?

Think of the marketing of CALMARE / Scrambler Therapy as some sort of magic act.  Most such performances rely on distraction, sleight of hand, a spot light drawing the eye from the unlit area of ruse.

Most recently, I came upon a much-marketed CTTC/CALMARE/Scrambler Therapy saleswoman who has done her bit with a series of videos, and for the cream and cherry on top, she has a blog.  What's fascinating is that her blog, with scant entries over the years, never mentions her intense suffering from a "pain condition," until CALMARE enters the textual scene.  And, then, she does not mention CRPS! It's as if she and her corporate backers are afraid of being too specific.  She gives a semi-accurate description of CRPS but doesn't want to worry her readers or cause friends and family to fret by saying exactly what horrid "pain condition" is beleaguering those poor legs of hers... Good thing that her bogus treatments worked wonders, though she adds that indelible soupçon of believability by mentioning that she may have to have "booster" treatments.

Her name was Amanda, Amanda Something.  For some sick reason, whenever I look up her name, Phil Ochs' song "Miranda" * jumps my brain, and I find myself humming along with my sober researching. 

In the beginning, much was made of the inventor and original patent holder, Giuseppe Marineo.  He was called, falsely, "doctor" and "professor."  As he became more of an embarrassment, he received more in the way of money and CTTC got more in the way of "ownership" of the miracle device, so the marketing geniuses could begin to fashion the background into which he might fade.

As various gynecologists and chiropractors, stethoscopes slung rakishly about their necks, receptionists shadowing them in short white coats, took over the public face of CALMARE / Scrambler Therapy -- along with some of the strangest testimonial-givers on the planet -- the "scientist" behind the earth-shattering souped-up TENS unit was cast into oblivion.

No one bothered to answer questions relating to his claims and intentions.  

How did this machine come to be a treatment specific for intractable neuropathic pain when it began as Giuseppe Marineo's personal brand of woo, wrapped in a fake curriculum vitae, protected and obscured by Delta R&D, his "bioengineering research centre with a unique history."  Marineo's goal was apparently the creation of a device in the tradition of the Fountain of Youth, a modulated electric buzz that would retard aging at the cellular level.

Woo, woo. A quick woo primer:

Woo generally contains most of the following characteristics:

• A simple idea that purports to be the one answer to many problems (often including diseases)
• A "scientific-sounding" reason for how it works, but little to no actual science behind it; for example, quote mines of studies that if bent enough could be described in such a way to support it, outright misapplication of studies, or words that sound scientific but make no sense in the context they are used in
• It involves the supernatural and paranormal (not necessarily)
• A claim of persecution, usually perpetrated by the government or the pharmaceutical, medical, or scientific community
• An invocation of a scientific authority
• Prefers to use abundant testimonials over actual scientific research
• A claim that scientists are blind to the discovery, despite attempts to alert them
• A disdain for objective, randomized experimental controls, especially double-blind testing (which are kind of what makes epidemiology actually, y'know, work)
• And, usually, an offer to share the knowledge for a price.

Oh, the woo you are about to muddle through!

Put on your waders, and unpack this introduction to how Marineo went from a one-man show to an incorporated one-man show with a tenuous connection to a research university.

[Delta R & D] was born out of individual research work begun in 1983 by Giuseppe Marineo, a researcher and bioengineer, who advanced theories to reformulate the concept of disease (and the corresponding treatment) from a biophysical rather than biochemical point of view. The idea was to restructure the known features of both according to the principles of thermodynamics by means of an analysis and the detailed specification of the relations between entropy, disease, repair processes and ageing.

This new approach to the interpretation of the traditional aspects of medical science makes it possible to go from a highly heuristic system to an extremely conceptual and rationalized system, which can create models of disease and treatment so sophisticated as to render the experimental results highly predictable. If the latter are in line with the predictions they automatically validate the development model.  

Furthermore, the very name of the theoretical system developed entails a natural transition from reductionist methods to systems theory which, in the present research, takes the form of a powerful working tool capable of providing adequate support for the development of therapies of practical utility.

In practice Marineo introduced into medical science the research and development criteria typical of engineering, in which the thoroughness of the preliminary theoretical work fully determines the expectations of the experimental verification of the method used. In 1987 the basic research was already sufficiently well structured to be supported by a technology capable of translating the theoretical system into a truly useful therapy.

The first experimental verifications fully confirmed the validity of the theoretical models developed and opened up concrete future prospects for the safe and non-invasive treatment of pathologies for which conventional methods had proved ineffective.
In 1998 the Italian scientific community, which had been constantly informed of all research developments, deemed the product of 15 years research to be scientifically valid, the theoretical principles and experimental data to have been clearly demonstrated and the bioethical principles regarding the respect and protection of the patient to have been respected.

In other words, the research carried out by a private individual was accepted and supported by the public authorities. It was consequently possible to begin official university and hospital studies, at the conclusion of which the first international publications were produced.

In order to support these changes, in May 1998 Delta R&D was set up, thus marking the beginning of the mature stage of this individual research endeavour. Although the original philosophy was retained, a logistical structure was now available to satisfy the new phases of development and to maintain and expand relations with the international scientific community. 

I dare you to unpack this into meaningful language reflective of actual science, or even good business.
Or this, from a website now removed, written by the great Marineo, himself:

The assumed pre-coding capacity is a more logical explanation than stochastic fluctuation (which in this case must be re-interpreted as a consistent modification of the information content per stimulus/time) the different discharge time characteristic used by the receptor for the same stimulus if this occurs in sufficiently short time intervals. In this perspective, to return to our model, the comparator?? Is the arbitrary module that sorts the information, compares it with a short-term memory and if it recognizes a stimulus similar to the preceding one, modifies the gain data and the information property which it passes on to the amplifier/attenuator (synapsis), a vital element that controls the passage/non passage of the “decoded” information stripped of spurious signals, associating it with the correct degree of intensity. Again with reference to the model, the noise and stochastic variations are separated since, in my analysis, at least some of these fluctuations actually consist of sub-information capable of modifying the learning capacity and sensitivity to the stimulus if repeated over short time intervals. If the data are reinterpreted in this sense, frequency modulated discharge sequences immediately took on a different significance when combined with the “pseudo-noise” modulation accompanying them and which became an essential element of the “primary” information. At this stage I considered that I had all the elements required to materially construct a pain scrambler (technically an information mixer), that is, a system capable of “masking” the pain signal.

Here's another, still extant (if badly translated by Google -- I apologize for my lack of skill in Italian) version of the the birth of the great regenerative process, the Scrambler Therapy.  Marineo simply MUST have a genetic link with the superb Ponce de Leon.  This comes in an English version... already cited.  It was fascinating to pick my way through the Italian, which bears little to no relation to its bastard English cousin.

In the mid 80s I completed the development of a theoretical model that interpreted on the basis of biophysical dynamics of chronic-degenerative disease processes, and more generally of an aging workforce. On the basis of this theoretical model I have subsequently developed a technology (Systems Entropy Variation Delta-S) in accordance with these principles that was potentially able to reactivate regenerative processes of tissues and organs without the use of stem cells.
In 2003, this research has received European approval for use in ambulatory and hospital liver cirrhosis. The results of phase II studies have been published in the Annals of the Academy of Sciences in New York and in other publications indexed. Despite this initial success, for reasons related to the lack of industrial sponsors, I found myself in substantial economic impossibility of progression in phase III clinical trials.
This research dissemination in the scientific community was so overcome by what I later developed the chronic pain, now known as the Scrambler Therapy ®. Contrary to what many believe, the "Scrambler Therapy ®" was born almost accidentally and indirectly from my studies on regeneration, although initially considered (sbagliandomi) only support the latter.
In particular in the field of regeneration in the late 80s I developed two lines of experimentation leading to verify if the theoretical assumptions that I had assumed were actually used in the clinic even humans. The first line of research related to cirrhosis of the liver, where the chances of success were predictably higher for most hepatic regenerative capacity of the organ.
The second line of research instead on the regeneration of nerve fibers, almost a complete utopia in those days, even if Rita Levi Montalcini had just got the Nobel (December 1986) for the discovery of 'NGF, the growth factor of nerve fibers . Inevitably occupandomi nerve injury I got in touch with what is, by definition, considered the worst form of chronic pain that is known in medicine, neuropathic, which essentially prevented the possibility to study the possibilities of regenerative nerve damage. Initially I sought the help of specialists in pain, but when I spoke of neuropathic pain were more discouraged me.
For a long time I turned to all sorts of pain specialist, seeking solutions also in acupuncture and hypnosis clinic, but the pain seemed to resist any attempt at treatment. I was about to resign myself to this situation by deciding to continue my research only on cirrhosis of the liver, where although always of limited series, I had already obtained preliminary results very encouraging, and free of the problems related to chronic pain that I met in nerve damage.
Just a few days as I was maturing this decision, an 'association of ill asked me to attend one of their meetings. I accepted, and put it back in the face of so much suffering and hopes of these people, I decided that if there was still no effective treatment for these types of pain, this does not necessarily meant that it was impossible to do so.
My knowledge of neurophysiology were already quite wide and deep, I was not so difficult to integrate with the specialized knowledge of the pathophysiology of chronic pain. Just as approfondivo this knowledge met the Gate Control theory, that is the dominant model and commonly accepted understanding of the mechanisms of pain perception. With some surprise I immediately realized that this theory was applicable only in acute pain. Conversely, I could not find at all its logical application in chronic pain, although conventionally accepted in the scientific community.
I understood that my assessment was practically heresy given the importance of this theory, the weight of scientific authors, endorsements obtained from its inception, and subsequent to the full consecration obtained after the seminal article published in Science in 1965. Then Thinking that he had missed something, I continued to deepen my studies, but most did this, the more my belief dell'inapplicabilità of this theory to chronic pain (especially neuropathic) prevailed.
I can say that it is exactly at this moment that comes Scrambler Therapy ®, because by identifying what I thought an error, I also found the way to a possible solution, which is now a clinical reality no longer experimental

About had enough?  Take a break from this thick, smarmy scientific writing and read something uplifting.

Calmare for Nobel Prize: Calmare Inventor Giuseppe Marineo is recieving some groundswell of support for a Nobel Prize this year, in the Physics, Chemistry, and Medical categories (he can only win one category) due to his invention of the Calmare medical device which cures pain without the side effects of narcotics.

Damn the limitation that keeps Giuseppe from winning in every category.  It makes a mockery of the man's work.

Or you can slog on, maybe picking up a copy of the story of his AIDS cure, available on eBay at the moment:  Dall' Altra Parte (The Other Side) for a mere 9 Euros.  There are other stories, besides his own tale, of his electromagnetic cure, notable at the time as it was being "tested" on poet Dario Belleza, and resulted in a charge of practicing medicine without a license and vaguely familiar charges of "totally inconclusive data."

Denying he had AIDS, commonplace enough for the times, Belleza told interviewers:

"The treatment was reserved for a group of five people," concludes Dario Bellezza "because the machine was not powerful enough. No one was tied to the bed, as it was written, it only used electrodes and patches to apply them."  

The electromagnetic machine, which worked through patched electrodes... WAIT!  That sounds VAGUELY familiar!  Could it have been, GASP, just an earlier version of the scrambling pain-hexer, the miraculous Calmare, now being snake-oil-marketed by Calmare?

It was further described in the press as witchcraft and charlatanism. 

Granted, what Marineo and the dead poet brought up in a war fought in the courts as well as the press, that people have the right to "diversity" of treatment, and to treatment considered "alternative," is a valid argument.

It's just painful to watch a vulture move from one corpse to the next, one hopeless illness to another, reaping, reaping, hopping away, with strips of flailed skin flapping from its beak, feeding itself... and divesting its prey of all humanity.

Is that over the top?  
Is it, really?

* Miranda lyrics, so that you, too, may hum along:

Do you have a problem,

Would you like someone to solve them,

Would you like someone to share in your misery?

Now, I don't know the answer, but I know a flamenco dancer

Who will dance for you if you will dance for me

[Chorus:]

Her name's Miranda

She's a Rudolph Valentino fan

And she doesn't claim to understand

She bakes brownies for the boys in the band.

Early Sunday morning

When the sermon lines are forming

And Saturday night is the memories that it gave.

She's busy in the pantry, far away from Elmer Gantry

Who is busy baking souls that he may save.

Everybody's soul but Miranda (Chorus)

The dice of death are calling

While the truck of time is falling

By the thumb stuck out on the highway of the years.

The tollgate at the turnpike is ignored by those who hitch-hike

And the Howard Johnson food is made of fear

But not Miranda 

(Chorus)

The sun burnt skin is peeling

On the doctors who are healing

And the license plates are laughing on the car.

The pain is so exciting

And everyone's inviting

You to look upon their operation scars.

But not Miranda 

(Chorus)

The condiments are clashing

While commercial planes are crashing

And the music of the evening is so sweet

Now fully in agreement

Oh, their feet have found the cement

And they all believe the signs are on the street

Her name's Miranda 

(Chorus)

In the bar we're gin and scotching

While the FBI is watching

They are tape recording every other word

The bartender is bleeding

Pardon me, I just was leaving

as another clever voice repeats absurd

But not Miranda 

(Chorus)

(repeat first verse)

© 2013 L. Ryan

List of Doctors/Organizations Providing Ketamine Treatments for CRPS / RSD

This list was current as of April 2011, when it was originally published. Please help me update it by leaving a message detailing new clinics, hospitals, and doctors who are providing subanesthetic Ketamine treatments for CRPS / RSD -- also let me know, s'il vous plaît, about any errors in the current listing.  Thank you, Sweet Readers!


Doctors/Institutions Providing (Subanesthetic) Ketamine Treatment for CRPS / RSD
STATE   CITY   DOCTOR   ORGANIZATION   PHONE   WEBSITE/EMAIL

CA Los Angeles Thomas Leverone 310-209-6500 ketaminetherapy@gmail.com
CA Los Angeles Joshua Prager Center for Pain Rehabilitation 310-264-7246 paindoc@ucla.edu
CA Los Angeles Linda Rever USC Pain Center 323-442-6202 rever@usc.edu
CA La Jolla Nancy Sajben Scripps Memorial 858-622-0500 oral Ketamine
CA Santa Anna Lawrence Miller 1450 17th St, STE 200 714-953-6000
CA San Francisco SF Kaiser 415-833-0095
CO Univ. of CO Alan Brewer 720-848-1970
DC Dr. Chin Geo. Washington Hosp. 202-715-4599
FL Hollywood Dr. Kaufmann Joe DiMaggio Children's Hospital 954 360 6383
FL Sarasota Doanld Erb, DO Institute for Advanced Medicine 941-917-5111
FL Tampa Anthony Kirkpatrick 813-435-8206 www.rsdhealthcare.org
GA Atlanta Erik Shaw, D.O. Shepard Pain Institute http://www.shepherd.org
IA Des Moines Steven Quam,DO Metro Anesthesia and Pain Management 515-221-9222
IL Palos Park Renata Variakojis 708-631-5550
IL Chicago Timothy Lubinow Rush Univ. Med Cntr 312-942-6631
IL Rockford Medical Pain Mang. Serv 815-397-8400
KY Louisville Christopher Nelson Bluegrass Pain Cons. 502-423-1021
Kas Leawood Dr. Simon Mid-America Physiatrists 913-599-2440
MA Boston Arnold Pain Center 617-278-8000
MA Boston Christine Peeters-Asdouria Beth Israel 317-278-8000
MS Jackson Kenneth Oswalt University Pain Management 601-984-5950
NC Winston-Salem James North Carolina Pain Institute 336-765-6181
NE Hastings Mark Brosnihan/John Dungan Manny Lanning Mem. Hosp. 402-463-4521
NJ Marlton Philip Getson 856-983-7246
NJ Morristown Edward Zampella Atlantic Neurosurgical Specialists 973-285-7800
NJ Camden Pain Management 856-983-7246
NV Carson City John Di Murro 775-841-4057
NY NYC Vadim Kushnerik Downtown Hospital 212-312-5247
NY Dr. Durkin 631-638-0800
NY NYC Seth Waldman Hosp. for Special Surgery 212-606-1015
NY/DC/VA Nameer R. Haider, MD see website www.killpain.com
NY NYC Ron Hertz Roosevelt Hosp. 212-523-6357
NY Syosset Northshore Hosp. 516-496-6506
NY Stony Brook Brian Durkin, DO Stony Brook Hospital 631-638-0800
OH Mayfield Hgts. Teresa Dews Hillcrest Hosp 440-312-8599
OH Centerville Amol Soin, MD Ohio Pain Clinic 937-434-2226
OK OK City Jack Marshall 405-775-9355
PA Bryn Mawr Matthew Kline Center for Pain 610-527-9500
RI Pawtucket Pradeep Chopra, MD Interventional Pain Mang, Ctr 401-7294985
TX Houston Everton Edmondson Interventional Neurology 713-797-1180
TX San Antonio Kaleb Shaw, MD Univ. of Texas, San Antonio 210-450-9850
UT Salt Lake City Andrew Tallbutt Life Tree Pain Clinic 801-261-4988
WY Casper Tuenis Zondag Neuroscience Center 307-265-7246
WA Yakima Waters Edge Pain Relief Institute 509-574-3805
New Zealand Aukland Greenlane Hospital (09) 638-9909

4/25/2014 addendum:  Please remember that the textual stuff below was painstakingly typed wayyy back in April 2011, hence some oddity.  For instance, Dr. Schwartzman has [alas!] retired...

*I cannot vouch for what you'll discover upon contacting the individual doctors and institutions listed above.  I can verify that this list is NOT complete -- for which we should all be more than a little bit grateful!  I say that because I know of several exclusions from my area -- exclusions that are completely warranted by the less than impressive approach being taken by those excluded!  For instance?  Well... the local doctor whose approach to the ketamine infusion is to LEASE an infusion machine to the patient, toss in an i.v. or PICC line, and send the patient home with bags of ketamine... That's right, you can do your ketamine treatments in the privacy of your own bedroom!  Oh, and the cost is as attractive as the "protocol" -- beyond the insertion of a line and the leasing of a pump -- it's...
FIFTY DOLLARS. 

Personally, by excluding that particular physician from this list, the list maker proved his bona fides!

You'll note some more obvious things, like the absence of Dr. Schwartzman of Philadelphia (Neurology Chair at Drexel). I can think of numerous reasons why that might be so, first and foremost that he has more patients and potential patients than your average bear, and second, that he may wear more the mantle of researcher and academic at this point. Mostly, though, I don't know. He is easy enough to find, as are the details of his protocol.

A word about the Schwartzman protocol: It is a research protocol, and therefore is not subject to any adjustment. The results need to proceed from a process that is double-blind and placebo controlled -- reproducible, ethical, heavily monitored and so on.

Uh-oh.  I feel a sensation of mounting bile.  Perhaps a moderate rant...
I am fed up with the CRPS / RSD patient culture -- online, at least. I should not have strayed from my neurologist's longstanding advice not to join online CRPS/RSD "support" groups. A few weeks ago, I found a group fairly experienced with ketamine, joined, shared my "story" (de rigueur), but mentioned prominently, and twice, that I did not wish to debate ketamine protocols, as I am in the position of using what is available to me. That I am unable to swoop into Philly on a private ambulance plane, "Dr. S" having dropped whatever insignificant thing he was doing to meet and escort me around his facility, does not mean that I am not invested in getting well. That I am no longer pursuing inclusion in the "coma" treatment studies does not mean that my efforts to beat "the monster" are either half-assed or half-hearted. (I am pretty sure, as are others, that it would kill me.)

Yes, despite declaring the ketamine protocol debate off limits -- that's all most people came back at me with... Not to say that there weren't any who attentively read my post and responded thoughtfully and with a clear intent of being... you know, *supportive* -- there were. Two. Two people. One is about as frazzled as I am, and we are enjoying behind the scene banter. It's a case of instant recognition of one's self in the other -- I'm very comfortable with her.

And it occurs to me that I pulled on her exactly that with which I am charging the Protocol Protectorate!  The difference was time and place -- we had at least perfunctorily "met," and we were communicating privately. She wanted to pursue a treatment for whom the only known advocate is a very shady doctor (*cough* *sniff* dr. H *achoo* in Florida *sneeze*), now retired but still in the business via an equally shady website and -- I innocently and unknowingly surmise -- some longstanding system of kickbacks. If folks will do just a bit of due diligence, they'll discover that *cough* *sniff* dr. H *achoo* in Florida *sneeze* did time for Medicare fraud. In a different state, a bit more to the north. Starts with a V.

So I spoke up and posed some rhetorical doubt.

It turned out that, in the interim of our communications, she had stumbled on some less than savory details on her own. She was doing what needed doing and I felt relieved. God only knows how many desperate people have fallen through the cracks, lost to these assholes armed with medical licenses.

But I have been through this process -- constant guarding against people with no aim other than fleecing patients so desperate for relief that they will believe the most amazing crap -- and it is tedious. Mind- and heart- numbing.

What did I expect from the group? What help could they realistically have been?

I wanted to know what, if anything, I could do to optimize the benefits of my treatments. There was only one clear response and it was buried in a bunch of condescending advice for the neophyte, and full of "Dr. S" this, and "Dr. S" that... In order to participate in his studies, Dr. Schwartzman requires that patients be off most meds, and all opiates. That makes sense to me... but mostly, it makes sense in his intensive research protocol.

Crud. Let me chat about something else for a moment. I am not completely sure of this -- I saw a video by Dr. Prager of L.A. from about a year ago in which he said the German arm of the coma studies had been shut down. That makes me sad even though I understand the forces at work.

It has to do with what happened to Laura Beckett, I believe, and while her situation is tragic, I don't see how "blame" can realistically be assigned or why the study had to be punished as a result. MRSA is everywhere, and I have some experience with contracting it, even in an ICU environment where standards are high. It strikes me as odd, as well, that the work in Mexico continues unabated with barely even a mention of the patient death that occurred there.  The implication in Prager's video is that her inclusion was on a compassionate-use basis, not as part of the research cohort.

It's a darned good thing that I recognize the dangers of knowing-a-little-but-not-much. What would be even better? If I could find more medical professionals to trust, with whom to share the burden of worry. I have a group of trusted doctors but none of them are, or will ever be, CRPS experts. When you have an orphan disease that is not at all sexy in its promise for monetary reward, you also have a disease that doesn't/cannot interest many mainstream treating professionals or fire up research consortia (Big Pharma) with burning passion. CRPS just doesn't have that special cachet that comes from infusions, not of ketamine, but of cash.

On the occasions when I pray, it is almost always in the form of intercessionary prayers -- perhaps the prayer of the pompous, definitely the prayer of the dilettante.

Self-interest is never absent, never far from my lips.

I pray for my local, real, available, and wonderful doctors and nurses. But I also pray for Dr. Schwartzman, Dr. Kirkpatrick, Dr. Prager. I pray for Laura Beckett and for the family and friends of Andrea Gianopoulos. They each own, somehow, a little bit of my wayward soul by virtue of their bravery and by the evidence of their faith. 

It's a rough weekend. I hit a pain cycle starting -- roughly -- Wednesday morning. If you noted my previous erudite discussion of the term and concept of "flare," let me say that I seem to be in the midst of shifting pain types, not just some sort of eastern purification of the pain -- *snort*! Some of it may be due to Buddy the Kitten's claws but I don't see that I can blame it all on the Wee One. Ask me again in a few days.

My anxiety levels hit their peak around 4 am last night. All I seem able to think of is how Monday's ketamine treatment is likely to be my last.



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3/3/12: A REPOST of "things i wrote in the night"

this repost from march of 2012, most memorable for its images, is brought to you by my curiosity over a sudden rise in its number of "pageviews." yes, i realize this is likely due to some new surge of interest in zhang dagian... well, maybe this repost will somehow do her a good turn, a mitzvah. it's far too late to help van gogh, and i am not really sold on jason ferguson. as for context, it appears to be one of my godawful home-after-the-hearsepital posts. i tend toward a full week of confusion upon my return to the manor...

many museums have established virtual tours of their holdings.  it's a great way to spend a few hours, together with a good cup of coffee.  the impetus for gaping, all schmaltzy-like, at art in the wee hours of a saturday morning?  an article in Rue89 about the chinese artist zhang daqian.  the emphasis was on what the art market is willing to bear, in terms of price, and how shocking that zhang daqian outsells picasso, gasp!

the art market is, of course, complicated -- just check out the information about auction results and other indices over at artprice.com.

were i a bit more evil, i bet i could turn art prices and some prefab notion of a free art market economy into frothing fodder for the GOP presidential aspirants, what with their errant attention spans, an opportunity to use the word "inflation," and crippling xenophobia. with a tweak here, and a tweak there, i can have the value of zhang daqian's work intimately entwined with foreign policy and the imperative to reduce the national debt.

just look at this swirling loveliness!  now try to turn your facile and waffling take on free trade agreements and illegal immigration into some sort of china policy that covers the art work of a master forger. ah, the twist, the rub!

i miss the heady days of the early republican debates, when the ideas for maintaining a strong national artistic border came down to having boots on the ground and electric charges in the fence.

boots with laces, 1886
van gogh

From the dark opening of the worn inside of the shoes the toilsome tread of the worker stares forth. In the stiffly rugged heaviness of the shoes there is the accumulated tenacity of her slow trudge through the far-spreading ever-uniform furrows of the field swept by a raw wind. On the leather lie the dampness and richness of the soil. Under the soles slides the loneliness of the field-path as evening falls... 
-- Martin Heidegger
The Origin of the Work of Art

Jason Ferguson | Koe | custom circular ditch, water, electric fence, & live cow
Eastern Michigan University Art Department

i found a small spiral notebook stuck in a plastic bag full of bills. in an attempt to keep track of goings-on in the hospital, i'd jotted down notes as reminders and testaments.

one day, two women from environmental services dominated several pages.

this hospital has a pilot program whereby mentally retarded [i really don't want to run a marathon on the euphemism treadmill this morning, so make whatever politically correct changes you deem necessary] workers work as nurse's aides, food service delivery folk, and ward minions.  one such employee was named annie, and she worked for environmental services, cleaning patients' rooms.

"Knock, knock.  My name is Miss Annie from Environmental Services.  I am here to clean and freshen your room. May I come in?"

it's a very nice introduction, and it made me smile, usually.

i wasted a fair amount of time interrogating visitors as to their identities.

for instance -- imagine that you are half-napping.  you jolt upward into complete awareness when the smiling, well-groomed woman in spotless blue scrubs -- under a knee-length white lab coat without embroidered identification or departmental badge swinging on a lanyard -- proffers a tiny, fake cough. she calls your name and then asks, as if asking this were a perfectly natural beginning to a conversation -- "so... what happened, darling?"

tell me that you would not, at that precise point, ask her who the hell she was, being careful to add "sweetcheeks" as an endearment.

so, yes, i liked miss annie.  i liked that she told me what department she represented and that she warned me, up front, about what she was gonna do.

miss annie was huge.  her voice was even larger than her actual frame.  sometimes it shocked me so that i feared being stuck on the ceiling.  even so, we developed a fondness for one another, even though we never much talked beyond her vibrant announcement and my "thank you, miss annie."

twice, though, i upset miss annie's world.  once, i was in so much pain that i needed to be left alone, isolated, packed away.  it came out as a cruel and strident "no, miss annie, you may not come in now...  please come back later."  it rocked her world and she could only repeat her lines, a little louder, with a few shifts in emphasis:

"Knock, knock.  My name is Miss Annie from Environmental Services, God damn it.  I am here, right now, right here in the here and now, to clean and freshen your your God damned room. May I come in?  Let me in, God damn it."

i acquiesced but spent the whole 10 minutes of her merciful mission sighing and swiping at my angry tears.  i also insisted that she wipe down the trapeze bars and help me find the two pens and a pencil that i'd dropped on the floor.

the next day, miss annie was back, didn't miss a beat. and when  "please, not now" became necessary once again, we conversed seamlessly, as friends.  well, no, not as friends.  as environmental services rep and patient.

when miss annie was not there, another woman took her place, and announced her name and job.  she lacked miss annie's style and overall panache. she was adequate.

one of my last days there, she arrived while i was writhing about in full spasm, trying not to claim a number on the pain scale that was above its limit of ten.  as i have many times maintained, calling out a 10+ rating just renders the whole silly effort to quantify pain... sillier.

i made an effort when she first came in, smiling, joking, even.  but then the spasms got serious and i dissolved into tears.  the next thing i knew, she was bent over me, yelling:

"do you know my face?  do you know my face?"

i don't know how i answered her, but i think i repeated this:  "what?  what?"

then, crafty devil that she was, she shifted verbiage, now demanding:

"do you know who i am with?  do you know who i am with?"

this was becoming pretty scary to me, i admit. my nurse came into the room with some medication and was probably shocked by my happiness to see her.  before i could speak, though, miss annie's replacement gave report:

this lady started out okay, nurse, but then she went rotten with pain.  she didn't know who i was. she didn't know environmental services, and her eyes won't focus. 

****************************************************************************
and so, dear readers, this is what i wrote during the night.  odd and disjointed, it; odd and disjointed, me.

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New Clinical Trial For CRPS At HSS

Randomized Controlled Trial of Ketamine Infusion With Continuous Epidural Infusion for Treatment of Complex Regional Pain Syndrome/CRPS/RSD

The study above can be accessed at ClinicalTrials.gov -- it began last month and ends in December 2017. They are seeking an enrollment of 60 at the Hospital for Special Surgery (535 E 70th St, New York, NY, United States, 10021).

Go for it! [That's a decidedly editorial comment from a know-nothing blogger who has 12 years "in" the CRPS Wild Ride Experience, so feel free to do your due diligence as to inclusion and exclusion criteria, risks -- and just ignore me egging on folks who are in the area and desirous of aiding research into this god-forsaken malady!]

CONTACT PERSON AND INVESTIGATORS:

Contact: Kaye Estioco estiocok@hss.edu      

Sub-Investigator: Jodie Curren, BSN         

Sub-Investigator: Robert Griffin, MD         

Sub-Investigator: Vladimir Kramskiy, MD         

Sub-Investigator: Christine Peterson, MD         

Sub-Investigator: Seth Waldman, MD         

Principal Investigator: Daniel Richman, MD    

The Hospital for Special Surgery, which is a fantastic place for all things even remotely orthopedic, is located here:  

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"And rend your heart, and not your garments..."

The most heartrending post I've ever read, from Ethan's Mom Rachel.

Rachel Hallmark posted a new journal entry.

If that link doesn't connect you, go to CaringBridge.org and enter "ethanhallmark" in the "VISIT" search box.  Then scroll down to the journal feed for today, 24 April 2014.

oh, garcia marquez, how i will miss you!

listen, folks, i admitted in the previous post that i'm on drugs -- the good, legal kind.  covered by my blessèd obamacare-ACA-presidentially-approved health insurance policy, for which, you wacked-out wingnuts, i pay good money.

well, not good money.  just money.

anyway.  [the best of segues]

here follows the provenance of this post, and you SHOULD know by now my obsession with provenance:

at least a bazillion people a day tramp through marlinspike hall (read the damn **ABOUT::THIS::BLOG** section over on the right side of the freaking page, would 'ya?), and wayyyyy too many of the folks come with a pass stamped "looking for information about that asswipe Jorge Mario Pedro Vargas Llosa, 1st Marquis of Vargas Llosa."

what's more?  our docents, docentesses, and the struggling underclass of the most recent priestly novitiate from next door (they earn coin to make desperate calls home) are overwhelmed with the number of theta and lisping Spanish-speakers (we report them all as likely nazis to Tête de Hergé Homeland Security) inquiring after vargas llosa.  just click the underline, light blue shaded (or is it purple?) text of his name in the preceding paragraph and you can read about him to your hearts' content. or HERE, click HERE!  at Wikipedia!

track in the gritty clay of our land, smear smooshed greeny asphodels around our pompeian mosaic floors, we don't mind the cleaning... it's of the mindset ruling your sneakers that we think whilst scrubbing away the dregs of nature with toothbrushes and tubes of Sensodyne! [don't you dare touch that sentence.]

why, o why, are we not receiving pilgrim upon pilgrim seeking after our magical collection of Gabriel Garcia Marquez arty-facts?

where did all this people clearly RAISED IN A BARN come from?  okay, okay, i know, they're likely of german descent, but we don't paint tar all over the sensitive skins of an entire people around here! that's not the marlinspike hall way!

oh, garcia marquez, how i will miss you! 

i need a new fentanyl patch.  and a percocet.

********* *** *********

vargas: SF= steepest part of a slope

********* *** *********

Gabriel García Márquez: Discurso por el recibimiento del Premio Nobel de Literatura en 1982 --

© 2013 L. Ryan

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A Letter From My Buddy Barack Obama

I love it, more Secret Service Envy headed my way!  Having been the only instructor at Major Gothic Wonder Land University to hold a required class on the day Ronald Reagan came to jabber at the undergraduates, and wave at the picketing grad students, I am a favorite of the Secret Service.  What they can't figure out is the "no-make ups allowed" major exam question that equally (always *equally*) excited my students -- made up of 14 upperclass undergrads and 1 relieved Divinity School doctoral student:

Explain, dissect, conjugate, and defend the following assertion:Michael Reagan, son of United States of America President Ronald Reagan will one day serve on the board of The John Douglas French Alzheimer's Foundation.

Of course, this pretty standard "no-make ups allowed" major exam question was in French, as this was a course designed to dunk -- by which I mean, of course, immerse students into French Lit.  As you can tell from the question, we had just finished reading Samuel Beckett's Waiting for Godot.

Oops.  Train of thought problems, yet again.  I was telling you about the letter I just personally retrieved from my private email account -- known only to my best of best Facebook Friends. [Loud guffaw! I have a fake Facebook account and about, oh, two Friends, all the rest being right-wing relatives.  My two Friends are right-wingers, as well, but tolerant.   Very tolerant.]

So, yeah, it was from Barack.  My buddy Barack.

[Look, let me settle this, as I just was barraged, nay, blitzkrieged by two Super Secret Facebook Friends who are actual full-blood relatives and consider themselves, and I quote:  "progressive as hell, girl!" Fine, let them assert their leftist tendencies.  Yes, their leftist tendencies surpass even my own, to the extent that I doubt either of them have ever voted in their entire political adult lives.  Not even for McGovern.  Okay... I'm telling lies now.  Let's just say that they may temper their support for President Obama due to expectations of a shift to the left by a rather large amount.  Not this profderien, no ma'am! I adore, respect, love, admire, and imitate this intelligent sign of life -- and his awesome family -- every chance I get.  Well, okay, so there are a few things, policy-wise, that could use a slight Marxist tweak, but, most days, I'm fine with that.]

That's right. The President, himself, writing to The Moi, care of, admittedly, the Haddock Corporation (now completely divested from Halliburton *).

 * Can you freaking believe that "Halliburton" pops up as a correction in SPELL CHECK?! How screwed up is that?  I mean does "amnety internatenal" show up in spell check? No, it does not, thankyouverymuch!  Jesus.

Cough.  Yes, my friend Barack wrote to thank me -- just me -- for my round-the-clock, high tech multi-year campaign on behalf of the watered-down Affordable Care Act.  I keep referring him to my other dearest pal, Bernie Sanders, but haven't heard yet how that's going (so much to talk about!).

In the past, as many a Beloved Reader of this blog recalls, I have shared a few of my personally keyboarded letters to our President -- never violating protocol, naturally, but always seeking advice from the now deceased Tante Louise on how best to post presidential correspondence. 
Well, okay.  Tante Louise and I may have flubbed a few posts in which my buddy Barack figured, but we toed the, er, red line in the, er, sand when it came to my personal, and by personal I mean one-on-one, tête-à-tête sorts of intimate, soul searching, letters.  The whole Flaubert and Bob Herbert catastrophe.  The admittedly odd basketball post.

Even when you limit a search of this blog to "Obama, ACA," there are just a half-dozen or so weird ones...  I mean, omit blog war waged on Walmart, and the regrettable incident in which I claimed not to be able to support "Obamacare" until Socialism was in place.  I was on drugs.  You can tell, I bet.  I mean, look -- clearly, I say often enough that Obamacare -- the ACA, the PCIP, whatever you like to call it -- saved my life.

Probably, that's all my vast reading public needs to know:  President Barack Obama saved my life.
And then pulls off this comedic email in which he pretends I had something to do with this brave legislative and moral effort [ ::waving:: at teddy!].

That is a true friend, indeed.

Oh hell, there is a man in a terribly plain blue suit that has been tailored, clearly, to hold a spare machine gun and drone in the small of his large back... peeking in the badly leaded hand-poured window panes that stud the upper chamber of the Computer Turret.  I have repeatedly and repeatedly asked Barack, even "cc"-ing Michelle, to have the damned Secret Service "STAND DOWN," already!

Jesus.

Lincoln's Presidential Seal

[Hi there, prof-de-rien!  How're they hanging?]

I had to take a moment to say thank you.

Lisa, you made history.

A long line of organizers fought for nearly 100 years to make health care reform a reality, and now we're seeing the results. Millions of Americans have health insurance today, thanks to reform -- some for the first time in their lives.

The work you did is how real, lasting change gets made, and I hope it will be remembered for years to come.

I'm so happy your name will be there, alongside mine, as part of OFA's permanent record of the people who made health care reform happen.

If you know anyone else who deserves to be recognized, tell them to add their name here:

http://my.barackobama.com/You-Made-History

Anyone who was part of this decades-long fight will tell you it was never easy, but it was always the right thing to do. Teddy Roosevelt knew it. Harry Truman knew it. Teddy Kennedy sure knew it.

No matter how hard it got, the results we're seeing today make it all worthwhile. Millions of Americans now have coverage, and even more have better health care, thanks to the work you did.

Take a moment to let that sink in.

It's proof that when people come together and fight for what they believe in, real, lasting change is possible.

I can't thank you enough,

Barack Obama





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