Disconnected!Dalai's Laws In Action...

My friend and colleague Henry (that is his name, but he doesn't go by it) called me a few hours ago. "Dalai," he said, "I've got bad news and worse news for you. The Bad news is that the downtown campus of one of our hospitals just got cut off from the Internet. Some ditch-digger severed a main AT&T cable, and we're completely dead. The Worse news is that YOU are on call! See ya!" Actually, he didn't just leave at that point, but he did his best to inform all possible clinical services, and especially the ER, that PACS would be dead. Fortunately, the hospital's suburban campus is still online, and we can divert the patients over there. For the moment. So far, I have only had to be rude to the downtown Nucs tech, who didn't get the word and did a V/Q anyway. I was able to send our guy who gets done at 8PM over there on his way home, so all is not lost, and the normal V/Q will be read in a timely fashion.

This is a wonderfully unfortunate demonstration of Dalai's Laws of PACS, in particular, Laws I and IV. Law I, "PACS is the radiology department" is quite obvious when PACS is dead. All we can do is look at the CT console for those direst of emergency cases that can't be shipped out. I suppose we could film the hundreds of CT slices....nah. Because Dalai's Fourth Law says, "Once PACS, never back." We are not going back to film. Ain't gonna happen.

We can do little but wait for AT&T to fix the communication problem. We were told that could take from 2 to 8 hours. Right now, we're at 9 hours and counting. What should we have done here? This is a situation that is foreseeable, but not easily solvable. We have backups upon backups, but we don't have a backup for the most critical component of all in a web-based system: the Network! While it is the Internet that failed here, we would be just as dead if our LAN failed, so I'll group them together. In today's case, however, it was obviously the WAN that croaked. At this point in time, there aren't too many alternatives for broadband access. In my town, we have DSL, run mainly by AT&T, and cable, run mainly by Time Warner. There are various permutations with MetroE's and Frame Relays and such, but ultimately, all of these require physical lines, wires, fiber optic cables, or whatever, and those can be cut. The only other possibilities would be satellite internet, which is relatively slow and expensive, or a direct microwave connection to an ISP, which would be fast but still expensive. (No, I don't have time to pull the numbers, being on call and all, but trust me on this.)

I'm thinking WIMAX, the promised nationwide WiFi system, might solve this problem. Put an antenna on the roof, and you're connected. It would certainly have avoided an entire hospital being shut down by a ditch digger. Although I suppose a lightning strike or other such event could knock out WIMAX as well. Maybe we need to go back to dial-up?

The only good to come of today's experience is that we are able to tell the ER docs to think long and hard before they order useless studies. OK, we didn't use the word "useless" but the message got across. Maybe the mentality will sink in. Probably not.

Night of the Living Democrats!...Starring Me and a Host of Celebrities!

The geniuses at JibJab have done it again with a series of do-it-yourself (sort of) videos. Above is one of a zillion possible permutations. See what you can do with it! There's also a version for Democrats, if you happen to be of that persuasion.

I just had to try it myself....

Intelerad Is User 50,000!!

On October 26 at 9:14 AM EDT, someone from Intelerad in Montreal, Quebec, became user number 50,000. Congratulations to the lucky reader. I'll be sending out your prize momentarily. You are now the proud owner of a 30-day trial version of the InteleViewer Workstation software! What's that? You already have one? Oh well...

We continue to use InteleViewer quite successfully at our site that still has no PACS. For $500 annually, I think it beats eFilm hands down. Frankly, for $5000 annually it would beat eFilm hands down. Outside of open source software, this is the best deal around for the smaller operation.

October has been the best month yet, and it isn't even over! Check out the stats:

If you guys keep reading, I'll keep writing. What a deal!

The Road To PACS....Or Ruin

Image courtesy of http://www.auntminnie.com

Every year, my friends at AuntMinnie.com review the various radiological offerings to be found at RSNA. Since I seem to make the trek to Chicago every year for this extravaganza, I appreciate AM's attempt to distill the thousand plus booths down to the hundred or so that I can actually visit. I actually do attend the education sessions at RSNA, which can be quite a frustrating experience with literally 50 of them going on simultaneously.

I have taken the liberty of copying AuntMinnie's PACS Preview and posting it below:

Agfa HealthCare(Booth 4106) Agfa HealthCare will highlight six suites of its Impax portfolio, each targeted at specific healthcare segments, at the 2007 RSNA conference.

Amicas(Booth 2583) Amicas will feature version 5.5 of its Vision Series PACS network and introduce version 2.0 of its Vision Reach module in its RSNA booth this year.

Ashva Technologies(Booth 6421) Ashva Technologies of Plymouth, MN, plans to showcase version 2.0 of its iMagic ultrasound image management software at this year's RSNA conference.

Aspyra(Booth 3307) Aspyra will feature new versions of its AccessRad RIS/PACS and AccessNet PACS software at the 2007 RSNA meeting.

Brit Systems(Booth 3503) Brit Systems will highlight a workflow package for outsourced radiology reading applications at the upcoming RSNA conference.

Carestream Health(Booth 2513) Carestream Health of Rochester, NY, plans to showcase the latest version of its Carestream PACS offering in its RSNA booth this year.

Cedara Software(Booth 1316) Cedara Software will feature its C4 integration platform and development tools for software developers at the 2007 RSNA conference.

Cerner(Booth 1365) Cerner of Kansas City, MO, will showcase developments with its ProVision Workstation at this year's RSNA meeting.

CoActiv Medical Business Solutions(Booth 5741) CoActiv of Ridgefield, CT, will emphasize its Paperless-PACS concept, which adds paperless capability to its Exam-PACS line, in its RSNA booth.

Connect Imaging(Booth 6551) Connect Imaging of Honolulu plans to debut PACS Dashboard in its booth at this year's RSNA conference.

DR Systems(Booth 2165) DR Systems will highlight new mammography features on its Unity RIS/PACS platform at the upcoming 2007 RSNA show.

Dynamic Imaging(Booth 4765) Dynamic Imaging will feature upgrades to its IntegradWeb line at this year's RSNA conference.

EBIT AET(Booth 3339) Italian vendor EBIT AET will present enhancements to its Risolution RIS/PACS portfolio at the 2007 RSNA meeting.

Eclipsys(Booth 6959) Expect Atlanta-based Eclipsys to focus on enhancements to its Sunrise PACS line at this year's RSNA show.

Emageon(Booth 8508) Emageon of Birmingham, AL, will spotlight its RadSuite Express PACS offering at McCormick Place in Chicago.

Empiric Systems(Booth 5738) Empiric Systems of Morrisville, NC, plans to demonstrate version 5.0 of its Encompass.Net RIS/PACS network in its 2007 RSNA booth.

Fujifilm Medical Systems USA(Booth 1129) Fuji will highlight the latest version of its Synapse PACS software at this year's RSNA conference in Chicago.

GE Healthcare(Booth 1729) Expect GE to feature its recent acquisition of PACS vendor Dynamic Imaging. On the product side, version 3.0 of Centricity Imaging-PACS will be highlighted in the company's RSNA booth.

Healthy Information Technology(Booth 8938) Healthy-IT of Newport Beach, CA, will feature upgrades to its TelePax offering on the RSNA show floor.

Heart Imaging Technologies(Booth 3588) HeartIT of Durham, NC, will bring its WebPax VS package to this year's RSNA meeting in Chicago.

IMCO Technologies(Booth 4183) IMCO Technologies of Pewaukee, WI, will highlight software upgrades on its IMCO-PACS at the 2007 RSNA show.

Infinitt North America(Booth 8520) Infinitt of Phillipsburg, NJ, plans to direct RSNA attendees to its Cardiology PACS offering.

Integrated Modular Systems(Booth 3204) Integrated Modular Systems (IMSI) will feature its ImageWebGate service, as well as several upgrades, at this year's RSNA show.

Intelerad Medical Systems(Booth 4759) InteleRad Medical Systems of Montreal will come to McCormick Place in Chicago armed with new features for its IntelePACS and InteleViewer software.

Intuitive Imaging Informatics(Booth 3965) Intuitive Imaging Informatics (I3) of Los Angeles will feature enhancements for its Rational Imaging and ImageQube PACS lines at the upcoming RSNA show in Chicago.

McKesson Provider Technologies - Medical Imaging Group(Booth 2542) McKesson will present the latest releases of its Horizon Medical Imaging and Horizon Cardiology packages at the 2007 RSNA meeting.

Medicor Imaging(Booth 3295) Medicor Imaging of Charlotte, NC, plans to introduce its MiPACS MedView image distribution software at this year's RSNA meeting.

Medsynaptic(Booth 1051) Medsynaptic of Pune, India, will feature its Web-based MedSynapse PACS line in its RSNA 2007 booth.

Medweb(Booth 3959) Medweb highlights for this year's RSNA meeting include upgrades to its Dashboard application and a 3D/4D WebPACS offering.

Merge Healthcare(Booth 1122) Merge Healthcare of Milwaukee will display a range of RIS/PACS offerings at the 2007 RSNA conference in Chicago.

Meta Fusion(Booth 6456) Meta Fusion will feature upgrades to its Helium RIS/PACS application at the upcoming RSNA meeting.

MIMvista(Booth 4174) MIMvista of Cleveland will present its RT-PACS offering in its RSNA booth this year.

Neurostar Solutions(Booth 3582) Neurostar of Atlanta will focus on enhancements to its Virtual Radiology Network (VRN) at the RSNA conference this year.

NovaRad(Booth 3202) NovaRad of American Fork, UT, will spotlight version 7.0 of its NovaPACS software in its RSNA booth.

Philips Medical Systems(Booth 4129) Philips Medical Systems of Andover, MA, will demonstrate versions 3.6 and 4.1 of its iSite PACS line of PACS software at this year's RSNA meeting.

Radlink(Booth 4711) Radlink of Redondo Beach, CA, will tout its ThinPACS network for single or multilocation office practices.

RamSoft(Booth 4303) RamSoft will show new versions of its One RIS/PACS and PowerServer PACS offerings at the 2007 RSNA meeting.

Rogan-Delft(Booth 6908) Rogan-Delft of Veenendaal, Netherlands, plans to showcase a range of additions to its View Pro-X (VPX) viewing application.

ScImage(Booth 2551) ScImage of Los Altos, CA, will emphasize updates to PicomEnterprise, as well as mammography and advanced visualization tools, at this year's RSNA show.

Sectra(Booth 6513) Swedish PACS vendor Sectra will feature version IDS7/dx of its PACS diagnostic workstation software in its RSNA 2007 booth.

Siemens Medical Solutions(Booth 7713) Siemens will direct RSNA attendees to developments with its syngo platform, as well as a range of advanced visualization software.

Thinking Systems(Booth 4583) Thinking Systems of St. Petersburg, FL, will debut new PET/CT and cardiac imaging functions for its ThinkingPACS line at this year's RSNA meeting.

Visage Imaging(Booth 2591) Visage Imaging, a subsidiary of Mercury Computer Systems, will place its Visage PACS/CS into the limelight at the 2007 RSNA conference.

Visus Technology Transfer(Booth 8401) Visus Technology Transfer of Bochum, Germany, will present new enhancements for its JiveX system on the RSNA show floor at McCormick Place.

Voyager Imaging(Booth 4050) Voyager Imaging of East Hawthorn, Australia, plans to focus on the benefits of its Voyager PACS image data prefetching technique.

I'm not seeing many new names this year, but perhaps the good news is that the vast majority of this rogue's gallery were present last year. I'm personally thrilled that Jive-X PACS made it another season.

To give Mike Cannavo, the One and Only PACSMan some fodder for his annual awards, just look at the names of some of the other systems. iMagic? Is that how it works? Carestream? Sounds like something a urologist might prescribe. MedSynapse? Uh, Fuji, are you taking note of this? Oh, Medsynaptic is based in Pune, India, and is likely out of the reach of trademark infringement suits. I notice Visage/Mercury doesn't mention their acquisition of SoHard software from Germany anymore. Helium PACS? Does it float, or do we talk funny after inhaling it? Eclipsys has Sunrise PACS; isn't that somewhat of a contradiction in terms?

I always thought the name "Freedom PACS" would be great; freedom from tyranny, freedom from bloatware, freedom from things that get in your way, and so on. The title is for sale, cheap.

The roadmap naturally notes the acquisition of Dynamic Imaging by GE, and we're all anxious to see how the booths merge. The sad fact is that if everyone who has ever been associated with DI (including users, potential buyers, lookie-loo's like me, etc) gathered in a corner of the GE booth, they might well take up about 5% of GE's massive plantation on the exhibit floor.

The way things are going, the 2015 RSNA PACS roadmap will probably be a lot shorter: GE, Siemens, Philips, maybe one or two others. These behemoths will have gobbled up everybody else. I have the feeling, though, that open source PACS, or at least vendor-neutral archives might reinvigorate the smaller operators in this game. We'll see. In the meantime, I really think Connect Imaging needs to bring me out to their place in Honolulu to have a look at their PACS Dashboard and other offerings....

Will Work For PACS...When National Healthcare Just Isn't Enough

Bandaged from head to toe to show the importance of the new PACS technology at Seaforth Community Hospital, Don Morton, of Seaforth, adds to the total as donations came into the Seaforth Legion or were called in to CKNX radio during the annual Healthcare Heroes radiothon held on Saturday. Photo by Susan Hundertmark, courtesy http://www.seaforthhuronexpositor.com/

You won't hear about this in many places, but PACS is a pretty expensive proposition. So what is a small hospital with limited funds going to do when it decides to take the plunge?

If you work at the Seaforth Community Hospital in East Huron, Ontario, you hold a Radiothon!

The Seaforth Community Hospital foundation came very close to achieving its goal of $50,000 with $49,713 in donations during the annual CKNX Healthcare Heroes radiothon on Saturday.“It was a very successful day with just terrific community support,” said foundation chair Ron Lavoie on Monday. . .(S)ome of the larger donations included $5,000 from the Seaforth TD-Canada Trust, $2,500 from the Seaforth CIBC and $1,000 from the Seaforth Lions Club.

PACS technology allows diagnostic tests, including nuclear medicine, CT scans, x-rays and ultrasounds to be produced with digital images, which can then be transferred electronically.Adding in the amount raised at Saturday’s radiothon, the foundation has raised $175,713 of its goal of $213,283 for the first phase of the PACS fundraising.When the first phase is achieved, Lavoie said the next three years will be spent working towards the second phase - $350,000 towards a new x-ray machine for SCH.

Dr. Heather Percival, a physician on staff at Seaforth Community Hospital, who apparently is not a radiologist, noted:

"This technology is absolutely essential. It’s important to keep us at the same level as the city hospitals. Without this technology, we are back in the so-called dark ages,” she said. Percival pointed out that small towns have to work hard to fundraise for up-to-date technology, pointing out that some U.S. cities have more MRIs than the entire province of Ontario.

OK, everyone, take note. This is the end product of National Health Care. Radiothons to buy PACS systems. No doubt the Foundation will be holding a bake-sale to continue to fund their PACS. They will eventually have to pay for a viewing station, electricity, Cat 5 cables, and so on.

The US health-care consumer probably would never consider phoning in a donation to pay for his or her scanner. I really think some out there are anticipating Hillary-care with glee, thinking the government will give us the same level of service we get now, but for free. Sure. Right. Just ask the fine citizens of East Huron how much "free" care they're getting. You might want to ask them how much tax they pay, in addition to radiothon donations. I wonder if said donations are tax-deductable in Canada?

Free My PACS

Walt Mossberg from the Wall Street Journal discusses problems caused by restrictions wireless companies place on customer's phones. Courtesy of http://www.wsj.com.

I generally agree with Walt Mossberg's technology assessments, published in the Wall Street Journal. I am not, however, a Palm Treo aficionado like Walt is, and I think he needs to get himself a new cell-phone. But that's a minor disagreement.

Cell-phones are the topic of Walt's latest rant, Free My Phone, published in today's WSJ. Walt is disturbed about the limitations placed on technology by the US cell-phone carriers:

Suppose you own a Dell computer, and you decide to replace it with a Sony. You don't have to get the permission of your Internet service provider to do so, or even tell the provider about it. You can just pack up the old machine and set up the new one. . .

This is the way digital capitalism should work, and, in the case of the mass-market personal-computer industry, and the modern Internet, it has created one of the greatest technological revolutions in human history, as well as one of the greatest spurts of wealth creation and of consumer empowerment.

So, it's intolerable that the same country that produced all this has trapped its citizens in a backward, stifling system when it comes to the next great technology platform, the cellphone.
A shortsighted and often just plain stupid federal government has allowed itself to be bullied and fooled by a handful of big wireless phone operators for decades now. And the result has been a mobile phone system that is the direct opposite of the PC model. It severely limits consumer choice, stifles innovation, crushes entrepreneurship, and has made the U.S. the laughingstock of the mobile-technology world, just as the cellphone is morphing into a powerful hand-held computer.

That's why I refer to the big cellphone carriers as the "Soviet ministries." Like the old bureaucracies of communism, they sit athwart the market, breaking the link between the producers of goods and services and the people who use them.

To some extent, they try to replace the market system, and, like the real Soviet ministries, they are a lousy substitute. They decide what phones can be used on their networks and what software and services can be offered on those phones. They require the hardware and software makers to tailor their products to meet the carriers' specifications, not just so they work properly on the network, but so they promote the carriers' brands and their various add-on services.

Now, the tie-in to PACS is obvious, and this really parallels the argument I presented in my older post, "Euros, Assumptions, and Greek Islands," wherein I bemoaned the fact that one cannot place an interface from Company A on Company B's archive.

It's somewhat ironic that I should be taking this stance. Remember my post about my visit with Dr. Bernie Huang? When I saw PACS in its infancy, it seemed to me that the only way it would be practical would be to package it in one box, i.e., sell the archive, the viewing stations, and probably the wires themselves as one package. I have to think I was right at the time, and in fact this approach represents about 99% of the PACS installs out there at the moment.

But today, PACS has matured and things have come full circle. There are vendors that make great GUI's, but are said to have weak back-ends, archive architecture, and some that have just the opposite reputation. Some use Windows components, and some use Sun/Unix based Oracle databases. There are SANs, NAS's, tape drives, DVD archives, and so on. Yes, I'm throwing a number of disparate elements into this mix, but you get the idea. Why should we be married to one company for every aspect of the PACS solution? Right now, the answer is that the vendors have us locked into the status quo. If you don't agree, just call your vendor and tell them you are going to migrate to another company's GUI. The only way to do so is to forklift out what you have and transfer all the data to the new system, GUI, archive, and all. Not so easy. It's just like trying to take your AT&T phone and migrating it to Sprint. You can't. It's not technically possible, because they are incompatible systems. At least PACS data can be migrated after a fashion, although any peculiarities in the way data is stored (like compression, for example) will bung up the process. (For a fantastic discussion of databases and archives and migration thereof, please have a look at Mike Cannavo's latest Aunt Minnie article, "Exploring PACS Secrets -- Straight talk about archiving and data migration.")

The thought of opening up PACS in the manner proposed is probably giving execs for the major vendors chest pain, or perhaps something lower. They will claim that this concept will interfere with patient care because their system won't work as it should. I respectfully disagree. Mossberg cites a similar decoupling in the telecom industry, that worked quite well:

We've been through this before in the U.S., though many younger readers may not recall it.

Up until the 1970s, when the federal government intervened, you weren't allowed to buy your own landline phone, and companies weren't able to innovate, on price or features, in making and selling phones to the public. All Americans were forced to rent clumsy phones made by a subsidiary of the monopoly phone company, AT&T, which claimed that, unless it controlled what was connected to its network, the network might suffer.

Well, the government pried that market open, and the wired phone network not only didn't collapse, it became more useful and versatile, allowing, among other things, cheap connections to online data services.

I suspect that if the government, or some disruptive innovation, breaks the crippling power that the wireless carriers exert today, the free market will deliver a similar happy ending.

And the same for PACS.

To Boldly Go Where No Man Comes Back From....

As DeForest Kelly, Mark Lenard, and James Doohan have discovered, the fame of Star Trek is fleeting at best, and eventually one must shuffle off this mortal coil, and go to the Great Beyond. Of course, James Doohan did indeed make it into space postumously, as his ashes were sent on a suborbital flight along with those of astronaut Gordon Cooper and 200 others.

But short of that, how can a Trekkie take the Star Trek Universe with him or her when he beams off this planet for the last time?

Eternal Image, maker of funerary for the passionate, has the following solutions:

The Star Trek Casket is designed after the photon-torpedo case used as Mr. Spock's casket in Star Trek II: The Wrath of Khan (image courtesy of: http://www.mikedunn.com):

For those so inclined, the 24th century reminescent Urn might be the best place to put your ash(es):

These items will not be available until next year, so please refrain from dying until then.

Amicas Gets New Prez....

My friend Peter McClennan, President and COO of Amicas, apparently will depart that position at the end of the year. I was tipped off last night to check Amicas' SEC filings, and discovered this:

(b) On October 1, 2007, AMICAS, Inc. (the "Company") notified Peter A. McClennen, the Company's President and Chief Operating Officer, that the Employment Agreement between Mr. McClennen and the Company dated March 28, 2005 (the "Employment Agreement") would not be renewed. The Employment Agreement provides that either party is entitled to give written notice of an intention not to renew the Employment Agreement prior to its expiration date, December 31, 2007, provided that such notice was given within a specified time frame. Mr. McClennen's employment with the Company will cease as of December 31, 2007

I think that's legalese for "they are parting ways".

I've come to know Peter over the years, and he is very capable and personable. He has nicely overcome his GE background and I think really helped to put Amicas on the map. I would hire him if I could afford him, which I can't.

I have only two bones to pick with Amicas as run by Peter. First, he appears to have supervised the removal of the beloved Green Amoeba logo:

The replacement is just not as catchy:

Secondly, Amicas has blamed DRA-2005 in large part for lackluster sales. I have had some discussions on this topic with some of the other execs at Amicas, and I guess we'll agree to disagree.

Dr. Steve Kahane, Chairman and CEO, will take over Peter's duties come January. Steve is also incredibly capable and personable as well, and I'm sure he'll do just fine. He is no newcomer to this sort of thing, having headed Datamedics and VitalWorks in the past.

I hope Peter doesn't go back to GE, but if he does, maybe he can turn around some of the mentality that gave us Centricity as it exists today. (More on that in an upcoming post!) Best of luck! I'll be glad to write a letter of recommendation, although a letter from this Dalai Lama might not be exactly helpful....

A Record Month!

As you know, I keep track of visits and such via Sitemeter.com. This month has ended with a bang, showing the most visits ever. I'll keep writing it if you keep reading it!

Falling Down

Image credit: http://en.wikipedia.org/wiki/Image:Falling_down.jpg

A significant portion of my business lately has come from Falling Down. No, not the old Michael Douglas movie, but rather the actual falling down of patients, mainly the elderly. I cannot tell you how many dozen examinations I have read over the past several weeks that were prompted by an old person falling. The average age for this particular problem is creeping up, although the range is widening overall. I'm seeing more and more exams on those in their late 80's and early 90's, although I haven't seen any on those 100 and over for a while.

According to the CDC as quoted by eons.com, falling down is "the leading cause of injury-related death in people over 65, primarily the result of hip fracture complications. (B)y by 2020, medical costs from hip fractures alone—resulting from falling accidents—are expected to cost the healthcare system between 20 and 50 billion dollars." Big problem. Really big problem.

It may be a stupid question, but why do old people fall down? And how can we prevent this from happening? There are several answers out there....

From www.laterlife.com, we find this:

Scientists at the University of Birmingham have been investigating this troubling phenomenon, and they’ve found that vision plays a part.

It seems that the normal thing to do, when walking through cluttered environments, is to look ahead to locate safe places to put one’s feet. But older people need to look much sooner to these targets, possibly through a slow-down of reflexes or a need to make sure that the way is clear.

Result is, they are in danger of looking ahead before they have sufficient visual information to negotiate the step immediately in front of them. And this makes for a higher risk of tripping and falling.

The eons.com article adds:

There are intrinsic changes associated with the aging process. The changes that increase the risk of falling are a degrading musculoskeletal system, sensory function, and gait changes associated with aging.

There are actually many factors that contribute to slip-and-fall accidents in the elderly. Medication side-effects can cause balance problems or dizziness, which can lead to falling. Elderly people have more chronic illnesses. Arthritis, for instance, is one of the major factors in falling. Pain associated with joints can cause falling. Fatigue, osteoporosis, dementia, and all sorts of things that more commonly strike the elderly, can lead to falls.

As my wife's grandfather, who passed away at age 93, used to say, "Getting old isn't for sissies."

So, what can be done about this? There is a long list of precautions to consider, such as these exerpted from the eons.com article:

Minimize changes in walking surfaces, and use slip-resistant coverings

Use lighter-colored floor surfaces to create color contrasts between walls and floors

Increase lighting and reduce the contrasts in lighted areas

Securely install grab-bars positioned for support

Don't wax floors

Avoid climbing and reaching to high cabinets

Always keep a night-light on in your bathroom

Use bathroom rugs with nonskid backing

Install light switches at the top and bottom of stairs

Be sure carpeting is tightly woven and installed so it doesn't move or slide

And so on. Perhaps the most important recommendation for the older generation is to maintain good health, and not to let the fear of falling get in the way of exercising, and enjoying life. You see, there's a lot more to look forward to as we get older than having some cranky radiologist read your hip radiograph!

Sniping for Fun and Profit

Cute, isn't it? But that's actually not the sort of sniping I'm talking about. Rather, I am referring to those low-lifes who are my nemesis on eBay... Let me elaborate.

I love dabbling on eBay. I love to pick up bargains, hard-to-find collectibles, necessities of life, what have you. Now, I'm not addicted or anything; I can quit any time I want to. Really. No, really!

Anyway, for years now, I've been trying to find an affordable piece of the Star Trek universe, preferably one that had something to do with medicine. Perhaps a screen-used scanner, or Dr. McCoy's uniform, or surgical scrubs. These things do appear on eBay all the time, and I have bid on a few. But, I haven't won any of them, and it's all because of the bloody snipers!

So, what's a sniper? eBay itself offers this definition of sniping:

Placing a bid in the closing minutes or seconds of an auction-style listing. Any bid, placed before the listing ends, is allowed on eBay. To protect yourself from being outbid at the last moment, enter the maximum amount you're willing to pay for an item up front, and eBay will bid automatically for you, making sure you're the high bidder until your maximum is reached. This system is sometimes called proxy bidding.

eBay has no problem with this practice, and why should they? The seller is happy, the sniper is happy, it's only the unsuccessful buyers like me that aren't happy! But think about how this works, and you may see it from my point of view.

When an item is listed for auction on eBay, a time limit of one, three or seven days is selected for the sale. Bids trickle in over this period. But, it is at the last possible minute that the sniper swoops in and tries to outbid, leaving others no chance to top him or her. Now, eBay's response about the proxy bidding system is well-taken. If I can only stomach spending $500 for McCoy's old tattered uniform, then that's what I bid as my maximum. But I'm going to feel really bad when Mr. Sniper cuts in 10 seconds before the auction is over and gets it for $501. This is the problem with the system: there is always someone out there willing to pay just one more dollar (or five when things get into the higher priced realm) for the item in question. In addition, some of these auctions end during working or sleeping hours (No, they are NOT the same, thank you), and it is impossible for me to sit on the computer and snipe, or snipe back, as the case may be.

There are those who live and die by sniping, and justify the practice till the cows come home. This site, for example, basically says that snipers aren't doing anything wrong, so leave them alone. Personally, I disagree. There is a certain degree of unfairness, of violating the spirit of the thing, by sitting and laying in wait, ready to outbid the bidder by the smallest increment possible. Why is it unfair? Because there is no possibility for said bidder to "fight back", except perhaps to place a ridiculously high proxy limit. Maybe that is the answer after all.

Technology has provided a solution, or perhaps aided the problem. There are a number of automatic bidding programs out there that will electronically snipe for you. I won't link to them because I think it is a nasty practice, but feel free to Google the concept yourself.

So, since I'm not happy with the status quo, how would I change things? In my bidding travels through the net, I have found a site for guns and knives and such called GunBroker.com. (You would be amazed at the weapons available on the 'net!) They have a little something called the "15 minute rule":

In a typical auction setting, there is always a called out counting that happens to allow buyers time to decide to place higher bids. This 'final call' is reset each time someone places a bid. . . .(B)ecause of delay caused by the Internet and other possible technological speed bumps, we have a 15 minute final call time.

. . .If there is bidding activity on the auction within fifteen (15) minutes of when the auction is scheduled to close, the auction automatically switches into a special mode analogous to the 'going, going, gone' period of a live auction. In this mode, the auction is automatically extended until there have been no bids placed within fifteen (15) minutes. . .The 15 minute rule makes auctions more fair, by allowing all bidders an equal opportunity to place their best bid. In other online auctions where an auction ends exactly at a given time, some bidders will hold their bids until the last minute or so, in the hope of winning an item on the cheap. This is referred to as 'sniping'. The 15 minute rule gives all bidders an equal opportunity to place their best bid on an item before the item closes. This way, no bidder loses an item to sniping, and the seller can be assured that he has gotten maximum value for the item.

In a recent survey, a feature similar to our '15 minute rule' was the #1 most-requested feature addition that eBay (R) users would like to see added to the eBay (R) site.

I'm really not sure why eBay won't do this. It seems a great deal more "fair" than the sniper system. Perhaps eBay is worried about auctions continuing forever, but I really doubt that would happen. At least every participant has a fighting chance, and isn't guaranteed to get away with something based on a loophole. (Remind you of any other practice I've been writing about?)

Oh well, I guess I might as well get hold of one of those sniping programs....

Entertainment in Rome

Observed just off the Piaza Navona. You've seen the white-clad "statues" of friars, and even the "Statue" of Liberty played by street-mimes. Here is something truly different....

The Ultimate Pointing Device

I have posted here and there about the various pointing devices on the market and how they work (or don't) within the PACS environment. They all attempt to translate your thoughts into motion on the screen in some manner. Wouldn't it be nice to eliminate the mechanical middlemen and just "think" your way through a study?

As reported in Medgadget, our friends at Microsoft are working on just such a project. No, their goal is not a new PACS interface, of course, but this would certainly be a great application for such technology.

The project is in a very preliminary state, but the essence is this:

We have built software infrastructure that acquires the signal from our EEG devices, transforms our data into relevant features for our machine learning algorithms to build predictive models, and classifies new data in real time. The system also allows us to easily store, playback, and visualize raw as well as classified data.

They have used this primitive prototype to control various tasks, including playing the video game Halo. That's not bad.

Some comments made on this topic suggest that the technology will be used for mind-reading, and other nefarious purposes. I seriously doubt, however, that such capabilities will be present for quite a while, as in decades at least. Would you trust Microsoft with the keys to your brain? Perhaps, as long as they don't try to apply patches or service releases!

In the meantime, consider the possibilities of powering through your daily stack by concentrating on the images. I guess this means I'll be even more sedentary than I am already. Maybe Microsoft can come up with some virtual muscle stimulation.

Don't Even Ask About Today's Special.....

Up For Bidding... A Fossilized Walrus' WHAT??

Image courtesy of: http://www.chait.com/

I should have been able to resist, but I just couldn't let my readers miss this one. This is not a joke, by the way. From the auction site of the I.M. Chait auction house:

Description:HUGE FOSSIL PENIS WITH PRESERVED SKIN

Odobenus species

Pleistocene

Tamyr Peninsula, Russia

This amazing discovery occurred while Russian fossil hunters were combing the defrosting permafrost for Woolly Mammoth fossils. Mistaking this extremely rare find for a badly weathered mammoth tusk, they threw it onto their truck and hoped that it would look better once polished. Luckily, a knowledgeable fossil dealer saw this specimen prior to any cosmetic improvements and realized what it really was; an actual mummified penis from an extinct species of Walrus. Buried in the frozen tundra for tens of thousands of years, the actual skin and muscle tissue which cover the baculum has dried, allowing for this extraordinary preservation.

Among mammals, whales have the largest penis but the walrus has the largest and most robust internal bony penis. So massive is this bony element that Eskimos use it as a killing club during their hunts. The shape of a penis bone or baculum is an important diagnostic feature used to identify species within five orders of mammals: Primates, Rodentia, Insectivora, Carnivora and Kangaroos (marsupials).

This truly one of a kind fossil "member" is among the most bizarre find of ancient erotica to date. Measuring an impressive 4 1/2 feet in length, it comes with a metal display stand.

Go ahead and bid. You know you want to. Estimated sale price for this piece of natural history is $16,000 to $20,000. Size matters, so they say....

Conversation with a Heart Surgeon on Sunday Morning

Dr. Michael DeBakey, THE Premier Heart Surgeon, courtesy of http://www.nasa.gov

Here is a conversation, transcribed verbatim, that I had with one of the premier cardiothoracic surgeons this morning at our heart hospital:

Dalai: Could I speak with the nurse taking care of Mr. X?
Ward Clerk: Dr. Surgeon is rounding, I'll let you talk to him.
Dr. Surgeon: Yes?
Dalai: Dr. Surgeon, this is Dalai. I wanted to let you know that Mr. X has a new, small left apical pneumothorax.
Dr. Surgeon: Do you think I give a shit?
Dalai: Well, I hope so....
Dr. Surgeon: OK, thanks....{hangs up phone before response}

Maybe he was kidding, and maybe he wasn't. That is still what I would call disruptive physician behaviour. Naturally, if I were to write him up, I would get laughed at. But you can bet your last dollar that if the conversation were reversed, I would be on the carpet in front of the MEC and Administration faster than you can say "Chest Tube". You can bet that same dollar that I would be criticised if I didn't let someone know about the positive finding. Damned if you do, damned if you don't.

Oh well, retirement in six years, 4 months, and one week, stock market willing.....

ADDENDUM

Anonymous from a large PACS company just posted this comment:

Hmmm... grouchy customer tears you a new one when you're just trying
to do your best.

Sounds strangely familiar.

Oh, dear, I have trodden on some toes, have I? Well, I do see the analogy Anonymous is trying to make. I have been on the case of the big PACS folks for a while, and some might say I have been relentless in my approach. Now, the situation above directly involved patient care. The patient had a positive finding, and I dutifully reported it. That the surgeon didn't want to know about this is his problem. I have a duty to the patient whose image I am interpreting to relay positive findings. Just ask any malpractice litigator. Had I shirked this responsibility, I would be in big trouble.

Anonymous' implication is that he and his company have done everything they should have in creating their PACS, and that I am being grouchy about their best work. I will grant you that Anonymous and his/her crew have very likely done their best within the parameters they were given by designers or whatever. My problem is that they didn't work with the users (or enough of them, anyway) to create the product that I and my partners want to use.

The purpose of complaining in this venue is to be heard, and with an international audience, I know at least someone is listening to me. I expect the vendors, to whom we pay a LOT of money, will at least listen and occasionally act on my complaints. Here is where I differentiate my situation from Anonymous' plight: The surgeon's b*tching and acerbic behaviour is foolish, because he knows, and I know that I cannot do anything different than what I did. He MUST be informed of a positive finding, whether he wants to hear about it or not. With my b*tching and acerbic behaviour, I do expect a change. That is the difference.

Things could be worse; one of my partners emails our CIO and PACS administrator with each and every glitch and hiccup of the system. Posting that sort of thing does no one any good.

Impressions of Compressions

There has been some talk on Aunt Minnie recently about compression, prompted by a Canadian study that showed you don't lose anything with lossy compression. Think about that one for a moment.

This prompted me to see for myself just how compression might affect an image. There is a ton of information on compression in this setting. Try the Wikipedia article on wavelet compression for starters. Frankly, the topic is so complex, I would have had to dust off my old engineering skills as well as my HP 41c, which I loaned to a physicist friend years ago. So, I thought it would be useful to (picto)graphically demonstrate what varying degrees of compression might do to a CT slice. I began with a DICOM image, the original size of which is 514 KB.

Then, using IrfanView, I applied JPEG 2000 compression (which uses wavelets) in varying degrees, with the results depicted below:

The number after "Lossy" is the degree of compression applied, which can range from 1 to 100, rather like the 1-12 selection offered for the original JPEG. IrfanView's JPEG 2000 compression plug-in uses the LuraWave JP2 module from LuraTech, if you're interested. You do have to keep in mind that I had to convert the images into regular JPEG for display here on Blogger.com, but you still get the idea. The image is pretty much unreadable at over 1:100 compression (I probably should have stated that as 100:1, but it's too late now!) However, I defy anyone to tell me that they can tell much difference between the higher quality compressions and the original. In particular, the lossless image is for all intent and purpose identical to the original, at least to my eye.

There are strong arguments made to store only the original full DICOM image, and this makes sense given the plummeting prices for storage. However, bandwidth, while ever less expensive, is still right up there. For example, we are having to consider the use of Metro Ethernet (MetroE) lines to boost the transmission speeds for our self-owned PACS. This will add somewhere from $50,000 to $100,000 to our yearly PACS expenses. Were we to use lossless compression, or even very high-level lossy compression, this would not be necessary. The question always comes down to this: Will I miss something on a compressed image that I would have seen on the full-fidelity original? Frankly, I don't think so.

Agfa Really Is For Sale!

My April Fool's post was just a joke, but it seems that life sometimes does imitate art. From Forbes.com:

BRUSSELS (Thomson Financial) - Ludo Verhoeven, chairman of imaging technology and software group Agfa-Gevaert NV said the company has received interest in buying all three of the businesses which it will be spun off into next year.
Asked whether interest was coming from private equity groups, Verhoeven said 'the only thing I can say is that there has been interest for all three businesses, and that's not bad news'.
He was speaking at a news conference for the group's half-year results.
The group plans to divide into three separately listed companies; Agfa Graphics, Agfa Healthcare and Agfa Materials.
Earlier, the group said it expects the company's demerger into three separate companies to be completed by summer next year, with the group implementing the transaction based on the closing balance sheet of Dec 31 at the end of this year.
The listing of independent companies will also take place before summer 2008.

Are you listening, GE? I'm not sure there is another Big Iron company out there that would be able to afford this little purchase. Or that would be at all interested, for that matter.....

Many thanks to AuntMinnie user Daryl Thompson who spotted this little tidbit.

ADDENDUM

BusinessWeek.com adds this:

Agfa Split Attracts Private Equity Interest
08/1/2007
Agfa-Gevaert NV’s split-up into three separate businesses next year may well lead to the sale of at least one of the demerged companies -- but whilst analysts agree the move is unlikely to take place in the short term, they see a number of possible buyers, including private equity groups and sectoral peers from both Europe and the US. On July 31, group chairman Ludo Verhoeven said the company has received interest from potential buyers of Agfa Graphics NV, Agfa Healthcare and Agfa Materials, but said a deal would have to be done at the right price. Analysts see the demerger as a much-needed move by a company which needs to 'get its act together', adding that it will unlock value to attract potential buyers. Arnaud Goossens at ING Securities sees the sale as a long-term goal: 'These businesses have been up for sale for almost two years,' he said, adding that many potential buyers have now invested elsewhere. Philips NV has been mooted as a possible buyer, but Siddy Jobe at Bank Degroof said the obligation to take on the declining analogue business, as well the digital hospital imaging systems, had put them off. 'If you're interested in healthcare, you have to take it all or nothing,' Jobe said. ING's Goossens, however, did not rule out the break-up of the demerged entities and said Philips could be eyeing Agfa's ORBIS hospital IT system.

Hey, wait a minute...Philips???? Didn't they just buy Stentor and make it their flagship program, ditching Sectra and inconveniencing the users of the "old" platform? I guess I'll have to learn to love iSite, eh?

Addendum 2

And there's even more bad news for Agfa, and potentially us Agfa groupies, from Forbes 7/31/07:

BRUSSELS (Thomson Financial) - Shares in Agfa-Gevaert NV plunged after the imaging technology and software group posted a disappointing set of second quarter results and put back the company's demerger by six months to focus on operational improvements...

'After a decent first quarter that gave hope for more improvement, the second quarter results are a major disappointment. Further... management admitted the major operational weakness and said it would focus more on operational improvement,' the broker said...

'The results show that Agfa is not yet worth any sign of confidence from investors. Management has a lot of difficulties in getting the ship under control.'

Uh Oh... Next thing you know, Agfa will be blaming me for their downturn, although the article suggests that the high price of aluminum is at fault. We'll see.... Actually, they did find someone to blame, acording to Forbes:

BRUSSELS (Thomson Financial) - Agfa-Gevaert NV has announced that Philippe Houssiau will be leaving his role as president of Agfa HealthCare, 'in view of the second quarter results'.

The company added that Carl Verstraelen will join the unit as Vice President Finance and Controlling.

Verstraelen will be put forward for appointment as CFO in Agfa HealthCare's executive committee after Agfa splits next year into three separate listed companies, the imaging technology and software group said in a statement.

He's Back!

I'm back from overseas, having stayed in Italy for a few days following the meeting cruise. We spent a couple of extra days in Venice, and then took the train to Rome for the rest of our stay, with a little side trip to Pompeii at the end. That was my favorite part of the whole trip.

One of the most macabre sights I have ever seen was to be found on the main street of Rome, Via Veneto. The Capuchin Friars have a church with an indoor cemetery sitting right next to hotels and restaurants. But this is no ordinary cemetary. Here is the description of just one of the rooms:

Crypt of the leg bones and thigh bones

The side walls each have four niches occupied by a Capuchin, standing and vested in the habit. Along the rear wall, the central block is a richly imaginative composition: up above, a cross enclosed in a circle; underneath, the Franciscan coat-of-arms: Christ's bare arm crossing the clothed arm of St Francis, surmounted by a crown of vertebrae. In the ground, 18 crosses mark the graves of various friars. The central oval frame in the vault contains an arrangement of jawbones decorated with vertebrae and, on either side, two large flowers made of shoulder-blades, with hangings of vertebrae. The corridor vault has three eight-pointed stars, a massive lantern hanging from the central one.

I have borrowed a photo from the Capuchin's website since they allowed no photography within the crypts. When they say "coat-of-arms", they really mean it.

More photos can be found on the website of someone who took some "forbidden pictures"....http://www.tapholov.com/bones_chapels.htm

At the Vatican we saw the usual stuff, including the cleaner, brighter paintings of the Sistine Chapel, and the innumerable works of art within the Vatican Museum. There is a relatively new tour of the excavations beneath St. Peters, which include a necropolis from before the time of Jesus, and possibly the tomb of St. Peter himself.

I had one particularly unusual experience. Upon first meeting our guide for the Vatican, he looked at me rather strangely. I thought perhaps that he had read my blog, but he didn't seem the radiological type. As we entered the museum, he apologized for starting, and said, "you are about to see yourself inside..." It seems that I bear a striking resemblance to the portrait of the Roman Emperor Hadrian:

Yup, maybe I'm the reincarnation of Hadrian, who wasn't a particularly nice guy. That would certainly go along with a lot of opinions, wouldn't it? Oh, well. Veni, vidi, vici, right?

Euros, Assumptions, and Greek Islands

You may notice some degree of stagnation on the blog, as I have not posted in several weeks. I’ll try to remedy that situation.

I am presently in Rome, Italy, following a cruise of a few Greek Islands, Split, Croatia, and Venice. It was actually a meeting cruise, with a number of lectures on CT by Elliot Fishman, M.D. and other radiological celebrities. I wonder if they realize that they were on the ship with the (in)famous Dr. Dalai… The cruise itself was OK, but I do have to give one warning: Unless you are clinically deaf, avoid the Royal Caribbean ship Splendour of the Seas like the plague. It is an older ship with absolutely no insulation between decks. We could rarely sleep due to the constant banging around and dragging of chairs on the deck above us. Not good. However, there was a great deal of CT knowledge imparted to the participants, and I'm going to try to apply at least some of what I learned to my daily practice. Although the meeting wasn't about PACS, I did acquire a few tidbits here and there. Several of the other participants have Agfa Impax 6 and hate it. One fellow replaced an old (2003) Amicas system with Dynamic Imaging and loves it. Dr. Fishman himself uses Emageon at Johns Hopkins, and complained numerous times that it chokes if they try to load a CT series that contains more than 100 images. That's 100, folks, not 1000. Their solution has been to use Siemens WebSpace, a remote client version of InSpace, for multislice CT studies of more than 100 slices, which is about everything they do there at Hopkins.

There is a thread on Aunt Minnie which was prompted by my recent article, Dalai’s Laws of PACS. This discussion has gone from hashing out what clinicians should expect out of PACS (a major point that I left out of the Laws) to a longer chat about vendor-neutral archives and databases. I don't claim to have all the answers on that one, nor do I begin to understand all the underlying DICOM issues involved. However, two experiences from this trip I'm on may provide some useful analogies.

The issue was rather well-stated by David Clunie (of course!) with this post toward the end of the long thread:

We have talked about the "vendor-neutral image archive", which could be the place in which images and other (standard) composite DICOM objects live; would it also be feasible to discuss a "vendor neutral image database" as a separate entity from the archive, which multiple PACS and/or "Image Manager" actors could access ? I say this, because it is useful to have central and accessible database of the images and various additional information that may not be strictly related to or extractable from the DICOM image headers and have no business in there (e.g., read status, legal name changes like getting married, etc.) - this information is needed by multiple production systems (e.g., different PACS, different RIS, web server, EMR, etc) in addition to the image locations, yet is perhaps separate from the "PACS" functionality per se. Also, during PACS migration, such a database might not need to be changed, or could be serialized in a "vendor neutral image database interchange format" that could be "read into" the next database. In the past various folks have proposed extensions to support PACS migration that serialized a snapshot of this information (even suggesting a huge DICOMDIR for this), but I am not sure that there has ever been a serious attempt to factor out a shared, live, standardized, database. In a sense, the VNIA and the VNIDB would to in-house PACS what the IHE XDS repository and XDS registry are to cross-enterprise document sharing; not that I am suggesting that XDS is necessarily the appropriate technical solution for this. Ordinary SQL access might be an option; another might be Grid Service based queries such as are being developed for caBIG imaging, which also have the benefit of a comprehensive security model.

Early on in the discussion, I think I was mentally considering the archive and the database as one, which is not strictly accurate. For me, the bottom line is this: I want the ability to plug different tools, modalities, and especially workstation GUI's into my database. Simple concept, difficult execution, apparently. But here is where the first European example comes into play. You are all familiar with the Euro, the new currency used by the multiple countries of the European Union. Anywhere within the EU, a One Euro Coin looks like this on the back:

But on the front, the different member countries can display their own design. Here are the coins from Greece, Ireland, and Italy:

My point here is that all these coins are worth one Euro. They look slightly different, but they do exactly the same thing. Such would be my vision for a Vendor Neutral system. I want to be able to buy a database from Belgium, as it has the reputation to be the best. I want to plug in a scanner from Germany, and have it talk to my database from Belgium without any add-ons, extra interfaces, or especially extra charges. I want my interface from Greece, my 3D app from Ireland, and so on. Quite roughly, interchange DICOM for Euro, and you see where I'm going with this. DICOM needs to be the unit of currency for PACS. The only problem with this concept is the vendors' insistence on the use of Private Attributes, factors that make their systems different, but don't translate from PACS to PACS. WindowsPACSMaven proposes a possible solution:

To alleviate the above mentioned issue with Private Attributes I decided with a colleague in 1998 that we would design a PACS using "Native DICOM". Native DICOM is DICOM V3.0 with no Private Attributes! To do this we partnered with a major university to be sure that no vendor attributes got into our design...By using Native DICOM we would be guaranteeing viewability anywhere that DICOM V3.0 is present. So if we can get Radiology to start to use Native DICOM through vendor and/or open solutions the problems with storage and retrieval will be minimized going forward from here. Because the Native DICOM concept is so radical I actually lost my job for promoting this concept and am now an independent software developer for healthcare! Because of my job loss I still have to remain anonymous so that I don't affect my future income possibilities since I do consulting for healthcare vendors.

One would assume that the big boys have something to lose with this approach, eh? Therefore, it must be good! OK, OK, there is a lot more to the issue than I've presented, but the idea is clear, and I think it has a lot of merit.

So how did we get in this situation? The second lesson from my trip might explain it. On the island of Corfu, we were enticed by Royal Caribbean's shore excursion brochure to take a "4WD trip into the hills of the island, where you will see villages rarely visited by outsiders." We were intrigued and signed up for the journey. When we got to the staging area, we found 20 little 4WD vehicles. So far so good. But upon closer examination, there was one little problem: the cars all had manual transmissions! This was a problem because I've never driven a stick, and my wife hadn't done so in over 20 years! But she bravely took the wheel, and skillfully drove up and down the hills, through little passes and treacherous switchbacks like this:

It was worth it, however, to see some of the wonderful, isolated little villages. At least that's what we told my wife when we got back! She was too busy driving, and in particular trying to keep from rolling back into the car behind us in the caravan to see the sights! Here are some typical scenes:

The lesson here is that Royal Caribbean assumed that everyone was OK with their way of doing things, that no one would have a problem with manual transmissions. They were so unconcerned with the needs of their passengers in this venue that they didn't even bother to publish the fact that the cars were only of this persuasion in any of their literature. This is they way it is, kids, it would cost us money to change it, and we assume you will like it and be comfortable with it.

I'm sure you see where I'm going with this. Do I even have to say it? Oh, well, I'm not known for my subtlety. Many PACS companies have done things a certain way for quite a while, and they assume you and I will like it. The fact that we may NOT be comfortable with it, and that we may have to waste the brainpower that we should be using to view the road, I mean the image, on driving the stick instead. The DICOM currency standard would be one way to solve this problem. One could, in theory, use an "automatic" front end to a database that otherwise had a "stick shift" GUI.

Let me wrap this up before I get even further lost in weird car analogies. Ultimately, the only "vote" we have is with our dollars, (or Euros) or those that come from our hospitals. I WANT the ability to do what I have described above, and I expect the market to provide it eventually. Royal Caribbean made what could have been a very dangerous assumption (had I tried to drive myself), and the non-insulated Splendour of the Seas deprived me of valuable sleep. My vote will be to never cruise on one of their ships again. I'll be certain to exercise the same sort of thing with other big purchases as well. Hint, hint.....

Ciao!