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Canadian drug "shortages"

Just got another email from RIH about more drug "shortages". Seems that the concepts of Nassim Taleb's book "Antifragile" haven't made it very far in the statist bureaucracy that controls every minute detail of the pharmaceutical industry in Canada.

The problem is that Sandoz is the sole supplier of many injectable drugs in Canada. Why such a situation is allowed is beyond me as it represents a single point of failure whereas a robust system would have multiple suppliers. Drugs such as lorazepam, hydromorphone and fentanyl are currently in very short supply. Now creating a drug solution of specified concentration for injection is not rocket science. As one of the GP's rather sarcastically commented at one of our hospital meetings recently, his patients have no difficulty in taking hydromorphone tablets and producing an injectable product from them. Such crude drug solutions do suffer from sterility issues; something which is readily dealt with by sterilizing the solution by passing it through a 0.2 micron milipore filter. That, and buffering it to pH 7.4 and ensuring it's isotonic to serum.

I've made sterile drug solutions of given concentration as I wanted my neural cultures to last as long as possible without bacterial infections. It was an action so simple that I was completely astounded when the shortage of injectable drugs came up as a major crisis in hospital pharmacies. The fact that pharmacists haven't been taught how to perform such simple operations is criminal.

The problem, at its root, is the absolutely insane statist regulatory climate that takes an operation as simple as dissolving the salt of a drug in normal saline and makes it into a byzantine regulatory nightmare that only the bravest (or most foolish) will attempt to navigate. Thus, we end up with a single supplier of iv drugs for the whole country whereas every junkie in Canada has absolutely no difficulty in providing themselves with injectable drugs.

To me the very existence of such a problem reflects a government totally out of control and a start in dealing with this problem would be to randomly fire every third bureaucrat and snivel servent as well as all members of the oxymoronically entitled "health protection branch". Next, one should take the totality of regulations enacted in the last 20 years and create a huge bonfire from the paper copies to erase this period of insanity from the history of the country. Then start teaching pharmacists how to dissolve a drug in a liquid -- one can use analogies like adding sugar to ones coffee. Sterile technique is easily learned and microbiology lab technicians can help out. Have hospitals prepare their own iv drugs and one no longer will have the absolutely idiotic situation where injectable drugs are not available in a whole country. Hell, I'm sure that the countries junkies would be happy to help explain how the process is done in exchange for a small donation of morphine and hydromorphone tablets.

Posted by Boris Gimbarzevsky at 1:55.20
Categories: Medical


The Black Swan: preliminary thoughts

I had some time off recently and had a chance to read Nassim Taleb's book The Black Swan. Every decade or so I have my weltanschauung radically rearranged by a particularly profound book; Norretranders The User Illusion in 2000 and Gleick's Chaos in 1989 (which lead to the book From Clocks to Chaos by Glass and Mackey which almost made me quit medicine for research again). It's interesting that these major changes happen about once/decade which is also roughly the interval between my making major life alterations.

Black swans are the totally unexpected, unpredictable events that occur a lot more frequently than people think. The name comes from the assertion, prior to humans setting foot in Australia, that all swans are white. Looking back at my life I find that every major change was the result of a black swan event (the majority positive). Black swans are the "unknown unknowns" that complicate ones life and, on a personal level can be the unexpected heart attack or stroke or winning a lottery and on a social scale the collapse of the world financial system (a work in progress), near total disruption of air travel to Europe by a volcano in Iceland and the use of hijacked airliners to attack the world trade center on 11/9/2001. Curiously (not so curious after you read the book), it's the "experts" who have been the least likely to predict such events.

Humans live under the delusion that their lives are orderly and predictable. This illusion is created by the reality generating apparatus that creates our percieved reality (not something that Taleb dealt with in detail but the primary subject of Norretranders book). This reality generating apparatus has a number of design faults which result in it ignoring the possibility of black swans or minimizing their impact. This results in a number of fallacies which Taleb explores in great detail and it finally made me aware of why most physicians are stuck on linear relationships between variables -- this seems to be built into the human brain. I worked with non-linear systems during my research days so, to me, non-linear relationships are obvious but now I understand why I get so frustrated with much of the medical literature.

One of the key concepts in Taleb's book is the division of events as either belonging to "Mediocristan", the nicely behaved (from a statistical viewpoint) part of the world where conventional statistics works and measured variables fall on a Gaussian probability distribution (bell curve). His example is that of human heights which fall into a very narrow range and the probability of finding a 12' human is so close to zero that it is zero for practical purposes. Then there is "Extremistan" the dwelling place of the black swans. Events from extremistan can't be described by Gaussian statistics and are things like number of books that an author will sell and one that is known to most people is the Harry Potter series of novels which were the creation of the previously unknown author J. K. Rowling. Coming from seemingly nowhere, the Harry Potter series of books had sold some 400 million copies by June 2008. Considering that a book which sells 100,000 copies is considered a best seller the Harry Potter phenomenon clearly belongs to extremistan.

I realize the section above is a crappy review of the book and plan on revising it RSN. What struck me about The Black Swan was that I was familiar with many of the underlying concepts but had never seen them laid out in this fashion. It's a book that I plan on re-reading in the very near future to nail down the key points. It's already influenced my thinking quite a bit especially in the area of climate science.

Taleb destroys complicated financial models as they are useless and haven't predicted a single recession over the last 30 years. When one reads the book, it is clear that the analytic approach used is totally flawed and increasing the speed of computers used to run the models or the amount of information they start with won't make a bit of difference. Black swans are outside of the reality of the models and can't be predicted; all that can be done is to prepare for them and try to mitigate the effects when they do occur.

This situation is uncannily close to the highly detailed climate models that are said to predict global catastrophe unless we all give up industrial civilization and go back to living in a primitive fashion that doesn't result in release of CO2 into the atmosphere. I'm sorry to say that physicians appear to have been particularly gullible in this regard with major Canadian medical organizations coming out in support of processes which would destroy modern medicine as we know it if the drastic CO2 lowering called for by various watermelon groups (green on the outside, red on the inside) was to take place. The distortion of science as a result of the delusion of anthropogenic global warming (AGW) may be severe enough to destroy science. Fortunately, there are many voices of sanity on the internet with Watts Up With That (WUWT) being one of the most popular blogs pointing out that the AGW emperor has no clothes.

The earth's climate (considered over a period of centuries) belongs to extremistan, not mediocristan but the global climate models (GCM) are firmly rooted in mediocristan. They are less than useless and it will be interesting to see how future generations view this particular form of mass insanity that affected the world from 1990-2010. The only benefit that the AGW movement has given the rest of humanity is the insight that the earth's climate is a lot less stable than we think but we're not the ones who are making the changes. The thinking exhibited by the AGW proponents is isomorphic with the anthropocentric view pre-Galileo that the earth must be the center of the universe. I wish we had the ability to control the earth's climate but that is a long long way off.

One of the latest attempts by the AGW forces was the publication of a paper in Proceedings of the National Academy of Sciences (PNAS) which tried to discredit scientists who don't believe in the preposterous claims of AGW by stating that 97% of climate scientists are believers in AGW and have a better publication record than the "disbelievers". Science is not a matter of consensus, it's about whose theory has predictive value and is resistent to attack. The paper in PNAS is a sign of desperation among the AGW adherents. I haven't read the PNAS paper as I can't get access to it online but the story was covered on WUWT at this link and there was a "hit list" of "disbelievers" at another site which I can't find the link for now. The posting I made is given below and I noticed as I was writing it that I was suddenly using concepts from The Black Swan. What follows is a corrected version of what I posted at WUWT.

That the PNAS has seen fit to publish a paper in which a central premise of a paper is the fact that 97% of scientists support the theory of AGW is a sad day for science. I don't care if 99% of scientists support a particular viewpoint; it just takes one scientist who demonstrates that the theory is false to produce a paradigm shift. There are numerous historical examples of where this was the case: 150 years ago 99% of physicians would have likely disbelieved the germ theory and it took the work of Semmelweis and Pasteur to finally convince the medical profession that they were on the wrong track. To make matters more embarrasing, Pasteur was not a physician.

Of course that is in the field of medicine which some can argue isnt a true science as consensus positions in many subspecialties are the norm (especially psychiatry). In the field of physical sciences one would expect true science to reign. AGW is a very sloppy theory and seems to be setup so it is non-falsifiable; IMHO Steve McIntyre has falsified AGW by his debunking of the hockey stick graph. AGW is such an amorphous theory that it seems anything that happens fits the theory; we have a colder than average winter and that is part of global warming. It is hotter than usual in the summer again global warming. It rains more, again global warming but then droughts are also forecast by global warming.

What has become clear is that most of climate science has become very unscientific. True science is open to anyone who is intelligent enough to take the basic premises of a branch of science, play with them and come up with novel testable theories. The sign of a non-scientist is the denigration of an individuals credentials when they come up with unexpected testable conclusions from data that "true scientists" have not. Steve McIntyre seems to frequently be attacked on this basis as his methodology for destroying one of the essential foundations of AGW can't be disproved by the "experts" in this area and Steve McIntyre is not an academic. Many of the novel discoveries in science have been made by non-experts or people with expertise in other fields as they are thinking out of the box whereas experts have great knowledge in a tiny area of science and no longer think much beyond their area of expertise.

I dont care if the person who comes up with the right answer is a cab driver, plumber or solar physicist; the main thing is if theyre right or not. We've seen failure after failure of AGW predictions and an ever increasing nebulous theory that now seems indistinguishable from a pseudo-scientific justification for unbridled statism.

From what I've seen, the well funded AGW establishment is unlikely to produce anything of scientific significance but is capable of producing immense harm. One has the situation where there are a small group of like-thinking "experts" who are the recipients of the funding and also serve as peer-reviewers of what are considered to be the most influential journals in the field (and thus determine which papers get published). These "experts" have graduate students who, through the process of confirmation bias and often not so subtle pressure from their thesis supervisor, reject the outliers they find in their thesis projects and come up with yet more support for the pet theory of their supervisor. This technique is fine if one is dealing with phenomena from mediocristan (the realm where normal distributions apply and conventional statistics works) but totally fails in extremistan which is the home of black swans, or unknown unknowns and also the regime corresponding to earths climate. We have been total failures in modelling the far more constrained financial systems with numeric models even with incredibly fine-grained data. The idea that one can use the same models (but faster computers) to model the highly chaotic climate system of the earth for which we know only imperfectly a few of the controlling parameters is the height of hubris (or insanity).

Throwing money at a large collection of climate "experts" would be analagous to creating a multiprocessor system to solve a problem in which every processor solves the identical problem with just minor differences. WUWT is the equivalent of a multiprocessor system in which the highly varied components solve differing problems in the realm of climate science and such a collection of individuals is far more likely to solve some of the difficult problems in this realm (or more importantly poke holes in poor theories) than the well funded multiprocessor system that is only working on a very tiny portion of the problem. This type of democratic science is very messy but far more likely to come up with solutions to climate science than the monolithic rigid science which is now indistinguishable from government. Democracy and capitalism are very messy multiprocessor parallel processing networks for solving social and economic problems but they are orders of magnitude better than central control solutions.

What I've found is that every time I change fields I come up with my most significant insights in the new field right at the beginning while I'm learning it; I'm glad I kept all my writings when I first got into medical school as they make me realize how myopic I've become about medicine now that I do medicine full time. To try to stay out of the expert trap I try to do some form of major career change every 10 years or so.


Google loves spammers

Google loves spammers. I can say this with complete assurance as I've sent 4 applications to Google asking them to cease and desist with the misuse of my name and not a reply from them at all. The whole issue concerns a temporary blog I created on blogger when I was shutting down my practice in Vancouver. This was at drgimbarzevsky.blogspot.com. If one clicks on this site, one now finds that it is associated with the Canadian Pharmacy spam criminals who also forge a lot of spam with drgimbarzevsky.com as the origin. I'm hopefully making a bit of an impact on their operations as all mail directed at drgimbarzevsky.com is sent to the abuse address of the most recent chicom server they're spamming from. Every few months I re-enable mail to come to one of my email addresses, find the IP of their newest server and then change my MX records to divert the millions of emails/year that are bounced back to me as a result of poorly configured mail servers (it's a simple operation to do a nslookup of "drgimbarzevsky.com" to see if it matches the IP address of the actual sender. If they don't match the header is forged and there is absolutely no reason to send it back to me).

I decided to look where this group of assholes is hanging out now and, lo and behold, they're now using a US server! Must be getting really hard up as usually they use chicom servers which seem to be happy to send any amount of spam as long as they get paid. I've got a list of Chinese IP addresses and don't let any of them through to any of my machines and building the equivalent of the great wall on the internet around China would result in a massive decrease in spam. OTOH this US based machine could be part of the botnet and all my email to the abuse department will do is result in one less zombie.

Here's the latest start of "medical services plan" which is what one gets if one clicks on drgimbarzevsky.blogspot.com

  • 20 يونيو, 2008
  • Medical Services Plan
  • Canadian Pharmacy with high quality medications!Bonus pills added to your order!
  • Canadian Pharmacy offers high quality medications: Viagra, Cialis, Levitra, and many medications! Various payment methods available: Visa, Wire transfer, echeck, Western Union or MoneyGram.

The first link maps to:

Lets see who owns nslookup gives:

  • 02/26/10 20:04:35 dns
  • nslookup
  • Canonical name: c-n080-u0390-18.webazilla.com
  • Addresses:

Then let's do a whois on this IP address:

  • OrgName: WZ Communications Inc. Org
  • Address: 131 W Wilson Street
  • Address: Suite 600
  • City: Madison
  • StateProv: WI
  • PostalCode: 53703
  • Country: US
  • NetRange: -
  • CIDR:
  • OriginAS: AS40824
  • NetName: WZCOMM-US
  • NetHandle: NET-199-80-52-0-1
  • Parent: NET-199-0-0-0-0
  • NetType: Direct Allocation
  • NameServer: NS1.WEBAZILLA.COM
  • NameServer: NS2.WEBAZILLA.COM
  • NameServer: NS3.WEBAZILLA.COM
  • Comment: Please send abuse complaints to
  • RegDate: 2009-03-05
  • Updated: 2009-09-25
  • OrgAbuseHandle: WZCOM1-ARIN
  • OrgAbuseName: WZCOMM Abuse
  • OrgAbusePhone: +1-408-404-3912
  • OrgAbuseEmail: abuse@webazilla.com
  • OrgTechHandle: WZCOM-ARIN
  • OrgTechName: WZCOMM NOC
  • OrgTechPhone: +1-408-404-3912
  • OrgTechEmail: bk@webazilla.com

Email to abuse address sent right after this posted. Lets see what happens when one contacts the server:

  • 02/26/10 19:28:14 Browsing
  • Fetching ...
  • GET /go.php?data=vI HTTP/1.1
  • Host:
  • Connection: close
  • User-Agent: Sam Spade 1.14
  • HTTP/1.1 302 Found
  • Date: Sat, 27 Feb 2010 03:28:15 GMT
  • Server: Apache
  • X-Powered-By: PHP/5.2.12
  • Expires: Mon, 26 Jul 1997 05:00:00 GMT
  • Last-Modified: Sat, 27 Feb 2010 03:28:15 GMT
  • Cache-Control: no-store, no-cache, must-revalidate
  • Cache-Control: post-check=0, pre-check=0
  • Pragma: no-cache
  • Location:
  • Content-Length: 0
  • Connection: close
  • Content-Type: text/html

Not that exciting so lets try which gives the same result. Interestingly trying the huge datastring crapped out SamSpade so perhaps it was designed as a means of preventing people from using tools like SamSpade to probe this spamsite. Most likely the data string has the origin of the link encrypted within it so the spammers know which are the productive blog pages and probably some botnet control info but I'm just guessing here. No, I'm not bored enough to start trying to crack this data as I've got way more important stuff to do.

Never, never, never click on one of those links using M$ IE as your chances of acquiring malware are very high. So lets try Opera hoping that this group of criminals hasn't got any Opera exploits. To ensure that nothing sneaks through lets also start Wireshark and log all of the traffic to and from my machine in the process.

Interestingly there's a totally different webpage displayed when one goes through Opera than when goes through Firefox. Pasting the above URL into Opera goes through at least one other IP address (all information captured by Wireshark running in the background) and eventually one is on the site: http://www.canadasmedicine.com/?c=click&ck=26492

Let's see what unethical registrars and ISP's are involved. First nslookup:

  • 02/26/10 20:22:00 dns canadasmedicine.com
  • Canonical name: canadasmedicine.com
  • Addresses:

Interesting, 2 IP addresses but we'll get to those in a moment. First lets find out who the alleged owner of this domain is:

02/26/10 20:22:21 whois canadasmedicine.com@whois.geektools.com

  • whois -h whois.geektools.com canadasmedicine.com ...
  • GeekTools Whois Proxy v5.0.4 Ready.
  • Checking access for xxx.yyy.zzz.aaa... ok.
  • Checking server [whois.crsnic.net]
  • Checking server [whois.tucows.com]
  • Results:
  • Registrant:
  • N/A
  • 13 Av Des Cedres
  • Ville DAvray, 92410
  • FR
  • Administrative Contact:
  • Berder, Ronan ronan@33drugs.com
  • 13 Av Des Cedres
  • Ville DAvray, 92410
  • FR
  • +44.02081338455
  • Technical Contact:
  • Berder, Ronan ronan@33drugs.com
  • 13 Av Des Cedres
  • Ville DAvray, 92410
  • FR
  • +44.02081338455
  • Registration Service Provider:
  • Hover, help@hover.com
  • 416.538.5498
  • http://help.hover.com
  • Registrar of Record: TUCOWS, INC.
  • Record last updated on 19-Jan-2010.
  • Record expires on 06-Jun-2010.
  • Record created on 06-Jun-2008.
  • Registrar Domain Name Help Center:
  • http://domainhelp.tucows.com
  • Domain servers in listed order:
  • Domain status: ok

The spammer says he's French but who knows where he's really from. All that this record tells us is that we have to do some more digging. Lets start with the domain servers and 33DRUGS.COM seems like a logical place to start.

  • 02/26/10 20:29:14 dns 33drugs.com
  • Canonical name: 33drugs.com
  • Addresses:

If those IP's seem familiar it's because they're the same two that popped up when we did nslookup on canadasmedicine.com. Lets find where these are located:

  • Results:
  • % This is the RIPE Database query service.
  • % The objects are in RPSL format.
  • %
  • % The RIPE Database is subject to Terms and Conditions.
  • % See http://www.ripe.net/db/support/db-terms-conditions.pdf
  • % Note: This output has been filtered.
  • % To receive output for a database update, use the "-B" flag.
  • % Information related to ' -'
  • inetnum: -
  • netname: AIRMARK
  • descr: TURKEY
  • country: TR
  • admin-c: HE337-RIPE
  • tech-c: HE337-RIPE
  • status: ASSIGNED PA
  • mnt-by: AS9121-MNT
  • source: RIPE # Filtered
  • person: HAKAN ERMAN
  • address: TAKSIM ISTANBUL
  • e-mail: hakan@air-mark.com
  • phone: +90 212 245 44 65
  • fax-no: +90 212 245 44 86
  • nic-hdl: HE337-RIPE
  • source: RIPE # Filtered
  • % Information related to ''
  • route:
  • descr: TR-TELEKOM-960902
  • origin: AS9121
  • mnt-by: AS9121-MNT
  • source: RIPE # Filtered

So one of our webservers is in Turkey and there are only 15 IP addresses in the IP block which suggests that either someone is making a bit of money on the side by sending spam, or more likely, one of the computers in that IP block is a zombie and part of a botnet. Now lets find the other server:

  • Results:
  • % This is the RIPE Database query service.
  • % The objects are in RPSL format.
  • %
  • % The RIPE Database is subject to Terms and Conditions.
  • % See http://www.ripe.net/db/support/db-terms-conditions.pdf
  • % Note: This output has been filtered.
  • % To receive output for a database update, use the "-B" flag.
  • % Information related to ' -'
  • inetnum: -
  • netname: CZ-SUPERNETWORK-20060214
  • descr: SuperNetwork s.r.o.
  • country: CZ
  • org: ORG-SS59-RIPE
  • admin-c: ZC10-RIPE
  • tech-c: ZC10-RIPE
  • tech-c: DC1000-RIPE
  • tech-c: ML7551-RIPE
  • status: ALLOCATED PA
  • mnt-by: RIPE-NCC-HM-MNT
  • mnt-lower: SUPERNETWORK-MNT
  • mnt-routes: SUPERNETWORK-MNT
  • mnt-domains: SUPERNETWORK-MNT
  • source: RIPE # Filtered
  • organisation: ORG-Ss59-RIPE
  • org-name: SuperNetwork s.r.o.
  • org-type: LIR
  • address: Bilejova 407
  • address: 46303
  • address: Liberec
  • address: Czech Republic
  • phone: +420296826296
  • fax-no: +420482731466
  • e-mail: zdenek@superhosting.cz
  • admin-c: DC1000-RIPE
  • admin-c: ZC10-RIPE
  • admin-c: ML7551-RIPE
  • mnt-ref: RIPE-NCC-HM-MNT
  • mnt-by: RIPE-NCC-HM-MNT
  • source: RIPE # Filtered
  • person: Zdenek Cendra
  • address: U Pergamenky 2
  • address: Praha 7
  • address: 170 00
  • address: Czech Republic
  • e-mail: zdenek@superhosting.cz
  • phone: +420296826296
  • nic-hdl: ZC10-RIPE
  • source: RIPE # Filtered
  • person: David Cermak
  • address: PRO-ZETA spol. s r.o. Praha
  • address: Mukarovska 1567/25
  • address: Praha 10
  • address: 100 00
  • address: Czech Republic
  • e-mail: david@prozeta.cz
  • phone: +420222742702
  • nic-hdl: DC1000-RIPE
  • source: RIPE # Filtered
  • person: Miroslav Laus
  • address: U Pergamenky 2
  • address: Praha 7
  • address: 170 00
  • address: The Czech Republic
  • e-mail: mirek.laus@superhosting.cz
  • phone: +420296826296
  • nic-hdl: ML7551-RIPE
  • source: RIPE # Filtered

This IP block obviously belongs to an ISP in the Czech Republic and, is probably another zombie PC. I'm sure that if you perform nslookups on canadaspharmacy.com on a daily basis you'll find that the servers change frequently. The whole process is an attempt to try to prevent people from tracking them down and I'm sure that there's no link between the online pharmacy spammers and this trail of evidence aside from control packets sent to the botnet and the only way that one would catch them would be to have a packetsniffer running constantly on one of the botnet zombies to record the control packets. If I was doing this, I'd also route control packets through multiple zombies before they ended up at the target machine and use either an internet cafe computer as the source of the control packets or on open WiFi link found while warwalking. Wouldn't surprise me in the least if this further level of paranoia was part of their SOP.

One of the enabling factors in this whole process is Google; one knows Google must be crooked when Al Gore is on their board of directors. This slimeball has raked in millions with the AGW scam and who knows what other shady deals are going down with Google; after all they are actively helping the chicoms censor internet access in China. Since I've notified Google multiple times regarding the misuse of my name in relation to canadaspharmacy.com and because they have done nothing, I can only conclude that they have some financial stake in this and are thus involved in illegally distributing spam. The other alternative is that those report forms on blogger are routed to dev/null and they could care less what someone puts on blogger unless it gets significant exposure in the MSM. It will be interesting to see if Google comes after me for the accusations I've made in this blog post. There is one potentially inflammatory comment if one sentence is taken out of context. Taking things out of context is what mindless programs are really good for. If Google's software looks for people accusing Google of performing nefarious acts then maybe I'll hear from Googles legal department the next time googlebots crawl my site. At that point we can talk about what it takes for me to remove my non-flattering references to Google both in this post and in the Keywords

I have some ideas of what the fate of spammers should be. SamSpade is a very nice tool with lots of convenient internet related tools in one package and I highly recommend it as well as Wireshark. Didn't realize how many SMB packets were flowing through my home network until I ran wireshark and captured >400,000 packets during the time it took me to write this. Time to take a look at WTF the offending machines are doing as they don't need to talk that much with one another.

Posted by Boris Gimbarzevsky at 19:30.22
Edited on: 26/02/2010 21:42.27
Categories: Computers, Medical


Electronic medical records

Updated version to come RSN.

Posted by Boris Gimbarzevsky at 23:20.36
Edited on: 16/05/2010 20:55.06
Categories: Computers, Medical


Musings on reality creation

Had a major breakthrough today in terms of neurobiology of consciousness. I have to admit that I haven't done much reading in this area recently but my pattern of medical inquiry has been to work independantly for a time to formulate my own theories on a particular topic and then to go to the literature and start talking to people in the field to find out what they're doing. It's been a very productive way of doing things as it allows me to not be biased by orthodoxy when I first start in an area and then I can see how far from orthodoxy I am when I've come up with a coherent model.

In 2000 I had one of the most profound intellectual experiences of my life when I read Tor Norretranders, book The User Illusion. I had picked this book up at a used computer bookstore in Bellingham thinking it had something to do with GUI design which, at one level, it did. What Norretrenders did in that volume was to demonstrate convincingly that reality is an illusion and had hard neurophysiologic evidence to back it up.

What I got out of Norretranders is that what we experience as conscious existence is neurobiologically a two part process. The experience of consciousness, which anyone who reads this is intimitely familiar with, and the generation of the artificial reality in which this consciousness resides are two seperate processes. The virtual reality generated by the brain is of such high quality that it fools most people into thinking what they percieve is the same as reality.

Benjamin Libet was the first to discover that the brain reorders time. This was done in several seminal experiments in which people were asked to press a switch whenever they felt like it or had their primary somatosensory cortex stimulated during neurosurgery. In the switch pressing experiment the subjects had their EEG recorded continuously and the pressing of the switch was the signal to back-average the EEG. What Libet found was that starting from 0.5-1 second before the switch was pressed there was a clear electrical signal which was unambiguously present when one backward averaged a sufficient number of spontaneous switch presses. This is the readiness potential and, while the duration of the readiness potential may be in dispute, it exists. If you ask the subjects who were performing the task how long the duration between them deciding to press the switch and pressing it was they answered that as soon as they decided to press it their finger went down. Obviously there is a disconnect between percieved reality and external reality here.

The other experiment involved direct brain stimulation in awake patients who were undergoing neurosurgery and the electrical stimulus was delivered directly to the primary somatosensory area where the body is mapped in an anatomic fashion. This homunculus is a distorted human as hands and face have disproportionately large areas of cortex devoted to their sensory representation. Libet stimulated the area of the brain corresponding to various bodily areas and found that a minimum of 500 msec of stimulation was required before the person felt anything. If their knee was touched and the primary sensory cortex area corresponding to the knee was stimulated simultaneously, then the subjects reported that they felt their knee being touched about half a second before they felt the, probably quite bizarre feeling, knee sensation from the brain electrical stimulation.

Libet's interpretation of these results is that consciousness is 500-1000 msec behind and that the brain reorders time in order to make this delay disappear. When I first read this it seemed immediately obvious and I was surprised today when I did a search for Libet's papers on Ebsco of how much contraversy there is regarding his theory.

The reason Libet's explanation seems so obvious to me is because of an experiment I did in 1993 when I was a resident. I had written a program that ran on a PDP-11 which timed events to 0.2 msec precision (which I used for testing fingertapping) and which also generated random intervals so that I could measure people's simple reaction times. The program was written for the UBC open house in March of 1987 and I got the PDP-11/23 a few years later when the lab I used to work in moved to newer computers.

What I had found puzzling was how my data on auditory and visual reaction time differed. Visual reaction time was tested by lighting up one or more LED's and then I would press a switch when I saw the flash. I replicated the well known phenomenon of inverse dependence of reaction time on stimulus strength; it took me less time to react to 4 LED's flashing at once than one. I then decided to look at auditory reaction time and this is where things got interesting. I thought my visual reaction time was too slow as it ended up being about 180 msec (all times from memory and will look them up RSN) but mean auditory reaction time was 128 msec, a full 52 msec faster.

This is a huge time difference and, as a musician, I can easily produce sequences of finger movements which are within 1 msec of each other when I repeat the movement and I can audibly discern even shorter auditory intervals. Initially I thought my setup must be faulty and I repeated the experiment multiple times and the results were identical.

I then setup the apparatus so that I would listen to the sound and see the light at the same time; obviously I was only able to respond to the auditory stimulus as auditory reaction time was shorter. My perception during this experiment was that the sound and flash occurred simultaneously. It was quite eerie when I realized that I'd stumbled over something quite significant but I couldn't explain it at the time. When I read Norretranders book I had an AHA moment as the explanation for the results of the experiment was that my brain was reordering subjective time.

A quick look at the medical literature today revealed that there is not one single paper in the neurophysiology or neurology literature which uses the terms "reality generation" or "reality creation" (there were some papers that used the term but most dealt with "post-modern science" ie they were unscientific crap. It seemed that what I needed to look at was the neurobiology of consciousness and there was no dual process consciousness generation paper that I could find aside from Libet's work. Admittedly I've only spent a couple of hours on this today and will continue to look.

For the last 10 years I've practiced medicine under the assumption that consciousness is comprised of two parts: (1) the self awareness part that we percieve as being conscious and (2) a reality generating algorithm (RGA) which creates the illusion of reality. (I know, RGA is a bad term but since I've used it in my writings for the last 10 years, it stays). RGA is responsible for reordering time and for only bringing certain parts of external reality into percieved consciousness.

To make things easier to follow (and require less typing on my part), lets refer to external reality as R. R is the part of the universe outside of the body in 3-space and is unknowable as we will never have the sensors to fully quantify R. The artificial reality that everyone percieves as "external reality" will be referred to as r*. Te reason for this is that the two hemispheres have quite differing views of R and produce virtual realities r for the dominent hemisphere and r' for the non-dominant hemisphere. Because of the corpus callosum, these two virtual realities are blended in varying ways and so we get r*.

Because humans can react far faster than 500 msec, most of our actions are subconscious with the RGA making up a story after the fact to explain why we did what we did half a second ago. Humans are excellent rationalizers and much of getting a patient history is cutting away the rationalizations to get to what really is going on.

With very similar sensory organs individual humans will have similar primary perceptual signals in response to the same stimulus. Unless a person has altered brain function due either to drugs or a brain injury they will never be aware of the primary sensory stimulus. Everything that comes into consciousness has been processed to an unbelievable degree and what we percieve as r* consists of the output of our individual sensory channel processors. For example, people believe that what they see is identical to what a camera sees but this 1:1 mapping of visual world to neural sensors occurs only on the surface of the retina. Even in the retina processing of the image begins and further processing occurs at the lateral geniculate nucleus of the thalamus, primary visual cortex and secondary visual cortices before we see anything on a conscious level. There is a much faster pathway through the superior colliculus which is why reaction time to a potential object entering the eye causes such a short reaction time blink. I had a patient once who had lost her sight because of bilateral occipital infarcts but she had no problem living on her own. If I quickly moved my hand toward her face she would blink and it was eerie watching her walk around her apartment not bumping into anything while telling me she saw nothing. Her only awareness of the visual world was through feelings such as "I shouldn't go there" when she came up to an obstacle that she would have tripped over if she was truly blind. Her midbrain visual pathways were functioning perfectly well and gave her enough experience of the visual world that she could live independantly.

When one looks at how people look at a scene one finds that there are very distinct patterns of eye movements in people when they look at some things and not others. The fovea has the highest density of photoreceptors in the eye and the portion of the image that lands on the fovea is seen with the greatest resolution. The parts of the scene that the brain doesn't look at are filled in by the RGA. This explains why I've sometimes fruitlessly searched for an item through the whole house and another person will notice that it is in full view in an area that I've searched. I tend to keep certain things in certain places and if an item is out of place, it may as well be invisible. When I first became aware of the selective generation of visual reality I worked on developing a number of visual filters (sort of like one does with the Gimp) to process out everything except what I wanted to see. The most successful one was my hummingbird filter which I used when watching hummingbirds during the summer in the UBC botanical garden. Basically when the filter was active my visual reality was divided into hummingbirds and non-hummingbird objects and I'm not sure if my subcortical or cortical centers made sure I didn't walk into walls or off the trails when the hummingbird filter was active. It was so efficient that I found a hummingbird nest and got to watch the development of the baby hummingbirds that summer. When I'm walking thinking of a problem my visual reality consists of possible routes and obstacles and I've lost track of the number of times people who I know have told me that I've walked right by them and not seen them at all. When I'm walking with my camera intent on photographing anything that looks neat I'm often struck by objects which I had no idea were there before even though I'd walked that route many times in the past (or I'll actually notice people I know).

The RGA choses what comes into consciousness and what stays out. When I lived in downtown Vancouver, I tuned out a lot of noises and simply didn't hear sirens which were a constant feature of living in the west end. The last time I visited Vancouver I was struck by how noisy it was compared to Kamloops. When people experience things that they can't make sense of they create a story that makes sense to them to explain the event which is why eyewitness testimony is so often contradictory.

Not only sensory stimuli are chosen to come into consciousness but so are memories and emotions. A person who is severely depressed has a very different r* than when they are euthymic. In talking with severely depressed people one is struck by how they seem to be completely unable to remember any time in their life that they felt well. Every memory they access is either one of a past failure, a personal rejection or of a bad feeling. Given natures propensity to recycle working algorithms it wouldn't surprise me if the memory recall circuitry is based on sensory pathway circuitry.

What got me going on this whole topic seemingly an endless time ago was the problem of dealing with chronic pain in patients. Someone who is actively working and concentrating hard on a problem doesn't feel pain because their attention is directed elsewhere. People with chronic pain are hyperfocused on the pain and seem to be unable to divert their attention elsewhere. The area of the brain associated with this selective attention is the dosolateral prefrontal cortex (DLPFC) which explains why prefrontal lobotomy is such an excellent treatment for severe pain (if one is concerned only with eliminating the pain). It may also explain why amphetamines augment opiates (reference in an old version of Goodman and Gillman's pharmacology textbook) as this will increase peoples ability to focus on other things.

For years I've been referring to a number of medical and psychiatric problems as "disorders of reality creation". The initial observations over the last 10 years have been entirely as a result of reading Norretranders book in 2000 and only today did I start looking in detail at the literature. Thus far the results are congruent with what I've found aside from the degree of contraversy over Libet's interpretation of his experiments. The next stage is to dive into the literature and find out what the current neurobiologic orthodoxy is at this time. I find that if one is doing something which is unorthodox it helps to know what the standard theories are so that one can prove to people, should ones practice be investigated for doing alternative medicine, that one knows the current consensus thinking and why it is wrong.

This is a preliminary post and will likely be altered substantially over the next few weeks as I get deeper into this area (assuming that I have the time and I haven't fallen too far behind on doing idiotic forms and asinine insurance reports which are the bane of a physicians existence). What we need is a new specialty of administrative medicine in which the anally retentive unimaginative severe OCD physicians would specialize in and any form that needed to be done for a patient would be referred to an administrative medicine specialist making my medical practice so much more enjoyable. It will probably never happen, but I can dream.

Posted by Boris Gimbarzevsky at 1:09.54
Categories: Medical