Galaxy vs Rapids in Leg 2

It is a two-legged conference semi-final which means the scores of the two matches are combined (aggregate). In the event of a tie, the first tie-breaker is goals scored away. If still tied, then the game goes to extra-time and if still tied to penalty kicks.

So what are the scenarios?

Currently, Galaxy 1 Rapids 0.

In leg two, what if ...
0-0 then Galaxy advance on aggregate having won 1-0.

Rapids 1 Galaxy 0 then the contest goes to extra-time as the aggregate score is 1-1 and neither team has an away goal.

Rapids 0 Galaxy 1 then Galaxy advance on aggregate having won 2-0.

Rapids 1 Galaxy 1 then Galaxy advance on aggregate having won 2-1.

Rapids 2 Galaxy 0 then Rapids advance on aggregate having won 2-1.

Rapids 0 Galaxy 2 then Galaxy advance on aggregate having won 3-0.

Rapids 2 Galaxy 1 then Galaxy advance on away goals (1) as the aggregate is tied at 2-2.

And so on ........

UPDATE: A easy and much better visual explanation of the scenarios!

Quick reference guides for the 2nd legs of @MLS conference semifinals, accounting for away goals rule: pic.twitter.com/aWQojtfsqe

— Steve Fenn 🏆🛡️__ (@StatHunting) October 31, 2016

Go Galaxy!

Additional observations:
I only saw on TV the 2nd half of the match. It did seem that the Galaxy had more possession but often the attempts on goal were not very high quality efforts. Of course, the goal they got was a somewhat lucky play. But sometimes lucky is what happens when you push forward and kick the ball into the box. Van Damme, the wild and crazy center back who thinks he is an attacking player, put a nifty move on a defender to free himself for a cross into the box. Dos Santos got a head on it and it bounced off a Colorado defender into the goal. Meanwhile, on the other side Jones got off a great shot which Rowe just barely got over to push it away. Two key plays and it could easily have been Colorado 1 Galaxy 0.

It could be the end of an era for Keane. He is probably only going to be in as a sub unless injuries force Arena's hand. Keane doesn't look anywhere near 100%.

Also, the Gerrard era has come and gone with a whimper. His first season wasn't all that strong. His second was much better. But for the amount of the contract, he simply had too many games out with injuries. He can still pass pretty well (lots of assists this season) and he could smartly motor around the field but only up to a certain point - too many miles on his engine - and was sometimes a defensive liability. Will be surprised to see him in the games except as a sub. Probably a late game sub if they need an extra player going forward to get an equalizer. But truth be told, you probably bring in Keane first for that scenario, McGee second, and then maybe Gerrard?

As of October 31 - RCP Electoral Map

The screen grab is from Monday morning. As you can see, the Clinton campaign is on the cusp of 270. Trump would need to run the table of toss-up states to win the election. However, the poll numbers behind the map haven't factored in the latest twist in the news. We have no way of knowing if there is yet another twist left in this crazy campaign.

In the abstract, this election was going to be difficult for the in-power party because running for the "third" term is always an uphill fight. The last time someone running for a "third" term was McCain and he lost in 2008 though a big factor was the economic crisis at the time. Gore was running for a "third" term and lost narrowly in 2000. The last successful election to a "third" term was 1988 when Bush defeated Dukakis. 

Clinton as a candidate has disadvantages: she has none of the charm of Bill Clinton and all the baggage of the Clinton brand name. She is an older candidate (fairly or unfairly) like McCain. She has the political stiffness of Gore. These are three huge negatives. On the positive, she positioned herself as the heir to Obama (Sanders positioned himself as Obama didn't go far enough) which solidifies her position among the party faithful. The other positive (fairly or not), she has played the first woman president card. Thus, she was positioned for a close election against a generic Republican candidate with a 50-50 chance of winning. 

However, Trump was a "black swan" event in the GOP pushing Clinton to a 75-25 favorite.

The remaining wild-cards:

How many "shy Trump" voters are out there?

If he is under-polling by ~ 1%, it won't matter

But if it is ~ 2%, it could be a longer night with Clinton probably still winning but closer than people anticipate.

If it is > 2%, Trump might draw the "inside straight" in the electoral college and win.

Any last minute twists in the news for either Clinton or Trump in the next week and a half?

There is less sensitivity to last minute news as more and more people vote early by mail and other mechanisms but still the bulk of the votes are cast on November 8 so some last minute shocking news could still shake the undecided or loosely committed voters.

UPDATE: Here is the latest from the team over at 538.

November 2016 California Propositions - in progress

My general rule is that initiative generated propositions should be viewed with a degree of skepticism as they are put onto the ballot by interest groups that gathered up enough signatures.

Ballot measures can also be placed by the California legislature. I view these with skepticism as well but at least in theory these measures are vetted by the staffs of the legislature and debated by the State Assembly and State Senate and voted onto the ballot.

This year there are 17 ballot measures of which 15 are initiatives.

Will march through the ballot measures in this blog post over the next week as I prepare to vote on November 8.

Prop 51 - $9 billion school bonds. Sounds good but usually bonds for schools come from the legislature. This is an initiative; thus, it has been questioned as perhaps unnecessary. The LA Times and Gov. Brown have come out against this.
No on Prop 51.

Prop 52 - Medi-Cal hospital fee extension. Orange County Register and San Diego Union-Tribune, two of the more conservative newspaper editorial boards in California, have come out in favor. Reason Foundation thinks the current situation is not good but that Prop 52 doesn't make it better. This fee is currently in use and the legislature has the option of extending it. This initiative would make it permanent.
Undecided on Prop 52. Leaning yes.

Prop 53 - Revenue bonds greater than $2 billion will need voter approval. According to the Official Voter Guide, currently, general obligation bonds require voter approval but revenue bonds do not. See this item for an explanation of the differences between the two bond type. The Voter Guide also says that currently most revenue bonds are less than $2 billion and would not be impacted by Prop 53. The initiative would raise the threshold for inflation each year. I like the general concept of voter approval of bonds since if the state is operating such a large project then the people should have a say. However, the $2 billion seems an arbitrary number though it would seem it is meant to put pressure on the high-speed rail and Sacramento Delta water projects. The conservative editorial board at OC Register agrees while conservative SDUT agrees in concept but feels this proposition is poorly constructed.
Yes on Prop 53.

Prop 54 - Post bills 72 hours before vote, record and post legislative proceedings on the internet. When liberal SF Chronicle and conservative OC Register agree on something, you have to consider it.
Yes on Prop 54.

Prop 55 - Extension of additional taxes on income over $250,000. Prop 30 passed in November 2012 established these rates with the provision they would expire in after 2018. This measure extends those rates to 2030. Prop 30 was passed amidst a massive fiscal crisis and was viewed as a temporary measure. Even liberal SF Chronicle is opposed.
No on Prop 55.

Prop 56 - raise tax on cigarettes to $2.87 a pack. Is $2/pack typical? Taxes on cigarettes vary from state-to-state. Currently, California's rate is in the lower half among the states. This rate change would place in the top-10 in the USA. Taxes on distilled alcohol and beer also show considerable variation state-to-state. Collecting some taxes on these kinds of items can deter their use and recover some revenue to help cover some of the social cost of these items. However, on the other hand, Reason Foundation offers some innovative arguments against this tax increase.
Undecided on Prop 56. Leaning no. 

Prop 57 - revise parole and sentencing procedures in certain cases. Sacramento Bee is in favor while San Diego UT is opposed. Criminal justice reform is an important issue but is this a good response? Reason Foundation points out pros and cons of prop 57.
Undecided on Prop 57. Leaning no.

Prop 58 - revises rules regarding bilingual English learning in schools. San Jose Mercury News says no while Orange Country Register says yes. Prop 227 passed in 1998 reduced the usage of bilingual English learning. This prop would reverse some aspects. Reason Foundation cites more local control as a plus to this proposition.
Undecided on Prop 58.

Prop 59 - this measure is an advisory to the state legislature encouraging them to reverse the Citizens United case. LA Daily News (conservative paper) and LA Times (liberal paper) is against it.
No on Prop 59.

Prop 60 - require condom use in adult film industry. Liberal SF Chronicle and conservative SDUT are opposed.
No on Prop 60.

Prop 61 - requires some agencies to negotiate drug prices based on the price offered to the VA. Sacramento Bee and Orange Country Register is opposed. Sac Bee says, "The initiative comes with too many uncertainties and not enough guarantees that things won’t get worse. We’re loath to admit the industry is right when it says this is an all-too-simplistic solution to a complicated issue."
No on Prop 61.

Prop 62 - ends the death penalty.
Prop 66 - modifies the existing death penalty provisions.
If one supports the death penalty one will vote no on 62, then decide whether prop 66 is a good revision or not. If one opposes the death penalty one will vote yes on prop 62 and no on prop 66. A handful of years ago, I was in the jury pool for a case where the prosecutor explicitly stated they would be seeking the death penalty. In the jury selection process it was pretty clear the respective lawyers were kicking potential jurors off the panel who made extreme statements about the death penalty. Some would say, we don't use it enough while others said no way no how should the state have the authority to take a life. Sitting through this process for two whole days - ultimately, like most in the jury pool, I was released from service - I had to seriously think about whether the death penalty is a viable punishment in our society. In theory, everyone convicted in a criminal case is found "guilty beyond a reasonable doubt" by a jury of 12 people. In California, if a conviction is obtained, the trial shifts to the penalty phase where the case if made by the respective sides for/against imposing the death penalty. Again, the 12 jurors must agree that the death penalty should be imposed. Do juries get it right? Do the appeals process afterwards get it right? In some cases, people are later found not guilty of the crime. One study claims the figure to be ~ 4%. Whether that is an accurate number and true for every state in the USA, I don't know. But that figure gives pause. Can a case be made for the death penalty? In looking for opinions regarding these two propositions, I came across this item from a reporter at the Sacramento Bee. He made two points: (1) the low likelihood of mistakes and (2) media coverage of murder trials tend to diminish the horrifying nature of the crimes that were committed. Regarding the possibility of error: The argument that innocent people may be put to death is suspect in California. Gov. Jerry Brown, a death penalty opponent, said this in 2012 when he was asked by San Francisco Chronicle columnist Debra J. Saunders if he had considered appointing a commutation panel for death row inmates: “As attorney general, I think the representation was good. I think people have gotten exquisite due process in the state of California. ... To think that they’ve missed anything like they have in some other states, I have not seen any evidence of it. None.” And describing the issue of media coverage: Four years ago, I wrote a column about Michael Lyons, 8, of Yuba City, who was killed in 1996 by a convicted sex offender named Robert Boyd Rhoades. I was familiar with the Lyons case because I covered it as a reporter. In the column, I was as graphic as I could possibly be because I wanted readers to understand what that case was about as they considered Proposition 34, a 2012 ballot measure to repeal the death penalty (it eventually was rejected by voters). However, the most distressing details about the torture and killing of that young boy were removed from my column by my editors. I don’t blame them for doing it. There are and should be rules of public discourse. But what I know about the final hours of Michael Lyons’ life has given me nightmares for 20 years. I never met Michael, don’t know his family, but I’ve cried for that child more than once. Michael would be in his late 20s if he were alive today. But he’s not alive. His killer is, though. Rhoades is on death row at San Quentin. Lyons wasn’t Rhoades’ only victim. Twelve years before he killed Lyons, Rhoades murdered Julie Connell, 18, of San Leandro. [...........] You have to sit in a courtroom and listen to the evidence in these crimes – and to witness the anguish of family members of victims - to truly understand why the death penalty can be an appropriate punishment for the worst criminals among us. A yes vote on Proposition 66 will speed up the appeals process and clean up the protocols for dispensing lethal injections. If those two issues were addressed, death penalty cases would not take 25 years to resolve.
Undecided on prop 62 and 66.

Prop 63 - regulates ammunition purchases and other aspects of gun ownership. Sacramento Bee is in favor while Orange County Register is opposed. As pointed out by Reason Foundation, if it passes, it will almost certainly be challenged in the courts as a violation of the 2nd amendment.
Undecided on prop 63. Leaning no.

Prop 64 - legalization, regulation and taxation of marijuana. There are personal health risks and societal costs associated with smoking cigarettes and alcohol, however, they are legal but regulated. Marijuana use is likewise not without personal risk and society costs but the cost of current "prohibition" is high. The reality is that marijuana is slowly being legalized in various places in the USA and California is bound to do so in this election or in some future election. Proponents (like Reason Foundation) say it is time to legalize and regulate it and raise money from taxation of its sale thus removing it from the criminal markets.
Undecided on prop 64. Leaning yes. Leaning no. Depends on which day.

Prop 65 and Prop 67 - rival plastic bag bans. Those who think plastic bag bans are a bad idea will vote no on prop 65 and no on prop 67 as suggested by the LA Daily News. Those who support plastic bag bans will vote no on Prop 65 and yes on Prop 67 as explained by the San Jose Mercury News. How should plastic bags be viewed in context? LA Daily News offers this, "A 2014 study of plastic litter in the world’s oceans found that plastic fishing gear accounted for most of the problem. Plastic bags and plastic film, combined, accounted for less than 10 percent of plastic items, 0.8 percent by weight. It simply isn’t true that grocery bags are a major component of ocean litter. It makes more sense to clean up litter than to ban a useful product, but advocates of the bag ban want to communicate the message that we all have an impact on the environment and should reuse bags to generate less waste. The 10-cent fee for carryout bags, proponents of Prop. 67 told the editorial board, helps consumers “internalize” that message. The heavier plastic and paper bags are more costly to manufacture and transport than single-use plastic bags. They’re bulkier in landfills when discarded. Taking into account the energy and water used in manufacturing, the diesel fuel used in trucking, and greenhouse gas emissions, the environmental impact of the bag ban is, at best, a mixed bag."
Undecided on prop 65 and 67. Leaning no.

More to come later ......

MLS Cup 2016 Predictions

Knockout round: easy enough, home teams win.

Semifinals: 

Seattle and Dallas should be a good matchup but I think Dallas has enough to advance even without Diaz.

LA vs. Colorado, even though I am a Galaxy fan, I'm just not convinced the Galaxy are up to par to other years when they made big runs in the playoffs

Red Bulls over DC though it should be a good matchup.

Toronto vs. NYCFC should be another good matchup and I think Toronto pulls off the upset narrowly. 

Finals:

Colorado edges out Dallas as Dallas miss Diaz.

Toronto pulls off a shocker and defeat NY Red Bulls.

MLS Cup:

Toronto becomes the first Canadian team to participate in MLS Cup and to win it!

UPDATE: Heh. Good to see that some other peeps (Dave Zeitlin and Andrew Wiebe) are picking Toronto to win the whole thing. Though one wonders if Andrew Wiebe is jumping off the Toronto bandwagon in favor of LA Galaxy? Perhaps clickbait for LA fans?! 8-) Anyway, it was a good win for LA but even a somewhat novice and naive soccer viewer like myself could see that RSL just seemed a half-step slow and unmotivated thus making the Galaxy look like world beaters. Colorado will be a different story. Will also be watching for any injury news about Gordon and Boateng (both subbed out after getting up slowly from the ground) who were the key drivers to sending RSL packing for the season. 

November 2016 - California Propositions - Endorsements by Party

17.

Count 'em: 17 ballot measures for the November 2016 election here in California.

Above is a chart of the endorsements from four of the political parties in California.
http://www.cagreens.org/elections/propositions
http://www.cademvote.org/endorsements
https://www.cagop.org/ballot_measure_endorsements
http://ca.lp.org/measures/

As you can see there are some differences: two of the parties like to support the initiatives while two of the parties are more skeptical about them.

The initiative process in California is of long standing (since 1911). If you are curious, this PDF gives, by year, the number of initiatives that attempted to qualify, qualified, and ultimately adopted/rejected by the voters.

Looking at the sum total over the years, initiatives are more likely to be rejected than adopted. And that makes sense: one, people may think the issue being raised by the initiative is not of concern, hence a NO vote; and two, even if they think it is of concern, do voters believe the initiative would actually be helpful?

Often times, after seeing the rival commercials on TV and reading the ballot summaries, the voter is left confused and thus vote NO rather than pass something they don't understand. Although, I suppose there are some voters who feel if it is an important issue then they vote YES as something needs to be done even if they don't know exactly what the initiative will do.

Anyway, my default is to vote NO unless I find some compelling arguments in the ballot summaries and in editorials from newspapers in favor of the initiative.

LA Galaxy 2016 Campaign

At the beginning to the season, the Galaxy brain trust made a lot of moves to strengthen the team for the 2016 season.

They gathered some European players (Van Damme, Cole, De Jong).

They gathered some MLS veterans (Larentowicz, Magee).

Mix these guys in with the Designated Players (Dos Santos, Gerrard, Keane) and spotlight a few youngsters and some solid role players and make a run at the MLS Cup. And they were running roughshod over a lot of teams. But as the season wore on, injuries piled up and it seemed the team was sputtering on offense and defense.

Though the club has surrendered only 39 goals, the fourth lowest in the MLS, they often look very shaky in the back line.

Thought the club has scored 54 goals, the third highest in the MLS, the most recent games have shown the Galaxy offense to be somewhat sleepy.

Fans are thinking whether Gerrard and Keane, the high priced DPs, should be benched in favor of the younger lesser known - but faster and fitter - players. At the moment, Gerrard and Keane are recovering from injury so the decision has been made for Arena and company. However, in the playoffs, this issue may rear its head.

The situation became so dire that Landon Donovan decided to come out of retirement to see if he could push the sputtering club to another MLS Cup run.

Last year, the wheels completely fell off the Galaxy late in the season as they tumbled down the standings eventually making the playoffs as a road club in the knockout round. And knocked out they were in a rainy Seattle night.

This year, they have locked up third place so the knockout match will be at home.

The regular season finale will be at home against FC Dallas. Dallas would like to win and keep home field advantage throughout the playoffs by having the best record in MLS. However, injuries to Diaz and Acosta will be tough to overcome for Dallas.

As for the Galaxy, they will continue to play their best non-Keane, non-Gerrard line-up which in the end might be their best line-up for the playoffs. On the other hand, since the Galaxy is locked into third place, they may run out the lesser known talents and give their mainstays a rest. Will see what Arena does with the line-up card on Sunday.

Swedish Soccer FFF and Elfsborg Update

Falkenberg's run in the top league of Sweden for all practical purposes will end after two magical years.

I had mapped out a potential route to avoid outright relegation (see table above). At the moment, the 14th spot (qualifies for a relegation playoff match) is occupied by Helsingborg with 22 points after 25 matches. Alas, FFF has only obtained a few draws and no wins over the recent stretch. Even if they win the next four matches, they would reach 22 points tying Helsingborg only if Helsingborg fail to collect any points over their next five matches. In the unlikely event this were to happen, I think goal differential is the tie breaker and right now FFF is -45 while Helsingborg is -21. It was a fantastic run for Laget Vid Havet. Will be looking to see how they fare in the Superettan. 

Meanwhile, Elfsborg are mathematically eliminated from Europa league. Norrkoping sits at the third spot with 53 points. Even with five wins by Elfsborg, they only reach 50 points (see table below). 

Malmo appears on track to take their 22 championship (most of any club). AIK and Norrkoping trail by seven points and are unlikely to make up that much ground in the four remaining matches. 

The top Swedish football league (Allsvenskan) probably rates as a third or fourth tier league in European soccer. I think few would dispute that the Spanish, German, Italian, and English top of the pyramid leagues are the best. The second tier would be occupied by a handful of leagues scattered across Europe from France to Turkey. The rest of Europe will fill in the third and fourth tiers. 

Within the Allsvenskan there are the historically dominant clubs like Malmo (21), Goteborg (13), and Norrkoping (13) that among them have won 47 championships. All other clubs combined have won 44 championships.

This is quite a bit more parity compared to the English Premier league where the "Big Four" (Chelsea, Man City, Man U, Arsenal) have won all but two titles. Man United has won 13 while everyone else has won a combined 11 titles. 

2016 NLCS Dodger Roster Guesses?

With the new series, the rosters can be changed.

In the 2016 NLDS, the Dodgers carried 11 pitchers and 14 position players.

Starting pitchers (4): Clayton Kershaw, Rich Hill, Kenta Maeda, Julio Urias
Relief pitchers (7): Kenley Jansen, Joe Blanton, Grant Dayton, Pedro Baez, Josh Fields, Luis Avilan, Ross Stripling
Catchers (3): Yasmani Grandal, Carlos Ruiz, Austin Barnes
Infielders (5): Adrian Gonzalez, Chase Utley, Corey Seager, Justin Turner, Charlie Culberson Outfielders (6): Howie Kendrick, Joc Pederson, Josh Reddick, Yasiel Puig, Andrew Toles, Andre Ethier

Since the NLCS is a seven game series and the Dodger relief pitchers put in a lot of innings in the NLDS, we could see the Dodgers carry 12 or even 13 pitchers.

In the NLDS, Kershaw started game 1 and 4, Hill started 2 and 5, Maeda started 3.

How many innings did we get from the starters?
Kershaw 11 2/3 (he had 2/3 as a reliever)
Hill 7
Maeda 3
Total from starters 21 2/3 innings.
Five games x 9 innings = 45 innings. However, in game 2, the Dodgers lost and did not have to pitch the bottom of the 9th. Thus, 44 innings of Dodger pitching. Of which, 22 1/3 innings in relief.

The most often mentioned possible pitchers to add is Alex Wood (long relief) and Jay Howell (situational relief). The question is add one or two for the NLCS? Also, there is talk that Grant Dayton might get dropped as he struggled in his relief appearances.

If you add one pitcher, who do you drop from the position players?

Culberson (backup infielder) and Barnes (backup catcher) are mentioned.

So what do you think?

Starting pitchers (4): Clayton Kershaw, Rich Hill, Kenta Maeda, Julio Urias
Relief pitchers (8): Kenley Jansen, Joe Blanton, Grant Dayton, Pedro Baez, Josh Fields, Luis Avilan, Ross Stripling, Alex Wood, JP Howell
Catchers (2): Yasmani Grandal, Carlos Ruiz, Austin Barnes
Infielders (5): Adrian Gonzalez, Chase Utley, Corey Seager, Justin Turner, Charlie Culberson, Enrique Hernandez
Outfielders (6): Howie Kendrick, Joc Pederson, Josh Reddick, Yasiel Puig, Andrew Toles, Andre Ethier

Here is the Dodger 2016 NLCS official roster:

Starting pitchers (4): Clayton Kershaw, Rich Hill, Kenta Maeda, Julio Urias
Relief pitchers (8): Kenley Jansen, Joe Blanton, Grant Dayton, Pedro Baez, Josh Fields, Luis Avilan, Ross Stripling, Alex Wood
Catchers (2): Yasmani Grandal, Carlos Ruiz
Infielders (4): Adrian Gonzalez, Chase Utley, Corey Seager, Justin Turner
Infielder/outfielders (2): Howie Kendrick, Kiké Hernandez
Outfielders (5): Joc Pederson, Josh Reddick, Yasiel Puig, Andrew Toles, Andre Ethier

What a choice .......

It is a real mess we are in.

On one hand, we have 35-40% of the public supporting Trump. Some of these voters are doing so because they want to give Washington DC the "middle finger."

To his supporters, a vote for Trump is a way to flip the middle finger to the system, the media, the elite, the liberals, the know-it-alls and the people who pretend they're better than "us." (excerpt from Mel Robbins at CNN.com)

Of course, that may feel good but do we really want that to be the basis for selecting POTUS?

I wonder what percentage of the Trump support is from the "lesser of two evils" voters versus the I want "to flip the bird" to DC voters?

On the other side, we have 40-45% of the public supporting Clinton. I don't know what percentage are doing so because they see Clinton as the "lesser of two evils" choice and how many have the fawning "Saint Hillary" mind-set.

I can understand the "lesser of two evils" voter. I don't like it but I understand it.

I can't understand the "Saint Hillary" voter. If a Republican candidate had the same baggage as Clinton, the Democrats would be screaming at the top of their lungs complaining about that baggage. The "Saint Hillary" voter is in denial about how much baggage the Clinton brand carries with it.

I can understand the anger at DC sentiment but the I want to give DC the "middle finger" voter is in denial about the consequences of voting for someone so unstable.

So what is a voter to do?

Johnson-Weld is a possible protest vote. They have good track records as governors but when the spotlight has been on Johnson, he shown himself not ready for prime time.

The Stein-Baraka ticket is the Green Party choice and they remain a boutique-niche party.

McMullin-Finn are running as independents and are having ballot-access problems.

So what is a former GOP now independent voter to do?

Episode 7: The Bowels Awaken (albeit rather slowly)

Day 8 - Tuesday September 13

The overnight MD for 8-West is usually just one person for the unit but since the team showed up it must have been the transition to the morning shift that happens around 5AM.

The MD in charge asked a few questions and the order was given: nasal gastric tube insertion. In a matter of minutes, the tube was placed and in a matter of minutes hundreds of milliliters of fluid was collected in the vacuum trap. This would be the eighth time I've had this medical device utilized for my medical care - the second time during this hospitalization.

Eight days earlier .....

Day 1 - Tuesday September 6

On this day, I was scheduled for Laparoscopic Lysis of Abdominal Adhesions (video) (text explanation) at 1pm.

Briefly, I had surgery for small bowel obstruction in 2004. As a result, I was at risk for recurrent small bowel obstruction (SBO) due to adhesions from scar tissue formation resulting from the surgery. Most adhesions don't cause problems but some do and in my case, recurrent SBO episodes took place in 2005, 2009 (spring), 2009 (fall), 2014, and 2016 (spring) all resolved by non-surgical management using the nasal gastric tube and supportive IV.

After the episode in 2014, the surgeon in charge of my care said the number of recurrences is getting to be unusual high and elective surgical intervention might eventually need to be considered. After the episode in 2016, the surgeon in charge of my care (different MD), made a more insistent recommendation that elective surgical intervention should be very seriously considered. As a result of that recommendation, I was scheduled for elective surgery on this fine fall southern California day.

I checked into the procedure treatment unit (PTU). I changed into the surgical gown - a neat little thing that can be hooked up into a warm air blower! The nurse placed the IV catheter into my left hand. A member of the surgical team gave me a quick rundown of what to expect. For this type of surgery two hours would be typical if nothing unusual is found inside. The plan was to use four laparoscopic sites. However, if things got complicated, they would resort to a laparotomy. Blood transfusion is not anticipated but my blood type was determined should it be necessary.

I was informed that the surgery in the surgical suite I was scheduled for was running overtime and that there is a 45 minute sterilization procedure for the room before it would be ready for my surgery. I would know the surgery would be soon when the anesthesiologist checked in with me.

At 2pm, the anesthesiologist came by and explained what will happen. He and one of the medical students on the team walked with me as the medical bed threaded its way to the surgical suite. He asked about my research work and I asked him about his. Once in the surgical suite, I was transferred onto to the surgical stage. The anesthesiologist hooked me up to an IV and he explained he was beginning the process of putting me under. I was beginning to fade out. He placed an oxygen mask over me. I think the last thing I said was, "God bless you all." He said, "God bless you too."

I woke up in the post-anesthesia care unit (PACU). I was told by the surgeon that my case turned out to be more complicated that expected. Instead of just a few adhesions localized to one area there were dense matted adhesions in two areas. However, the team decided a laparotomy was not needed though it took nearly four hours to release all the adhesions.

With the anesthesia worked out of my system, I was moved into the transitional recovery unit (TRU). The regular surgical unit patient rooms on the eighth floor were full so I would be cared for in the TRU that is meant for recovery of out-patient procedures during the day. However, in a pinch they can be converted to regular recovery if somewhat cramped space for in-patients.

Day 2 - Wednesday September 7

A little after midnight, I hit the call button and reported feeling nausea. I was given some anti-nausea medication. I think it was around 2:30AM when I hit the call button again as the feeling came back and was much stronger. This time the overnight MD came in and explained nasal gastric tube insertion was necessary since I was suffering from post-operative ileus as my bowels were asleep as they don't like to be handled and four hours of handling had just taken place.

Day 3 - Thursday September 8

By nightfall, room 8331 opened up in 8-West. The IV fluids kept me hydrated. The NG tube suction kept the nausea and abdominal pains at bay.

Day 4 - Friday September 9

In the afternoon, the amount of fluid collected by the NG tube decreased enough that they removed the NG tube.

Day 5 - Saturday September 10

I began on some liquid diet with the plan of a discharge on Sunday. I felt the liquid food was still feeling a bit "heavy" but it wasn't too bad.

Day 6 - Sunday September 11

I was advanced to some solid food but it was was still feeling a bit "heavy" and it felt worse that on Saturday. The MD examined by abdomen and canceled the discharge order. One thing MDs try to avoid is sending people home only to have them come back into the ER with post-surgery complications. They thought that the post-operative ileus might still be hanging on.

Day 7 - Monday September 12

I went back to the liquid diet. It was still feeling a bit "heavy" and it was beginning to feel painful in my belly. I was given toradol since opioid (morphine and morphine-derivative) meds often slow down the digestive tract.

Day 8 - Tuesday September 13

Sometime after midnight, I can't remember when, I felt very bloated. There was so much air trapped in my belly that I belched repeatedly and it seemed to go on forever but it was probably just a couple of hours. Eventually, I hit the call button to report my situation to the nursing staff. They suggested that I get up and walk and see if it would clear up. I was able to walk around for a handful of minutes but I was starting to feel very weak and unstable and the nurse could see that I was at risk of falling so she brought me back to the room and had me sit in the chair. It seemed like a long time but was probably less than an hour when things started to go seriously sideways.

The nausea was welling up fiercely but vomit attempts come up dry after multiple attempts. The abdominal pain was off the charts; easily a 9 or 10 on the 0-10 pain scale the staff asks their patients to report their pain experience. I found sitting in the chair was getting very uncomfortable so I lowered by myself to the floor and put my face in the bucket in the hope vomiting would bring relief. But relief did not come.

I realized this was not going well and I hit the call button but was too weak to explain the reason for my call. The nurse came in and it was clear I was in distress and she was soon joined by several others. They tag teamed carried me off the floor and put me into bed and after a few questions and my weak attempts to describe what I was going through, the nursing staff paged the medical staff.

UPDATE: Was revisiting this post 1 year later and thought I'd add a few thoughts about morphine type pain medications. Clearly, there are occasions where receiving morphine and morphine-derivatives is entirely appropriate medically. For my SBO condition, I have generally declined the morphine because they can "slow down" the intestinal tract. You may have seen TV ads for the condition called OIC, opioid induced constipation. For people who have chronic pain and take opiod type medications, they often have constipation. Thus, in most of my hospital stays, I opted out of the morphine but did take it on a few occasions. So indeed, there were occasions when the pain was just too much and I would get the shot and the pain would dial down and one even feels a little euphoria as a result. However, at least for me, I would feel a miserable "brain haze" and overall "icky feeling" as it wore off. 

The overnight MD for 8-West is usually just one person for the unit but since the team showed up it must have been the transition to the morning shift that happens around 5AM.

The MD in charge asked a few questions and the order was given: nasal gastric tube insertion. In a matter of minutes, the tube was placed and in a matter of minutes hundreds of milliliters of fluid was collected in the vacuum trap. This would be the eighth time I've had this medical device utilized for my medical care - the second time during this hospitalization.

The NG tube drew out liters of fluid through the day.

I found solace recalling the familiar Psalm written by David.

Psalm 23

The Lord is my shepherd, I shall not want

He makes me lie down in green pastures

He leads me beside quiet waters

He restores my soul

He guides me in the paths of righteousness For His name’s sake.

Even though I walk through the valley of the shadow of death

I fear no evil, for You are with me

Your rod and Your staff, they comfort me.

You prepare a table before me in the presence of my enemies

You have anointed my head with oil

My cup overflows

Surely goodness and lovingkindness will follow me all the days of my life

And I will dwell in the house of the Lord forever

Day 9 - Wednesday September 14

Somewhere around mid-morning, I was wheeled down to the x-ray unit where contrast was delivered through the NG tube. The plan was to take a series of x-rays to monitor the flow of the contrast through my GI tract to see what was going on inside. Suffice to say I threw up some of the contrast but enough was inside me for the study to go forward. I can't recall how long I was down at the x-ray facility and at what intervals the x-rays were taken. Eventually, I was wheeled back up to 8-West where the portable x-ray unit would take additional pictures at designated intervals. By 3pm the nausea and pain from the fluid build up was too great and the NG tube suction was restarted. Additional x-rays were shot in the afternoon and early evening.

UPDATE: Revisiting this blog post almost a year later, I should note in regards to morphine (see notes on day 10), I did take some on this occasion in the late afternoon. Though the pain wasn't as intense as it was on day 8, it had just been so many hours of discomfort that I took the shot. Would also like to discuss, anti-nausea medication. The feeling of nausea is miserable. We know that feeling from sea-sickness (for those who have that problem - I do!) - that "I need to throw up and need to throw up now feeling." Of course, a lot of times, we don't actually throw up and it just feels icky. Anyway, I find nausea medicine takes the sensation back a couple of steps. It still doesn't feel great but it takes the edge off of it. And like the morphine, I did find myself getting a little foggy in the head as a result of taking it. So I did opt out of the nausea medicine when the nausea wasn't too bad. But I definitely did take that medication more frequently than the morphine.

Day 10 - Thursday September 15

The team ordered a CT scan with IV contrast for the morning. By the afternoon, the team told me that the contrast study from the previous day and from today showed that some of the contrast dye did make it into my colon but some was still trapped in the small bowels and that there were indications of looped bowels suggesting obstruction. It was likely I had some combination of small bowel obstruction and post-operative ileus. Whether one proceeded the other was not clear but the treatment for both was the same: NG tube and watch and wait. Surgical intervention would only be called upon if strangulation occurred.

Day 11 - Friday September 16

Up to this point, I had been given various saline solutions with dextrose to keep me hydrated and supplied with energy. However, this is not a complete nutritional profile. Since it was clear I would not be leaving anytime soon, provision needed to be made for me to receive total parenteral nutrition (TPN). Since this material cannot be delivered by the standard peripheral IV, a peripherally inserted central catheter (PICC) line needed to be installed.The specially trained technician swabbed my arm with disinfectant, laid out the sterile materials, visualized the vein in my arm with the ultrasound and threaded the catheter into the vein and eventually ending in my heart. Total time from beginning to end: 20 minutes. During this hospital stay, one song I learned in high school came to my mind during the many moments of discouragement. It is a simple song but it redirected my eyes toward God and sustained me.

Matthew 11 (Wes Terasaki)

Come unto me, all who are weak 

Weary and heavy laden 

Gentle am I, humble in heart 

And you shall find rest for your soul.

All things are given unto those who believe 

Princes and lowly ones His blessings receive 

And just when I think that means everyone but me 

Jesus comes beckoning to me 

Enter the holy gates just as you are 

No need for a happy face, just come with your heart 

And Jesus will bring us a joyful melody 

If only His calling we heed 

We are His little ones, children of God 

Children and fellow heirs of His kingdome come 

And we share the greatest love the world has ever seen 

Here in the Lord's family 

Day 12 - Saturday September 17

The TPN bag was hung this evening. One bag had amino acids for my protein needs along with vitamins and minerals and a much higher percentage dextrose (sugar for calories) compared to the regular saline/dextrose IV bags. The other bag contained lipids and phospholipids.

UPDATE: Revisiting this blog post 1 year after this experience, I thought I'd mention a bit about the nutritional situation. The doctors went to TPN because they knew I would not be eating food anytime soon. The saline mix plus sugar IV that I had been receiving maintained my electrolyte balance which is absolutely essential as NG tube suction involves the loss of electrolytes that if not replenished would have potentially fatal consequences. At a nutritional level, by this point, the sugar in an IV is not enough nutrition. At this stage nearly 2 weeks into my hospitalization, my body had run down whatever stored sources of sugar I had, burning fat reserves to provide enough calories to keep various bodily functions going, and beginning to break down muscle to keep my supply of protein up for other higher priority functions. More nutrition was needed.

Day 13 - Sunday September 18

Rinse and repeat: the PICC line continued to give me TPN over a 24 hour period and the lipid bag was infused over 12 hours. NG tube output was measured during each shift and comparable replacement fluid was infused during that shift.

Day 14 - Monday September 19

Rinse and repeat: the PICC line gave me TPN over a 24 hour period and the lipid bag was infused over 12 hours. NG tube output was measured during each shift and comparable replacement fluid was infused during that shift.

Previously, the daily meds were: famotidine, lovenox, and atorvastatin. One new thing added was Reglan, three times a day via IV.

Today, I was issued "patio privileges" which meant I could tell the nurse that I was going to take a walk away from the 8th floor and could even go outside to the patios of the hospital. Since I was still dependent on the NG tube suction, the recommendation be away for a maximum of 30 minutes. I didn't have the energy to take advantage of it on this day but would in all the subsequent days.

Day 15 - Tuesday September 20

Rinse and repeat.

Day 16 - Wednesday September 21

The day started and seemed headed toward rinse and repeat. However, today, the team decided to test if I can go without the NG tube suction. The NG tube stayed in but I was unhooked from the suction starting in the late morning. If I felt nausea or pain, I was to report it to the nurses and they would examine me and reconnect me to the suction if needed. Interestingly and positively, no nausea or pain arrived after many hours "off leash!"

Day 17 - Thursday September 22

By the afternoon, I had been off suction for over 24 hours so the team decided it was time to remove the NG tube!

Day 18 - Friday September 23

Liquid diet was started. Since my bowels had been asleep nearly 3 weeks, I was told take a sip every 10 minutes and don't push it. Just go slow.

Day 19 - Saturday September 24

More liquid diet. Take a bit every 10 minutes or so and don't push it. Just go slow.

Day 20 - Sunday September 25

Pureed food. Take a bit every 10 minutes or so and don't push it. Just go slow.

Day 21 - Monday September 26

Limited solid food. Take a bit every 10 minutes or so and don't push it. Just go slow.

The nutritionist came to check in on me in the morning. She anticipated I might be discharged on Tuesday. When I get home I was told to take it very slow. Wait a couple of weeks before adding raw fruits and vegetables.

The order was given to taper off the TPN. Because of the high dextrose content, they don't want to just stop the flow. The flow rate was cut in half for a couple of hours and then cut in half again for a couple of hours and then stopped all together.

By the afternoon, the PICC line was removed.

Day 22 - Tuesday September 27

Limited solid food. Take a bit every 10 minutes or so and don't push it. Just go slow.

By 1pm I was officially discharged!

Another song that gave me comfort and strength during my three-week stay was this old classic hymn.

Great is thy Faithfulness (Thomas Chisholm)

Great is thy faithfulness, O God my Father

there is no shadow of turning with thee

thou changest not, thy compassions, they fail not

as thou hast been thou forever will be. 

Great is thy faithfulness! Great is thy faithfulness! 

Morning by morning new mercies I see

all I have needed thy hand hath provided

great is thy faithfulness, Lord, unto me!

Much appreciation goes to the staff of 8West, Team "L," the surgical group, and all the professionals at Ronald Reagan UCLA Medical Center for their efforts in my care. I am grateful we can find such people to do this kind of work - they are amazing.

Also, much thanks go to family and friends who visited and supported through prayer me and my wife through this health episode.

And most of all, God has shown me so much love and grace through Mrs. Rambler who was my heartbeat and rock to lean upon during this extended stay in the hospital.

Previous SBO hospitalizations:

2004 - part I, part II, part III

2005

2009 spring

2009 fall

2014

2016

Disclaimer: The material above is a description of my health experience. Though I have attempted to be accurate I am not a medical professional. If you are in need of actual medical advice, please contact your physician.