November 30, 2009


Tonight over dinner, my son and I were talking about school, his specifically. He's been slacking off a bit and I was enquiring as to the reason why. The gist of it is that he doesn't like what they're teaching. His words, "when am I going to use what is a subject or predicate of a sentence?" Gee, I can't possibly empathize with him on that. My reply, "and when am I going to need to know what amino acid substitution occurs for sickle cell anemia?" He then went on to complain about pretty much every subject (subjects I all enjoyed, by the way), even Texas history. Now Texas history is just plain cool, probably second to the American revolution as far as idealism goes. Crockett's statement "You may all go to Hell, I'm going to Texas" is pretty self explanatory to anyone from Texas. Having stood in the hallowed halls of The Alamo, it pained me to hear him bash it. I suggested to him that perhaps he should keep a more open mind as to the importance or significance of certain knowledge. Touche. Physician, heal thyself.

November 24, 2009

How cholera, gatorade and potential diabetes treatments tie together

I'll be damned. I actually learned something quite interesting, from biochemistry no less. And to make it more bizarre, it ties three seemingly disparate things together - cholera infection, gatorade, and potential diabetes treatments. Most likely, it's interesting to me because it ties into some interesting physiology. In this strange amalgamation, first there is the cholera bacterium Vibrio cholerae. A nasty bug, it can be quite lethal with amazing speed. It is capable of dehydrating and killing a person in less than 24 hours. How? Basically, the bacterium has figured out a way to permanently open up a Chloride channel in one's intestinal cells (a side note, it also happens to be the same chloride channel affected in many Cystic Fibrosis patients). So your intestines starts continuously pumping out chloride. That sounds innocuous, right? Well, the problem is that water always, always runs downhill and always, always follows an osmotic gradient. That means that when separated by a membrane, water tends to equalize on both sides of the membrane such that the solute concentration (in this case chloride) is equal. So in pumping chloride out, it also draws water out of the cells and into your guts. That then passes out of you in a horrible watery effluent. To make it worse, the bacterium also inhibits the influx of sodium into your cells which means more solutes in the lumen of your gut and more water rapidly draining out of you. Enter gatorade. Or several thousand years ago (the exact dates are historically unknown) when a famous Indian physician named Sushruta prescribed drinking water with rock salt and molasses in it for diarrhea. He lead the way for the Florida Gators' drink of Gator-ade. See, your gut has several ways to bring in sodium and thereby water as it follows the concentration gradient. One way is through sodium transporters. The problem is those are inhibited by the Cholera bug. But your gut is clever. It has another way. Glucose (ie, simple sugar) and sodium can hook up together and catch a ride across into the gut that bypasses the other mechanism and cholera doesn't touch this one. So glucose and sodium are able to enter the gut and mitigate the diarrhea. Fast forward a few millenia into the modern era and this same biological concept which can simply and effectively treat an otherwise horribly deadly disease, is also the basis for all those fancy sports drinks. I'm fascinated by the utter subtle simplicity of the treatment of the cholera infection. Drink just water and you're in trouble as it won't get absorbed. But add a bit of sugar and salt, and now you've reduced the mortality from >20% to just 1%. Now THAT'S an effective therapy. But wait, there's more. Pharmaceutical companies are taking further advantage of this concept (this part is real world, not classroom). There's a sodium-glucose transporter in your kidneys that is responsible for the preventing you from literally pissing calories away which wouldn't be too favorable in the old days when food was limited. But in the modern era where calories are overly abundant, it becomes a clever way to take advantage of your urine. The beauty of the approach is that it lowers glucose safely without pushing your metabolism in any other directions like some of the other meds (Avandia anyone? if you're not familiar, just google it). It also spares your pancreas which is crucial to diabetics. My former place of employ worked on one of these inhibitors and it's currently in Phase II clinical trials (BMS has a compound in Phase III). I never worked on it myself but I had some friends who did and I hope it succeeds for their sake. If nothing else, it'd be a good reward for those people who literally collected GALLONS of mouse and rat urine (CSI is so wrong on how labs really work). And while it would be extremely rewarding to prescribe a drug that one helped develop, I'd settle for being able to prescribe something I watched close colleagues develop. Betcha thought it'd be impossible to tie cholera, gatorade and diabetes together.

November 20, 2009

turning point

“Well, Frodo, now at last we understand one another.” Faramir to Frodo (The Two Towers, Chapter The window on the west) It has always irked me that if looking for Tolkien in the bookstore, they always have him under Sci/Fi or fantasy, never under literature. And that’s what the book really is. A book written NEARLY half a century ago, it remains the #1 all-time best selling book worldwide, aside from the bible. That’s saying something. One of the great things about Tolkien (or any true literature for that matter), is that one can reread it any number of times and depending on your stage of life, get different things out of it. My wife calls it “bibliotherapy”. It truly taps into essential qualities of humanness which explains its staying power. Take the quote above. It’s said between two characters who are faced with difficult choices. But it’s more than that. In his choice to let Frodo go or succumb to the temptation of power, Faramir’s choice has dominion over Frodo’s choice to continue on his journey. A moving scene in the book, it’s also a powerful scene in the movie. At this stage of my life, I have a different interpretation. In some sense, it can be viewed as a conversation that can take place within one’s self. There is Faramir – strength, wisdom, and dominion by might. A bit of the conscious will. And then there is Frodo – a small, unassuming character chosen by fate to bear a terrible burden which ultimately ends up wounding him beyond healing. A bit of the intuitive subconscious. And then there is the juxtaposition between the two. By strength of will, Faramir can dominate Frodo and take control of the situation. And so in life, do we yield to strength of will or do we follow the uncertainties of the subconscious? What if it even means potentially losing a part of one’s self in the process? And why do I love this quote so much? Because the two say to each other, now we understand each other. There is an acceptance and agreement between two competing paths. The dominate aides the subconscious in what ways it can, but ultimately yields to a wisdom that is beyond simple strength of will. There is a sense of fate about Frodo that is never clear except in its danger. But he can do no different than to follow his fate, even though he wishes he did not have to. And that’s how I feel right now. I had…..a, shall we say, rough time with Block II. Afterwards, I feel different. I feel a sense of coming to terms with myself. In a different time, in a different place, I could go through med school by strength of will as I suspect most do. But not at this stage of my life. It simply will not work for me. This time, I yield to a different motivation that is fuzzy and terrifyingly unclear, yet still drives me forward towards a distant goal. That’s vague, I know, and probably difficult to explain. But Tolkien knew it and so did Frodo and Faramir. And while we’re on the subject of Tokien, if you want a book that revels in classic Greek tragedy, I highly recommend Children of Hurin which was completed by his son. A dark, foreboding tale that should be up there with the likes of Hamlet or Odysseus.

November 18, 2009

November 16, 2009

yin and yang

I spent my Saturday morning studying crap like this diagram.
So I rewarded myself by staring at this......Oh, wait, that's not what I meant. It looks like I dug a hole for David to take a dump in. Really, it was for a tree. It was just a bonus that I had his ass in my face while digging the hole. Not to mention the fragrant odor of the chicken shit manure wafting my way. It might as well have been a latrine. Well, at least there were no trips to the ER.
The hole was for this tree. It's a bottlebrush variety called 'Hannah Ray'. I have one over by hammock. When I took this picture, it had a good 6 monarch butterflies on it, 3 different species of bees, and other unidentified pollinators. Just a month ago, it had 4 hummingbirds fighting non-stop over it. I'd lay on the hammock for a study break, close my eyes, and hear the hum and chattering of them fighting.
But what about the other side of the yard where my wife and I eat eggs on the weekends? I had planted a native yaupon (Ilex vomitoria, you gotta love that latin name of vomitoria). One Christmas, I had purchased a yaupon as our living Christmas tree. It was covered in red berries (it's a holly) but a bit too Charlie Brownish for the rest of the clan. That was at our old house but I brought a small transplant along to our new one for memory's sake. But as I sat on our patio, I realized that it would outgrow it's spot. So why should the hammock have all the beauty? I planted another one right behind Michelangelo's David for balance.

November 14, 2009

Friday evening tutorial

I'm hoping this weekend turns out better than last. Last Friday started well. My wife and I were enjoying the cool evening having a beer out on our patio.....until our son came out saying he cut himself with scissors. Well, he tends to be a bit overdramatic so I reluctantly went inside to take a look at his finger. As soon as he removed the paper towel, all that I saw was blood. Uh-oh. I applied pressure to staunch the blood for a couple of minutes and then took another look. Still lots of blood. Uh-oh. It's nearly ten o'clock on a Friday evening so the family doc is out of the question. We're in between insurance so I'm reluctant to take him to the ER because I have no idea what it'll cost. I break out my hiking first aid kit. Iodine, sutures, forceps.....where's my lidocaine. Ah crap. I look at it some more trying to convince myself I can just butterfly it with glue. Reason overrides that and justifiably so. So I grab my keys and wallet and off we go. We first stop at a privately run minor emergency center thinking maybe I can bargain with them or at least hope that they'll cut me a break out of professional charity since I'm training to be a doc. $350 just to get into the door. It's a slow night and the doc overhears my conversation with the clerk. He takes a quick look at over the counter. Well, according to the Brits who are always trying to save money, inscicions slightly smaller than his so long as they're not on a nerve or joint can be left open to heal so long as they're cleaned really well and packed with neosporin. Hmmm.......I seriously consider it until I realize the ramifications of trying to keep Huck Finn's finger clean from dirt for a week. Off to the Tomball ER we go. The front desk was really nice but they wouldn't give me an estimate. I cajoled some more and they finally said that it'd probably run ~$200-300 and they could work with me so long as I'd put $25 down that night. Deal. Fast forward about 4 hours and this is what we finally got. 4 stitches. He did a good job but I think I could've sewn even better. I've thrown so many suture loops on animals it's ridiculous. But I didn't have lidocaine and after watching the nerve block, I realized that though I could've probably hit the right spot (had I had lidocaine), I wasn't 100% sure. I also learned the important lesson that lidocaine for digit nerve blocks canNOT have epinephrine in it as it can cause some serious damage to the finger when it constricts everything down. So I learned about wound closure courtesty of my son's "stupidity" (his words, not mine). I wish I had someone to practice on now. I do need to get me some lidocaine for when we go hiking, though. And while not directly tied to my medical training (other than it ruining my Saturday morning studying as I didn't get to bed until 4am), this event has everything to do with being a doctor. It's got me thinking a lot about how medicine is paid for and all the problems associated with it. I don't want to get into the broad sweeping debate about the healthcare bill (monstrisity, I should say) but I think this event does illustrate some very deep problems inherent in our system. #1 - In what other situation in life would you go into a business transaction, and make no mistake about it, that's what this is, and have NO idea what something is going to cost. The only reason I was able to get an estimate was because I begged and cajoled. I was told by one clerk that they're "not supposed to give that information out." #2 - Anytime that one does not know the cost of something, the value will be lost. It's a sad fact of life but life ain't fair. Why does everyone demand the same level of healthcare? It doesn't happen anywhere else be it your car, your house, or your education. We can't all afford Harvard. Take cosmetic surgery for example. There are a whole range of options. One can get the top of the line impants so that they look real or go for something that looks good but not perfect. They both work, so to speak but cost has to be figured into it. #3 - Regarding plastic surgery, it's pretty telling that the costs of surgical procedures have come DOWN over time. Why? In a word, competition. It's about the only part of our healthcare that is subject to free market competition. I always laugh when people talk about socialized medicine as a boogey man. Take a look around. Our system is so far removed from a free market system it's laughable. Doctor supply is limited by training, insurance essentially has a monopoly, doctors are not allowed to negotiate with patients, etc, etc, etc.

November 10, 2009

vitamin C

Steve had a post about a recent study showing alcohol consumption lowering the risk of developing Type 2 diabetes and that got me drinking. But not just anything. As I said in my earlier post, my garden is there to provide me endless distractions. One form is in homegrown citrus. My Meyer Lemon is coming into production and that means 1 thing - homemade lemonade. Well, 2 things really because that homemade lemonade makes one heckuva margarita. Here's how it works.
Step 1 - Obtain Meyer Lemon tree, plant it and forget about it.
Step 2 - Obtain Jack LaLanne Power Juicer. I'm not kidding. A year or so back, we were sitting around flipping channels and came across a friggin' infomercial with Jack hawking his juicer. I laughed and went to keep flipping channels. My wife and son protested. Seriously, we sat there watching this cheesy sales pitch but it worked. A short time later, we got our juicer. But it was a bit of a pain. My wife and son loved it but they weren't the ones cleaning the stupid thing. So I was going to send it back unless I could come up with a good reason to keep it. Fortune smiled and my dad had more Meyer Lemons than he knew what to do with. History was made and on to the next step. Check.
Step 3 - juice the suckers and add alcohol.

Here are the recipes.


* 4 Meyer Lemons (makes about 1 cup of lemon juice). They're sweeter than the average lemon and much juicier (thought to be a cross between a lemon and an orange) so other lemons may require more.

* 1 cup simple syrup but when the Meyers are in full ripening mode, I cut the ratio to 1/2 cup sugar to 1 cup water. Otherwise, it's too sweet.

* 3 cups cold water.

PS - For an even more interesting drink, substitute one cup of water with 1 cup of fresh squeezed oranges. One caveat, you have to drink it all that night. The orange juice goes a bit acrid the next day.

Margarita courtesy of my mom. I'm not sure how she came up with this concoction but I don't even like margaritas. But I love this one. One taste of this, and you'll not drink that high fructose corn syrup crap mixed with tequila again.

In a typical 12 oz glass add:

* 1 shot Jose Cuervo tequila (come on, this is Texas after all)

* 1 shot Grand Imperial. Yes, Imperial. I can't hardly spell Grand Marnier and I certainly can't afford it. So the knock off of Imperial works great.

* 1 shot Tuaca. I have no idea what this is. According to their website, it's an alcohol with orange and vanilla. Whatever. When you combine it with the other three, it's wonderful.

* Add a couple of ice cubes and fill up the remaining glass space with homemade lemonade.

Oh, yeah, this is a blog about med school so I guess I should give something medically. Vitamin C catalyzes the reaction which hydroxylates proline residues in collagen. That's good. And there are also some claims that it may augment the production of monoamine neurotransmitters, ie the feel good things like serotonin. I don't know how strong the data is behind that. Vitamin C is claimed to do everything under the sun but one thing is sure, the homemade margarita helps my mood.

November 7, 2009

backyard diversions

Though my undergrad degree was Biology, it was weighted heavily towards field biology, especially botany. So I can never stray very far from the outdoors, even while pursuing my MD. That's a bit of a challenge in the suburbs of the 4th largest city in the US. But I've taken great care in my selection of plants for my yard. It doesn't always look the best but it serves one of its primary purposes - to provide me with endless distractions courtesy of the natural world. It's a helluva lot better than TV. My son found this. We were sitting outside one afternoon and he noticed a monarch butterfly acting strangely. Our first thought was it just emerged from its coccoon so it's wings hadn't hardened yet. Upon closer inspection, we spied a praying mantis ruthlessly devouring the monarch's head, upside down no less (that's some danged good peristalsis and sphincter control).
It did not seem amused at our attention. If you click on the picture to get the larger one, the mantid's head looks a bit freaky. For an even cooler picture, check out this one from another blog with obviously a much better camera and more talented person behind the lens.
I deliberately planted this member of the legume family (Cassia corymbosa, or Senna corymbosa depending on whom you ask) to be a host plant for various species of sulfur butterflies. I'm rewarded with tons of butterflies ranging from pale yellow to almost orange, especially in the fall.
It's a Where's Waldo with birds, though this yellow breasted chat isn't trying very hard. A great example of Zahavi's Handicap Principle if I ever saw one. I must confess that I had to have help id'ing this one from Plantwoman as A) I'm not much of a birder and B) this guy has never shown up in my yard before.
This hawk was also a new visitor. He's either a Cooper's or a Sharp shinned hawk. I can't tell, but either way, birds of prey are always wickedly cool. At first, I had no clue what he was doing on my fence. I live in a new subdivision where I think me and 2 other people have bothered to plant anything, so there's not a lot of habitat potential going on. But I do believe that I have a family of small field mice that are eeking out a living in my garden. I saw the hawk pay close attention several times to where the I suspect the mice live. He even jumped down off the fence once to make a strike but came up empty.