christmas vacation

I'm about ready for classes to start up again. Why? Well, let's just say I'd like to meet whomever started Lowes and beat him with a garden hose. Home improvement. I hate it. I have a shirt with Homer that says DDIY - Don't Do It Yourself. But before this journey started, we had ripped out the carpet of our downstairs floor. At the time, our beloved dog of 13 years (best dog I've ever had) had begun to lose control of his functions. My wife and I both hate carpet anyways so out it came. We were going to put down a nice wood floor. Oops. I got into med school. So long salary. So long wood floor. Hello, concrete. Concrete in a stunning but functional gray with glue leftover from the carpet starts to look a bit tacky, even by my redneck standards. So as a present to us, my dad and brother helped, well drove really, a project to stain our concrete. My brother builds custom cabinets for a living, really nice stuff. For fun, my dad built his house from scratch on a whim. Me? Those construction genes must skipped me entirely. So needless to say, they know what they're doing and if they don't, they have enough experience to figure it out. If it were me, I would've quit after scraping the paint on the concrete for 5 minutes in futility. (photo credit to my wife on the pictures)

Quickrete advertises 3 EZ Steps - Prep, Stain, Seal. It's that simple....yeah, right. Here are the three of us prepping the floor. Want to know why it's expensive to have someone stain your concrete floor? The materials aren't terribly expensive when compared to wood or tile. But there's a LOT of prep work. My bro is on the left hand scraping the paint overspray with a putty knife. Not fun. My dad is happily grinding the concrete. It took the three of us two days to get the floor ready.

Next came the staining. There was a bit of a learning curve on that, like never, never, ever use a pump sprayer that has any metal parts in it when using an acid stain. They failed to mention that in the directions. I still should've figured that one out but to my credit, the acid didn't hurt skin so I thought brass would hold up to it for more than 3 minutes. There's a lot of waiting in between steps. At this point, it's stained and dry. I'm pulling out the leaf blower to remove any dust that's settled on it before sealing.

I sealed myself into a corner, well, out of the house really. I actually was smart enough to plan it that way. I then climbed a ladder into a window along the stairs. This was at 12:30 am so I'm more than a bit tired at this point, never mind inhaling fumes for 4 hours. It's still drying right now but so far it's looking like it'll be really pretty.

Here's what it looks like after drying about 12 hours. One of the cool things (or detriments to perfectionists) is that you never what the staining is going to pattern like. The concrete is highly hetergenous so you get a highly variable staining pattern. I think it makes it beautiful. After the initial round of stain dried, I went back with a squirt bottle to add some "character spots". See the stuff on it? That's hay...as in what horses eat. I needed all the fans I could get so I borrowed some from my dad which were stored in his barn. At the previous step, that stupid box fan blew for over 24 hours straight without so much as a stolon of hay errupting from it's crevices. But after I put the sealant on? It decides to vomit it out in great quantities. My wife wanted rustic...well, she got it.

All in all, I'm really pleased with it and very much graciously indebted to my dad and brother. I'm going to be providing them free healthcare for as long as I practice in return. I don't think many people realize the degree to which whole families kick in to support someone through med school. It's kinda like marriage. You're not just marrying your spouse. You're marrying their whole family. Same deal with med school. Everyone, not just the student, goes through it in some way. But I've had enough of this stuff. I'm ready for something cerebral now.

stupid, part deux

So, I got my board scores back from the biochem final. My wife says I need to be smacked down a bit to prevent me from getting a big head. By some miracle, I knocked the exam out of the park. Not every med school in the nation takes this one but of those that did, I scored in the top 1 percentile. When it got converted over to a number grade for our class, it was a 102.8....out of 100. It bumped my class average up to high pass, and only 1.8 points away from honors. Not sure how it happened. Only thing I can figure is that A) the profs did quite a good job at presenting to us the necessary material and B) this test was very different than the ones we take at school. As I said in the previous post, it was more doctory. It wasn't regurgitation. It was figuring out what ails a patient. That gives me a ton of confidence that I will actually be a good diagnostician. (I can't be a surgeon because despite performing thousands of surgeries on rodents (some quite complex and difficult) I shake pretty bad. It's one thing to have a mouse die on the table because one slipped. It's quite another thing to have a person.) I've had actual doctors tell me that I'll be good at this and then they get confused that I didn't seem to believe them. I guess I needed to prove it to myself. I also learned two other interesting things from this exam. 1 - nearly every single biochemical/metabolic disturbance leads to hepatosplenomegaly. Very non-diagnostic in these instances. Which leads me to #2. 2 - After reading about the 60th question of patient histories, it becomes tedious to read the same symptoms over and over and over . I could feel myself skimming to find the critical one. Hepatomegaly, fatigue, blah, blah, blah, blah, oh, they have lysosomal enzymes in their blood? That's I cell disease and the defect is in the mannose 6 phosphate process. Next! Now, I can completely understand how doctors don't appear to listen when you're reciting your complaints. Probably 90% of the patients in their waiting room have similar vague symptoms that are completely nondescript other than letting you know that something ain't right. They're looking for those 1 or 2 specific symptoms that let them zero in on a diagnosis. And they want you to hurry up and spit it out so they can figure out what's wrong and move on to the next patient. I need to not do that. The nondescript ailments are every bit as real and important to the patient as the diagnostic ones. After all, the discomfort of those general problems are probably what landed them in your clinic in the first place. I need to listen with both ears and full attention. That, and you never know when you might miss something.

pied piper of phlegm

The ingenuity and creativity of Sandy Hawkins is just plain cool. I am always impressed by innovators and inventors, people who are not only able to dream up new ideas, but they are also able to bring them from their mind to something tangible. http://www.popsci.com/bown/2009/innovator/pied-piper-mucus In a nutshell, this device is a simple tube with a reed-like flap that when blown, produces a frequency that immediately loosens phlegm in the lungs. So elegant in its simple physics. It's apparently being reviewed by the FDA for approval in Chronic Pulmonary Obstructive Disease (COPD). As someone who every winter often struggles with bronchitis, I'll probably want to try it out. I'm sure it'd have potential applications in cystic fibrosis patients, as well.

generics

Amidst all of the debate about the cost of healthcare, the concept of generics comes up a lot. What most people don't realize is that drug research companies actually have to do massive clinical trials involving thousands and thousands of people spending nearly a billion dollars in the process. With a price tag like that, there is obviously some vested interest in getting your formulation right. Self interest ain't a bad thing. Generic manufacturers do not have to do that. They just have to do a very small trial in a handful of people where the drug is given once and then blood levels are drawn. That's it. From what I've heard of other docs, generics tend to be ok for things where if the dose is off a bit, it won't matter much. Say you're taking an antiobiotic. The thing has been on the market for years, the synthesis is usually pretty straight forward, and there isn't much to the delivery. You're taking 500 mg of the stuff, sometimes twice a day. If the company is sloppy and only gets it partially right, it's not going to matter much if there is actually only 450 mg of the active compound in the pill. It'll still work. But for other drugs, say coumadin, the difference between the efficacious and lethal dose ain't that wide. There, it's not worth it to play around. Well, some new research from consumerlabs that just came out seems to expands that list. It seems that Teva had come under fire for their generic Wellbutrin, a common antidepressant and smoking cessation drug (and possibly weight loss when combined with another old drug, we'll see how the trials pan out). Well, their product is a slow release and so the synthesis gets a bit trickier. Patients started complaining and one site run by pharmacists (http://www.peoplespharmacy.com/) started to pick up on the signal. They passed on the information to the FDA and it prompted the FDA to require some more trials from Teva. When that'll get completed is anyone's guess and I suspect that the Teva probably knows it cut some corners and will quickly clean those up for the trial. Consumerlabs.com didn't wait. They tested it on their own and it turns out there more than just price differences between the brand and generic. The generic had vastly different kinetics of release which could explain the complaints of patients (wellbutrin without the slow release would need to be taken 3 times a day). So to recap, private citizens complained and a private website picked up on it. Then a private company addressed the complaints. Now consumers should be free to chose. But that's not the way it'll work. We'll need to wait on the ridiculously slow FDA. I think that this is a very salient point when debating a centralized healthcare system where bureaucrats in some far off distant land dictate what works instead of you and your doc deciding together what works best for you. Generics not working? It wouldn't be considered at all by that monolith when the cost savings are blinding them. http://www.peoplespharmacy.com/2007/10/12/generic-drug-eq/

Reason # 432

I was reminded on one of the reasons that medicine appealed to me. I had to go down to visit my gastroenterologist in order to switch meds due to insurance differences. Nothing really changed about my situation (I have some weird dysphagia that is controled with proton pump inhibitors) so we started talking shop. She was very supportive of my decision to enter med school and said that she was proud of me. When asked what year I'm in (my first), her face showed an obvious grimace at my reply. She hated the didactic part. In a nutshell, she said that she didn't remember *blankety blank* from that part of her medical training. This is from a doctor who's waiting room is peppered with numerous awards for her practice and care. She also said that I won't regret it. While it's possible to get burned out, there's always something else new to try with an MD. She loved her practice. And that was the heart of one of the reasons I chose medicine. Everybody got's gripes about what they do but at the end of the day, she made visible impacts in her patient's lives. I saw it firsthand. Want to know how fun it is to be out to dinner with your wife, or worse on a business trip with your CEO and CSO, and have food get stuck at the back of your throat? It won't go down and it won't go up. Let me tell ya, it ain't fun. And this doc helped me to treat that successfully. It was a good, yet not so subtle reminder that this will all be worth it in the end.

it is finished

Done. Breathe. It feels.....weird. While my grey matter can process objective data pretty quickly, it's quite slow to digest and ruminate over emotions. Below all the usual suspects of finishing - relief, joy, free time, etc - runs one that is a bit hard to describe. I am standing upon a continent and the earth begins to move. Something at my core seems to have emerged. A new land mass bubbling up from deep below through a fissure in the land mass. What it is, I don't know yet. The lava hasn't stopped flowing. After that it still must cool, changed by the weather and then colonized by life. Who knows what it will look like then? Or, among the cacophany of often disparate characters that is my psyche, a hereto unknown individual stands up and demands to be counted. Small at first, it is growing, morphing, becoming self aware, and changing with each rising and setting of the moon. Its voice grows as a wave resonates, it's hum growing until its vibrations are palpable.

stupid is as stupid does

When I was growing up, I was what my wife amicably dubbed me a "geek jock". I was the one with straight A's but I also tend to think a bit.....differently than others. I can't explain it. Sometimes my brain just functions off on its own wavelength. For example, whenever doing something stupid like soaking tennis balls in gasoline and then lighting them to kick around and play soccer, I was NOT the responsible one saying, "hmmmm, maybe this isn't so bright." No, I'm the one who had the saying "when doing something stupid, you gotta be smart about it" so I'd make sure we'd have a hose handy. Or, with bb gun wars, we had to wear raquetball goggles. Inevitably, I'd eventually end up doing something stupid and my friends would jab at me, "how can someone so smart be so stupid?" So fast forward a decade or two. It seems I haven't evolved past that point. I'm on cloud 9 after my block III exams. I'm pulling an honors in histo and I'm only 2 points away from high pass in biochem. During the final couple of lectures of the semester, the biochem profs keep talking about the National Board Medical Exam (NBME) and giving pointers on how to do well on it. It's somehow factored into our grade for biochem. Well, knowing absolutely nothing about med school, I just assume that they're referring to the Step I exam, which is the first of three licensing exams to become a doc. Step I is taken at the end of the sophomore year, though. Why do they keep talking about it now? Seems a bit odd. The light bulb is yet to go off. During the review for the final, the prof pulls out a bunch of questions from a website that are simulated NBME questions. They are, shall we say, a tad different than the ones I'm used to seeing on our exams. He'd read the question and then ask people to raise their hands for A, B, etc. I was doing pretty well. They started to get progressively harder and I was one of the few ones still raising my hand for an answer. I wasn't right all the time but I could at least formulate something better than a flip of the coin. Then they got ridiculously hard. The light bulb is yet to go off. Friday morning, I make sure to get to school a bit early so as not to risk getting stuck in traffic and missing the exam (that'd be bad). Got my ritual Chick-fil-a lunch and ipod jamming and I walk up to the wall to check out my seat assignment. I make sure I have the correct class and the title says "National Board Medical Exam Biochemistry". The light bulb begins to flicker. It's not bright 300-watt bulb, mind you. No, it's more like a half-burned out bulb from three Christmases past. But that little filament is starting to glow. Oh, shit. I quickly get my laptop out and go to blackboard. I download the part separate from the syllabus, all the stuff about contact info, whom to call in case of emergency, blah, blah, important details....wait, what was that? That part about the final? Oh, shit. Something about the final is from the NBME and must be passed in order to pass the course. Oh, shit. The light bulb is glowing in all its 3-watt glory now. I quickly race to the NBME website and pull up the biochem section. The questions really don't look much like the exam ones I'm used to. Have I mentioned that I don't do as well on standardized exams? It's because I think a tad differently. The exam is 125 questions and nearly every question presents a small paragraph of a patient case history. That makes for a lllloooonnngggg exam because you really have to think with every question. You can't just go into auto pilot and know that the 6th amino acid is the point of mutation for sickle cell anemia. It's much more.....doctory. Hey, wasn't I complaining about the material not being material to being a doctor? What's that about being careful what you wish for? We essentially had to diagnose what metabolic/biochemical problem was going on in each of these case histories. Let's just say I wasn't exactly prepared for it to the full extent that I could've been. Honestly, I would've kind of enjoyed it had I prepared by studying for this type of exam. But I learned a couple of good life lessons. #1 - Always, always, ALWAYS read the fine print. I did it for my mortgage. Why the hell didn't I do it for the full syllabus? #2 - This situation was probably very good training for becoming a doctor. I went into a situation completely blind, albeit through my own negligence. I didn't panic. I shutout any emotions about anger towards myself for dropping the ball. I kept my wits about me and I stayed focused on solving the problem. I have to pass this test, period......I'm sure I passed the test. You only had to get into the top 7th percentile which equates with getting about 36% of the correct answers. Talk about your curve. That should also speak towards the degree of difficulty, though. Whether I got a score good enough to get high pass in the class is another story. So even though my stupidity makes me think I may not be such a good doc sometimes, the way I reacted after the initial bout of stupidity reassures me that I am capable of being a good doc in the long run. I won't always get everything right initially but I'll always make it right in the long run.

Block III

Block III is done and in the bag. By some miracle, I aced it. I got a 95 on my histo/cell bio exam and a whopping 90 on my biochem. Not too shabby considering I earned a stunning 76 on my Block II biochem exam. Maybe studying really does help. Huh. Live and learn. I'm starting to remember how to be a student and in the process I'm remembering that when I wanted to be, I could actually be a pretty decent student. I'm also playing around with different learning styles and I seemed to have figured out some things that work well for me. That whole 'want' thingy seems to be a problem, though. When I could care less about a subject, I've yet to figure out a way to make myself care long enough to master more than one exam. We'll see how I do on the finals now. I'm determined to make honors in histo/cell biology. Biochem, well that's another story. I was shooting for a high pass (I was two points away as of Block III) but the final may have thrown a bit of a monkey wrench in that. That's another post, though.

alchemy

I'm driving down to the med center to take my first Block III exam. It's a cool crisp morning and the sun is brightly burning against a blue sky for the first time in several days. Rush is cranked up and belting out over the stereo via my ipod and traffic is light. The butterflies in my stomach are forming into attack formation. I am ready. And in an instant everything seems to take on a sharp and utter clarity. There are moments in life where everything seems to not so much pause as to come into focus. Alas, they are but brief moments and almost painful in the knowledge that quiet transcendance is emphemeral. The day to day grind will enter back into the picture. Things will become uncertain and pain rears its head again. One aches for that moment to last unto eternity, or at least through the day. That's not entirely true, or I should say accurate, as that paints an incomplete picture. Alchemy is often viewed as something to be scoffed at. Turn lead into gold? Crazy. But in its time, the alchemy tradition was one that was inherited from the Greeks. It was a rediscovery of modern man - one that sought to take the material elements of his world into his hands and fashion them into something of beauty and value. It was the beginnings of modern day chemistry. The ipod that transmits it's electronic signal over my car stereo is no different in spirit. It takes simple metals and electricity and turns them into piercingly touching sounds. And so are these moments of clarity in life. If you let them, they are moments of alchemy. Signals are sent and received across synapses. Memories are built. The psychological has become the physical. Transformation. Alchemy. To borrow a line from Rush coming out over my ipod: pleasure leaves a fingerprint as surely as mortal pain in memories they resonate and echo back again

last sprint

Well, it'll be the last of many, many, many sprints. Block III exams are tomorrow and then the week after that are the finals.....And then a Christmas break. Unlike Block I where I felt nervous, and Block II where nearly benign apathy had set in, for this final push I'm excited. I'm not exactly sure why but several reasons pop into my mind. The easy one is that I'll be done with this semester. I can be lazy and let my mind wander wherever it desires. I can drink beer and tinker in my yard (I have plans to dig a small pond). But if I go a bit deeper than idle relaxation, it signifies much more. Applying and getting into med school was a lot of work and effort, to be sure. But completing this semester makes it more concrete, more tangible, more expected. Before, everything was uncertain and filled with doubt. Now, it's starting to become familiar, average, routine. And that's a good thing at this stage. A very good thing.

oohhhhmmmmmmm

Over the past few years, I've grown more and more interested in what is described rather simplistically as the mind-body connection. It's common sense that the physical stimuli can alter our mental state. Pain hurts. But the converse is a bit more tricky. Can mental states alter the physical state. I'm sure everyone's known one of the positive thinking happy-go-lucky people. I'm sure their positive thinking works wonders for them. Some of us aren't so cheery, though. But what if you don't necessarily have to believe anything? What if simple mental exercises can still impact health? There's a growing body of evidence that says that it can. Here's an abstract from the recent American Heart Association's annual meeting. Patients with established coronary artery disease were randomized to usual care or usual care with meditation. The meditative group saw a 43% reduction in ALL cause mortality, not just cardiovascular disease. That's not a trivial thing. The caveats are that this was a very small trial (200 patients) with just African American participants. But if a pharmaceutical compound shows a 43% reduction in mortality in patients with established CAD, I can assure you that they'd be quite excited.

Irony

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.

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.

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.

animals

We live in a zoo. I should've been a vet.

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.

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.

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.

Check.

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.

Lemonade

* 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.

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.

psyche

As someone leaning towards primary care, I found this blogpost quite interesting. In it, the doc states that ~85% of the ten most common ailments brought to the attention of family docs has no definite material cause. http://acountrydoctorwrites.wordpress.com/2009/09/13/the-power-of-words/ In other words, it's all in their head, which is the phrase that many use to dismiss it. My response is that most people have some degree of fear of public speaking. Stage fright is absolutely "just in your head" but explain that to someone who's about to lose their lunch before a speech. It's every bit as real as a material pain like a broken bone. Over the past ten years, I've become more interested in some eastern modalities. Western medicine is great at putting Humpty Dumpty back together but not so good at dealing with chronic disease. In other words, if I get into a car wreck, I want a top notch Western trained surgeon. But for my periodical shoulder pain which has both a material cause (old football injury) as well as a psychic component (stress), nevermind external causalities such as cold fronts, or the odd hurricane (holy crap did hurricane Ike last year kill my shoulder), Western medicine has been horrible at helping me to deal with it. Two rounds of physical therapy and a sports medicine orthopedist gave me no relief. Accupuncture, however.....that had some surprising effects. I'm becoming fascinated by the mind-body connection and how it relates to health and healing.

dream

A foul mood has set in upon me of late and much of it centers around frustration with this grand journey of becoming a doctor. I'm probably being a bit impatient with both it and myself. I knew this would take time. I know that I'll be better off for going through it. One way I knew that it was time for some introspection was that I started dreaming again. Normally, either I don't dream or I don't remember them. I'm not sure which it is since the end result in the morning is the same. I used to be skeptical of dream interpretation, and still am to a big extent....except the times that I've tried it. Have you ever written down your dreams and honestly asked not what they meant, but what they felt? That's after all their way of communicating. My dreams are so bizarrely nonlinear as to be quite absurd so understanding in the logical sense is pointless. But I finally started writing them down (I had done it once before in my life) and I focused not on how ridiculous they were but what I felt in the images. It's made me a believer that it's pretty good tool to get in touch with your soul. It helped me realize what exactly was bothering me. There's a lot of fluff out there with respect to dreams. The best source of information for me was the psychiatrist Carl Jung. A fascinating man with fascinating ideas. There's a museum down in Houston near the med center that I visited once a few years back. It's called The Jung Center. So I took a step back and looked at the bigger picture. And that's one of the problems. I'm a big picture kinda guy. As such, I hate getting bogged down in the details when I can see the end result. I'd rather just up and head to the end result via a shortcut. Ain't gonna happen in this instance. So I have to just let it go and keep my kinetic energy going. I will keep trying ways to get this interesting and fun, like trying the low carb thing to make biochem, er, fun. And on a good note, I'm up to an 85 and an 86 on today's two biochem practice exams. The last one would've been higher had I not circled the wrong answer despite clearly knowing the correct answer. Time for a beer or three at that point. 93 on histo so I'm done with that one. I need to focus on studying for the practical on that one.

Liver

I mentioned in a previous post that the liver is an altruistic organ. It's true if you think about it. It detoxifies the crap we shouldn't put in our body, it packages lipids (calories) for the periphery, it makes glucose for the snooty and picky brain which won't touch lipids, it handles excess ammonia from other tissues, nevermind what it does for alcohol. It puts up with all the metabolic pickiness of the other organs. And true to form, if you take that analogy to it's logical conclusion, any purely altruistic organ (or person) is going to get walked all over. Drink too much? The liver takes the hit. Eat too much? The liver jumps on that grenade as best it can, too. Hell, even when it's hurting, it's a wallflower not wanting to draw attention to itself. It's not like if your lungs hurt. You KNOW when those hurt. Liver? You'll pick it up on a physical, maybe. Or you'll pick it up only when it's severely damaged. The liver should stand up for itself once in awhile. Meanwhile , it strikes me that the intellectual brain is probably the most selfish as it needs glucose and will maintain oxygen perfusion at all costs, even to the detriment of other organs (come to think of it, the kidneys and heart do, too, those greedy bastards!). But it's also the one that determines if you're dead (it ain't liver-dead that makes you dead, it's brain-dead that's dead-dead so I guess it can justify it's self centered view. I've got a lot of time to think on my commutes to and fro school. Hey, it's better than cursing at the reject who just cut me off.

studyin'

Not much time for blogging as this block of biochem is kicking my butt. My practice test scores yesterday? A 60 on the first and a 72 on the second. D'oh! I got up to an 82 today (or 86 if the answer key is wrong, and, yes, they can be wrong which makes studying fun). That makes me feel a little better. I wasn't looking forward to failing biochem. That'd put a damper on my mood.

Direction

How many times do we wonder if it's even worth it There's got to be some other way Way to get me through the day Keep going on till dawn How many times must another line be drawn I found my mind wandering the other day and it kept coming back to this whole process. If I'm honest with myself, I have to admit that never in my life have I gone deliberately into something and had absolutely no clue as to where it might end up. Marriage, parenting, college...sure I was clueless as to how it would go, especially maybe in the beginning, but I could see what was at the end. This? I have no idea. I started this road winter of 2006. That's nearly three years just in the decision making process. And here I am knowing that I'm capable of it all but it feels a bit like I'm already just going through the motions. For instance, next week are the Block II exams. Unlike last time, I'm not the least bit stressed. I'm actually pretty indifferent towards them. I'll pass. The hard part is winding myself up to even study for them. Throughout a lot of my life, I would often feel a bit of a thrill with mastering materials. I've done it enough times that it's starting to get a bit wearisome. A sort of been there, done that and how many more times do I have to prove that I can regurgitate this stuff? From the song above, how many times do I draw another line. It always happens in the end but this time it's taking a little bit longer to get psyched up. I'm hoping that once I get into the actual doctor stuff down the road, that will change. That was certainly true of my undergrad degree. I pretty much hated most of my first few years. It wasn't until my senior year when I got into the upper level classes that I thrived. Straight A student once that happened. So I suck down the nasty tasting medicine and draw another line in the sand.

Medical training

I was once told that in order to truly offer insightful criticism to a process or institution, one had to be a part of it. To some extent, that's true. Since reform of the way doctors do business is so much on everyone's tongues lately, I thought that whenever I saw something of note, I'd comment on it. So one complaint I've heard is how hard it is to find good doctors. Personally, my family had this problem. When my dad went through some heart difficulties, I figure the rate of finding good doctors was about 50%. It was true of family practice and it was true of highly specialized electrophysiologists. To make it worse, those in the lower 50% weren't just not good. Some of them were downright dangerous. So here's my question. Any population has a bell curve and down at the bottom are the idiots. Do doctors have a disproportionate (less or more) number of idiots in the field or is just that the idiots are just so much more obvious? One might expect that a field that supposedly weeds out the lesser talented would have less idiots. I'm not convinced of that. I don't think that the process necessarily cultivates idiots, but I do think that it may cultivate the wrong sort of talent. Doctors aren't doctors because they're good at being doctors. They are doctors because they are good at taking tests. Obviously, I've just over generalized about a huge profession of which I hope to belong to someday. But my point is that test taking weighs HEAVILY on deciding whom can become a doctor, not on skills. There are so many standardized tests along the way as to be ridiculous. But let me not go off on generalities. Here's a specific example that might help illuminate the point. In histology, three times during the semester we undergo what is dubbed "Team Based Learning". It's essentially a very basic patient history with a biopsy slide of the relevant organ. The goal is to get people thinking very basically about diagnoses. Well, today it was liver and the hypothetical patient was an alcoholic. Pretty clear case of liver disease due to over indulgence in spirits. One look at the slide and the liver had a TON of inflammation, ie lymphocytes. Everybody in our group said the same thing after looking at the slide. One of the questions inquired as to which cell type was increased. Pretty easy to say lymphocytes. Apparently, one group didn't put the correct answer because the peripheral white blood cell counts were not increased. No biggie. Everybody gets things wrong. But the student proceeded to argue their case to the professor that "how were they supposed to know that peripheral counts didn't correlate with tissue activity?" And in my head, I am thinking, this kid is falling into the fallacy that doctors more and more are falling into and that is treating numbers rather than disease. With the advent of all these new fangled technologies, there is a temptation to rely too heavily on these high tech diagnostics. They are powerful tools, to be sure, but they are replacing the art of thinking critically. Had this student taken one look at the liver, it wouldn't have mattered what the peripheral blood looked like. Think critically and ask, should the liver be full of inflammation under normal circumstances? Which gets to my original point. The class is selected based on their ability to take tests (myself included). This student was clearly arguing from the standpoint of test taking. At no point where they actually interested in learning why alcoholism leads to inflammation. They just wanted the points. At the end of the course, I'm going to go talk to the professor and give my two cents. I think he should expand on these situations and get these kids to start thinking rather than regurgitating. I'm starting to see why some med schools have forgone grades for a pass/fail paradigm. Stop worrying about points and start thinking about how you'll treat patients.

Day 8

Weight - 220.8 (-4.2 lbs) Nothing much to note except that even three starches a day (muesli for breakfast, garlic mashed potatoes at lunch, pita at dinner) is still leading to weight loss. I even had a bowl of ice cream. Incidently, have you ever measured out a true serving of ice cream? It's worse than a true serving of wine. 1/2 a cup of ice cream ain't much. I turn it into health food by dumping cocoa, not hershey's chocolate milk stuff, 100% cocoa powder in addition to walnuts and coconut (unsweetened as I'm obviously counting calories with my dessert). That rinky dink half a cup probably runs 300-400ish calories. And my exercise capacity is abyssmal. About 1 mile of jogging and I'm about to keel over. I'm going to have to up the healthy carbs just a bit more because the 2nd block exams are coming up and I've got to be able to use my brain. I don't have time to train my brain to work on ketones. My gluconeogenesis process must be off, which is to say, I could have less efficient burning of fats or catabolism of proteins. And now the weekend where I tend to not really fall off, so much as jump off the wagon. Last weekend was the Renaissance Festival. Two words - funnel cake. I think I ingested 8,000 calories that day. This week is OU vs UT. One word - beer. Maybe I'll touch that light beer crap. Yeah, right.

Day 7

Weight - 221.2 (-3.8 lbs) Attitude - still trying to find that sweet spot where I balance capability with weight loss. At this point, I'm not limiting fruit intake (fructose) at all, I drink milk (lactose), still eat chocolate but that still wasn't enough glucose fuel for me. So I had to start adding truly starchy items like breads or potatoes and I think that for me, having 2 starchy items a day allows for weight loss but my metnal cupasity ain't quite firing on all cylinders yet. I'm going to allow for three servings on days I exercise. Biochemical lesson - Ketosis, finally. I pause to admit it, but the whole way one's body fits this together is actually kinda cool. Our body cobbles together our metabolism out of bits and pieces. To me, it is NOT some highly tuned fine machine. It's some organism that has managed to keep afloat despite itself. I think that it all starts with the brain (and red blood cells). The brain requires glucose. Why, I don't know. From what I can tell, fatty acids can cross the blood/brain barrier. Red blood cells (RBC) require glucose because they have no organelles, ie they have no mitochondria (the little factories) in which to burn fats. So they must utilize glucose. Why they don't have organelles? I suspect it's because RBCs are essentially there to transport oxygen and that's it. After about 4 months, they breakdown and die. They really don't need any DNA or organelles to do that job so it must give some advantage to not waste the materials on them. Kinda analagous to replacing some factory workers with a robot. A brain is not really required to perform the task. So back to ketosis. Those two NEED glucose. Well, let's take an ancient ancestor of ours named Mog. Let's say he can't kill anything for a few days and has yet to find any good fruits around. The brain has to keep going and the RBCs have to keep carrying oxygen or he's going to run into a world of hurt when trying to avoid a predator. The body has cobbled together a clever solution to deal with it. It needs glucose so why not make it? For that to happen, two main elements are required. #1 - a carbon skeleton to build a glucose molecule (think of it like a frame on a car) and #2 - the energy to drive the process. Our body uses fats to drive the energy and protein to use as the carbon framework. It seems strange to consume energy to make energy but we do that all the time. Think gasoline. It takes energy to find, extract crude oil and refine it into useable gas. The net result is that we get more energy from that process. That's one of the complaints about corn based ethanol - it consumes as much, if not more, energy than it provides. Our bodies, are like the corn scenario, not the crude oil. We burn calories (in this case fat) in order to build glucose. It's a net caloric loss which is one of the reasons that weight comes off so quickly with these low carb diets. Like I said, not the best of designed systems but it works. But your body can only burn so much fat for 2 important reasons. First, fat breaks down into a compound called Acetyl CoA. It then goes into a process that everybody saw in high school biology called the Krebs Cycle (or TCA cycle for tricarboxylic acid cycle). It's a cycle so the beginning is the end. The CoA is liberated and recycled to join up with more fat and keeps going. Two problems occur when Mog is cruising through fat to make glucose. He pulls intermediates out of the Kreb cycle to synthesize glucose whole cloth. It's a cycle. If he keeps pulling things out, it doesn't cycle anymore. So it slows down which means less glucose and less energy. Enter the second problem. There's only so much CoA your body has. It's a finite pool and when Mog hasn't eaten, it's all tied up in breaking down fats (in financial terms, it's not a liquid asset at the moment). So he has to free up some of that CoA. Enter Ketosis, your body's last resort at keeping things moving. He changes Acetyl CoA into molecules called Ketone Bodies. Those can exported from the liver and used in the muscle as a source of energy (the brain eventually will use them after prolonged periods, something like 6 weeks). So Mog's liver has saved the day. He has provided the muscle with an alternative source of energy while still allowing for the synthesis of glucose. It's an energy wasting process in the long run which makes it a useful tool for losing weight in the short term. Long term weight loss with any means is a different story.

Day 4

Weight - 224.0 Attitude - better now that I'm figuring out exactly the balance in my body of carbs and ketosis.

Observation - Between day 2 and 3, I was pretty well into ketosis (dropped down to 222.8). An interesting observation was that I felt warmer. I mean considerably so. I noticed it especially while sitting still studying for awhile. Usually, when I sit still for decent periods my metabolism must shut down because I get cold really easily. Didn't happen. In fact, I had to knock the air temp down a bit. I don't know if basal metabolism increases on this diet or perhaps ties into uncoupling protein. I'll have to look those up.

Biochemical lesson - Uncoupling protein. Wow, applied knowledge. In turns out that a quick search of the literature revealed that high protein diets do indeed increase expression of uncoupling proteins....in rodents. It turns out rodents have a high amount of brown adipose tissue (or BAT). BAT, unlike the white adipose tissue (WAT), is common in rodents but no so much in humans, well adults. In newborns, it's critical. Newborns are not able to shiver but they've obviously a way to generate heat. It's through these uncoupling proteins. Your body generates energy by a process called the Electron Transfer Cycle. Think of it like a dam generating electricity hydrologically. Instead of the water flowing away, though, we have a process by which we would put the water back up behind the dam to go through the turbines again and again. Sounds like a self perpetuating machine, right? It's not. We obey the laws of thermodynamics. We get the energy from our food to drive the process to convert the energy it forms that are useable to our body.

Well, with these UCPs, it's like a hole in our dam. The water comes back through the dam, bypassing the turbine so no electricity is generated. Even worse, our body then spends energy putting that water back up behind the dam. The energy is then lost as heat. Hence, weight loss. People thought this a great way to lose weight. Back in the 30s, a compound called dinitrophenol was used. Not a good idea as it was a bit toxic. You can still buy it on the internet, though I would NOT recommend it. It can actually induce fatality by.....too high of a fever.

The other issue is that much of this heat generation/weight loss occurs in BAT. In rodents, BAT is pretty common so they can lose weight quite easily this way. In adults, BAT is quite minimal so it's not really applicable to humans. That's not to say the UCPs don't function in other tissues whereby weight loss could occur. I'm definitely feeling warmer, though. I'll have to do some more digging to see if these diets can induce uncoupling in humans.

Day 1

Weight - 225.6 Measurements - NA Attitude - light headed Observation - increasing protein content and cheese certainly slows down the ol' bowels which probably explains why I gained weight. My colon is probably impacted. Biochemical Lesson - How important glucose is. I really can appreciate how much your brain is dependent on glucose. Despite eating fruit, chocolate and drinking some wine, I'm still pretty foggy. I'm guessing that means I depleted my glycogen stores pretty quickly. What's glycogen? A huge polymer of glucose chains, it's essentially your body's way of storing glucose. After a meal, the glucose that is not used by tissue for direct energy is stored as glycogen in the liver and muscle. As an aside, whenever we looked at liver histology we always fasted the animals in order to deplete the glycogen stores. It made the liver a lot easier for the pathologist to read. Your liver is the main source of glycogen synthesis since it can make it from dang near any metabolite....except fat as we learned previously. There's another critical tissue to 'fogginess' that can ONLY use glucose (the brain eventually will use ketone bodies but more on those later). Red blood cells have no mitochondria so they are completely dependent on glucose for energy. I'll have to double check but I suspect that they'd get their stores from Mr. Liver. I don't know how much oxygen transport decreases as glycogen stores are depleted. You do need glucose in order to make 2, 3-BPG which is a regulator of how oxygen is bound to hemoglobin (it makes it easier for your RBC to kick off oxygen and deliver it to peripheral tissues like the skeletal muscle). Less 2, 3-BPG, I would imagine would mean the hemoglobin would tend to hold onto the oxygen a bit longer thereby decreasing the amount of O2 delivered. But what the threshold is for that and if the ketogenic diet approaches that, I have no idea.

Glycolysis

I know y'all were dying for some more metabolic diagrams. Honestly, this dry erase board thing is working out pretty danged well. And then snapping a digital photo preserves it for later studying after I wipe it clean. I suppose I could use software for it but for a non-digital native that can remember when computers first came out (they used cassette tapes!), I prefer the feel of the pen in my hand.

Here's glycolysis in all its glory. 10 simple steps and you convert Glucose to Pyruvate without any oxygen. It drives the brain and red blood cells as that's pretty much it for them as far as fuel goes. Skeletal muscle can use both depending on the fiber type (fast twitch use glucose as it's faster and doesn't need oxygen, slow twitch use fat as it lasts longer). Cardiac muscle on the other hand uses more fat (70%ish fat vs 30%ish glucose if my memory from my research days holds true)

Solution to a problem

I'm not real big on abstract learning. I've ALWAYS learned better through real world experiences. After all, there are those who can be told about it, there are those who can read about it, and there are those who have to piss on the electric fence to know what it feels like. Me? I'm that last one. So I'm confronted with a problem of being presented with all these metabolic pathways that amount to strange abbreviations with arrows going off in hundreds of directions with long, strange words over the arrows that often end in -ase as in synthetase, dehydrogenase, kinase and the like. And now I have to commit these to memory. If I were a good student, I could memorize them and regurgitate them like a good little med student. That ain't me. So I needed a way to actually understand and learn them. The instructors especially focus on how these pathways are regulated which to their credit, makes sense because both disease and drugs oftentimes affect these same regulatory steps. As they elucidated pathways, they'd use starvation as an example of how if one path is altered, the body responds by turning up (or down) a different pathway. It's like squeezing a balloon. You compress one side and the other bulges out. As my feeble brain tried to assimilate the info flying at me, it suddenly dawned on me that the changes induced in starvation look similar to those impacted by low carb diets. Ah-Hah! Methinks here's the chance to apply info to real life. I need to lose a few pounds for reasons I'll elucidate in a different post. Low carb presents a quick and relatively easy way to do that (I love food too much to diet, per se) and more to the point, I'll actively begin to THINK about what's going on inside me. In the process, I should hopefully not only learn these metabolic processes well enough for the exam (2 weeks away) but I'll actually understand them to remember later in life. Plus, I hope to actually be a physician someday so I'll have some first hand experience with weight loss to better empathize with my patients. So I will document my experience of a low carb diet (somewhat South Beachish, not really Atkins - it's really a bit of a mix of my own ideas with others). Imitation is the sincerest form of flattery, so I'm going to adopt a similar format as this blog, which incidently, has two very good blogs and they are worth following if you're interested in health. A good source of information. Day 0 Weight - 225.0 Measurents - didn't remember to take any Exercise - very modest as I'm pretty much horribly out of shape and started up weakly a week ago. Attitude - Crappy. I've done the low carb thing before and I hate it. Well, I hate anything that restricts what I can eat. Observation - a great way to avoid studying while not napping! Biochemical lesson learned - While singing to I'm not sure which tune, "Oooohhhhhh, you can't make net glucose from Acetyl-CoA." I'm not kidding. Two professors sang this in the lecture hall. It was great because it sure as hell stuck. I won't EVER forget this lesson anymore than I can forget THIS Sung to pop goes the weasel X is equal to negative B, Plus or minus the square root, Of B squared minus 4 A, C ALL! over two A. What the hell does that mean? See, your picky brain won't, well can't, use fats for energy like muscle can. It needs glucose. Even the slow witted like myself can see the potential problem. Depending on where you get your info, your body needs about 120 grams of glucose daily to just get by. So if you eat less than 120 grams of carbohydrates, a problem arises. Like our government, you're spending more than you bring in. And just like our government, you can print your own! And just like the government, it's at the expense of someone else. The problem is that fat breaks down into Acetyl CoA and that CANNOT be converted to fat. They're kind of like the lobbying class. Amino acids, ie protein, however, can be converted to glucose. Enter in high dietary protein content. Instead of losing muscle mass (which DOES happen in almost all clinical trials of weight loss either through pharmacological means with or without dieting although I don't know about low carb body composition), your body starts using your increased dietary protein to make energy. Apparently, my body is not as good at that as others. You see, by 3pm-ish, I was starting to go into a 'brain fog' meaning I was getting dumber by the minute, presumably due to decreased brain glucose. Sure, I know that the 'experts' say this will pass within a few days. Not me. I tried this once before. I kid you not, it was the 6th day and I was a blithering idiot. So much so that on a trip driving to Dallas (I would have probably been a safer driver had I been drunk), I had a conversation with my wife that went a bit like this: Me: Blah, blah, blah Her: You just told me that 5 minutes ago. Me: Really? No. Really? I did not. You're just yanking my chain. Her: Yes, really. You seriously don't remember that? Me: Ummm.....No. Should I? Her: When we get to Dallas, you're going to go to the sports bar to watch the Michigan game. When you do, please, please, PLEASE drink some beer and eat something with carbs. Me: Thinking to myself (Who am I to ignore a wife that pleads with their husband to drink a beer?) Now just blankly stare off into space as my brain has frozen...... So you can see that decreasing the efficiency of the ol' gray matter during med school is probably not a good idea. So I eat fruit, beans, some chocolate and try to find a balance between ketosis and stupidity (more on ketosis later).

High Tech

I'm going high tech now. So the other Saturday, I'm down at the med center for a New to Biochemistry Club meeting (NBC). It turns out that during my undergrad and over a decade in pharmaceutical research, I had managed to avoid ever learning anything remotely similar to biochemistry. I take that back. During my undergrad, I learned the process of fermentation pretty well while brewing mead, but I digress. During this review (how I love to spend my Saturdays!), the prof asked how many people had dry erase boards in their apartment. I chuckled until half the group's hands went up. So my significant other bought a cheapie dry erase board from Wallyworld. It's not as high tech as the laptop screens that I see the kids using but it actually worked pretty well.

The first trick is to have a good study partner. I prefer ones that don't say anything. Talking tends to get in the way of learning.

For those of you who've had biochem before, this is pretty elementary. It's TCA, beta oxidation (both saturated and unsaturated), and the all important alcohol metabolism. That reminds me. They're supposed to be edumicating us on how to be docs. Yet the entire part on alcohol was ALL bad. Here's what ethanol can do wrong, here's what acetylaldehyde can do wrong, blah, blah, blah. Hey, the liver is an altruistic organ after all. What's he whining about? Not ONE thing mentioned about the many beneficial effects of alcohol. Moderate imbibing of alcohol is, afterall, one of the few characteristics that always pops up on lifestyles that lead to increased survival. Surely there's some biochemmie doohicky in there somewhere that helps to wave one's hand in explanation of that fact.

Joys of AP

One of the benefits of taking the Alternate path, aside from my sanity, is that I've been able to attend every one of my son's football games so far. Heck, for one the refs didn't show up so I even helped out by reff'ing one. It brought back a lot of fun memories. He's #44 standing next to me in the red shorts and zebra shirt.

Hey, no whistle, keep hitting. I'm not going to call that a late hit on my own kid....Especially when I told him "no whistle, keep hitting". And neither I nor the other ref (from the other team so it was fair) had blown the whistle. I also taught him how to hold when blocking (he's tight end) by keeping your hands in close. I actually had one of the opposing team members come complain that #44 was holding and could I look out for it. Hey, I didn't see it. He had his hands in. Duh, that's the point kid. Plus, we were getting slaughtered so a few missed calls weren't going to matter.

As I said, an absolute blood bath. Here I am instructing him after they just ran yet another touchdown, this time to his side (linebacker on defense). I think I was politely telling him that the next time, he'd better get his )#(*% off the blocking TE and get in there to deliver a blow to the running back.

Next game. Here you can see the ref signalling the ball going in the other direction. Why you ask this picture?

Because we were winning 13-12 in the 4th quarter and the opposing offense was driving down to take the lead before good ol' #44 (look at those excited arms jumping up) recovered their fumble and halted the drive. They won this one. A rematch against them was not pretty. It was their only win. More fun than a barrel full of NADH going to the Krebs cycle.

Block I

Block I is done and gone. The semester is essentially divided up into three blocks. At the end is a test. Combine it with a final and you have 4 tests each worth a quarter of your grade. All or nothing. The histo/cell bio exam wasn't too bad. Unofficially, I think I got an 87 which falls into the High Pass range. 2.5 more points and I would've been Honors. Oh well. Biochem was a bit more challenging. Whereas I finished the histo in ~30-35 minutes, the biochem took about an hour and 20 minutes. When I left, probably 80% of the lecture hall was still full. Lucky me, they decided to change the test format this year so it was much more involved. They wanted to make it more like the board exams which I can appreciate. But when you studied 10 years worth of previous tests that were all in an identical format, you can imagine the "oh shit" feeling when you start to read the questions and realize they don't look anything like before. Still, I did better than I hoped. An 84. One point away from High Pass. So I proved to myself that I can actually take and pass these things. I'm still struggling a bit with being 'average' but.....when you're average in a pool of students where 8,000 applied for 220ish spots, suddenly average ain't so bad. Stupid societal labels. On to Block II with slightly more confidence.

Another study break

Last day before the last test of block I. The weather was a bit cool and it had rained so that meant one thing....

It's kayaking time. It's a swamp up in The Woodlands that I like to go to but the as it's been so dry of late, the water level was too low. You gotta love REI. Where else can you go deck out a honda civic to carry kayaks?

It's kinda hard to take pictures and kayak at the same time. That and I don't have a waterproof camera so I'm using our old rinky dink Olympus from way back when. Went looking for alligators but I have yet to see any. I did see a decent number of birds - great blue heron, cormorants, a hawk (not sure what he was but had a reddish belly), some unidentifiable ducks that never let me get close enough.

As far as swamps go, it's pretty cool.

I did come across one cool plant. It's a cardinal flower. While going back to see it, I also came across a racoon.

End of the line. The way was blocked by water lotus. Sure, you can paddle through them but they up the resistance and then keep snagging up your paddle. I don't mind going through small sections but I couldn't see the end of this batch.

Study Break

I've had enough studying for today. It's Sunday right before the first block exams and on the old tests, I'm up to 80s for both classes. I'd like to do better but not enough to study even more hours. I'd rather take a study break with my son and pick our first pomegranate - first of the season and ever. I planted it at the request of my wife and I'm glad I did. He's wanted to pick it for that past week. I needed a break.

Look at that hair. And that's AFTER it's been cut. It used to be even more unruly before school started. He used to be in Boy Scouts but I still had to tell him to move his fingers. I've bandaged his fingers before. I didn't feel like it today.

For those of you who aren't familiar with pomegranates, here is what they look like inside. They take a bit of effort to get at but they are good. No bugs inside so that was a good sign.

He liked them a lot. He said that they were even better than store bought ones. A good break. The satsumas and lemons should be ready in about a month or so.

Block I

I haven't posted lately because I'm coming up on my first round of tests. The structure of the semester is actually pretty straightforward. There are three blocks with a test at the end of each one and then a comprehensive final at the end of the semester. That's it. Simple, huh? At this point, I'm taking old tests which in theory, "do not exist" but everyone knows that they exist. The profs just won't answer any questions about them. It's basically the med school's version of "don't ask, don't tell". For me, it helps enormously. I learn by questioning, not by rote memorization. I would wager a guess that studies on how to learn would confirm that retention and understanding is probably better across the board for most people when they engage in a more Socratic method, rather than the what I like to call, the foie gras method. Force feed as much as possible. I'm feeling a bit better now about the tests. The first practice test I took in biochem was a whopping 67. It would be passing but just barely. I'm not looking to be top of my class but I ain't looking to be at the botttom either. So after the ones today, I'm up to the 80s for both histo and biochem. To the extent that these tests will be similar to the ones I take next week, that's good. The biochem prof said that the average for the first test is usually 79-82. So if I hit lower to mid 80s, I'll be happy with that. At least I tell myself that. Deep down, I'd like to get an A but that's not too realistic for me. I'm still not used to competing at this level. But then again, I'm not burning the candle at both ends either. I heard some students today saying that they were in the gross anatomy lab until 2:30am. Why???? At that point, I don't care so long as a I pass. I'm sane (that's debatable), I've gone to everyone of my son's football games (even ref'd one when the refs neglected to show up) and I get to see my wife. That's a trade I'm willing to make. I just tell the competitive part of me to shut the hell up. I'm just not a Type A personality.