phallocentric

In anatomy, spatial relationships are very important for pretty obvious reasons.  If you say an injury is on the front of a person, you have to understand what 'front' means.  So we attempt to avoid confusion by using very precise terminology.  One major relationship is dorsal versus ventral.  It seems obvious at first glance.  Dorsal is where the dorsal fin would go like on a dolphin or shark.  That would mean your back is dorsal and your chest is ventral.  But what do you do about parts of the body that move?  What's dorsal on your arm?  Or, your hand?  Furthermore, what's lateral on your hand?  It would depend on what position your hand is in.  Physicians (especially radiologists) get around that by establishing a concept dubbed Anatomical Position.  In the anatomical position, the body is standing facing forward with arms to the side and palms forward.  The legs are also straight with the feet pointed straight down.  What about the penis?  You'd think it'd be the state that is the most common, ie relaxed.  Nope.  It's when it's in an erect state.  So what the average person would call the front is really the dorsal (or back) portion.  Obviously whoever decided that had to be a male.

you mean I'm above average?

My last post on not studying probably came across a bit flippantly.  While I do enjoy writing, I'm no professional and I freely admit that sometimes concepts and writing ideas fall flat or just plain fail.  Despite my grumblings and shall we say, less than ideal study habits, I am actually right where I need to be in life.  It's a process and I'm trying to find the right path for me.  And despite my limitations, apparently, I'm not a complete idiot.  For the gross anatomy final, we took a national board style exam.  We just got the scores back and while I was a couple of points below the class average (damned overachievers), I'm in the top 75th percentile nationally.  Normally, on a standardized test, that'd be bad for me.  But considering the competition at this level, that ain't bad, especially given I am severely impaired when it comes to spatial relationships which is what anatomy is all about (seriously, I can get lost in a closet).  On biochem last year, I was in top 99% nationally.  I put those together and start to think that maybe, just maybe it's possible that I can do well on the board exams.

support

I'm a hard person to get to know.  No, that's an understatement.  It's damned near impossible to really get to know me.  So when a cadre of former colleauges presented me with this gift basket full of beer, chocolate and more beer......it meant a lot to me.  Two of them have had the misfortune of watching a loved one suffer through and ultimately succumb to cancer.  Nothing creates a mutual understanding like shared pain.  I can explicitly recall when one was going through it several years back.  I remember some long and difficult conversations in my office.  I tried to help in whatever small way I could.  Honestly, I didn't think I did much in comparison to the pain they were going through.  Now that the shoe is on the other foot, I know now that sometimes those small tokens of caring can make all the difference in the world.  Thank you!

finish line

I'm done.  I crawled across the finish line but I did cross.  I'm still waiting on some scores before I have my final grades.  Now I've got 2 weeks off.  I'm not sure what exactly I'm going to do with them.

never before has so much been studied so little

It's more than a bit ironic that when I would most need to be a good student, oh, say med school for example, would be when I somehow decide to be a pitiful student.  Last year, I was a decent student.  Not great, but not horrible either.  I got honors, high pass for the most part.  This year?  It disturbs me how little I studied this semester.  No honors but I still passed.  With this approach, I will still get to be a doctor.  It's a bit disconcerting, to be honest.  I can use the explanation that I've had a lot going on emotionally and certainly that's part of it but if I'm honest with myself, I admit it's not it.

I can't really understand it myself.  In hindsight, though, I can decide what to do with it.  Strapping on my psychiatrist persona, I think two things are going on.  I did this once before.  When I was an undergrad, I was a slacker during all the intro classes.  To put it simply, the classes bored me.  I didn't care and nothing anybody did or said could make me care.  My senior year when I was into the supposedly hard upper-level classes, I made straight A's.  I was friends with the professors.  I was even a teaching assistant because I found the stuff so cool.  I think the same thing is happening here.  When I relayed this to a friend and former colleague, in a sarcastic and dry, truthful manner told me, "you've got a bbaaddd attitude.  You need to hurry up and get into the clinic."  I think he's right.  This crap bores me to tears.  With every test, I feel like I vomit up a part of my soul and say, "see?  I proved I could memorize your crap yet again.  Can I please move on to the interesting stuff now?"

My subconscious, though, I think is also at work.  It's having me deliberately acting a slackass to prove a point.  It's telling me, "you can do this."  That may sound trivial, but to me, it's a very big deal.  I had (and to some extent still have) reservations about if I'm capable of doing this.  Down the road in my residency when all sanity has abandoned me and I have to study for my board specialization test, I hope I look back on this moment and tell myself this,  "You studied for a total of five, count'em five measly hours for your comprehensive developmental final.  You studied a semester's worth of material for a whole 4 hours the night before and 1 hour the morning of.  You passed the class.  Imagine the possibilities when you actually apply yourself."

Now, I should probably go study for my gross final.  But I only need to get a whopping 23 to pass the class.  You can see my dilemma...

maroon

     There's a popular university northwest of here that's really more of a cult.  The graduates drive maroon trucks, wear maroon clothes, and say 'whoop!' at damned near everything (I've heard a grad say it during lecture...how the hell did that person get into med school?).  I'm pretty sure their blood even turns maroon once they graduate and receive initiating into the high church.  Like I said, it's a cult that demands complete allegiance in everything.  I think I may have been subversively assimilated. 

    Let me back up to explain how.  A few weeks back, I started getting sinusitis and ran to my family doc.  Quite expectedly, my bp was less than desirable as I was throwing down sudafed with regularity.  I blew off my doc's concern saying that it'll return back to normal after this is all done.  To prove my point, I started measuring my bp once I recovered.  Ahhhh, crap.  It didn't come down so much.  The top number was consistently running 135-142 which puts me on the verge of Stage I hypertension.  The bottom number was 77-81 which places me in that same range.  Having done a wee bit of hypertension drug discovery, I couldn't help but pick up a bit of knowledge along the way.  I know full well that prehypertensive is really just a polite way of saying, "you're not hypertensive...YET, but you will be in short time.  Let's get you medicated."  Short of making some decent lifestyle alterations, pretty much everyone in that prehypertensive group inevitably progresses to full blown hypertension.  It's just a matter of time.

     Losing weight is one of the reliable methods but that takes time.  Strike one.  Hypertension also runs in my family on one side.  Strike two.  I wanted to do something in the interim until I could shed some pounds.  Enter the color maroon.  There were a couple of fascinating papers outlining the effects of beet juice on blood pressure.  It's just a couple of papers but they look convincing because in it, they outline the mechanism.  Anytime someone has A) observed a phenomenon and B) explained said phenomenon with proper controls, it starts to gain credibility in my book.

     The group observed two things.  First, they established that supplementing with a pill of nitrate similar in dose to the amount found in a glass of beet juice lowered bp.  Second, they established that the reduction in bp is due to the conversion of nitrate to nitrite by bacteria in our body.  How did they do that?  They had subjects drink the beet juice but then spit out their saliva once they swallowed the drink.  Let me reiterate.  They drink AND swallow the juice.  The juice is in the stomach and gets absorbed.  After that, they begin to spit out their saliva.  That blocks the bp lowering effects.  By spitting out your spit, you remove that recirculation of nitrate in your saliva to allow bacteria to do their thing.  It turns out that bacteria in our body (saliva) convert the nitrate to nitrite.  That nitrite is then converted to that nobel prize winning compound nitric oxide.  Nitric oxide has a rather large reputation in the cardiovascular field.  I'm sure you've even heard about it, or at least its effects on the blood vessels (think of nitrates for a person with angina which improves coronary blood flow or viagra/levitra/cialis which improves penile blood flow, both through the production of nitric oxide).  That's right, it dilates your arteries and lowers blood pressure.  (You gotta love the fact that with thousands of publications and a nobel prize, the best we can do is a drug to improve erections.  Drug development is really about stumbling in the dark hoping to get lucky.)

     The beet juice (250 ml drank twice a day) was shown to decrease bp by just the amount I need.  I'm not about to start eating beets ad nauseum (it'd require three beets a day) and the juice itself is cost prohibitive so I got some freeze dried powder hoping it'd do the same thing.  After just three doses (mix a teaspoon in a small glass of water), my systolic came down to 124 and diastolic down to 70.  Perfect.  And it's about the same monthly cost as a generic antihypertensive would cost for my crappy insurance.  People in alternative medicine always like to tout 'natural' rememdies as being without consequence or side effects unlike evil pharmaceuticals.  Ain't true.  The stuff tastes horrid.  Swallowing an ACE inhibitor would be SO much easier.  I despise beets so I guess if you like beets, then it'd be great.  But I think they taste like crap.  And speaking of crap, it turns it maroon.  Whoop!  I must be becoming an aggie.  If my feces are maroon, I might as well go all in and get a maroon truck and start growing maroon bluebonnets.

Reference #1

Reference #2

Do some more reading (shouldn't I be studying for finals???) and find that it can also improve exercise tolerance.  I gotta believe given the mechanism, it should help beat erectile dysfunction but no papers on that.

farewell

Goodbye Mr. 62-year old male, colorectal cancer with metastases to the liver.  I took my last gross practical test last night which means I am DONE with cadavers (short of any surgical rotations down the road).  The whole class was a blur and I'm not sure that dissecting is the most effecient way to learn anatomy but I do feel that it was important.  Ultimately, it's a rite of passage.  There's something to be said for digging your hands into a body cavity, seeing what cancer does to organs, holding a human heart in your hands, or seeing the effect of a penile pump for that matter.  It's both awe inspiring and immensely humbling.  Maybe I learned more anatomy than I realize (I passed after all) but more important to me is that I'll take away the experience of reducing the human body down to its most simple elemental terms and carry that appreciation with me the rest of my life.  So I thank you Mr. Cadaver.

For anyone considering willing their body to medical training, here's a website.

mistaken identity

A buddy of mine had suggested urology as a potential career choice as it seemed to be a good gig.  I may have to rethink that possibility.  We had our last practice practical tonight in gross anatomy.  On one of the tags, it was some structure that resided in the pelvis.  I thought to myself that it looked a bit like a vagina and was trying to figure out what portion of the female reproductive canal they were after (os or isthmus of cervix).  Turns out it was a prostatic urethra.  That's the part of the urethra that goes through the prostate gland.  Of a male.  Yes, men have prostates and women have vaginas with a uterus.  You'd think that'd be self evident in the training of a physician.  So not only did I get the structure wrong, but I got the entire gender wrong.  In my defense, the cadavers are really disfigured by now so structures are anything but self evident.  And the prostate in question was really, really, really large.  I felt better after I heard a string of students say that they made the same mistake.  I, however, failed to hear anyone say that they mistook the anal sinus for the vaginal vestibule.  I pulled that bonehead, too.  I think I'd have to reconsider the notion of OB, too.  Heck, with those identifications, I'm not sure I'm even qualified to have sex.

am I my brother's keeper?

"Tell me, can this radioisotope kill the tumors or is it just to relieve the pain?"

I pause.  What do I say?  I tell the truth, at least as far as I know it to be true.  "It's to alleviate the pain."

"So they can grow back.....What's the point?"

Those conversations are hard, which is to grossly understate the nature of the matter.  I've had people tell me that I don't need to be my brother's doc, so to speak.  I can just be his brother.  And my answer to that?  "Bullshit."  When my brother asks me questions like the one above, how can I walk away from that?  What man could look his brother in the eye and have the brazen cowardice to walk away?  To be honest, I'd rather be hit repeatedly with a 2x4 across my head than to have to answer those types of questions from him.  No....that's not true.  I hate the circumstances that have brought about the necessity of questions like those.  I did not ask to bear the crux of those types of questions.  They hurt to answer.  I answer them as even keeled as I can.  I hold back the emotion and let it out later.  And I've had a lot of those types of conversations lately, and not just with my brother either.  They're emotionally gruelling and they take their toll on me.  But then my brother didn't ask for this disease and his pain.  Bony tumors hurt.  Chemo hurts.  Radiation hurts.  Getting stuck hundreds of times with needles hurts.  Watching him talk to his kids 300 miles away hurts.  And so while my pain is real and sometimes aches so deep as to hurt viscerally, I will honor that connection we share no matter how much it hurts.  Cain, who whined, "am I my brother's keeper?", was a coward and a shell of a man, after all.

radioactive piss

It's Thanksgiving eve and we've just finished up another all day experience at MD Anderson.  My brother's van pulls into my driveway to drop me off and he turns around and asks me, "do you mind if I use your bathroom?"

............(My brother's urine is now radioactive.  He was dosed today with Quadramet (samarium 153 SM lexidronam).  It's a radioactive compound that preferentially gets taken up by osteoblastic tumor metastases (translation=tumors that secrete bone-like substance but they don't create healthy bones).  It's a bit of a trojan horse strategy, really.  Once those bony tumors take up the samarium, they get hit with beta particles which knock the tumors back to alleviate bone associated pain.  It doesn't go to any soft tissues so there are infinitely less side effects than standard chemo options.  On the other hand, it doesn't hit the soft tissue tumors like chemo)..........

"Yes, yes, I do," I replied in predictable smart-assed fashion. "You can pee on my lawn and see if you can make a radioactive tracing.....On second thought, the dogs may lick it......but you can pee on my side yard. I don't like those neighbors anyways."

And I laughed a laughter that went straight to my soul.  The image of being 12-years old and writing one's name in the snow while emptying the ol' bladder contrasted starkly with the seriousness of the situation here and now.  Not one of simple mirth, that laughter encompassed all the joy and pain that have been visited upon such occasions during this journey, each with their own costs.  And it felt good to let go of everything, of life, of cancer, of death even if only for the most brief moment of time.  Laughter has been in short supply of late so at that moment, it felt so good to laugh in such a soul reflexive fashion.

My brother opted to use my bathroom over the yard....but I secretly hope that tonight, he sneaks out into his back yard and makes a big J.  The thought brings a smile to my face.

random fact

Just learned that wonderful cut of steak by the name of tenderloin actually comes from the psoas major muscle.  The reason it's so tender and juicy is that it's a non-weight bearing muscle.  That alone makes it prized but it's not a terribly large muscle so it's limited in quantity.  Combine the two and you get an expensive but tasty piece of meat.  In humans, it's the major muscle (along with the iliacus) that lifts your thigh up at the hip, aka your hip flexor.

learning is fun(ny) sometimes

Your nose has three bones residing within your nasal cavity called conchae, or turbinates.  The reason I know that, besides gross anatomy, is that some years back I had surgery on my nose and my turbinates were shaved down to help breathing.  What I did NOT know was that the tissue covering the turbinates is highly vascularized.  If fact, it's awfully similar to another tissue in the male body.  I am referring to, of course, erectile tissue.  When your nose gets stuffy, your nasal epithelium becomes highly engorged with blood.  And what is a common therapy?  Pseudoephedrine (or phenylephrine since that stupid law that makes sudafed a regulated substance).  It's a sympathetic agonist that constricts your engorged blood vessels.  That allows more air to flow through your nose and you can breath better.  Likewise, when someone takes a cialis and gets an erection that won't go away (priapism), guess what the first therapy to try is?  You guessed it.  Pseudoephedrine (or phenylephrine).  Next time you get a stuffy nose and need a decongestant, I bet you'll think about it in a different way.

something to hold to

Through the drizzle and fading twilight, I walked from my school back to MD Anderson where we'd spent the last 4 days.  Up the escalators, a short jaunt to elevator T, and up to the MRI floor.  My brother was still getting his MRI as my parents waited in the chilly waiting room.  As I walked up to receive the rundown on how the visit with the radiation oncologist went, the look on my mother's face portended a grim assessment.  Her only words said through a clenched mouth, "I wish you had been there."

My brother has bony metastases throughout his pelvic area causing him considerable pain.  Option 1 was to knock them back with radiation to alleviate the pain.  From reading the radiation oncologist's summary, it was concluded that beam radiation was off the table.  The pain is diffuse and does not localize to any one met.  To irradiate all of them would be to invite disaster.  There are simply too many of them.  To make it worse, my brother and parents could overhear the telephone conversation between the radiation oncologist and attending oncologist.  (Note to self - never allow yourself to be overheard by the patient having a medical conversation with another doctor).  I think the phrase that stood out to my parents was when the radiation oncologist, whom we had invested hope to be able to alleviate the pain, uttered something to the effect of, "I'm not sure why you sent him to me.  There's nothing I can do."

Option 2 is to pump my brother with something along the lines of strontium or samarium.  Those preferentially will go to bony tumors and hopefully knock them back a bit.  That would then be followed up by enduring another round of chemo.  And so we wait to hear back from the nuclear specialist.  Even that, though, is palliative only.  It's to reduce pain and suffering.  There are no curative or restorative therapies proffered.  So I try to reconcile what I know medically, statistically, clinically with being a brother, a son, a human.  And I guess I'm still ruminating what to do with that.  Yesterday, I took the day off from studying and tried to find some understanding of that.  I meditated, I pondered, I grew angry, I pontificated, I blustered, I grew sad.  All that I can conclude is that I find no absolution in my rational point of view.  And so I tell my brother, I'll be there for him every step of the way to whatever end.

sex & death

In the basement of the gross anatomy lab, one professor says to another with a bit of a smirk and shrugging his shoulders, "It's pumped up and I can't find the off button."

Only later does it dawn on me what exactly they were referring to.  We were dissecting the genito-anal region that day and it seems one of the donors had a penis pump implanted.  Somebody decided to see if it worked.  In case you're wondering, Mayo Clinic has a rather informative drawing of what it is and how it works.  It's simple, really.  And I can assure you that it definitely works.  After all, if it works on a cadaver, I'm pretty sure it'd work in a living person.  I guess Freud was on to something when he said life is all about "sex and death". 

happy to be wrong

I have a near pathological need to be right.  You can ask my son.  He keeps a running tally of the number of times I've been wrong.  I think I get it from my dad.  If you ask him if he's ever been wrong, he replies, "Once.  I thought I was wrong but it turns out I was right."  As a result, when I start to draw conclusions, I usually have a pretty strong degree of confidence in their accuracy.  So it was with my brother's progression.

My brother has been suffering miserably of late.  He's lost 40 pounds, his pain levels were increasing dramatically and has difficulty even walking.  Not what one wants to see from a cancer patient.  But he was confident that the primary tumors were behaving.  In his words, he said 

"my gut instinct tells me they are stable. Don't ask me why I think that...I just have a feeling. The rest of my body: that's another story."

Pain is usually one of the most reliable prognosticators for progression of cancer.  But visceral sensation in the chest is just not that precise.  Just think of a heart attack.  It often feels like pain in the shoulder or arm, not the chest.  And when my brother's primary tumor shrank upwards of 60ish percent with chemo, he never felt any difference in his chest.  My fear was that he wouldn't be able to discern a 30-40% increase in the primary tumor.  It'd still be smaller than it was originally.  So when he was telling me of his immense and growing pain in his shoulder and hips, I grew troubled.  I figured the primary tumor would fly under his pain radar.  I inferred that if the tumors in his hips were growing, then most likely the ones in his chest were, too.

Today, we got the preliminary results of the PET and CT scans.  It was a mixed bag but I've never been more relieved to have been wrong in my life.  The primary was mostly stable (there was one small ancillary growth near the primary).  The bony metastases in his hip and leg bones, however, were growing.  My brother...well, I'm not sure how he feels about it.  Me?  I breathed a big sigh of relief, which I know sounds odd but here's my reason.  If the primary had grown, because of its location near the lungs and great vessels of the heart, it would be life threatening, plain and simple.  The tumors in his hips and legs, though, are not trivial.  The risk of a fracture is real and dangerous.  A fracture would require major surgery.  The bony tumors have absolutely impaired his quality of life and my heart aches to see him in such pain.  It impairs his mobility and morphine just doesn't work that well on bone pain.  But a tumor invading the hip bone does not carry the risk of a tumor invading the lungs or aorta.  And that's why I am greatly relieved.

synchronicity

Roughly half a century ago, the physician Carl Jung wrote about a concept dubbed 'Synchronicity'.  In his words, it was "temporally coincident occurrences of acausal events".  In other words, they are two events that are wholly unrelated by cause and effect, yet nonetheless are still related.  Most people would call it a coincidence.  When subjugated to common sense, it seems absurb.  Coincidences are coincidences.  Nevermind it was developed by one of the forefathers of the modern psyche in conjunction with Wolfgang Pauli (developer of the famous Pauli Exclusion Principle) and Einstein (relativity).  It has, shall we say, a bit of intellectual weight behind it.  And when I think about it, a lot of what he think is absurd.  Gravity, after all, seems ridiculous when analyzed in the same fashion.  I pick something up, let it go, and it drops.  Why?  Gravity.  What's that?  A force.  Huh?  A force.  You mean  like Star Wars?  When it comes down to it, I don't truly comprehend gravity but I can still see it when it happens.

I'm not sure I understand synchronicity either but I do think I experience it from time to time.  I experience moments that seem utterly removed from cause and effect but still quite related.  This morning, while studying lectures about the pelvis, I'm answering questions emailed from my sister-in-law about the excruciating pain my brother is feeling in the.....pelvic area.  A certain sense of intellectual unravelling begins to occur at that point with it being replaced with wonderment and strangeness.

trust to your instincts

The last block caught me more than a bit unprepared.  Couple that with all the emotional milieu (we're also now babysitting our nephew overnight a couple nights a week), and it can get a bit unsettling.  Though completely unintentional, my son reminded me of a valuable life lesson by watching his football games.  You see, he plays defensive end in football.  He's not real keen on offense as he just "likes to hit people".  For some reason one game, he got put on kick return.  I could immediately tell that he had absolutely no clue what his assignment was.  He kinda wandered around a bit and wasn't sure exactly where to line up.  But his instincts told him, "don't just stand there, hit somebody and take them out!"

He got knocked down but he made danged sure that the guy he hit wasn't going to make the tackle.  I especially love how A) he cleverly brings the guy down without getting a flag (learned that from his dad), B) the kid he hit has to readjust his helmet and runs off in the wrong direction, and C) my son gets up to go try to find somebody else to hit.

                                    
Later on, he had another kickoff return hit. This time, he's out for blood and takes not one but two kids out.  Enough to make a dad right proud.....and good advice back to his dad.  Trust to your instincts.  Don't just stand there, hit the books.



they always come in three's

I finished exams and did end up passing but that was soon to be the least of my worries.  I checked my cellphone noting that I had a voicemail from my mother-in-law.  I immediately knew something was off as she never calls me unless something was wrong.  Sure enough, she was asking for my opinion for her sister who was just diagnosed with colorectal cancer.  To make it worse, my wife's aunt had just lost her husband of over three decades to heart failure.  Her uncle, who was 62, had very much been a father figure to her so it was a hard and difficult loss.  And the cherry on top is that my brother has lost over 40 pounds the last few months and is struggling with severe neuropathy in his feet brought on by the chemo.  He only half jokingly said that he could go as a skeleton for Halloween.  Another week like this and I'm going to start buying wine by the cask.

test

It has not been a good week for me.  I blew my chances at honors or high pass in Gross Anatomy and I think I might have just failed an exam for the first time in Developmental Anatomy.  And I'm not even sure why.  Well, I bombed because I didn't know the material half as well as I thought I did.  What I'm not clear on is why I didn't know it.  Or, more to the point, why I didn't even want to know it.  I've yet to come up with a satisfactory answer.  It's not like I'm not capable.  I dislike this class immensely but I've conquered classes I hated before.  It's almost like I wanted to see how far I could push the envelope of complacency and still do well.  See, my whole academic life I was always at the top.  At some point in my life, I guess I no longer wanted to compete for those accolades.  Then when I got into med school suddenly I was average since everybody there was in the top of their class.  But it didn't make me feel insecure.  It made me feel like not wanting to compete for grades.  I'm not sure why.  And so I guess I swung the pendulum a little too far in the opposite direction towards 'not giving a damn'. 

human?

I was the first one into gross anatomy lab the other day and so raised up the cadaver out of the tank.  After peeling back the towel, I was struck by how little it resembled a human anymore.  The brain has been removed, as have the heart and lungs.  The ear, both inner and outer, is dissected, the voice box is exposed, and one eye has been removed.  The skull little resembles anything anymore.  The face is gone as are many of the bones that would form the scaffolding causing it to look like a face anymore.  We've chipped, sawed, and cut everything away leaving little but a shell of tissue, muscle and bone, at least from the chest up.

present tense

The first question I usually get from people is, "how's med school going?"  After giving an impression of the struggle that it is, their response inevitably rides along the lines of, "it will all be worth it in the end."  I can understand why they say that.  It's a measure of reassurance, of hope, maybe blind faith.  Myself, I certainly plan on it being worth it in the end.  But below the surface, that misses the bigger point.  I was never willing to sacrifice this much of my life for something down the road.  The journey itself has to be worth it.  The older I get, the more I refuse to live in the future or for what lies down the road.  Living in the present tense makes more sense.  It's a concept concept to more eastern philosophies.  I'm not sure how it got lost along the way in the west.  After all, when Moses asks God his name, his response?  I am.  Not, I am this or I am that.  Simply, I am.  This breath, this step, this moment, this all encompassing trip is as much a part of me as when I am all done.

impressions

Here are some random and unrelated thoughts from my first block.

1. The hand is enormously complex.  There are tendons, nerves, muscles, vessels running everywhere.  I have a whole new respect for hand surgeons.
2. Always tell a patient what you are about to do and why, especially if it's a woman and whatever you're doing is near her breasts.
1. As a corollary, if you need to elevate a woman's breast in order to listen to her heart, use the BACK of your hand.  If you use the palm, it qualifies as a caress.  That tends to cause lawsuits.
3. Holding the lungs in your hand is cool.
4. Holding the human heart in your hand is even cooler.
5. How did med students learn before google?  Seriously.  I use it nearly as much as my texts.
6. MUCH of med school is self taught.  The profs are there and they provide the material but in the end, it's just you and the material.
7. On the other hand, I'm impressed at how helpful and caring the faculty across the board have been.
8. When you can eat breakfast while watching the video on how to do the gross anatomy dissection for the afternoon, you are pretty much desensitized.  Of course, I ate during the Miracle of Life video during our birthing classes many moons ago so I've been desensitized for awhile now.
9. With the exception of the gunners, the large majority of students are just trying to survive, much less excel.
10. When I take a step back and look at it all, this is soooooo cool.  I love it.

time stand still

With the exception of my wife and son, much of my family is perplexed at my nearly obsessive insistence on attending every Rush concert possible whenever they decide to tour.  They deem it out of character for me and just plain odd.  This round, they came at the perfect time - the weekend after my first round of exams.  Houston was Saturday night and my brother's family got me tickets to the Dallas one Sunday night.  Like I said, perfect timing.  (The only downside was I wasn't able to go to San Antonio's concert since it was the night before an exam.)  So I was wracking my brain trying to come up with a way of demonstrating why Rush is a necessity for me.  I could describe that they are arguably one of the most influential bands of modern history; or, that any chance to see arguably one of the best living drummers in the world is not an opportunity to be missed; or, any rock concert where one gets literary allusions ranging from Hemingway to Twain to McCullers to Shakespeare is rare and impressive; or, how upon when asked what my rather reserved nephew thought of the first set at his first Rush concert responded with a grin and a hoarse voice from all the screaming, "I'm deaf and I can't talk."

But in the end as is often the case, my muse (my wife) answered it for me.  She's rather a late-comer to Rush and probably likes watching me watch the concert as much as the concert itself.  Or, so she says.  But I saw her tear and choke up with their second song of the night.  It's a song that she's not seen them play before and has desperately wanted to hear for several years now.  It's also one of those songs that personally, I can't listen to very frequently.  With familiarity, it begins to lose its raw power in its melancholic and ephemeral appreciation of all that is life.  So maybe after reading the lyrics to this song, my family will perhaps understand my obsession a bit better.  As someone who just finished the first round of exams and with no immediate trips to MD Anderson is ready for a break, who's laid it all on the line by changing careers midstream, who's dealing with a teenage son growing up way too quickly, who's dealing with a brother and cancer, whose life seems to be speeding past inexorably, this song epitomizes why Rush is Rush to me and could not have been a better theme song for my weekend.

I turn my back to the wind
To catch my breath
Before I start off again.
Driven on without a moment to spend
To pass an evening with a drink and a friend

I let my skin get too thin
I'd like to pause
No matter what I pretend
Like some pilgrim
Who learns to transcend
Learns to live as if every step was the end

Time stand still
I'm not looking back
But I want to look around me now
Time stand still
See more of the people and the places that surround me now
Time Stands still

Freeze this moment a little bit longer
Make each sensation a little bit stronger
Experience slips away
Experience slips away

I turn my face to the sun
I Close my eyes
Let my defences down
All those wounds that I can't get unwound

I let my past go too fast
No time to pause
If I could slow it all down
Like some captain, whose ship runs aground
I can wait until the tide comes around

Time stand still
I'm not looking back
But I want to look around me now
Time stand still
See more of the people and the places that surround me now

Freeze this moment a little bit longer
Make each sensation a little bit stronger
Make each impression, a little bit stronger
Freeze this motion a little bit longer

The innocence slips away

The innocence slips away...

Time stands still

Summer's going fast, nights growing colder
Children growing up, old friends growing older
Freeze this moment a little bit longer
Make each sensation a little bit stronger
Experience slips away
Experience slips away...
The innocence slips away.

opportunity cost

It was about 11 o'clock at night and I was done studying.  Well, let me clarify that.  You're never really done studying.  There's always more material that could be reviewed or another concept that could be learned in greater detail.  There's just too much information possible.  You just reach a point where you've had enough and say, "I'm comfortable getting whatever grade I've earned at this point."  So I grabbed a giant glass of that elegant box wine and headed outside to listen to the toads.  On my vitex tree, I noticed quite a few moths dining on the nectar.  Then a small branch moved and a moth escaped with its life.  Peering in for a closer look, I saw a big ol' praying mantis with its forearms ready to do battle with a moth that strays too closely.  Just plain cool.

After watching it for a few minutes, a part of me was saddened.  A not-so-insignificant part of me has the heart of a field biologist and by opting for medicine, that in a very real sense closed the door on other opportunities.  I don't regret choosing medicine but that doesn't lessen that part of me that yearns for other possibilities.  Such is life.  So I enjoyed the brief bittersweet moment for what it was and saw what else I could find with my camera.

An anole sleeping amongst the leaves of my Mexican buckeye.

fear

     If one were to survey med students regarding what motivates them to do well on their exams, I'll bet that 'fear of failure' would rank high on the list.  I know it does for me.  About 2 weeks ago, we took our first mock practical exam in gross anatomy to 'let us know where we were at'.  I guess I should explain how a practical works.  There's a large room where we dissect the cadavers.  The faculty go around and 'tag' structures with a metal pin through a muscle like the 'flexor carpi ulnaris', or a piece of brightly colored string around an artery such as the 'deltoid branch of the thoracoacromial trunk', or an arrow on a radiograph (x-ray, CT, MRI) pointing to the 'greater tubercle'.  Armed with a clipboard, an answer sheet, and a four-leafed clover, we are expected to walk up to a station, observe the structure and write it down.  A bell goes off in 45 seconds and then you repeat.  The 45 seconds of observation go way too quickly but then there are rest stations where the 45 seconds last an eternity.  That goes on for 50 structures.

    So my first practice practical result?  A whopping 10.  And that's on a scale from 0 to 100.  That's right, I had 45 X's on my answer sheet and only 5 checkmarks.  Nothing to write home about unless it's to apologize for being clueless.  Granted, this practical was executed by the pedagogues (student assistants who aced the class in years past and often want to be surgeons) and they admitted that it was much harder than the real one would be (the highest grade I heard was a 50).  But still, a 10?  That doesn't exactly instill confidence.  A week after that one, there was a second mock practical only 3 days before the real exam.  That means if you bomb this one, you only have the weekend to learn the stuff.  I had, shall we say, studied with a bit more enthusiasm.  And this isn't a trivial amount of information.  To give you an idea of the volume, here's the material for Block I, excepting the cadaver.  They tend to frown upon taking body parts home.

This time, I got a 70.  And then I started asking around how others did.  Scores were still in the 50s so I was psyched.  Real practical rolled around on Monday, and they posted the answer key that evening.  We have a carbonless copy of our answers so we can self grade.  Since it's not multiple choice, there is some subjectiveness to what answers they'll accept or reject.  Depending on their degree of mercy, I got somewhere around 80 give or take some points.  And the written part, somehow I managed an 86, a high pass grade only 2 questions shy of honors.

     And I'm left wondering, what could happen if I was actually a diligent student and applied myself?  Knowing myself, I'm pretty sure I'll never know the answer to that question.

tension breaker

I'm bubbling in my horrifically long last name on the scantron while the professor drones on in a monotone voice about the rules of the exam, "no cellphones, no electronic devices, blah, blah, blah."  This is the first exam of Exam Week and it's the doozy gross anatomy so the tension is high.  Then there's a pause where silence settles in over the room and in that same dry and monotone voice, he states:

A man is driving down a lonely country road.  In the opposite lane, a woman is driving down the same country road.  As they begin to pass each other, the woman leans out of her car and yells, "PPPIIIGGG!!!!"  The man leans out his window and yells back, "BITCH!"  Then the man hits a pig in the road and dies.

The whole auditorium errupts into laughter and you can just feel the tension in the room lessen.  I've come to really love the faculty at my school.

review - the alchemist

While sitting in the waiting room for my brother's MRI down at MDACC, I happened to look next to me at the book shelf.  The first book jumped right out at me.  Titled The Alchemist, it is ironically "a fable about following your dreams".  I had never heard of it or the author but I took it home and gave it a go.  How could I turn down a book about omens when I basically find it as an omen?  It's a simple, yet not simplistic, beautiful story.  I'm not even sure how to explain it other than to say:

READ THIS BOOK

In retrospect, it's an enormously popular book that flew off the book shelves in the 80s and 90s.  I can see why.  I wonder if I had read this book earlier in my life, would I have made a career change earlier.  It's one of those books that if read with an open heart and mind, can influence you on how you view the journey through life.

fritos

Frustrated and not being able to locate the internal pharyngeal nerve, one of my tank mates suggests that I move to a different part of the dissection.  I wasn't making any headway and only making myself angry so it seemed like a good thing to do.  The clavicle needed to be removed.  So I traded scissors and delicate dissections for a bone saw.  Actually, it's more like an autopsy bone saw.

I grab the saw and it makes short work of the collar bone.  You can imagine that in cutting bone, some dust is going to be given off.  And you can also probably imagine that with any power saw, friction is going to generate heat.  Apply friction and heat to a body tissue which generates a dust, and you can imagine that a smell is going to be generated.  I'm here to tell you that it is NOT a pleasant smell.  The murmuring of students over the hum of various saws suggested that it smelled like Fritos chips.  Not sure about that.  If chips ever smell like that, I wouldn't feed them to my dog as a punishment.  Maybe a batch of Fritos chips that have gone horribly awry in unholy ways.  It made one of my tank mates queasy.  I doubt that she'll ever eat a frito pie in her life again.

beauty

I never would have thought of a pathology report as beautiful.  But when it's applied to my brother's tonsils, sweeter brevity could not be imagined.

a bright spot

With everything going on in my life - med school, family, dealing with my brother's cancer - I haven't spent much time tending to my garden. The heat and dryness of summer along with the relentless march of weeds has left much of it looking pretty ragged. In some real sense, that's a very good representation of how I feel. But despite it all, there are a few bright spots. During a study break, I mowed the lawn, drank a beer or three and just sat observing this Cassia corymbosa. It's loaded with flowers and ever since I planted it, I've been rewarded with a steady stream of yellow sulfur butterflies. I'd like to think there's some deeper meaning of life to it - the resilience of life, maybe. Maybe not. But all that I walk with is a brief respite where everything in life just halted for a moment and I could breathe.

omens

About thirty of us are sitting in a waiting room not unlike a doctor's office.  Surrounding us are 14 exam rooms where awaits our first patient as medical students.  Rather than unleash us on actual patients, the medical school lets us make our mistakes on trained actors.  The coordinator calls out our room assignments and partner.  Then a british voice comes over the intercom informing that the group before us has 5 minutes and they are to exit the room.  It makes me feel like we're on a British Airways flight.  Then it informs us to proceed to our room.  Ours is lucky #13.  On the outside of the room is the patient's "name".  I kid you not.  The name was Ms. Robinson.  My partner and I both turn to each other laughing and enter in.  She fulfilled the role of her namesake well.  From a place of maturity, she tutored us in our art and gave us our first taste of that doctor-patient relationship.  It was wonderful.

a mother's prayer

These are my mom's words that she wanted posted.  I just typed'em for her.

August 27, 2010
     It is my birthday today and I'm sitting next to my beautiful boy's bedside at MD Anderson.  He has just had a tonsillectomy, and we are praying they aren't malignant.  Please God, please God.  When I first walked in and saw him he looked so pale and still - my heart lurched - oh God please let him be OK - the fear of losing him is so overwhelming at times, I just want to lay down and die.  And if only I could give my life for him I would of course.  It doesn't work that way.  I need to be here for him.  I need to be strong but dear Lord it's so hard.
     But leave it to my Joshua who is just coming out of anesthesia.  His eyes flitter open a tiny bit and he whispers "Happy birthday" to me.  He, who is facing the battle of his life, remembers to wish his mom a happy birthday!  I stuff back tears and say, "only you sweetheart, keep thinking about others before yourself" and then you ask if anyone has talked to the kids.  Again, your unselfish nature, undiluted by anesthetic, comes through.  This is my Joshua, my beloved son, my precious son, where if goodness and loving kindness would only guarantee health, it would be so.
     As I'm standing by his bed, holding his hand, I'm praying, "Lord, please heal him and let him be with us a long, long time...It's been such a short time, please Lord this is so hard."  Then I open my eyes and look at all the old faces in the beds surrounding Josh's.  My heart breaks seeing my son's young face with his beautiful bald head and face with no eyebrows.  Then a little guy, maybe 7 or 8, is being wheeled in with his beautiful bald head, with his parents in tow and my prayer changes to tearful praise.  Thank you, Father.  Thank you for the years we've had.  I beg there will be more, but thank you!  I praise you for the gift of my boys - my three wonderful boys!

anger

I push the "Up" button on the speed control of the treadmill.  My breathing becomes more rapid but it's not enough.  I now increase the incline.  My legs start to feel like lead weights but it's still not enough.  I increase both the speed and the incline.  My chest heaves up and down with each breath burning inside.  Sweat now begins to stream down my body.  But it's still not enough.  I get off the treadmill and begin to punish my body hoping to trade emotional pain for physical pain.  Pull ups then squat jumps and then I drop to the ground for push ups.  I continue to push msyelf harder and harder, hoping to trade the saltiness of sweat for the saltiness of tears.  I now have a better understanding of people who cut themselves.  It's somehow easier to feel the physical pain than it is the emotional soul wrenching angst.  I strip from my phenol imbued shirt and stare into the mirror.  Sweat is now streaming down in rivulets from my body.  Hoping to get a glimpse into the window of my soul, I stare into my own eyes .  All that I see is a fire burning with anger.

Anger at having to see my brother white as the blanket covering him while he recovered from his biopsy.  Anger at the injustice of it all.  Anger at everything.  He just finished six rounds of chemo.  The tumors actually responded.  Doesn't he deserve some reprieve?  No.  He's getting a biopsy of his tonsils and now the pain in his joints have returned.  What did he do to deserve this?  He did not smoke.  He was active and in shape.  He was healthy.  He was so young.  But then fairness is immaterial in this battle.  I limp out to my car now exhausted physically as much as emotionally.  There is no purgative effect.  There is no feeling better afterwards.  There is only anger, anger as impotent as screaming into a hurricane.

brachial plexus

Brachial plexus?  Never heard of it you say?  Well, pull up a chair and a beer and let me tell ya about that evil monster.  Let me first give you just a clue about my thoughts on the hideous beast.  The next time someone says how wonderfully designed our bodies are, I'm going to tilt my head back and let out a deep belly laugh because I have seen the brachial plexus with my own two eyes.  I have held its chords with mine own fingers.  It is a labyrinth where upon if one stares upon it too long, one goes in mad with confusion and frustration.  An endless knot, it is.  Still want to see it?  Ye be warned.

I spent nearly four and half hours dissecting this monstrosity of nerves on our cadaver.  That's what it is.  It's a collection of nerve fibers that go through your armpit and at that spot they for some reason decided to have an orgy of confusion to wreak havoc on future med students.  They cross and criss-cross and then merge back again just to piss you off.  You couldn't come up with a more confusing bundle of pathways if you wanted to.  It's worse than the drunken Aggie designed Houston freeway system.  But I can proudly say that out of all these bundles going off in inumerable directions, I only cut one single nerve in the wrong place.  Now I just have to figure out a way to remember these buggers long enough for the exam, never mind what they actually do.... 

lessons I've learned from gross anatomy

I was quite proud of myself.  I had successfully finished my dissection and felt like I had a decent grasp of the material.  The warm water ran over my body rinsing away that horrible phenol smell.  I thought to myself how glad I was to bring a change of clothes.  The last thing I wanted to do was sit in rush hour traffic for an hour or more smelling like phenol.  If you've ever smelled phenol, you know what I'm talking about.  It's not an overly horrible smell like week old rotting garbage or anything (not that it smells pleasant either).  But it's an exceptionally powerful smell that permeates EVERYTHING - your clothes, your hair, your pores - everything.  So I was glad to be ridding myself of it.

Then it hit me as I stood smugly washing myself.  I brought clothes.  I brought soap.  I did NOT bring a towel.  Standing there in the shower with the water running off me, I have no intention of drip drying or riding home soaking wet.  So I gingerly walk over to the blow dryer trying not to slip and bust my butt.  It's right next to the door of the bathroom, too, so I'm crossing my fingers that no one walks in while I'm standing buck naked air drying myself.  There is simply no way to do that without looking like a complete freak or pervert.  Med students is ssooo smart.

Lesson #1 - always remember to bring a towel when showering.

chisel & hammer

Our turn finally came to start cutting into the cadaver today.  There were two main tasks.  One was to isolate a small area below one's skull dubbed the "suboccipital triangle" which you can see in the photo below on the right. 

The second requirement was to pound through the vertebrae and isolate the base of the spine.  I am paired with two very nice but very diminutive in frame girls.  So when the option was between delicate cutting or cracking bone, guess which job I got? 

You guessed it.  My first experience with the cadaver was putting a chisel up against the bone, grabbing a rubber hammer, and whacking away relentlessly.  And strike away I did.  I really didn't know what I was doing.  Instead of preparing for the dissection yesterday, I spent a good 10 hours down at mdacc instead.  After a clusterf*#@ of a visit that I'm not going to get into right now because my blood pressure will hit around 200 mmHg, let's just say studying was the last thing on my mind.  But I figured I've cut into an animal or a thousand in my time so I'd just sort of wing it.  How different can human be from rodents really (sarcasm alert)?  Well, I screwed it up at first.  Being used to rodents, I went far too shallow.  Apparently, though, it looked like my winging meant I knew what I was doing.  One of the proffs said that he didn't offer me any advice since it looked like I knew what I was doing.  Sweat dripping down my brow, I was NOT about to let my first dissection end badly.  Pride wasn't going to let me go with my tail tucked between my legs on the first day of cuttin'.  So I hammered until my hand began to tingle and even my scrubs were starting to darken with sweat.  Finally with a crack that was both palpable as well as audible, I knew I had it.  I stuck my finger down into the depths of the back and felt what I just knew had to be the spinal cord below.  Jackpot. 

I removed about 6 more vertebrae, cleaned everything up and brought the pedagogue over to confirm my dissection.  All the necessary structures were there clear as a bright sunny day.  It was beautiful.  That may sound twisted to the average person but I truly do mean beauty in every sense of the term.  Seeing the beauty of the nerves branching off in hundreds of directions to bring pleasure and pain into our lives...how can that not translate into beauty for me?  And yet that means employing barbaric methods that would land me in jail if done outside of this place of learning.  After all, this once was a living and breathing human being replete with hopes, fears, dreams and disappointments.  Doctors, at least the good ones it would seem to me, would almost require a curiosity and fascination about life and death.  I wouldn't be able to do what I did without that appreciation and morbid curiosity. 

And yet life has a way of encouraging your demons and your fears to meet you half way.  Our cadaver?  He died of cancer, colon cancer to be exact.  And one of the key landmark vertebrae that I chiseled through?  Lumbar #5 which is the exact same vertebra that first revealed to us that my brother had cancer.

review - siddhartha

Synopsis - a classic by Herman Hesse, it tells the story of a young Brahmin's journey towards finding nirvana.  He starts off as a young precocious and gifted youth who figures out that none of his elders have reached enlightenment.  So he strikes his own path.  An ascetic beggar who forgoes all pleasure, a rich businessman who enjoys all pleasures, Siddhartha tries it all until he finally finds enlightenment near the end of his life.  While ostensibly a fictional novel, it's really more of a philosophical treatise in story form.

Medical relation - my wife and I (re)read this for a book club.  While discussing the book, many of the participants felt that the character was arrogant, especially when he disobeys his elders and challenges them directly.  I leaned over to my wife and whispered, "but he was right."  And I've seen that with doctors many times from both sides of the coin.  There are simply times when facts need to superscede emotion.  And the ego of both the patient and the doctor need to play second fiddle to getting the correct diagnosis.  The trick is knowing when you're right and when you're not, hence the appearance of arrogance.

Conclusion - I love this book.  I've read it multiple times at different stages of my life and it's never disappointed me.  There are so many life lessons to learn from it that I won't bother to go into them all.  There is one worth mentioning, though.  There's an old chinese saying that goes something like, "if you meet the Buddha along the road, kill him."  A bit harsh to western sensibilities as not many would advocate that about religious figures of the west, but in a nutshell it means that everyone must find their own path, even if at the expense of societal guidelines about what should or should not be done.  What's good for the goose, is NOT necessarily good for the gander, so to speak.  As someone who's never gotten along with convention too well, I relate wholeheartedly to it.  I'm glad, too, my wife finally read it because once she did, she realized that to understand this book was to understand me.  At only 120ish pages, it's a short read but it induces a lot of rumination about life which makes it all the better to discuss with someone else.  I can't recommend this book enough.

weird

We're down in the basement which seems appropriate.  The floor and walls are concrete while the fluorescent lights cast a harsh glow.  Again, apropo.  We raise the body up out of the tank and peel back the towel as the fluid drips back down into the pool of fluid.  A nameless body stares empty up at the ceiling with one eye open and the mouth slightly agape.  The six of us stand there for a minute taking it all in.

"This is weird," one student states.

Seeing the hand saws residing on a cart behind us, the type one can buy at Home Depot, I reply, "it's about to get a whole lot weirder," knowing full well what those saws are for.

1st day

Ever see the movie Groundhog Day?  It's kinda stupid but the main character is forced to live the same day over and over again.  I feel a bit like that today.  See, I've already gone through this first day of medical school.  I've heard these first day lectures, I've felt that 'oh shit' nervousness, been there, done that.  It's a big case of deja vu.  Last year, after that first day I then had a existential crisis of sorts, nearly dropped out, and decided to break the first year up into two years.  It adds a year to my training and more debt but I don't regret it for a second.  As I look back, I become more and more grateful for that option.  It allowed me to work some stuff out, it gave me the luxury of experimenting with different learning methods (a LOT of med school is almost self taught), and it gave me the freedom to spend a lot of time with my family, especially my brother during his diagnosis. 

     I look back at the blog posts during that time and all that I can say is that I'm in a very, very different place.  In short, I was a basket case last year.  I could hardly eat for a week.  Now?  I'm hardly nervous at all and to be honest, I'm almost, just barely, kinda sorta in a strange way starting to look forward to it all.  That's a big change from this time last year when I was ready to chuck it all and run.  While supposedly, the first year was divided in half, it seems like this semester will be a bit fuller.  I have Developmental Anatomy (boring but I've come to terms with having to plug and chug information), Gross Anatomy (the bulk of the semester's work from everyone I've talked to), Intro to Clinical Medicine (this one sounds cool as we begin to learn how to give a physical on paid actors) and Clinical Applications (integrates all the information in the classes in a sort of case study approach so I'll be forced to relearn the stuff from biochem and histology last year).  With the exception of developmental, I'm looking forward to everything else.  In honor of last year's experience, I'm fasting until this evening (a bit like Ramadan type of fasts) so as to give my body a gentle reminder of where I was, where I've gone, and where I'm at now.  It feels good.

an open letter to my canadian relations

My parents and my son are up in Canada celebrating the 60th anniversary of when my dad's family immigrated from the Netherlands to Canada after WWII.  My school starts up on Monday so I wasn't able to go.  As such, I was left in charge of my dad's lawn care business while he was gone.  Translation?  I had the pleasure of mowing 57 yards in 4 days in heat indices hovering around 110 degrees.  Sounds fun, right?  Maybe it was heat induced dementia brought on by severe dehydration, but I had a bit of a vision of what it means to be my father.  So I'm writing an open letter to those participants in the Great White North entitled:

"Papa: The Man, The Myth, The Legend"

To the Canadian Clan,

     Greetings from down yonder in Texas.  There walks among you one who is a bit of a traitor.  He's renounced his Canadian ways and become an American.  Worse, he's a Texan much like that former president who so endeared himself to the rest of the world.  I could say a lot of wonderful platitudes about his Texan ways like how he loves brisket, how he built his house with his own two hands, how he's beyond a devoted husband/father/grandfather, how he chokes up at the song "I'm proud to be an American".  But that wouldn't mean anything to y'all.  You see, I'm down here substituting as El Patron (that's Spanish for 'the boss') keeping his lawn care business running in his absence.  And I am both dumbfounded and humbled by his customers.  Why, you may ask?  Well, let's be honest.  His job is essentially that of a glorified janitor for people's lawns.  I'm not trying to be demeaning but my point is this.  How many in society know the janitor?  How many of you know, I mean really know the janitor at your place of employment?  I'll go one step further.  How many of you know about the janitor's family? 

      Perhaps his customers can say it better than I can.  The 72-year old Hindu who in his soft British accent stated, "Your father is sooooo nice" and then went on to enquire about how my brother's battle with cancer is going.  The 40-something Hispanic woman with whom I traded stories about watching a loved one go through chemotherapy.  The 80-something little old lady who remarked, "I can't tell you how nice it is to have a good honest Christian man."  Or, the retired Aggie (don't ask, you wouldn't understand what an Aggie is) who said "How's your dad doing?  We've talked a lot about your brother and he's on our prayer list when I go to bible study every Saturday."  Or, the bank teller who responded when I cracked a small joke at my father's expense, "I'm not going to let you get away with that.  Ain't right since he's not here to defend himself.  I'm going to defend him.  He's a good guy."

      After walking many miles in my father's shoes, both figuratively and literally, I had an epiphany.  Here is a man that touches and deeply impacts every single person with which he comes into contact.  Despite retiring from the ministry, he's still inspiring compassion in the random people he meets.  How many of us can say that?  So I encourage y'all to get to know that strange American in your midst.  Don't be shy.  As he's both a redneck as well as an educated man, he can converse on nearly any level from mechanics to philosophy.  Ask him a question about air conditioners, or what's Texas like, or plants, or Calvin's theory of double predestination.  Based on the numerous customers of his that I just dealt with, I guarantee you won't be disappointed at getting to know him.

Sincerely,

Isaac

thoughts from behind the mower

My shoes began to break down while mowing yards.  On one, I even attempted to use that magical glue of the universe - duct tape.  But even that eventually gave way and the entire bottom of my right shoe fell off.

"You lost your sole (soul)," my dad quipped, quite amused with his pun.  So the rest of the day I walked uneven.  Every step was off center as I went up, down, up, down, up down.  And what surprised me most was my reaction.  I didn't get angry or frustrated.  First, I laughed.  Then it prompted me to begin to think about the mechanics of walking and why do we even wear shoes in the first place.  A year or two ago, I probably would not have reacted in such an even keeled manner.  It makes me wonder where I'm at in life.  The concept of "being happy" is not one in which I put much stock.  Happy is too fleeting; just one emotion among a broad spectrum of all that is life and nowhere near enough to encompass all that we experience as human beings.  Besides, enough has happened in my life the past year that would induce anything but happiness.  And at the end of the day, I'm just not a happy person.  But I do not necessarily feel the opposite of happy either.  No sense of despair (except before exams).  So how do I describe it?  It's clearly there.  I could see it in the way I reacted to losing my sole.  It's not merely a desire to make the best out of a bad situation.  Again, I'm anything but an optimist.  It's a deepness, a depth, an anchoring of emotions with the Self.  A discovery of soul, to pardon the pun.  For better or worse, that sense of center seems also to be just as fleeting sometimes as happiness.  And I guess that's the trick of life, to figure out how to deepen that sense of center and let go of the rest.  Happiness and sadness, joy and pain, they all come and go.  Holding to that depth, to that Self, to that soul.  Aye, there's the rub.

a break?

"How do you feel about it being the last time at MD Anderson for awhile?  Getting a break?" I enquired of my brother.

"Ask me again in three days when it's done," his reply short and yet loaded with emotion.

Three days of scans, needle sticks, and endless waiting for the doctor passes.

"So how do you feel now?"

"Conflicted."

"How so?"

"I was hoping for more than just modest responses to the tumor.  And the other nodule....."
"You said 'conflicted'.  What would be the flip side of the coin?  The good news."

His pause, pregnant with expectation, was long, "I guess I didn't hear any good news from the doctor."

My mom concurred.  Irony seems to reign supreme as I'm the eternal pessimist and of the three at the table, I'm the only one who felt any measure of good news.

"You realize that only 15 to 20% of people with your disease respond to frontline therapy.  And of those 15-20% a certain amount just have their tumors stay the same size.  EIGHTY-some percent have their tumors continue to grow in the face of the chemotherapy."

"And what happens when I stop the chemotherapy?"

My heart broke at that moment.  I confessed we didn't know.  The concept of a 'break' is illusory at best.  Yes, there is a break from chemotherapy.  But the disease is still there.

medifast - sexercise

As a red blooded male, this is just plain awesome of medifast.  I'd like to meet the individual who decided to include this in their Exercise Log.  They allow you to record all manner of exercises, intensity and duration which then calculates your caloric burn based on your body weight.  To what am I referring specifically, though?  A picture is worth a thousand words....(warning to my parents, this will probably make you uncomfortable...)

It includes not only sex but how involved it was and how long it lasted.  Let's look at the caloric expediture of a 'quickie' from the female perspective, shall we?  It involves minimal effort and only lasts 5 minutes.  Your reward (other than happy husband)???  A whopping 7 calories.  But what if you're involved, too?

Sorry ladies.  It only bumps up to 11 calories.  But what if it's a night, er, nearly an hour of passion?

For 48 minutes of vigorous sexual activity (and I'd love to know how they defined and calculated that), you burn 101 calories.  That doesn't sound like a lot but when you're only eating 800-900 calories daily, that's just north of 10% of your total caloric intake.  That's not trivial which is why they probably decided to include it as an exercise activity.  (Plus, it keeps one's mind off of being hungry.)  Couple that with walking with dog for half an hour and you're up to 20% thereby inducing some serious weight loss.  On their website, they say that over 15,000 physicians recommend their plan.  If they keep promoting activities like this, they may have to make it 15,001.

review - the good earth

In keeping with reading good literature, my wife and I joined a book club and first on the list was The Good Earth by Pearl S. Buck.  It tells the story of a rural farmer in 19th century China as he struggles with bounty and famine, floods and droughts, marriage and parenting.  Life, basically.  It was an interesting book as the characters were all very human complete with their shortcomings and flaws.  But perhaps most interesting to me was the take from the book club.  Most of the members are women and nearly 80% of them completely and utterly bashed the male protagnonist while defending the female protagonist despite them both having flaws and insecurities.  I, on the other hand, saw them both as being unique individuals with neither being the better person.  It made me wonder what being an OB would be like being around that much estrogen.

review - the picture of dorian gray

Synopsis - a young Victorian playboy - handsome, rich, young, and all the embodiement of the excitement of youth - is captured in a portrait by a painter who becomes a close friend.  Adonis-like in form, the Dorian is memorized by his own beauty and one day while looking at the painting realizes that the form in the portrait is the one aging, not him.  It continues to age accumulating all the hideous stains of sin and a misspent, hedonistic life while he remains emaculate in life.  He eventually loses it, murders his painter friend and destroys the painting thereby ending his own life.

Medical relation - this book should be read by cosmetic surgeons.  Way too much of a hang up on beauty as an end in itself and justification for all things.  Half the time I can't tell if the author (Oscar Wilde) is condoning the "beauty as an end" or criticizing it.  In trying to be coy about it, the beauty thing comes across as cheap and tawdry, much like some aging actress who has had wwaaayyyy too much bad cosmetic surgery.

Conclusion - this is the first classic that I haven't liked.  In my estimation, there are three major components to literature - Plot, Character(s), and Writing Style.  The last one is a bit tricky.  For instance, I've read books where the plot was so-so, the characters were decent, but the writing style was phenomenal (Salman Rushdie comes to mind).  I'll read over a sentence or paragraph and based on the word choice and flow it's a sensual experience in and of itself much like eating a deeply satisfying meal.  It's great if the meal is accompanied by good friends and family or if it makes sense (hamburgers and french fries go along, not hamburgers and stir fry which would be analogous to the plot).  But if the food is spectacular, that's enough to justify a meal even if you're surrounded by jerks.  Well, Oscar Wilde's writing style is just not for me.  Way too many homoerotic overtones for me.  And it's not just that, they were way too ridiculous and over the top.  At times, it seemed cheesier than those horrible books where Fabio graces the cover artwork or some teeny bopper Hannah Montana song.  I wouldn't want to read those absurd, completely unrealistic and untrue to life lines in any relationship - homo or hetero.  It had a very interesting concept and just took it nowhere.  To have that in what is supposedly literature just seems infantile to me, and incidently the mark of intellectualism.  I wish I could have read this book in a college or high school class so I could have ripped it apart in a paper.  I disliked it that much.

thoughts from behind the mower

     I'm out in the elements where the heat indices approach 110 degrees working all day.  I've started working out at the gym with my son.  And I actually gained weight.  In my twenties, I never had any trouble with weight.  I subscribed to the simple notion that weight was all about the simple equation:

calories in = calories out

     To lose weight, just eat less and exercise more.  I'm realizing first hand that's a simplistic biological notion.  Your body is not a like your checking account.  It's as if your checking account could grow or shrink irrespective of how much you make or spend.  So I've realized that when I started working out, my appetite increased voraciously to compensate.  And I didn't necessarily eat bad things either.  Likewise, I've read of multiple studies where starving oneself leads to a slowing of metabolism which is why diets are yo-yo in nature.  It's not only the weight loss that's difficult.  It's the maintenance that's equally hard but just as important.  And I'm not sure the medical community has come up with a satisfactory strategy for that yet.

medifast

     My wife is attempting to lose weight and based on my research of the literature, she elected to go with Medifast.  And after a few days of her experience with it, I have to say that from a physician's perspective, I'm impressed this company so far.  First, a bit of background on the approach.  Medifast is not the approach to lose 5 pounds.  As its name implies, it's pretty much a medical fast.  It's severe.  But the approach seems physiologically sound so far.  The premise is to get the individual to eat about 900 calories.  Like I said, it's severe. 

     The method is to eat 5 of their prepackaged, better living through chemistry, instant 'meals' every 2 to 3 hours.  They consist of shakes, oatmeal, pudding, soups, eggs, etc. so there's quite a lot of variety and the one's we've tried so far actually tasted better than I expected.  You're then to eat one real meal that consists of 7 oz of fish like tuna, or 6 oz of meat like skinless chicken breast, or 5 oz of lean cuts of beef.  Somwhere along the line (3 servings at your real meal or spread out throughout the day) you consume 3 servings of low carb veggies like green beans, asparagus, bell pepper, etc.  Add'em up and you get around 800-1,000 calories daily.

     To keep you honest and on track, you can go into one of their centers and get weekly one on one counseling.  The center we visited boasted of a 93% compliance rate.  That was phenomenal to me.  And then the sticker shock hit and I could see why their compliance was so high.  If you're going to dump that kind of money on something, it's going to weed out the nonserious types.  We had to move to plan B which was to simply purchase the meals online.  But along with that you get access to their online program which helps you track your progress.  You first log your weight and measurements.  You then daily log each of your individual meals and exercise.  The great thing about the software is that it automatically calculates the calories for you.  I expected it to do it for their products but it does it for restaurants, too.  My wife was at a workshop and so had Chick-fil-A.  Type in '8 piece nuggets' and bang, it pulls it up for you with all the nutritional information (calories, fat, protein, carbs, sodium, etc) all listed for you.  On the side is a running total for your daily calorie input, your calories burned through exercise, and your deficit.  It's quite reinforcing to see that negative number jump out at you.  It then gives you weekly status reports based on the information you provide to tell you how you're doing with your goal.  If you're not on track, it's easy to track down whether you're eating too many calories or not meeting your exercise goals.  It's impressive.

     Overall, I'm impressed with this program.  I've had to alter slightly the dinners that I make.  I can't slap tuna salad on a pita and melt pepperjack over it and expect that to work for her anymore.  All that we had to buy was a $7 food scale and their meals online which aren't considerably different than a grocery+eating out bill.  It's damned cheap when one considers future doctor's visits, medications, and just overall psychological and physiological health.  As a husband, I'm trying to be very supportive (a definite requirement for the program if you're not getting the counseling at the center) but it's been pretty easy because as a physician and scientist, I'm inherently intrigued by this program's approach so it's become (to me) an interesting real life case study of how weight loss works for one individual.  So I've convinced my wife to let me blog about the pros and cons of it which wasn't easy for her since she's a pretty private person (or should that be a private pretty person?).  It's an opportunity for me to learn and I thank her for that.