parts of the whole

Residing within your brain, thousands of nerves make thousands of connections creating thousands of possibilities. Parts of the whole. And out of that milieu, a multitude of personas, quirks, egos, animus and anima, self identities vie for control. At times, some are at odds with each other. Others dominate while some hide like wallflowers. And so next week, I journey up to Dallas to be with my brother when he meets with his oncologist to go over the results of the biopsy and full body CT scan. Which part will show up? I am his brother, to be sure. But I'm also a doctor-in-training. When hearing and interpreting these types of data both the emotional and rational responses will vie for control. Reason and emotion. Water and oil. And I guess that's part of becoming a doctor. Putting aside your emotions for a moment in order to think clearly and focus on solving the medical problem at hand. But to do that without losing your humanity, to be strong for the other person, to be the proverbial shoulder to cry upon while still helping to determine the best common sense course of treatment, to keep sight of the whole without losing the parts, to listen to all the parts, both the dominant willpower and the subtle intuition....aye, there's the rub.

in an instant, life changes

No hero in your tragedy No daring in your escape No salutes for your surrender Nothing noble in your fate The words drift over me and a sudden rush of emotion hits. I slam my fist down onto the counter top. The physical pain brings the emotional pain. The tears well up. I can only speak for myself, but I suspect there's a point in every doctor's training where one realizes that these are no longer abstract facts one is cramming. There are real lives involved. The stakes have been raised. I just got off the phone with my brother and his wife. What initially was supposed to be an MRI to diagnose a potentially herniated disk, turned out to be a life altering day for all involved. An abnormality was found in the 5th lumbar consistent with a neoplasm. Not what one wants to hear from a back doctor.

four legs good, two legs bad

This image just cracked me up during the lecture. The title, a quote from Animal Farm can help to enlighten it's purpose. But there's quite a salient point to it. On the left is a map of the skin reflecting which nerve is responsible for sensations from that portion of the skin. For example, the thigh is L2 which means the nerve enters the spinal column at the second lumbar vertebra. If you stop and think about it, it becomes a bit puzzling as to why the arms and legs are mixed with different nerves. Why? That's where the goofy picture on the right comes in. When viewed through the lens of a quadraped, the nerves entering the spine in order make perfect sense. It's only odd if viewed through a strictly bipedal fashion. One of the many ways in which the theory of evolution helps to explain biology.

Occam's Razor

I've been accused of being an arrogant know-it-all so I try my best to keep it in check. No one likes an A-hole, myself included. But when I'm right, and I know it, I struggle to keep it check. And one of the concepts I've wrestled with is, if med students are so smart, why are there so many stupid doctors out there??? I thought my experience was an anomaly, but in talking to others, it doesn't seem to be. But here's a brief history of where I'm coming from. Family member, hereby known as Patient, had an episode of unexplained syncope. While driving. And didn't tell me until well after a family reunion because Patient knew I'd give them the riot act. Fortunately, no one was hurt during the episode. Confounding factor, Patient had some sort of unidentified nasty infection beforehand and had been on Levaquin, which in rare cases may induce Torsades. No doctor visit (patients can be somewhat stupid, too, I think it's the human condition) except to Family Care Doc #1 who thinks it's Prostatitis based on age and some now resolved infection. Ooookkkkaaayyyy, not sure how that explains syncope. Next Family Doc #2 says "you must've been dehydrated, that's it." Ooookkkkaaayyyyy. Finally, I convince Patient to go to a specialist, whom we shall dub Cardiologist #1. He's internal medicine and not a surgeon so ostensibly, Cardiologist #1 should have some diagnostic skills. He recommends that with the new ablation therapies, they can cure, yes cure arrhythmias right up. Warning bells begin to go off. In my job, we avoided the field of arrhythmia because we deemed it too friggin' difficult for drug development. So surely, it must be easy to clear right up. So off we go to Cardiologist #2, an Electrophysiologist. His Fellow, Cardiologist #2.5 (Fellows don't really count as real docs, do they?) takes the case history and relays it to Cardiologist #2. His first recommendation, let's run some tests. So after the whole battery (echo, nuclear stress test, EKG), only two things come up - enlarged atria and mild atrial fibrillation (hereby dubbed A-fib). Cardiologist #2 says, let's throw Patient on the table and see what makes his heart tick. Seems a bit rash to me, but then a surgeon's first recommendation usually is the knife. Patient opts for a more conservative approach. Cardiologist #2 then prescribes a beta blocker which IS the standard front line therapy for arrhythmias, including A-fib. But, um, did you happen to look at Patient's chart? Patient's pulse is in the 60s and bp is 120-125 over 60-65. I told Patient, do NOT take that medicine unless you'd like to fall back down after climbing a flight of stairs. Good grief. I do a bit of homework on nodal ablation and the long term outcome trials are in process. No one knows how this procedure works long term but Cardiologist #2 and #3 were both telling me it's great. Did I mention that we're in the largest medical center in the world and home to some of the greats in heart disease? I tell Patient to ignore witch doctor, I mean Cardiologist #2. We go to another electrophysiologist, Cardiologist #3 and his Fellow, Cardiologist #3.5. More tests, lots of EKG testing over 24 hours and an event monitor for a month. Nothing more enlightening. He does honestly reply that the long term outcomes for nodal ablation aren't know so at least he's honest with me. He also states that nodal ablation doesn't work very well in patients with atrial enlargement so just go ahead and scratch that pipe dream. So he finally prescribes a Tilt Table Test. Real simple assessment of the baroflex response. Patient FAILS horribly. Cardiologist #4 performing the test prescribes an alpha agonist. Is that a good idea for someone with atrial enlargement and A-fib? Cardiologist #3 basically leaves it at, learn to live with it. Fast forward to my second semester of my first year of med school. I'm reviewing the cranial nerves (really fun mnemonics to learn them! just google 'dirty mnemonic cranial nerve') and for each one (there are 12) I need to associate the clinical deficit if that nerve runs into problems. I get to good ol' Cranial Nerve X (I knew the roman numerals I learned in grade school would come in handy at some point in my life) - the Vagus Nerve. It does all manner of different things but one of the biggies when it comes to problems is the vasovagal response, basically a failed Tilt Table Test. You've gotta be kidding me. Quick search on google confirmed by some legitimate medical journals. Vasovagal Syncope is THE most COMMON form of loss of consciousness. Started reading the Prodrome description and it read a LOT like Patient's initial description right before Patient lost consciousness. Read a bit further and in Circulation was a trial that showed that crossing one's legs and squeezing prevented syncope over 95% of the time. Long term outcomes on drugs were equivocal with no demonstrable benefit. So why were some pushing drugs? So there's even a simple way to manage this condition? Good grief, you're telling me that 2 family practitioners, 4 cardiologists and 2 fellows couldn't think that maybe, just maybe, THE most COMMON form of loss of consciousness might be a good place to start to explain loss of consciousness? Occam must be looking for his razor at the prospect that this is where Western enlightenment has descended to. Like I said, I thought, nay hoped, that this was an anomaly, but I've heard too many other people relate similar stories. I'm getting all worked up again at the remembrance of missed diagnoses past. And depending on whom you believe, medical errors may account for a LOT of preventable deaths in our country (A lot of deaths or overestimation). Wherever the number may fall, given my experience, I'd wager that it's higher than we should be comfortable with. Don't get me wrong. There are some very good doctors out there. I know firsthand. My son's birth was a difficult one and I am thankful to this day that the OB we had knew her stuff backwards and forwards and backwards again. But this is still disturbing. So during my training, I'm keeping my ears and eyes open for why our country might be training some obviously very intelligent students to be dangerously incompetent. Any thoughts?

diversify

The professor walks in and starts a discussion about dreams, specifically nightmares where some thing is chasing you - a monster, a demon, an unknown - and you feel terrified. Everyone's had them. For me, there's always the feeling that my legs are frozen and just won't move right. The prof (and this is from my undergrad, not med school) throws out the question "what do you do?" "Wake up" "Turn on the lights" "Run faster" The class shouts out the answers (there are some great advantages to a small liberal arts school) but the prof keeps shaking his head 'no'. The class quiets as it gives up and he gives his answer, "you turn around and ask it what it wants." Indeed. Probably some of the best psychological advice I've ever heard and I learned it in a literature class about fairy tales and fantasy. Go figure. So I've been in a funk lately that started right before exams but then promptly got shoved right back down again to prepare for exams. Tick, tick, tick, tick. Thing is, the monster keeps after ya....or the bomb goes off. So afterwards, I decided to turn around and ask it what it wants. The problem is listening to the answer. It's not like going up to someone and asking if they're hungry. I'm essentially asking one part of the cacophony of inner voices what's bothering it. And that part may have wants that are at odds with other parts of me. And none of them will shut up until they've all been listened to. I think I heard it but one can never be quite sure until the funk dissipates. In studying from home, I first found it great not having to drive downtown anymore. But staying at home, I started to get distracted from studying. But that's not what the funk wanted. I was getting distracted from my diversionary time. Instead of studying hard for an extended period and then being free the rest of an afternoon to read or go kayaking or putter in my garden, I'd slowly get around to eating breakfast, dink around the web and before I knew it, I'd wasted half the morning. I'd then have to make it up by studying and by the end of the day, I didn't get enough studying done or enough hobby time either. The funk was pissed about missing out on the fun time. So this week, I've been better at getting down to business....and fun. I decided to start blogging again about my garden to force myself to be creative in other ways. Now I just need the weather to let up or I'll be kayaking in the cold rain.

cancer and low carb

Slowly, but surely, I'm plodding away through "Good Calories, Bad Calories" by Gary Taubes, and I gotta say, it's intriguing. It's a long book and he documents it well, but one summary that he puts forth is that no sugar/carbs, no cancer. That's quite a bold statement given the current dogma about fat being the end all and be of all of evil foods. But Albert Einstein College of Medicine is initiating a trial to test that premise. The RECHARGE Trial (REduced CarboHydrates Against Resistant Growth Tumors) is aiming to look at a ketogenic diet and the effects on cancer that they suspect are dependent on high blood sugar levels like metastatic breast cancer. I'm no oncologist and cancer research is out of my realm of experience (mine was more cardio/metabolic), but I gotta say that expecting any effects after just 28 days seems alwfully optimistic in my view. But it'll be interesting to see what they find. A cursory glance at pubmed reveals that the premise is not without merit. It's certainly stimulated me to reassess my brief flirtation with diet induced stupidity, I mean ketosis.

dogma

My son attends a private parochial school so they unsurprisingly have quite a hostile view towards the theory of evolution, even to the point of bringing in a scientist to debunk it. As a scientist, I was trying to explain to him the concept of dogma. It's kinda hard to do to a budding teenager. Even harder is the concept of empiricism. As a scientist, I go where the data leads me. I have no emotional interested vested in any theory. Case in point. While not an environmentalist (too much political baggage), I do consider myself a conservationist. My garden is composed of largely native/hardy/wildlife friendly plants. But as a scientist, I'm also not dogmatic. A pragmatist if you will. Having trouble getting motivated and needing a break, I decided to solve an environmental problem. We have ants that started coming into the kitchen which is up against an outside wall. And not just any ants. They're those studid crazy raspberry ants. What makes these things so bad is they can go for electrical equipment and they were coming in the house through an outlet. I tried every ant killer that Lowe's had to no avail. So when faced with a problem, I wasn't dogmatic. I chose an option, that many would probably consider a bit stupid, redneckish if you will. But I bet it'll solve the problem. While they're resistant to all the pesticides, I'm not aware of too many members of Kingdom Animalia that are resistant to extreme heat. And in the end, which is safer - a neurotoxin applied liberally or a small controlled burn? This behavior may be a bit disturbing in someone aspiring to be a doctor, but I look at it more as someone who is not slave to certain idea or concept and go with what works practically. And sometimes, that is the redneck way....

irony

I love irony because it can drive a point home like few other things can. A sledgehammer, a wrecking ball, a canon can all work but irony seems so much more refined. Like when the president holds the Mayo Clinic up as a shining example of a model clinic. So what does the Mayo Clinic do? Some of them have stopped accepting medicare patients because they're losing too much money on them. So wait. Explain to me how we're supposed to save money by using a clinic as a model that no longer can afford to treat medicare patients? The first step to solving a problem is properly identifying what the problems actually are. It seems that the politicians involved don't even know what the underlying issues really are.

bioluminescence

But he's still heading down those tracks

Any day now for sure

Another day as drab as today

Is more than a man can endure

The shovel slices into the dirt, falling into the rhythm of the music while clearing my head. At the lyrics above, I pause to let my mind wander. A year ago, these words would have resonated and stung. But what about when you've headed down those tracks and you're following your dream? What then becomes the non-reality? The fantastic yearnings? A strange proposition. I've heard it said that following your dream is dangerous in that it then becomes common and vulgar thereby ruining the magic. That hasn't happened to me but I felt that longing for so long it's a bit odd to not feel in limbo anymore. It is dark now but I still need, well want, to finish the task at hand. Plus, I'm not sure how I feel about having versus pursuing a dream and need some kinetic motion.

Wait, what was that? Down in the dark hole that I've dug is a small glowing dot. This is suburban Houston. I haven't seen any fireflies in a LONG time and I've never seen any glow worms here. It fades and I think my eyes have tricked me with a play of light. I continue digging and lo and behold, there it is again except now there are two of them. I run inside, grab a flashlight and holler at my son to follow me outside. He's not keen to be parted from The Simpsons but a lover of the outdoors, he comes reluctantly. Anxious to get back inside, he impatiently asks what is he supposed to be looking for. I dig some more and sure enough, a gasp from his mouth errupts as he spots it. Good. I'm not imagining it and losing my mind. He flashes the flashlight but only sees an earthworm. Huh. He's had enough and runs back in. I continue to enlarge the hole while my ipod continues to churn away. As life often works it, another string of lyrics gently reminds me of my way...

More than just blind ambition

More than just simple greed

More than just a finish line

Must feed this burning need

In the long run...

From first to last

The peak is never passed

Something always fires the light that gets in your eyes

In this case, the light that fired in my eyes happended to be the bioluminescence from the gardner's best friend - the earthworm.

medical reform

Interesting assessment from the Dean of the Harvard Medical School about the medical reform bills floating around out there. This part sums it up for me. "The rhetoric on both sides is exaggerated and often deceptive. Those of us for whom the central issue is health—not politics—have been left in the lurch. And as controversy heads toward a conclusion in Washington, it appears that the people who favor the legislation are engaged in collective denial."