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.