Not Rocket Science

It's been a while

2009-07-06T20:16:00.001-07:00

...and, I'm back.

I recently turned a corner in residency, being now a fifth-year "lab resident." That means that I'll have rare periods of clinical responsibilities, but otherwise will spend my time working on a variety of research projects, most of which will concern the care of spinal disease. I'll also resume 'normal' work hours for the most part, so I can say goodbye, hopefully, to the dark circles under my eyes and the twenty or so pounds of excess flesh I've lugged around with me for the past several years. Even more importantly, I can spend some time writing. Perhaps I'll even write on this blog.

A few issues these days really have me steamed, and most of them concern health care reform and health care bureaucracy (a word for which I harbor such an intense antipathy that my brain refuses to remember how to spell it, no matter how many times I look it up). Without going into specifics in this instance, I'll just highlight the fundamental problem, as I see it, with the creation and enactment of any truly beneficial reforms to our current system.

That problem, I think, is that people with little to no appreciation for the day-to-day challenges of taking care of patients are the ones making the decisions. We have career economists telling us how the finances of health care are to be managed; we have politicians and journalists (and economists) telling us that inevitable events can never happen, and if they do then it impugns our entire health care system; and we have pundits from both sides struggling to represent their own interests without anyone actually sitting down to, as my high school A.P. history teacher would say, "wrap their minds around the problem." President Obama, to his credit, is making an effort of sorts to listen to physician input. However, the whole of physician input cannot be encapsulated in a single New Yorker article written by an academic surgeon--particularly when that article highlights an instance of physicians providing "too much treatment" without making any sort of common-sense attempt to understand the generative forces that created that situation. (Though I'm tempted to go in for a David Foster Wallace-style endless footnote here, I'll just state parenthetically that perhaps the reason some physicians are becoming more entrepreneurial, inserting themselves into multiple revenue streams aside from simply seeing patients, is that physician reimbursements have been flat or declining for the past twenty years; and that when you have a segment of the most highly intelligent, educated, ambitious, and capable people in the population who feel they are not being reimbursed at a scale commensurate with their efforts and sacrifices, we shouldn't be surprised to find them getting their cookies from some other jar). Yet hear we are, facing perhaps the biggest legislative decision our country has faced in over fifty years, and we're doing it with a bunch of blind men as our guides.

My proposal would be as follows: create a think-tank of health care practitioners representing multiple sectors of the health care 'machine,' and charge them with the task of coming up with a solution to the health care crisis. Cloister them in a cabin in Montana, with a small library of books on health care policy, Medicare regulations, economics, political science, and history, along with detailed descriptions of how health care is provided in the twenty or so countries who seem to have found the greatest success with universal health care. DO NOT include in this think tank any career economists or politicians; instead, provide contact information for such people who can serve as consultants, should any questions arise that need immediate answers not available in the reference library. Finally, give this think-tank a deadline, say one month or so, to come up with a concise framework for health care provision in this country.

Why would this idea work? Well, because you'd have people who know what it's like to take care of patients coming up with solutions that respect patient care FIRST, and all other considerations secondarily. You'd also be entrusting the decision to people who have some skin in the game and who have to live with the end results, rather than to somebody who's going to sit back and criticize and condemn no matter the outcome.

So, anyways, that's my suggestion. We'll see if it garners the same reception around the White House as Atul Gawande's article did.

A long letter to the NY Times

2008-10-25T13:12:00.000-07:00

I wrote a long reply to an opinion piece in the New York Times today, only to find that they had ceased accepting any further reader comments. In an attempt to have someone else in the world read this thing beside myself, I’ll post it here. The opinion piece in question can be found here.

* *

As a neurosurgical resident—someone immersed (and sometimes nearly drowning) in our health care system—I take issue with the contention that American health care is the “worst” or provides too little for too much expense. Sure, our system has pitiable faults: we insure far too few, our preventative care lags behind that of other countries, and we devote an onerous proportion of our nation’s GDP to medical care, among other problems. However, this country is the best place in the world to be if you’re sick—and by this I mean really, imminently-likely-to-die sick. We Americans believe in and practice the hail-mary pass, the last-ditch effort that fails most of the time, but every so often pulls off a miraculous victory. That’s a beautiful, unique thing, which you won’t find in the U.K. or Canada. It’s also quite expensive.

In addressing this issue of expense and quality, the authors propose that we somehow fix the health care situation by making health care more like pro sports. If that means I get paid like a pro baseball player, then hey, I’m all for it. Otherwise, I think we need to examine their flimsy analogy a little more closely.

The authors suggest that our medical care is hampered by our lack of data-driven methods. Well, when we examine the American health care system with respect to other countries, we’re actually doing fairly well. The U.S. is a world leader in advancing the cause of evidence-based medicine, and the effects of this trend have reached into every corner of the profession. Thanks to the prolific output of clinical trials, even a lowly medical student can contradict a medical professor if her point is backed with published evidence; this wouldn’t have happened twenty years ago. And I think we’re seeing the positives day-to-day, with more standardization of care and less therapy by doctor fiat. However, what we don’t see as evidence-based medicine becomes more widespread is a decrement in the cost of care.

The problem here is that, with respect to the cost issue, the authors demonstrate their own adherence to a hidebound rhetorical tradition: the logical fallacy of begging the question. They assume as a premise of their argument that evidence-based treatments will be less expensive than those based upon “informed opinion, personal observation, or tradition.” In reality, clinical studies are almost universally designed to demonstrate which therapy is more efficacious, not more economical. In all likelihood, further evidence-based trials will push us toward newer therapies that utilize more health care dollars, as these newer therapies are those that have proliferated in the “profligate” current age of medicine, rather than in earlier, more parsimonious times.

As for the question of quality, evidence-based medicine no doubt has its benefits, but it’s not the panacea the authors would suggest. Certain areas of medicine do not so easily lend themselves to clinical trials. In particular, surgical therapies hinge upon experience and tradition; one would be hard-pressed to create a study evaluating a new, alternative treatment of uncertain efficacy, as neither patients nor hospital research approval boards would be eager to turn away from an established, manifestly effective surgical technique. Suppose your loved one suffered a serious surgical illness; would you want her to receive the tried-and-true, “traditional” treatment strategy, or to be randomized into a study involving an experimental arm with an untested and quite possibly inferior therapy?

We also need to think about the issue of whether we really even want what evidence-based medicine can provide, especially with regard to that spectrum of care that approaches, at its extreme, futility. What if the evidence proves that, in a certain situation, it’s not wise, as illustrated by the data, to try to save your life or that of a loved one? Because, you see, in the author’s baseball analogy, that aging star player whose contract the data-driven team won’t renew corresponds to the aging, debilitated, or otherwise acutely ill person arriving in the emergency department. Should we care for him? Or would it be more cost effective just to let him die, to divert those hundreds of thousands of dollars to some other form of data-driven care rather than spending it on a “hidebound,” heroic effort that could very well save a life, albeit at tremendous expense? This may sound farfetched, but it’s exactly the sort of decision upon which cost-effective care in many industrialized countries is based.

The essence of prudence is sacrifice. I, for one, do not believe that we as a nation are willing to give up our heroic care.

In any case, I applaud the authors for wanting to improve our health care system. What they need to realize, though, is that the problem facing us is complex, and that evidence-based medicine is an important but fractional component of the approach we will have to employ to improve our health care system. To get there, though, we’ll need more than glib analogies and empty rhetoric.

By the way…as for the author’s proposed institute for evidence-based medicine—sounds great! Sign me up. Who, by the way, is writing the check?

Marathons and motivation

2008-08-24T14:02:00.000-07:00

I've managed to squeeze a few hours of Olympics into my schedule in the past week, including much of the live broadcast of the marathon. Much hype surrounded this event in the American press, as one of our athletes--Ryan Hall--was considered a relative favorite to attain a medal. The New Yorker even ran a story about him, suggesting that he represented the changing of the guard in American distance running, with our country finally bringing to the Games a team capable of threatening the African nations for distance running dominance. [As a side note, not much recognition in that article was afforded to Meb Keflezighi, the American who brought home silver from the last Olympics; perhaps we Americans hesitated to claim an athlete with a decidedly African name?]

As I watched the marathon unfold, though, it became rapidly evident that the Kenyans and the Ethiopians would duke it out for the medals, while the American hopefuls would likely fade into double-digit placing (except for Dathan Ritzenhein, who graduated from my alma mater, finishing ninth). While I listened to the relatively strong commentary on the race, I pondered why it was that Americans continue to lag behind their African counterparts, when it seems increasingly that their training regimens and various other modifiable factors are indistinguishable from the Kenyans. Then, all of a sudden, one of the announcers provided me with an epiphany.

He described how Kenya has in recent months suffered tremendous civil strife following a controversial presidential election, resulting in what is essentially a civil war between the country's two major tribes. The Kenyan distance runners, then, came to these games with a great weight on their shoulders: because their country holds distance runners in such esteem, the team hoped that by bringing home a gold in the marathon--a feat which, bizarrely, the Kenyans have never been able to achieve despite their tremendous running prowess--they could help to alleviate the conflict in their nation and unite the two warring tribes. Think about that for a minute.

So, on the one hand, you have the US distance runners, who run to pick up a bigger running shoe contract; to have themselves featured in a New York Times article, perhaps; to garner the respect of some small fraction of the general public who gives a shit; to achieve a modicum of local fame, and in the process maybe have fewer beer bottles thrown out the windows of trucks at them during their training runs; heck, maybe even to have the other runners give them a second look when they take the starting line at international competitions. Then, on the other hand, you have the Kenyans, who just run to end civil war and save the lives of thousands or even millions of their countrymen.

Suddenly, this country's inferiority on the international distance running scene makes perhaps a bit more sense. Congratulations to Sammy Wanjiru for bringing the first Olympic marathon gold to Kenya--may it provide the profound national impact you and your teammates have dreamed of.

Outside Hospital

2008-06-08T10:59:00.001-07:00

One of my co-residents told me about this video, and of course I'm probably seeing it about six months, at least, after the peak of its popularity. But for anyone with any experience working at an academic medical center, this portrayal certainly rings true. Even more interesting on a personal note, the guy playing the CEO of "Outside Hospital" was a friend of mine in medical school: he was the 4th year class president when I was the 1st year class president. He's apparently now an internal medicine attending at U Penn.

A good way to end the week

2008-04-18T10:02:00.001-07:00

I'm officially finished with night float. No more nocturnal rotations, ever. My diurnal rhythms will henceforth be afforded the respect they deserve.

As an added bonus, in the past couple of days I've received acceptances from a couple of literary journals: an online flash fiction journal called HeavyGlow, and a print journal called Bellevue Literary Review. I've been trying for a couple of years now to break into BLR, so that's a great feeling. Two acceptances in one week, after nearly a year-long drought! Crazy.

Now, I sleep.

The thrill of victory and the agony of defeat

2008-04-12T07:46:00.001-07:00

Sometimes in neurosurgery the greatest technical triumphs coincide with the greatest patient care defeats. That is, often those tasks that require the most manual dexterity or technical proficiency only present themselves because your patient is in a dire situation. I can provide an example from a recent call night. We had a patient come in with a severe subarachnoid hemorrhage. Here's a CT scan:

That whitish stuff towards the center of the picture (worse on the right, which, in the backwards world of radiological imaging, refers to the patient's left) is hemorrhage that's not supposed to be there. The astute interpreter of head CT scans will also note significant cerebral edema, with effacement of the basal cisterns. That is to say that the cisternal spaces around the brainstem, in which cerebrospinal fluid normally circulates freely in a healthy brain, have been compacted by the pressure in the cranium. Not surprisingly, this patient was what we would term moribund; on the five point grading scale of severity of subarachnoid hemorrhage, he was a five. When he arrived in the emergency department he showed practically no sign of neurological function.

However, this patient happened to be quite young--so young, in fact, that we wanted to give him every possible chance at recovery. In this case that included administering a medication, Mannitol, to reduce the intracranial pressure (ICP), as well as hyperventilating him (which also reduces ICP). The next option to entertain for treating high ICP is to drain off some cerebrospinal fluid from the ventricles of the brain. Here's another scan:

This is an image of the patient's brain at the level of the foramen of Monroe. Those two little darker slits towards the center/front of the scan are the lateral ventricles where they come together and drain into the third ventricle through the foramen of Monroe. When we place a ventriculostomy catheter, which is a rubber drain that we slide into the brain for the purposes of draining off spinal fluid, we try to put our catheter in one of the lateral ventricles with the tip right at the forament of Monroe. Normally we do this in patients with hydrocephalus, who have scans that look more like this, with very large ventricles...

...which clearly provide a much easier target than I could shoot for with my patient. Under normal circumstances if we have to put a ventricular catheter in someone with ventricles that small, we use special computer-assisted image guidance to ensure that we can place the catheter appropriately.

My point here is that a ventriculostomy in this particular patient was to be no small task. In fact, it would be the sort of thing that a neurosurgery junior resident could brag about.

So here I am, it's 2:00 am, and I'm dealing with this extraordinarily sick patient who needs a catheter slid into his infinitesimal ventricles. So I run up to the neuro ICU, gather my supplies, and set up for a ventriculostomy. I talk to the family, and explain to their stunned and barely comprehending faces that their loved one is in exceptionally critical condition, and that this procedure, though unlikely to help, is the only thing we can offer that might make any difference to his neurologic outcome (this sort of glum prognostication is par for the course in neurosurgery).

After the family agrees to proceed, I hurry back into the patient's room, which has now collected a handful of interested onlookers. Usually we perform these procedures in our neuro ICU, where the placement of a ventriculostomy hardly garners a shrug, but in the ED its novelty usually attracts an audience of several techs, nurses, and residents.

I act fast, because I know that every second matters for this patient's already poor prognosis. I shave the scalp, mark out my landmarks on the skull, and tape the head to the bed to keep it still. Then I prep the skin and ready my supplies. After placing sterile drapes over the area, my first move is to confirm my landmarks (this is of utmost importance when the ventricles are small), and then slice a 2 cm opening in the scalp. The most nauseating move--for the onlookers, that is, the uninitiated--comes next, which is using a hand-held drill to (quite indelicately) drill a hold through the skull. After puncturing through the inner margin of skull you need to clean up all the errant bone chips, at which time the only thing separating you from the brain is a thick lining of connective tissue called the dura mater. This I puncture open, and now all that's left before I can relax is the passage of my rubber catheter into the slit-like ventricles six centimeters deep.

Any time I advance a catheter into the brain and pull out the stylet, I expect to hit paydirt with the first shot. I have to have that expectation--after all, this is somebody's brain. But sometimes you pull out the stylet and nothing comes out, and you drop the catheter down below the level of the ear to help the fluid flow out and still nothing comes, and you feel this sense of visceral free-fall as if you've just crested the top of a roller coaster and your gut knows you're sinking before your brain does. I hate that feeling. It's guilt and fear and shame and regret all rolled into one. So then you have the pull the catheter back out and reassess everything--your landmarks on the skull, your angle of approach, the size and position of the patient's ventricles--everything. Because you have to get it right the next time.

In this case, it took me a couple of passes to find this patient's very small ventricles. But I found them. Spinal fluid shot out of the catheter tip, with an opening pressure of 45 cm of water (measured according to the height of a fluid column). That's three times the upper limit of normal, and this despite the mannitol and the hyperventilation. That is, as we say in the business, bad.

But I nailed it. Not with the first pass, but I managed to pass a rubber catheter blindly into someone's head and hit a target about the size of a poker chip turned on its side. I should have felt proud. I should have bragged about how I managed to place an impossible ventriculostomy under less-than-perfect circumstances in the middle of the night. I should have printed out the patient's next head CT scan and run proudly around the department with it.

Except the patient didn't survive to have a second head CT scan. The ventriculostomy didn't help. So instead of a victory celebration, I had to explain to the family that their loved one continued, despite our best efforts, to have no sign of neurologic function.

Technical victory. But defeat in every way that matters.

Let the light shine in

2008-04-12T07:39:00.000-07:00

Conversation just had:

Wife: "What are you doing?"

Me: "Writing a blog post."

Wife. "Oh. I think I need to open a window in here or something. Something to remind us that we're part of the world."

Me: "What makes you think we're part of the world?"

BACKFIRE

2008-04-11T01:55:00.000-07:00

3:55 am. Getting killed. Just grabbed a razor and some cream from supply room and shaved the beard. Back to work.

Call nights and superstition

2008-04-10T07:17:00.000-07:00

I'm on night float again, meaning I show up in the evening and man the call pager until the troops arrive again the following morning. A night on night float can range from eerily quiet--prompting such incredulous behavior as paging oneself to ensure that the call pager still works--to frantic, with no end to the work and seemingly every patient trying to die off on your watch. One would think that there would be such a thing as an average night, and that we woudl have roughly a normal distribution of nights ranging from quiet to scarily busy. However, it seems more as though, rather than normal, the true distribution is bimodal. You either get killed or you float by. Of course that's an oversimplification, but the fact of the matter is that you never know what a call night has in store for you, and whether you'll walk out the next morning smiling at the brilliant sunshine or just hoping it will illuminate the path to the nearest trashcan in which you can deposit your pager--and your career--post-haste.

In part, I think this unpredictibility contributes to the learned helplessness that comes to characterize the junior resident in neurosurgery, but that's a topic that I'll address some other time.

For now, I just wanted to mention that superstition has a stronghold among neurosurgery residents. And when I use the term, "neurosurgery residents," I mean me. For instance, my face itches. Badly. Why? Because I haven't shaved since last Saturday night. I haven't shaved because I've had good nights all week long--a rarity, and in fact a statistical singularity--and therefore the reptilian part of my brain concludes that the unifying thread for each of these benign nights, my growing facial hair, must be the reason why. So, of course, I can't shave. Far better to scratch my neck, uncomfortably contort my face every couple of minutes so that other residents diagnose me with Tourette syndrome, draw the ire of my chairman (who thinks that every resident should be clean-cut), and suffer the ignominy of walking around with my sorry translucent excuse of a beard. ("Hey Ian, is that dirt on your face?") I only have one more night this week, and my facial hair can get me through.

Of course, I've now just completely jinxed myself. Tonight I'll probably have about twelve consults and three ventriculostomies.

One of my attendings, though, once posited an interesting hypothesis. He said that perhaps the future--in this case, a call night--is comprised of a finite number of realities (future quanta, if you will), and that each of these possible realities already exists in different dimensions of what might ultimately constitute the future. However, the Heisenberg uncertainty principle, or something akin to it, applies to these future quanta just as it does to the momentum of an electron: that is to say that by observing one of these future quanta--by predicting it or calling it to mind--we alter it, and from the standpoint of its potentiality for a future outcome, render it infinitely less likely to occur. For this reason, then, it behooves the neurosurgery resident to enter into each call night predicting every imaginable catastrophe, for in so doing he/she removes each one from the realm of possibility. It's an interesting idea. I'm tempted to try it before tonight's shift, by delineating all of the ways the night could go terribly wrong. Surely then things will all be well.

Hmmm...

Nah. I think I'll just grow the translucent beard for another day.

...

2008-04-08T23:03:00.000-07:00

I think I'd like to revive this blog--a little bit of the old Internet Lazarus effect. Although, really, this blog has perhaps seen more visitors in the last several months than it did in the preceding year or so, simply by virtue of Google searches about Kapali.

Every time I write his name, see a picture of him, or even have a vague passing thought about Kapali, I can hear his laugh--throaty, baritone, and unencumbered, the way you'd think that God would laugh.

I want everyone to know about what happened to him, and how. The facts of his death--the mechanism--befuddle people. Nobody can seem to fathom how a simple punch to the face can kill somebody. Ever since grade school we've been conditioned to believe that a punch results in a bruise, some lost recess time, and in the worst case, for adults, perhaps some legal repercussions that lead to onerous court visits and exhorbitant attorney fees. But very few of us can understand how a punch can claim the life of a healthy man in his mid-twenties.

What if we did understand it? What if every man and woman who came of age in America knew that being punched in the face can cause debilitating neurologic injury? What if, before squaring off to argue with another guy in a bar, a man would think, "Well, I'd better be willing to die if I really want to get into it with him"? How would that degree of knowledge saturation change things?

It's a recognized phenomenon in neurosurgery that head trauma can lead to instant death. Many years ago a neurosurgeon by the name of Genarelli researched head trauma in dogs, and found that a certain percentage of them instantly succumbed upon a cranial insult. The mechanism is presumed to be a sudden autonomic discharge, as if your body heaves all of its adrenaline into the bloodstream at once, and it overcomes the cardiorespiratory system. There's even a term for it: "commotio cerebri," similar to the term commotio cordis that refers to sudden stoppage of the heart from an impact to the chest (a phenomenon that has claimed the lives of many football and baseball players).

Though we know about it in neurosurgery, it doesn't receive much attention. Most of the time the victims plow their cars into walls at high speed and such, so we don't think much of the outcome. However, in a few instances, a simple punch in a simple fist fight is the insult that ends a life. Somehow, in this country, this fact remains a well-kept secret.

In Queensland, Australia, that's not the case. They have a state-sponsored campaign entitled "One Punch Can Kill," because they recognize the risk posed by fighting among the region's youth. So motivated individuals are making an effort to spread the word, to ensure that twenty-somethings don't blithely wander into bars and think that a physical altercation might be, at best, a way to test their manhood, and at worst, a way to get bruised up. In Queensland they want their youths to know that they can die from fighting.

I want the same thing in this country. I want everyone who sets foot on a playground or on a sports field or in a bar to know that they can die if they fight.

In Fight Club-- for some time one of my favorite movies, and indeed a favorite among many a soul-searching young male--Tyler Durden says, "How much can you know about yourself if you've never been in a fight?" I think that question resonates with some young folks in America. But I want them to realize that you might as well ask, "How much can you know about yourself if you've never drunk a liter of antifreeze?" Or, "How much can you know about yourself if you've never fallen off a 7th floor balcony?"

A single punch can kill. Kapali taught us that. If we can spread this knowledge, and if, as a result, just one person who would have died from a punch instead chooses to walk away, Kapali will not have died in vain.

Now I just need to figure out how to educate the entire country.

Petition

2008-03-18T20:02:00.000-07:00

I imagine most people who find their way here these days do so via a Google search for "Kapali Swamy," and hence already know about this petition. Nonetheless, I want to post this link to a petition related to my brother-in-law's death and the subsequent travesty of justice perpetrated by the Cullman, Alabama kangaroo court.

Justice for Kapali Swamy

Kapali Giridhar Swamy

2007-12-24T18:24:00.001-08:00

"One of life's quiet excitements is to stand somewhat apart from yourself and watch yourself softly becoming the author of something beautiful, even if it's only a floating ash." -- Norman Maclean

Kapali's ashes were scattered off the California coast near Catalina Island on Sunday, 12/23. The sun shone for him, and the wind and the waves were calm. As Kapali's remains floated down to the ocean, a seal surfaced ten yards away and barked, splashing and playing like a child with a new best friend.

The day was minted for you, Kapali.

In Loving Memory of Kapali Swamy

2007-12-06T14:53:00.000-08:00

My brother-in-law, Kapali Giridhar Swamy, was killed on the morning of November 18, 2007. He was loved by more people than I've ever even met. The circumstances of his death are tragic, and the local media has since been horrific in its abuse of a good man's memory.

I wish I could say more, but words do not always come. For now, here is a link to his MySpace page:

Kapali Swamy

I love you, brother.

Update for friends and family who have arrived here via Google:

Kapali G. Swamy Scholarship Fund

We are initiating a scholarship fund at Birmingham-Southern College in Kapali's name. The fund will be used to provide a stipend for one winner each year to pursue a complete, independent filmmaking project, which will hopefully serve as a springboard for a career in film. It was something Kapali spoke often of pursuing himself, so in honor of his memory we would like to grant a financial opportunity to creative students at Kapali's alma mater.

Donations can be sent to:

Birmingham-Southern College
Office of institutional Advancement
c/o Keith Thompson, Associate Vice President
Box 549003
900 Arkadelphia Road
Birmingham, AL 35254

Vacation time

2007-09-13T09:31:00.001-07:00

I'm just going to start typing and pretend that it hasn't been months since I last posted anything here.

Right now I'm on my (very belated) honeymoon in the Cayman Islands. My little wife has been sleeping away the morning, and I'm on the computer; the rain, it seems, is not on a hiatus, and so our morning plans of horseback riding on the beach have been postponed until tomorrow. Meanwhile we find ourselves with nothing to do but lounge in our room.

Ah, but I can write.

Or can I?

I have plans--big plans--to write a very long story (read: a novel) that has a neurosurgeon as the main character, though it's not, per se, about neurosurgery. The problem that I encounter, and have encountered on numerous occasions in the past when trying to write about work, is that I really don't want to write about work. It's a shame, because neurosurgery is certainly the most interesting province of experience I have, and my writing on this topic would likely be of much greater interest, on average, than anything I can conjure with my imagination or glean from my otherwise ho-hum life. But, dang it, my work is hard, and it seems that when I finally have some free time and find myself sitting in front of a keyboard with an idea in mind, the last thing I want to do is venture into the realm of brain and spine diseases--especially not when I could write something odd and/or frivolous.

So instead I find myself sitting down at the computer with the idea of writing, but because visiting work even in my imagination feels so genuinely like work--except, without the time pressures of, say, somebody's brainstem herniating out the base of his skull, I wind up just surfing the Internet or looking up random facts on Wikipedia (i.e. Cymothoa exigua is a parasite that subsumes the anatomical function of a fish's tongue). And so hours pass, and little or no writing occurs.

Anyhow, I have been following the story of the Buffalo Bills player, Kevin Everett, who suffered a C3-C4 spinal injury that, as far as I can tell, is rather unclearly characterized in the news media. From what I can tell he suffered a fracture-dislocation at this level, requiring surgical decompression and stabilization. However, as for the status of his spinal cord, I'm thinking that he might have central cord syndrome, as his hands/distal upper extremities seem to be predominantly affected at this point, and he is rapidly regaining function in other parts of his body. If he does have central cord syndrome (which is likely the assumption made by Dr. Barth Green, a neurosurgeon who stated earlier this week that Everett would walk out of the hospital), his prognosis would be highly favorable for him ultimately resuming a normal life. Of course it's always hard to tell; with neurological recovery, as one of my attendings is fond of saying, "You get it if you get it." One can never predict.

In print

2007-06-02T14:42:00.000-07:00

Yesterday I received a copy of the new Ars Medica, the medical humanities journal that was gracious enough to print one of my short stories. It's a nice volume, with one of those "perfect-bound" covers with an attractive collage of historical medically-related artwork. I suppose I should derive some special feeling from holding an actual printed volume in my hands and seeing my work inside it, but really it just feels okay, and strangely not surprising.

I have this weekend off, and I'm devoting it to doing a little writing and transitioning myself back to working during the day and sleeping at night (just finished five weeks of "night float"). Here's an excerpt from the story I'm writing:

Declan patted Shelby’s head gently, feeling the oiliness of the dog’s fur begin to coat his fingers. Just three weeks ago the dog had still looked artful, his sleek muscles rippling with every graceful movement. Declan had acquired him two years ago from a company that rescued greyhounds, saving them from euthanasia once their racing careers had concluded. Shelby had been a champion, having at one time won thirteen straight races; now the genetics that had made him light and lean, a machine designed for singular speed and efficiency, rendered him particularly ill-suited for starvation conditions. What negligible fat had existed on his frame had long since been utilized, and his body had set to work burning its own muscle to maintain basic functions. It was all Shelby could do now to walk several feet away to defecate; he urinated right where he lay, at the foot of the stairs. Every time he petted him, Declan cried.

It's another light-hearted one, as you can tell.

Medical news

2007-04-01T10:16:00.000-07:00

Here is an interesting article from the New York Times, about utilizing circumcision as a means of reducing the spread of HIV in African nations.

Even more interesting than the article, though, is the fact that the head of the WHO department recommending this public health intervention is named Dr. De Cock.

The one good thing about working nights

2007-02-20T07:41:00.000-08:00

I can drink hard liquor at 9:00 in the morning and convince myself that there's nothing wrong with this.

Oops

2007-01-25T16:23:00.000-08:00

Yesterday I forgot the necessary condition before embarking on a long rant about...anything. Namely, make sure somebody is listening.

Oh well.

Bad science, popularized

2007-01-24T07:58:00.000-08:00

I just read about a recent study published in JAMA that details an apparently disturbing trend among high school football players: employing tremendous efforts in both the weightroom and at the training table in order to beef up to the magical 300lb mark, which will make them not only more effective players, but also more coveted objects for college recruiters.

Ambitious kids wanting to get better at something -- that sounds terrible.

Thanks to these kids' efforts to pack on the pounds, the study shows, 45% of them are now meeting "clinical standards" for being overweight, and 9% meet standards for severe adult obesity.

The study has sparked an outcry in the press, with concern over the deleterious health effects to which these high schoolers are exposing themselves in pursuit of their goals. After all -- what happens if they don't make college ball or the pros, and wind up being just behemoths without a cause? Or even if they do find success, think of the terrible health consequences of being so big! Arthritis, heart disease, diabetes, and the list goes on. The horror!

But then again, imagine if the authors of this study had used just one shred of scientific integrity or cogency in propogating this drivel.

The principle metric employed in the study is the Body Mass Index, or BMI. This tool, arrived at mathematically by dividing one's weight in kilograms by one's height in meters squared [kg/(m)^2], was designed to provide a numeric tool for classifying people of average (read: flabby) body composition. The tool was intended to be used for sedentary individuals -- i.e. people with minimal muscle mass. The blatant flaw in this metric is the lack of any accounting for actual body composition, in terms of the balance between fat, muscle, bone, and viscera. Consequently it becomes extremely inaccurate in people with either ectomorphic (slender) or mesomorphic (thick, muscular) frames.

Now given this flaw, you can use your imagination to think of the worst possible applications of this metric. Could we use it on Olympic gymnasts? Hmm...no, they drop off the bottom of the chart, because the metric was never intended to be used on them. But wait! -- on the other extreme, there's no limit to the abuse of statistics when we injudiciously apply the BMI to strength athletes! Sounds like a red letter day for piss-poor clinical research!

For example: take a look at these guys, from the 2002 Mr. Olympia contest. Each one has less than about 5 or 6% bodyfat. They are the very antithesis of obese. And yet, the winner of that contest, Mr. Ronnie Coleman, weighed in at 245 lbs for his 5'11" height -- for a BMI of 34.4. HE'S OBESE! HE'S OBESE! SOMEBODY CALL RICHARD SIMMONS!

So why, pray tell, would a group of seemingly intelligent scientists decide to use the BMI as a tool for assessing a group of high school football linemen -- guys who spend hours in the gym, packing MUSCLE onto their frames? You'd be hard pressed to preselect a group of people for whom your metric would be less appropriate.

Why not study the frequency and volume of their menses?

Why not study their gas mileage?

Why not compare their performance to the S&P 500?

The point I'm making here, in case it isn't painfully obvious, is that using the BMI on these guys is arrantly asinine. This is a catastrophic blunder in judgment, to use a purportedly scientific metric in such an injudicious fashion. And yet this study found publication in a journal of high repute with the public, and sparked a roar of controversy among the thoroughly uneducated press. After all, if a bunch of scientists applied this test and got these results, they must know what they're talking about, right?

Hmm.

Now I recognize that high school football players are growing bigger -- more muscular and fatter. But with a few exceptions, they are NOT obese. They are just big. So what. Will they have developed behaviors that will ultimately lead them to become obese, and to threaten their health when they are no longer athletes? Yeah, maybe. But why is that so unfathomable? Why is it becoming so hard to understand that success has its tradeoffs -- and that in most cases, the greater the success the larger the tradeoff employed in bringing it to fruition?

The press would rather have these kids wallow in mediocrity. Concerned health groups want them to eat 8 servings of fruits and vegetables and get 20 minutes a day of aerobic activity, to lead low stress lives and take Prozac if things get out of hand, and to always be mindful of their life expectancy. Well, you know, there's nothing wrong with that approach, per se, but it seems as if the principle societal pressure these days is for people to be average. We can't have our teenagers trying to get huge and become millionaire football players, because John Q. Public is already huge (but doesn't want to be) and is nowhere near being a millionaire (but desperately wants to be).

The way I look at it, I'm just glad to see these kids striving for something. They're not whittling away their lives with a Nintendo Wii joystick in their hands, and they're not in the parking lot smoking pot all afternoon. Good for them! I hope they succeed -- and if not, I hope they can find the tools to prevent the potential negative health consequences of their behavior in the future. But for now, the kids want to be great.

Let's let them try.

Um, like, ouch

2007-01-07T11:55:00.000-08:00

Um, like, ouch
Originally uploaded by Ian__.

Because I've somehow decided that this blog must contain public service messages from time to time, I'll say this:

WEAR A SEATBELT. Or end up with a head like this.

Thanks!

The streak has ended

2006-12-08T08:06:00.000-08:00

I was surprised yesterday to find that after 22 rejections, an actual, real-life literary journal has decided to publish one of my short stories. This is somewhat of a setback for my enterprise of morosity and self-loathing, but I'll recover, no doubt. I'll just need to sprawl on the floor and listen to some Seether and Korn for a while, and all that sought-after negativity will come flowing back over me.

All right, enough chit-chat. Time to get depressed again.

Moral of the story: Don't get shot in the head, execution-style

2006-11-28T17:26:00.000-08:00

GSW
Originally uploaded by Ian__.

This is a CT scan of an unfortunate gentleman's head. His occiput is on the bottom and his forehead on the top in this image; a bullet entered in the back and traversed his entire brain, exiting above his left eyebrow. He did not do well.

Don't play with guns, or play with people who play with guns.

The last day

2006-10-08T10:35:00.000-07:00

Today is the last day of my vacation. Tomorrow I'll be saddled with the call pager all day. Just thinking about it spikes my blood pressure.

But on the plus side, I've enjoyed some great entertainment the past couple of days. On Friday night, I saw The Departed. Wow. If you put practically any other crime movie in history up against it, The Departed would kick the crap out of it. With steel-toed boots on. And then it would stomp on the other movie and do that heel-twist thing, leaving little tread marks all over the place.

So it's good -- you should see it.

I also just watched Walking Tall on cable, which of course after watching The Departed is like washing down a 25 year old single malt scotch with Boone's Farm kiwi-strawberry flavored wine. But it was still entertaining.

And last but not...well, yeah, last and least I watched this week's episode of Grey's Anatomy, entitled "Sometimes a Fantasy." I had taken a hiatus from watching this show, and in the meanwhile it appears that the show is even more about sex and less about medicine. Thanks to this show the American public now thinks that interns are not the least bit overworked, but significantly oversexed. Oh, and internship continues in perpetuity, apparently -- these folks started their intern year when I was still a fourth year student, and now that I'm well into my second year of residency they're still slogging through intern year. Gotta love T.V. time.

Really there wasn't all that much of medical substance to comment on here. Yes, there is such a thing as congenital absence of pain, as the little girl Megan suffered in this episode. Typically these patients end up with severe problems with their eyes, their mouths, and their joints. Think about all the times you've bitten your tongue or your cheek and then rebitten it again, and again, and again...despite the fact that it's excruciating. If you felt no pain, you'd basically just end up biting things off, remodeling the inside of your mouth to make room for those terrible gnashing teeth. Besides that, every little thing that got in your eye would stay in there, causing corneal ulcers and consequent visual problems. As far as orthopaedic injuries are concerned, these patients typically develop what's called Charcot joints -- eponymous lesions characterized by destruction of the joint space due to ongoing, severe trauma. So I suppose what I'm getting at here is that such a child would not present with a cut on the shin; she would have presented for medical care long before, even if she was in foster care.

Oh, and putting your hands in a bucket of ice water is a crappy way to assess pain sensation. Such a stimulus would hurt initially, but the pain would subside over time as the cold temperature exerts an inhibitory effect on nerve conduction -- completely backwards from the way the test was demonstrated in the show.

On the neurosurgery side of things, Dr. Burke performed a corpus callosotomy on a patient with refractory seizures. This sort of procedure has historically found some utility in treating patients with severe seizure syndromes such as Lennox-Gastaut; such patients can suffer atonic seizures known as "drop attacks" during which they fall, hit their heads, etc. The procedure does not abort seizures, but it helps keep the seizure focus lateralized to one hemisphere so that it does not spread and cause loss of muscle tone on both sides of the body. However, corpus callosotomy carries with it many attendant side effects, including disconnection syndromes (this was alluded to in the show when the patient exhibited word finding difficulties). Because of this morbidity, corpus callosotomy has in recent years been superceded by a variety of less invasive surgical techniques which I won't belabor. Suffice it to say that the show fails the reality check in that the patient seemed a little too highly functional to proceed straight to corpus callosotomy as his first surgical procedure. And honestly any good surgeon would have explained to the wife that the patient might have speech difficulties -- so she likely wouldn't end up screaming at him to say the name of their baby. That was a bit of prime time melodrama.

All in all the producers of the show seem to be targeting the Desperate Housewives audience more so than the ER crowd, with their constant parade of overwrought sexuality. Whatever works, I guess. It's just a shame that the program creates such misconceptions about the nature of surgical training.

Update

2006-10-06T14:08:00.000-07:00

Texas Chainsaw Massacre: The Beginning was somewhat of a letdown -- one of those movies that makes you walk out of the theater into the light of the afternoon sun and think, "Wow, I'm a fundamentally worse person now than I was just 90 minutes ago."

But really, what did I expect?

P.S. I can't wait for The Grudge 2 to come out next week.

Vacation week

2006-10-06T08:33:00.000-07:00

I'm presently at the tail end of one of my three allotted vacation weeks for this year. Consequently work is the furthest thing from my mind; instead I'm focused on partaking of the landmark cinematic events of this year (i.e. the opening of The Texas Chainsaw Massacre: The Beginning) and frittering away my time with writing.

So far I have submitted several of my stories to literary journals, and so far I have received 17 flat out rejections and -- encouragingly -- one rewrite request. That's all I have to sustain my optimism at this point: that one rewrite request from the Bellevue Literary Review, and the knowledge that one of my rejected stories made it to the final round of consideration for The MacGuffin. So that's progress, right? I also finished a rough draft of my novel-thingy, so if anyone out there wants to publish a story about a dude who believes in zombies and can't come to terms with the past, pleast let me know.

Okay, gotta go shower so I can make the noon screening of TCM: The Beginning!

Ch-ch-ch-ch-changes

2006-09-25T19:50:00.000-07:00

Residency changes a person. Sitting here at my computer I just took note of my burgeoning potbelly and I thought of how I used to be an athlete. I used to run upwards of 90 miles per week in an effort to perfect my form, condition my heart, and strengthen my legs so as to race as fast as possible in cross country and track meets. Now I work upwards of 90 hours per week in an effort to perfect my efficiency, thicken my skin (because this residency is not easy), and develop technical ability so as to perform an adequate job as a brain surgeon. And in each case -- during my running days and now during my residency training days -- I have forsaken many (all?) of the simple pleasures in life, eschewing hedonistic activities entirely for the sake of pursuing a goal. I have lived by the motto one of my cross country coaches in college espoused: "Res severa verum gaudium" -- translated (loosely) as, "to be serious is the greatest joy."

Wait -- wasn't this post about change? Oh, yeah. So the difference between then and now is that when I was in college I would come home from a 20 mile run at 8000 feet altitude and I would read voraciously about running. I would immerse myself in imaginary scenarios, picture myself running faster, dream of running more. The more I ran the more I discovered a well of motivation to pursue running; and even when my racing seemed poor, the training itself became such a joyous rigor that I gladly undertook it. Then when injury cut short my running career I spent several years in a tailspin, trying to sublimate this almost irrepressible urge to run.

Contrast that with my situation now. Now I work seventeen hour days and come home wanting nothing more than to watch T.V., or turn on a movie, or write a short story, or jack around with the novel I tease myself into thinking someone might ultimately care to read. The last thing I want to do is read about surgery. That's not to say I don't do it, because my innate perfectionism compels me to maintain at least a modicum of competence. However, it seems that the love just isn't there. The will to persevere originates extrinsically now: the hope not to be humiliated in case conference, the desire not to sound like an idiot when talking to other physicians, the need to stay on par with your peers. Of course providing quality patient care is a motivating factor, but frankly the more I see and do the more I realize that quality in patient care is not something measured in skill, but in compassion. But that schmaltzy statement is a topic for another post. (In another three months, perhaps?)

In any event, I just felt like blathering on about nothing of any particular importance to anyone but me. Meanwhile I must note that I've worked out probably five times since this year of my training began. This from someone who used to consider himself an exercise addict.

It seems I've fallen off the wagon. Or is it back on the wagon? Whatever.

The scene of the crime

2006-06-29T19:48:00.000-07:00

The scene of the crime
Originally uploaded by Ian__.

The joys of call

2006-06-12T16:32:00.000-07:00

DSC01427
Originally uploaded by Ian__.

Imagine four pagers clipped to the waist of your pants. Then imagine each one going off twenty times, with questions ranging from the annoying ("Mr. Johnson just pooped on the floor and fell in it, what should we do?") to the frightening (Ms. Fahnestock just had a thirty beat run of v-tach and now she's unresponsive, what should we do?). Now imagine toting these pagers and putting out fires for thirty hours in a row, without sleeping or eating anything of substance besides graham crackers stolen from the 'patient food' pantry. Next envision yourself falling asleep standing up, three times, in the middle of x-ray rounds -- I'm talking full-blown catalepsy-style fits, with loss of postural control and everything, catching yourself just a split second before hitting the floor and/or having your head plummet square between your attending surgeon's shoulderblades. After that think of scrambling around on rounds for two hours, dreaming only of how unimaginably wonderful it would be to have the privilege of attending to certain basic biologic functions such as urinating.

Well, that's just a taste.

Could our brows get any lower?

2006-04-30T12:06:00.000-07:00

Time Magazine released its "100 People Who Shape Our World" issue this week. Of particular interest to me was the "Artists and Entertainers" section.

Among the honorees is George Clooney, for his good looks and the fact that he doesn't spread them around indiscriminately like some other Hollywood bachelors.

We also see Reese Witherspoon. Why? Because "in [her] eyes there is the gleam of a competitor." Hmm...that really could shape the whole world, couldn't it?

They also threw in a guy named Renzo Piano, an architect about whom the author says, "I don't think there's anybody like him." Uniqueness in stark contrast to, say, that sentence?

Time presents Will Smith, as he "is something more than clothes and quips."

Also making the list is Tyra Banks, for of course "she is dynamic, positive, and real, and we are only at the beginning of her special brand of global domination." Here's to global domination by a supermodel! Yeah, baby, shape my world!

Alas, only one writer makes the "Artists and Entertainers" section. It's Zadie Smith. I haven't read anything by Zadie Smith, so she could very well be the most influential author in the world. Beats me.

It just surprises me that a periodical -- a typed, printed, written periodical -- can conjure only one writer worthy of mention as a shaper of our world. I think that says something -- either the people who created this Time Magazine edition don't read, or, scarily, the world itself, by and large, no longer reads.

I don't know what their excuse is. I work 15 hours a day and I still read. Come on, people, get off your intellectual asses.

For the record

2006-04-28T21:14:00.000-07:00

It's a well-established fact that calories consumed on a post-call day don't count. As a corollary to this theorem, I would like to introduce the Free Alcohol Rule as well. Alcohol consumed at the end of a night-float week (night float meaning working 14 hour night shifts, for the enlightenent of the uninitiated) has no effect on one's liver, cerebellum, or psyche. It's just free alcohol. In my case it's almost all of the single malt scotch remaining in my paltry collection in the cabinet, with an effete little apple martini thrown in for completion of the inebriation at hand.

For the purists out there, yes, I admit, the adulterative effect of the apple martini could in fact negate the free alcohol corollary. However, I hold that consumption of two drams of aqua vitae in advance of the apple martini does, in fact, prevent the vitiation of the soul that would otherwise be attendant with consuming such a shameful beverage. Even if it is Isle of Jura Superstition, which is probably the one of the worst single malts I've ever had.

I have a small stash of Laphroaig still in the cabinet, but I'm saving it for a rainy day.

P.S. I feel it incumbent upon me as a neurosurgeon in training to cultivate certain refined tastes, such as an appreciation for scotch. Certainly a significant portion of my mental energy during the remainder of my training shall be devoted to recalling the color, nose, body, taste, and finish of various single malts. And as for whether or not one would want his brain surgeon drinking whisky, I remind you that alcohol steadies the hand.

Throat afire

2006-04-22T14:04:00.000-07:00

Listen carefully, and you might just hear billions of virus particles propogating their semi-living existence on my tonsils and pharyngeal mucosa.

Ouch.

Being sick forces one to realize the unusual nature of medical work. If you work at a bank, in contrast, you can just call in and say, "I'm really in sad shape today, I can't make it." And so your boss shrugs and tells you to get well and come in tomorrow, and perhaps the bank doesn't open as many accounts that day. But if you're a surgical resident, acquiring an illness means nothing but more misery for yourself. Staying home is simply not an option. With work hours restrictions cramming an increasingly large amount of work into smaller periods of time, the limited staffing of residents at academic medical centers find themselves already burdened by a tremendous rush to stay afloat amidst the daily responsibilities of patient care. Add to that the absence of a colleague, and suddenly all that work that the sick resident would have performed must merely be absorbed by the remaining few. To me, it would be unconscionable to burden my co-residents with the additional workload. With a virus like the one that causes my present (additional) suffering, I must proceed with work as usual, the only exception being that I have to wash my already-chafed hands even more frequently and wear a mask and gloves for patient care. But it has to be done. In any case, here is a sample list of acceptable reasons to miss work in residency:

1) Being under anesthesia, having surgery actively performed upon oneself
2) Being in the midst of the five or six requisite hours of recovery following the above-mentioned anesthesia
3) Carrying a disease that is so communicable as to jeopardize patient safety, i.e. tuberculosis or ebola
4) Coma
5) Abduction, by aliens or otherwise
6) Having been drawn and quartered
7) Being a quad apotemnophiliac who has fulfilled his/her lifelong dream (look it up)
8) Being homogenized by a giant blender as an unfortunate consequence of a visit to a smoothie factory

...Well, I guess I can't really think of any more. So that's probably about it. Some well established excuses that are NOT legitimate reasons to miss work:

1) Having an IV catheter in your arm (you can always cart the IV pole along with you during rounds)
2) Protrusion of some/all bowel contents, so long as they can be reduced manually and have their proper location maintained by the use of duct tape
3) A nail in the head (see image below)
4) Being the victim of a criminal penectomy -- i.e. Johh Bobbitt, were he a resident, would have been required to appear at work that day with adequate gauze bandages in place to prevent drippage of blood onto charts and mayo stands
5) Foreign objects in the rectum, no matter how large (you should know better)
6) Being a hemi apotemnophiliac who has recently fulfilled his/her lifelong dream

Phew! That was enough work for me today. Fortunately I'm not due back at the hospital until tomorrow at 6:00 am. Meanwhile the immunologic battle will rage on.

Nailed. A piercing headache, perhaps.

2006-04-01T16:00:00.000-08:00

AP
Originally uploaded by Ian__.

Have you had a bad day? Is the hollow, effeminate voice of Daniel Powter reverberating endlessly in your mind? If so, then take heart, dear friend. Just remember it could always be worse -- you could have a four inch steel nail in your head like this guy.

Oh, and if that's not enough to warm your soul, just add this word to your lexicon:

MULIEBRIA

Cheers!

Hmmm...

2006-03-30T16:56:00.000-08:00

Ahem

Hello.

I'm not dead.

I'm actually doing quite well.

I haven't blogged in months.

My blog is dead.

Hmmm.

If anyone out is still out there, I send my regards!

Perhaps I'll try to update this blog from time to time.

As you can surmise from past performance, I do not feel inclined to make any promises about the frequency of blog posts. And even if I were so inclined, one would be foolish to believe such promises.

Anyhow, I hope everyone feels happy and well-fed.

Forgotten, but not gone

2005-07-31T20:18:00.000-07:00

Hey there, remember me?

I created this blog several months ago for the express purpose of using it as a means of capturing my thoughts and observations during my residency -- a sort of online, ready-access, minimally-private diary. During those first few months I caught the blogging fever, posting new content multiple times per week, actively seeking interesting blogs to frequent, and even going so far as to waste hours upon hours trading imaginary shares in blog stock. Now that my residency has begun, though, my utilization of this space has dwindled to essentially nothing, and the original purpose for this blog's existence seems to stand no chance of fulfillment. What gives?

Well, I have found that, after spending thirteen or fourteen hours a day writing innumerable orders, consoling frightened or bereaved families, participating in interminable morning and evening rounds, completing any number and variety of mundane patient care tasks (such as ensuring Q3 day bowel movements from patients whose intestines have been silenced by opiate inundation), and performing surreal neuro exams on comatose patients ("SHOW ME YOUR THUMB! CAN YOU SHOW ME YOUR THUMB? MR JOHNSON!" -- performing gruff sternal rub on patient's chest, inducing him to extensor posture -- "Oh. It looks as if Mr. Johnson is herniating. Can we get the head of his bed up to 30 degrees and start mannitol, please?"), it seems that the last thing I want to do is end a sentence. Oops, I mean the last thing I want to do is come home and revisit the sights and sounds (and smells) of the day by blogging about them.

Nevermind that an 80 hour work week leaves little time for idle pursuits -- the real hindrance to my blogging of late has been that, when I'm not at work, I simply don't want to think about work. So I have come to the conclusion that if this blog is to survive, I will have to enact a concerted paradigm shift such that this forum need not be my work diary, but rather my work escape -- a place where I can write about whatever comes to mind, rather than about whatever happened at work. In other words, I will likely keep writing about the random, mindless crap I wrote about before I started work. Will that keep me coming back here more frequently? I can't answer that question for sure -- but the shift in mindset will certainly decrease my activation energy for beginning to process of sitting down at my computer and blogging.

So, if anyone out there still reads my blog (thanks, Lemming Fodder!), I appreciate your patience during these lean times. Though the realities of work will likely prevent me from posting here very frequently, I do not intend to allow Not Rocket Science to expire -- so don't forget about me!

Twitching and unpacking

2005-06-27T21:27:00.000-07:00

So, what's new... I have just recently moved into my new house, and I have made several weak, ineffectual stabs at unpacking and creating a lived-in look in the place; I have completely avoided any useful preparation for my internship, having wasted my free hours leading up to this Friday's start date by watching digital cable rather than reading about the neuro ICU (where I will begin); I have continued my trifling attempts to round myself into shape, running three miles each day (weight is now down to 195-ish -- that is, prior to a monumental ice cream binge this evening); I have submitted a short story to Glimmer Train, which will likely be rejected post-haste; and most pertinent to this space, I have once again uttlerly neglected my blog for days and days. Through it all my mood has remained about as warm as the waters of Lake Ontario. With that in mind, I would like to thank my girlfriend for her forbearance in dealing with my lack of patience and my multiple temper tantrums throughout recent days.

Is anyone out there still reading my blog? I certainly can't blame you if you've given up any hope of revitalization -- but rest assured that I have aspirations, if not realistic plans, to keep this thing up and running.

P.S. -- I almost forgot about the "twitching" part of my title. It seems that my right upper eyelid has developed a sense of humor: it chuckles to itself throughout the day, its broad hair-spiked belly contracting in glee at unheard jokes and inaudible witticisms. The medical term for this eyelid twitching that haunts my days and torments my attention is myokymia, with myo- meaning "muscle," and kymia- meaning "interminably harrassing poor Ian in retribution for some wrong committed in a prior life." I understand that the conventional wisdom is for a person with myokymia lasting longer than a week should seek medical attention, meaning that a male such as myself, with dreams of one day possessing a modicum of machismo, must wait for at least six weeks before even contemplating visiting a fellow physician. Two down, four to go.

A reprieve

2005-06-18T14:22:00.000-07:00

I learned yesterday that I will commence my internship by doing a neurology rotation, which entails beginning work one week later than anticipated. Now that I know I needn't worry about having patients' lives depending upon my judgment until July 1st, I have happily resumed a life of sloth. I've spent my day sitting around, watching the NCAA Track and Field Championships on CBS, and surfing the Web -- altogether a none-too-exciting day. However, I did happen upon one choice morsel from USA track and field history. I'm sure you all remember Carl Lewis -- the man who dominated the world sprinting and long jumping scene for years? Well, he has apparently made his mark on the world in more than just the stadium. I have procured for your listening and viewing enjoyment the following video link. However, please be forewarned that this mesmerizing footage will transport you to an alternate, bizarro dimension from which you may not return. View at your own risk.

P.S. No, don't worry, it's not porno.

Speechless

2005-06-13T19:44:00.000-07:00

Every once in a while, a news story will completely undermine my understanding of humanity, and leave me utterly incapable of producing any meaningful comments on the matter. Following this link led me to just such an earth-shattering, paradigm shifting story.

I'm not sure how long the content will remain in place, but hopefully those of you who are interested in abnormal psychology will have the opportunity to read this article.

Update: The link has apparently changed, and the story of a 50-something man who lives as a baby (an AB/DL -- short for Adult Baby/Diaper Lover) has passed along into the ether. The highlight of the story was that this individual actually trained himself no longer to be continent -- a task requiring much assiduousness and ingenuity, such as bolting his toilets shut -- so that he would be dependent upon diapers at all times. Wow.

Blogger's constipation

2005-06-11T15:37:00.000-07:00

It seems I continue to have infrequent blog movements, and those movements that I have are slow and painful -- a real case of blogger's constipation. I'm not sure how long this problem will last.

Perhaps the blogger's constipation is due in part to the fact that nothing of note has transpired in my life for the past week. My final week of vacation before I enter the hospital for the rest of my life has passed rapidly and uneventfully, though I have encountered my share of beaurocratic obstacles. It took a full day and a half to obtain a Missouri driver's license, as apparently somebody else's driving record became appended to my social security number in the national DMV database; unfortunately, this other driver happened to have a suspended license. The aftermath took about four hours worth of haggling with various representatives of the illustrioius motor vehicle departments of MO and CO, but finally some gracious supervisor in MO did the just thing and granted me the freedom to obtain a new license. It was only my last week of freedom for seven years anyhow -- I didn't really want to spend it any other way than at the DMV.

Other than that, I have an Advanced Cardiopulmonary Life Support training class this coming week, so I've already had to begin studying for that. I can get no rest, it seems.

I did, however, manage to see a few movies, including Crash. I highly recommend it to anyone who lives on earth.

Well, I have no other thoughts to express and even fewer words in my mind with which to express them. I think I'll go swill a big glass of gritty Blogamucil and hope for the best.

Of dreams and yo-yo diets

2005-06-02T22:09:00.000-07:00

I've been trying to work myself back into shape recently. I know, I know, I should just accept that at 28 the best years of my life are behind me, and acquiesce to the inexorable decline of my athletic capacity. But alas, I find myself assualted on all sides by reminders of the glory days of my past sports career, and frankly, I want them back. You see, despite being now over 200 lbs, I was once a svelte collegiate distance runner pounding out 90 mile weeks on the roads and trails near Boulder, Colorado. Running was more than just an extracurricular pursuit for me, as I structured my days -- and my entire life, really -- around it. I dreamt of running, I daydreamed in class about running, and while I was out there running, I thought about all the running I would soon do. Such an obsession seems absurd to the non-runner, but many who have succumbed to running’s whiles will understand what I mean. Err… they would, rather, if I actually had a readership of greater than 10 people. Anyways…I managed at one point to become a pretty good collegiate runner, though injuries always plagued my training and confounded any attempts to place well in big races or secure admirable times. Ultimately injuries would cut my entire career short, relegating me to the weight room in a futile attempt to keep from becoming a complete and total morass of fatty flesh. As it turns out I became a morass of partly muscular, partly fatty flesh. But I proceeded to medical school and kept myself largely busy enough not to waste wistful hours dreaming of what might have been.

As I mentioned before, though, the reminders have haunted me of late. At first, I brought it upon myself by reading a book called Running With the Buffaloes, which details the glorious 1998 cross country season of my team – during my first year as a non-runner. What a surreal experience that was, to read a book about people with whom I had toiled for hours and hours, doing precisely the things I had done and feeling remarkably similarly about them as I had. At the turn of every page I thought that my name should materialize, and that I should come running into the tale in a blaze of the glory I never had. But the book ended, and I found myself dreaming the self-flagellating dream of What I Would Do Differently If I Could Go Back, Knowing What I Know Now. With that backdrop I have found myself constantly bombarded by images of running. Suddenly my little city in the heart of Missouri has become a running mecca, and everywhere I turn I see scantily clad people striding their way down sidewalks and through parks. To make matters worse, Nike just released a new commercial to molest my memory. It is a take-off on the famous beach running scene in Chariots of Fire, only instead of a bunch of British actors, the guys running by the surf are a bunch of the top distance runners in the country. Lo and behold, after recognizing Alan Webb and realizing that, indeed, Nike populated its running group with real life running superstars, I managed to discern the visage of Adam Goucher, on whose team I had once run. How strange, to see the same face bobbing along on a commercial that I used to see every day in practice!

Anyways, to cut to the chase (yeah right, in the midst of this ridiculously prolix post) I have lately begun trying to ramp up my own running. I keep thinking to myself that the injury that ended my collegiate running has surely healed, and indeed it seems not to bother me at all. In fact, my legs have felt pretty darn good on my mediocre diet of 2-3 miles of running a day (one must build up gradually in these sorts of things). However, a large problem remains: I am one HUGE man. My body has decided, for better or worse, that I weigh 208 lbs. First, I lost about 10 lbs without difficulty over the course of a month. Then, in about two weeks, all that weight slathered itself back upon my frame as I found myself utterly incapable of controlling my food intake. Then, I regained focus and plunged once more below 200lbs. But all of a sudden…WHAM, I’m eating everything in sight and once more attaining my 208 lb set point. Why is this so difficult?

Perhaps this whole running thing was not meant to be after all, and I should just stick to trying to learn brain surgery exclusively. Ahh, the best laid plans of mice and men.

Back in town

2005-05-31T20:47:00.000-07:00

I'm finally back in town, finished with my post-graduation travels to my and my girlfriend's respective family homes. I anticipate having several days ahead of me devoted to running errands and finalizing details relating to my new house; however, I will liberally sprinkle some time wastage among my other duties and tasks. In that vein I hope to watch a few new movies and generally lay about.

Thanks to everyone who commented on my blog in my absence! Hopefully I'll think of something interesting to write in this space in the coming days.

Ian M.D.

2005-05-20T23:35:00.000-07:00

I graduated today! It's late, so I'm not going to say much... but I delivered a commencement address at my med school graduation ceremony, and had the distinct honor of sharing the stage with Dr. Michael E. Debakey, our invited commencement speaker. After that I spent some quality time with my mother and about twenty of my girlfriend's friends and family. What a day!

I'm sleepy.

Grey's Anatomy -- "Save Me"

2005-05-15T21:22:00.000-07:00

This episode's title was "Save Me," and the plot synopsis from the abc.com website is as follows:

Meredith grows increasingly dissatisfied with the unknown details of Derek's life. Meanwhile, Alex treats Devo, a patient whose religious beliefs jeopardize her chances for recovery; Izzie contemplates reconnecting with her estranged mother; Zoey, a pregnant woman in her 40s who's been diagnosed with cancer, disagrees with Cristina's medical advice; and the interns are mystified by Cable, a patient who's being treated for seizures and who thinks he's psychic.

The show seems to be hitting its rhythm in terms of developing the relationship between Meredith (Dr. Grey) and Derek (the neurosurgeon), with an abundance of witty banter and a gradual peeling back of Derek's layers. Unfortunately, Cristina -- the heartless mannequin in scrubs -- continues to make me want to send the remote control hurtling through the television screen. I can thankfully say that I have yet to encounter any such insufferable personalities in medicine, and I hope that trend continues.

As for the medical details of the show -- well, I think they still need serious help from an actual physician. If any of the writers would like my assistance in that regard and happen upon this blog at some point in the future, I hope they consider this my offer to provide much needed consultation for a nominal fee.

* One of the patients on the show had a temporal lobe arteriovenous malformation (AVM). Interestingly, the writers hit upon a truth in suggesting that such a lesion can cause seizures and behavioral changes which could be mistaken for psychic phenomena; indeed, temporal lobe masses such as AVMs are classic causes of "uncinate fits," in which patients exhibit bizarre patterns of activity, olfactory hallucinations, and other unusual phenomena. Unfortunately, the writers missed the mark in suggesting that an AVM is a lesion necessitating immediate therapy. Unless it has already begun to bleed, AVMs typically have a lifelong risk of rupture of roughly 2-4% per year. Given that the patient in question was young, he should have been advised to receive treatment, but it needn’t have proceeded in any sort of hasty fashion. In fact, depending upon the size and exact location of the AVM, he might have been a candidate for non-invasive radiosurgery to ablate the lesion rather than an open neurosurgical procedure. Such a treatment takes a longer time and carries with it the risk of rupture of the AVM before efficacy is achieved, but it spares the patient the considerable risks of morbidity/mortality from surgery.

* Another patient on the show had an ascending paralysis that prompted Derek to take him to the operating room for removal of a presumed expanding hematoma. It’s pretty darn unlikely that an MRI would lack the sensitivity to visualize a lesion large enough to compress the spinal cord; the only way that such scenario would be likely to occur would be if the spinal canal were particularly narrow, which of course would itself be evident on MRI.

The rest of the medical content was relatively straightforward, making accuracy easier to achieve. I’m still rather amazed at all the hook-ups taking place on the show. How do all the interns find time to have carnal relations with their attendings?

Back to blogging

2005-05-15T21:10:00.000-07:00

Wow, my blog is truly moribund. I'll try to give it a good precordial thump to restart the old heart tonight.

I've found myself quite busy with outside pursuits lately, especially the planning for my senior class show, as well as the writing of two speeches. I delivered one of these just last night at my school's alumni reunion banquet; all in all I think it went well, though as usual I spoke far too fast (apparently what feels excruciatingly slow to my brain is, in reality, rather rapid) and tended to fidget incessantly while talking. At least my girlfriend managed to tape the proceedings, so I have some evidence of my speaking flaws as a starting point from which to improve.

Let's see...in other news, I finished reading a book called The Twenty-Seventh City, which is the first novel written by Jonathan Franzen (the author whose name became famous more for the Oprah Book Club brouhaha than for his writing, although he writes quite well). I picked it up mainly because it is based in my new hometown; the picture of the Arch on the cover was enough to convince me to shell out the money. All in all it was only an average read, more compelling for Franzen's prose than for any profound thematic concerns or illuminating characterization. I did, however, learn a few more tidbits about my little city in the Midwest, and as a result I can now amaze my friends with random pieces of trivia.

I just started reading Catch-22 -- one of those all-time great novels that over the course of my formal education I managed to neglect or avoid.

I also finally saw another episode of Gray's Anatomy, so I suppose my next post should serve to resume my prior habit of reviewing this ABC program.

This is supposed to be my vacation

2005-05-08T21:44:00.000-07:00

As of Friday evening, I no longer have any medical student coursework or rotations to perform. My work here is almost finished. However, I seem to have an ever-ballooning docket of extracurricular obligations demanding my attention; today, for example, I helped a friend move into his house (a task which I will find myself repeating about twice a week until everyone I know is settled his/her new abode), then later spent the bulk of my evening doing laundry and preparing the lesson for another neuroscience case session. At least tomorrow, when I take a seat in front of a group of eager 1st year students, I'll be clothed in an undershirt and a black button-up shirt on top, with the intention of keeping my axillary hyperhidrosis below the threshold of detection.

When will I get to relax? All next week I'll be working frantically on our class variety show -- the organization of which falls largely in my lap -- and preparing a speech for our graduation on May 20th. After that perhaps I can resume the mental hibernation my taxed cortex so desperately desires.

Full circle

2005-05-04T09:52:00.000-07:00

I just spent the past hour teaching a clinical case session to a group of 1st year medical students. I must say, I felt rather strange sitting there with all eyes upon me -- the supposedly knowledgeable one -- while trying to engage my tired brain. I also learned a couple of important things. Importantly, one should never have contempt for a teacher in front of a group who demonstrates a brief stint of pure idiocy. When not under scrutiny, the brain often undergoes subtle lapses of concentration that can be circumvented entirely by a deep breath and a deliberate closure of the eyes; however, when an entire audience clings with tenuous attention to your words, somehow the gravity of the situation can stretch out those concentration lapses like taffy on a warm summer day -- and soon the sticky mess adheres to every thought until fluid communication becomes impossible. Teaching is hard.

Also of note, withold your snickers and derisive glances when a teacher displays with every raise of the arm a massive, ignominious armpit stain. For some reason, the armpits serve as the barometer of public speaking; when I am in public, my armpits don't sweat, and when I am speaking, my armpits don't sweat, but whenever I speak publicly, the sweat glands dump their salty product all over my clothes. I didn't realize this fact until I got to med school, but now I feel ashamed for every having made fun of my high school english teacher's huge pit stains.

Well, time now for a journey to the health club for an hour on the stationary bike. You wanna see sweat? I'll show you sweat.

The Amityville Remake

2005-05-01T22:21:00.000-07:00

Well, after spending several hours in an anatomy lab surrounded by formalin-soaked corpses in various stages of dissection, I figured the best way to cap off my evening would be to take in a horror flick. The only viable option appeared to be the new remake of The Amityville Horror, so off I went to watch it -- by myself.

Okay, at this point I imagine that half of you found nothing in the previous sentence to cause consternation, and the other half are aghast at the idea of venturing to a theater unaccompanied. I do it fairly often, though, so I suppose that makes me either independent or in need of counseling.

Anyhow, the movie turned out not to provide the scares it promised, largely because it offers nothing new; it merely takes the plot of an old movie, tweaks it mildly, and then throws in what is apparently the new sine qua non of horror -- freaky children. Of course, from the very beginning horror movies have featured children in their plot lines, to great effect in such cases as The Exorcist (the original) and The Omen. However, I think the past six years mark the beginning of a new trend, which is the inclusion of sinister, dead, ghostly, ghastly children as the prime mover for fright. I trace the origins of this recent trend to The Sixth Sense, released in 1999, which showed the world that nothing is scarier than little kiddos done up to appear cadaveric, walking around like zombies, vomiting and looking preternaturally somber. After the success of that film, we saw a boom in movies with moribund munchkins -- just look at The Ring 1 and 2, The Grudge, and now The Amityville Horror. And these are just the movies in which freaky kids figure prominently; they also make startling cameos in zombie movies (Resident Evil: Apocalypse and Dawn of the Dead), psych flicks (Gothika), and surely many more that I’m neglecting.

The thing about these movies is that they not only employ freaky children, but rely almost solely on seemingly gratuitous imagery of ghost kids looking as though they stood up and walked out of the morgue – they have bullet holes in their heads, pale faces with blue veins snaking across them, fixed and dilated pupils, etc. Further, these kids demonstrate peculiar behaviors such as howling like cats and displaying their black-hole little mouths, turning green, and staring through the audience members’ souls. If called upon to locomote, these freaky ghost children will generally move like normal children, except they do so at 2 X film speed so as to make their inexorable advance towards the screen seem ever so inescapable; moreover, if changes in elevation are involved, such as climbing down stairs or out of deep wells, the children will invariably climb like Gollum in The Lord of the Rings, with their legs reaching out above their heads thanks to the tremendously improved range of motion that death apparently confers upon the human hip joint. Oh, and one other thing – if the dead child is a girl, she will have long, black, wet hair that hangs forward to obscure her face, hiding, of course, the hideous mangled atrocity that some makeup artist has created underneath. And, of course, if at any point a mirror appears in one of the scenes, a dead child’s image will materialize in the background.

Well, I’m rambling on. The point is that horror film makers think they have lit upon a ready-made scream-producer in the scary dead child, and they seem intent on burning shiver-inducing kiddie images onto our retinas. As I just realized tonight with The Amityville Horror, though, the scream-o-matic child has lost its novelty.

And I have certainly lost interest in seeing any more films with dead toddlers.

P.S. I found this interesting article about the lasting effects of horror movies on children. Of particular interest to me was the fact that "52 percent of the sample reported disturbances in normal behavior such as sleeping or eating after viewing a frightening film or TV program." Hmmm... sounds about right. After watching the movie Alien as a young kid, I refused to eat at the dinner table for months for fear that a little xeno-beastie would pound its way out of my chest and land on the pork chops. Also, I like this quote: "For about two months after the movie, I had nightmares about blood," the participant said. "The nightmares didn't always involve sharks, but always contained gross amounts of blood. To this day, I remain horrified of blood." Well, I watched more horror movies as a kid than anyone else I know -- and now, after all those years of blood, guts, and gore, I'm going to be a surgeon. Go figure.

P.P.S. I'd like to know -- what do you think is the scariest horror movie? Which scenes still haunt you when the lights go out at night? What images and sounds from horror flicks send a chill down your spine?

Resurrecting the dying blog

2005-04-28T22:58:00.000-07:00

At last, I have finished moving my unfathomably large mass of totally worthless belongings from my apartment. Sure, the task required most hours of the day for several consecutive days, but I suppose it was worth it if it meant saving a box of old 1st and 2nd year med school exams, college course notes, the boxes that once housed my speakers, stereo receiver, computer, and DVD player (you never know when you might need all that perfectly molded styrofoam and form-fitting cardboard again), five year old cleaning supplies, etc. I think that someone my age should have no difficulty filling a 10X10 storage room to the brim. It's perfectly normal.

On the other hand, I might just suffer from the particularly intractable hoarding variant of OCD, in which sufferers cannot for all the world bring themselves to part with even the most trifling trinket. Oh well, I'm sure OCD actually becomes more an asset than a liability in the world of neurosurgery, so my psychopathology should serve me well.

(Okay, okay, so in my defense I did throw out about 100lbs of "trash" from my apartment, including some items that many people would consider useful and worth saving. In all cases I had to squelch the little voice in my head that clamored for recognition, the Cassandraesque crier predicting in no uncertain terms the calamity that will surely befall the world if that rust-encrusted set of old forks and spoons reaches the garbage bin. It's going to be okay, right? Yes?)

Gathering no moss

2005-04-24T21:57:00.000-07:00

I spent most of today gradually trying to pack the remaining items in my apartment and clean some of the mounds of trash I have accumulated over the years. It appears that I have succumbed to the genetic tendency in my family of hoarding every single item in my possession, regardless of its significance, until all available space in my living quarters has been obliterated. Thankfully, with the help of my girlfriend playing the part of the voice of reason, I managed to lighten the load at least nominally today, though I still have about 99% more junk than any 28 year old should reasonably possess.

I'm tired. As for blogging, it seems that all I have to offer are thoughts of a dry brain in a dry season. There I go pointlessly quoting people of infinitely greater writing ability than my own, meaning that once again it's time to step away from the keyboard and call it a night. Hopefully this coming week holds the promise of better blogging efforts.

Busy, busy, busy

2005-04-22T22:21:00.000-07:00

I've found myself occupied by a never-ceasing list of chores this week, which has significantly impinged upon my efforts to relax. Doesn't the rest of the world know that I still need some time to recover from the last four years of med school effort? Anyhow I keep having to dash about town doing this or that, and tomorrow I need to move out of my apartment -- always one of my favorite pastimes.

I did, however, find time to locate this interesting website. It appears that the city in which I live is the base of operations for a large zombie-fighting syndicate. Consequently, this should be one of the safest places on earth in the event of a zombie apocalypse -- so I've got that going for me, which is nice. I think I'll go pop 28 Days Later into the DVD player and fall asleep to the sounds of rage-infected corpses marauding London.

Ian in the House

2005-04-19T20:49:00.000-07:00

I finally watched the show House, M.D. tonight on Fox. I was impressed -- it was a quality drama, certainly more engaging than Grey's Anatomy. The characters actually seem to have some depth, and one gets the impression that the script might actually have been written with the consultation of a real life M.D. That's not to say that the show accurately depicts the workings of a hospital, as it too falls victim to the universal TV medical drama fallacy that any single doctor can and will care for every type of patient and disease that walks through the door. It appears that TV scriptwriters skirt the issue of specialization as an expedient for limiting the number of characters in the show while still allowing for breadth in subject matter, a dramatic contrivance for which I can't say I blame them. Nonetheless, most disease entities presented in House actually exist, and the on-screen presentation fortunately does not completely do away with verisimilitude. The 'mystery' format also makes for fun watching from the standpoint of a medically trained individual, as it provides the opportunity to guess the diagnosis ahead of the revelation in the show (for instance, I called the upper lobe lung cancer and the Lambert Eaton Myasthenic Syndrome in the pregnant patient in tonight's episode).

Of course, I could nit-pick every detail and tell you that small cell lung cancers occur much more commonly close to the lung hilum, rather than the periphery; that any doctor who suggests the diagnosis of myasthenia would also recognize that eyelid weakness is the first and most sensitive manifestation; and that nobody walks into the OR without a mask, as Dr. House did during the emergency thrombectomy; etc. But frankly I'm more inclined to be charitable towards this show than towards Grey's Anatomy. At least this show won't lead my future patients to think that I'm just another surgical intern like the ones on 'that TV show,' and hence must be a blundering fool. Oh well.

A little thing called a personal statement

2005-04-18T23:14:00.000-07:00

I don't feel like writing anything new or readable tonight, so I'll once again pull from some obscure folder on my computer's desktop a sample of writing from ages past...

Oh, this will serve the purpose. When we apply to residency, we must submit as part of our application the quintessence of self-aggrandizement known as the Personal Statement. I, of course, wrote mine about neurosurgery. So here, for your mirthful perusal, is the personal statement I submitted to 30 residency programs across this great nation of ours. If you read it, WOW! If not, I don't blame you. At least I can cheaply subvert the otherwise ineluctable advance of blogger's guilt this way -- no complicity required on your part.

NS Personal Statement

Unbeknownst to me at the time, when as a teenager I first raced around a track, I began to lay the foundation that would ultimately prepare me for a career in Neurological Surgery. Throughout high school and college, competitive distance running remained an essential component of my life. And though my running career was far from illustrious, marred by injuries and studded by failures, I learned a great deal about myself and gained an uncommon level of perseverance. When I began running I was not especially talented, but over time I developed my endurance by running at times over 90 miles per week. Eventually, I successfully walked on to a top collegiate track and cross country team, in the process learning well that that I could not dictate the innate capacity of my heart to pump or my legs to move, but that I could devote myself wholly to my training, and then run with such abandon as to extract every trace of potential from my genetics. This diligence and dauntlessness has come to characterize my approach to all the endeavors in my life, and will serve as an important asset for embarking upon a career in neurosurgery.

Another lesson I learned from running that prepared me to enter the field of neurosurgery is the importance of teamwork. The runners on a cross country team run for an individual place, and the sum total of their places becomes the team’s overall score; thus each member must perform his absolute best in order that the team as a whole may succeed. Additionally, racing and training have their own team tactics, the most important of which involve simply encouraging and supporting each other in a difficult endeavor. By becoming a dependable team member and supporting my teammates as we all strove for a shared goal, I feel that I learned many skills that will make me a valuable neurosurgery resident.

Thus I feel that my running helped to develop my incipient potential to become a neurosurgeon. Since then, I have honed that potential by becoming a leader in my medical school community, serving as the president of my class for all four years. In this capacity I have often gathered my colleagues together into a cohesive unit to accomplish a shared vision. Perhaps my most successful – and enjoyable – leadership endeavor has been to rally my classmates together to create and perform two “class shows” that gained renown within the medical school. With these activities and others, I believe I have developed leadership skills that will make me a successful neurosurgery resident, and ultimately a contributor to the advancement of the field.

While these past experiences will serve as a foundation for neurosurgery training, the strong interest I possess in the field will serve as my continuing motivation for success. Nothing else in medicine strikes me as more compelling; perhaps that is because, among all the systems of the body, only the nervous system serves as a springboard for philosophy, and contains those essential elements which make us human. Further, the fact that the brain is insuperable from an individual’s personhood makes caring for patients with neurological problems a tremendous responsibility, towards which I feel an innate attraction.

During my 4th year sub-internship on Neurosurgery, I had a particular patient encounter that illustrates my attraction to the gravity of neurosurgery. He was a very young gentleman – in his early 30’s – whose career as a professional athlete had been hampered of late by pronounced headaches affecting him daily. As the days passed the headaches grew worse, so he finally sought care; the MRI that followed from his workup revealed a large right frontal ring-enhancing lesion. After he came to our service and had his lesion resected, the pathology report confirmed what we all feared: he suffered from a glioblastoma. In some people’s eyes, this young man’s example could illustrate the futility of some cases in neurosurgery – performing an operation that at this stage remains essentially palliative in nature, and, as one of my classmates so unceremoniously put it, akin to “polishing the brass on the Titanic.” I, however, look at it differently. This was a man in the prime of his life, who suddenly saw his entire world abolished in a matter of days – and who, were it not for his surgery, would likely have died within weeks. The resection of his tumor clearly did not cure him, but it undoubtedly extended his life by several months, likely even a year or more. Related to this point, Wilder Penfield once explained in a letter to Harvey Cushing, at a time when his sister was dying from an oligodendroglioma he had previously resected, “Simply to postpone death is very much worthwhile, for life when we measure it by weeks and months becomes a very precious thing” (J Neurosurg 95:148-61, 2001). The surgery on this unfortunate young gentleman had similarly given him and his family the gift of precious weeks and months to reconcile his previous worldview with his new reality. Perhaps we were just “polishing the brass” with that operation – but I recognize the nobility of the polishing, the beauty of the shine, and the great privilege associated with maintaining the luster to the very end. Clearly this man had a worse prognosis than many patients treated by a neurosurgeon, but the fact remains that neurosurgeons treat some of the sickest and most vulnerable patients, and thus they participate in not only some of the most painful defeats, but also the most uplifting successes in all of medicine. To help patients at their time of greatest need seems to me to epitomize what it means to be a surgeon, and it remains my primary reason for entering neurosurgery.

Grey's Anatomy -- "No Man's Land"

2005-04-17T20:01:00.000-07:00

I returned home just in time to grab some dinner and watch Grey's Anatomy. This episode, entitled "No Man's Land," had the following plot synopsis gleaned from the abc.com website:

Cristina's encounter with a former nurse, now a patient at Seattle Grace, changes her forever; Derek and Meredith treat a construction worker who has miraculously survived an injury but is now faced with tough decisions about his future; and a patient recognizes Izzie from a lingerie ad, which makes her the subject of hospital gossip.

This turned out to be a fairly entertaining episode, though the writers continue to take significant liberties with their presentation of the world of surgery. I present to you this week's list of gripes:

1) Interns do not all arrive at the hospital at the same time and don their scrubs to the accompaniment of the morning's motivational speech, compliments of the chief resident. Actually, interns will arrive at the hospital at varying hours depending upon the particular demands of the surgical service to which they happen to be assigned at the time. Also, 4:30am is typically not a time for loquacity; even if the chief resident were naturally inclined to speak at length about the day, her natural volubility would likely wane significantly at such an early hour.

2) Patients do not come to the surgical service to die. Even an ex-scrub nurse would likely receive admission to a standard medicine floor, though her status at the hospital might earn her a single-bed room.

3) I admit, words spoken through a surgical mask lose some of their impact, without the listener able to observe snarling lips and defiant clenchings of the jaw. Nonetheless, nobody removes a surgical mask in the middle of a procedure just to make a point; doing so compromises sterility, and it's a great way to find yourself kicked out of the room post-haste.

4) Sandra Oh's character, Cristina Yang, remains a hideously distorted caricature of the heartless surgeon in training. In this episode we watched her try to save a DNR (Do Not Resuscitate) patient who had come to the hospital to die; somehow, we are led to believe that this surgical cyborg had formed such a bond with her patient -- though no evidence of said bond ever became apparent in their interactions -- that she was pushed by a flood of emotion to forgo reason and sense in the interest of saving the patient's life at all costs. Well, I suppose that notwithstanding the problems of plausibility with this exchange, we can hold out hope that the writers might use this "epiphany" as a door through which to inject some semblance of humanity into a character who is otherwise as cold and sterile as the scalpel she aspires to wield.

5) I realize that essentially any injury -- conceivable or not -- can befall a person, and that practically everything -- including a head-full of nails accidentally incurrred -- has probably happened at some point in the history of medicine. However, falling down the stairs with a nail gun would more likely splinter the torso and legs with nails, rather than the top of the head, due to inherent limitations in the length of the arms and the standard manner with which one holds a nailgun (i.e. with the index finger on the trigger and the tip of the gun pointing away from the hand, a position from which it would be impossible to put a nail in the top of the head). Nonetheless, for the sake of argument let's assume that such a nail-ridden skull could result from a fall. These nails pierced the skull and entered the brain along its convexity, pointing inwards radially; although an optic nerve injury could result, as the show alluded to, most likely the patient would not escape without some damage to the motor or primary somatosensory cortex. The nails plunged right through these areas, judging by the head CT depicted. So "Jorge" would likely have had difficulty with movement or sensation of his face or his arms. As it turned out, the nails caused him essentially no harm, but a hypothalamic tumor caused his fall down the stairs. I didn't get the best look at the MRI showing the tumor, but operating too aggressively on a tumor in and around the hypothalamus can, indeed, lead to significant changes in memory and even personality.

6) Oh, one more thing -- any neurosurgery attending who has to have his interns perform a literature search in order to inform him that the risks of surgery include bleeding & infection, and that surgical outcomes are better when the procedure takes less time, really has no business cutting into somebody's brain in the first place.

Well, that's all I have for tonight. I could say much more, but I'm beginning to bore even myself, so I think it wiser for me to sign off for now.

I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race

2005-04-14T19:52:00.000-07:00

Or maybe I'll just go to a wedding.

I'm heading out of town early tomorrow morning, destination Louisville, KY, to serve as a groomsman in my friend's wedding. I shall return Sunday night -- in time, of course, to watch Grey's Anatomy and post my comments here. I hope everyone has a great weekend!

Bloggedly blogless

2005-04-13T21:28:00.000-07:00

I have no inspiration for tonight, so I will resort once again to posting some online quiz results for your delectation.

What Monty Python Character are you?
brought to you by Quizilla

Missed House

2005-04-12T22:14:00.000-07:00

Well, I had the best of intentions as I began the evening: I was to grab a quick Del Taco dinner, then nestle down on the couch just in time to watch House on Fox. Mmmm... I miscalculated slightly, departing for Del Taco right around 8:00pm Central time, which just happened to be when House began. I caught the last five minutes of the show, which seemed interesting; unfortunately, though, due to my disorganization, I have too little fodder to comment on House this week. I hold out hope that next week, when my girlfriend returns and provides some semblance of structure to my disheveled life, I'll finally see House and add it to the list of medical shows which I shall review on this blog.

In an effort to salvage the evening, a friend and I watched Sin City at the theater. It was pretty good, a mix of Quentin Tarantino-style violence, film noir mystery, and good old fashioned sexual allure. I have a feeling that it will require a second viewing at least to collect the myriad connections between the delicatedly interwoven plotlines.

In other news, a touch of irony. I first learned the word untonsured in the opening chapter of Ulysses; now, after having employed the word in one of my blog post titles, I have jumped to the #1 "untonsured" search rank on Google. The next three search results quote the passage from Ulysses from which I gleaned the word in the first place. It's funny how that works.

ADDENDUM (5:54PM, 4/13): penis

Grey's Anatomy posts

2005-04-11T11:16:00.000-07:00

It now appears that the primary source of search traffic leading to my blog (aside from the occasional "bifid penis" or "severed penis" search -- why did I ever have to mention the word penis?) relates to Grey's Anatomy. In the interest of increasing my blog's navigability, therefore, I have added a little drop-down menu just beneath my profile box on this main page that links to all of my Grey's Anatomy posts. As always, I aim to please.

Also, I stumbled upon a local Seattle blog that offers some insight into the dubious geography of the show, as well as other Seattle-related info.

Back in town just in time to catch Grey's Anatomy

2005-04-10T20:08:00.000-07:00

I spent Saturday and the better part of today in Chicago for my friend's bachelor party. I learned two things: 1) Having a Super Bowl ring, as my friend's soon-to-be brother-in-law wears on his left index finger, opens more doors than you can imagine. People with Super Bowl rings do not wait in line. I must set about procuring a Super Bowl ring for myself as soon as humanly possible -- hopefully the gym is still open at this hour, and I can pound out a couple of sets of bench press. 2) Strip clubs make my skin crawl. When I have a bachelor party of my own, I think I'll insist upon all of us spending the day opening doors, pulling out chairs, throwing our coats over puddles, and otherwise engaging in chivalric behaviors as symbolic atonement for all the mischief and debauchery of bachelor parties throughout human history.

Anyways, the party overall was a lot of fun, and I got to see and experience my friend become increasingly bellicose as the night wore on, culminating with him sucker-punching me -- unprovoked -- in the right kidney. But hey, at least I have two of them, right?

So I returned home just in time to run a few miles, eat, and sit down for a full episode of Grey's Anatomy. As I've previously mentioned, I have voluntarily assumed the role of the paladin of medical truth who shall combat the evil misinformation proffered forth by ABC with this drama. Today I was actually surprised to find relatively little (in comparison with earlier episodes) with which to quarrel insofar as actual medical information is concerned, though situational and character realism remains quite a deficit in this program. Major points, in no particular order:

1) I really expected them to royally screw up the brain death issue. However, I think the writers sneaked in a consult from a real life person who knows something about medicine! In fact, patients with demonstrably absent brain activity and corneal reflexes undergo an observation period of six hours -- assuming that corroborative tests, such as an EEG, have been performed -- prior to the pronouncement of brain death. Interestingly -- and it's too bad the show writers didn't work this one into the storyline just for kicks -- brain dead individuals can actually exhibit a particular spinal reflex, aptly titled the "Lazarus reflex," involving the patient sitting up in bed . Oh well, that was a missed opportunity for dramatic sensationalism.

2) Based on this show, you would think that the only way any organs ever get donated is via surgical interns having the bright idea, "Hey, this guy's brain is dead, but his body isn't! We can donate his organs and save a few lives, but more importantly, WE CAN SCRUB IN ON AN ORGAN DONATION CASE! SWEET!" Nah, it doesn't work like that. Most hospitals have firmly established policies and procedures to ensure smooth harvesting and distribution of available organs, provided the family agrees and/or the patient's wish to donate was known in advance.

3) Donation matching isn't quite as quick and easy as checking the blood type. Most major organs, aside from the heart, are also typed according to major histocompatibility antigen proteins in order to reduce the risk of transplant rejection -- although newer anti-rejection drugs have made this increasingly less of an issue.

4) Most interns know how to speak to family members better than the character Cristina, who has all the tact and compassion of a yam.

5) Most interns don't scream, yell, and gesticulate while watching television, prompting you to suspect that perhaps the Super Bowl is on (and I'm playing WR, earning my ring), when in fact all they are watching are some old tapes of operative procedures. Enthusiasm is good; too much enthusiasm is pathologic.

6) A patient whose peritoneum has been punctured by nails (or whatever those metal foreign objects were that protruded from the belly of "Viper") does not present the next day with a wound dehiscence (i.e. wound falls apart)and an evisceration (i.e. bowel contents pouring out); the rent in the connective tissue would not be large enough. Rather, his peritoneum would simply become infected, and he would more likely return to the ED in septic shock. But sepsis is less exciting than bowels falling out, and with sepsis we don't get to see Ellen Pompeo (Dr. Meredith Grey) mounted up on top of the patient in some sort of medical heroics that also serves double duty as sexual innuendo.

7) Interns are busy. Repeat: interns are busy. Just in case you missed it, INTERNS ARE BUSY. They don't sit around in the E.D. waiting to cherry-pick the best patients, they don't spend all day and night in a brain dead patient's room, they don't observe every case that rolls through the O.R., and they don't somehow manage all to appear in the same place in the same time. In actuality, they find work constantly thrown upon them, in all the far reaches of the hospital, and generally make themselves scarce in all places but the patient floors where they have five thousand chores to complete before evening rounds. Watcing Grey's Anatomy, I almost begin to believe that my intern year will be easy easy easy. Apparently, it's all glamorous romance, subversive machinations (such as every time somebody defies Dr. Burke, who in reality would probably scalp somebody by now), and heroic holding of bowels in place! I can't wait for the fun to begin.

I love VH1

2005-04-06T18:05:00.000-07:00

vh1_love_90s
Originally uploaded by Ian D..

Say what you want about VH1's surfeit of "I love the (insert favorite decade here)" and "Best Week Ever" shows -- I'll still keep coming back for more. It's perfect television for those with a limited attention span: brief, catchy segments, peppered with comedy, that highlight the most newsworthy events of...whenever. These shows bundle humor and nostalgia into one potent combination pill. Most importantly, these VH1 masterpieces encourage me to plant my arse on the couch and budge only to feed and eliminate. What could be better?

In other news, it turns out that the majority of the searches that yield my blog these days relate to Grey's Anatomy. So, I hereby appoint myself to the position of Grey's Anatomy Misinformation Filter; be sure to check back every week for the latest update on all that is false and misleading on the new ABC drama.

I have not, alas, seen the show House. Maybe I'll check it out sometime soon -- provided it doesn't conflict with "I Love the 90's Part Deux."

Astounding productivity

2005-04-05T23:56:00.000-07:00

Please allow me to allocate space on my blog for the list of things I accomplished yesterday (i.e. the current day, as I have not yet retired for a night of sleep):

Okay, thanks for reading!

(I'm about as useless as an ordure-caked wad of toilet paper; sorry for the gross-out.)

This week's gripes about Grey's Anatomy

2005-04-04T17:01:00.000-07:00

Okay, so I missed the first half hour of the show again (I seem to have begun a pattern here), but nonetheless I'll take my stab at dispelling Grey's Anatomy - induced misconceptions.

1) Most hospitals have places to store severed penises. Those places do not include the trustworthy hands of surgical interns. Nevermind the fact that ice evinces an inherent proclivity to melt, and that after just a few hours the severed penis would be floating in lukewarm bloody water; unless, of course, the surgical intern devoted much of her already limited time to opening her little red and white cooler, dumping the broth from the penis soup contained therein, and re-packing the cooler with ice. Anyhow, the take-home-message is that severed penises are kept in special severed bodypart refrigeration devices, and are not carried around ad nauseum by surgical interns.

2) At an academic medical institution, the chief of surgery typically does not hand-pick his successor. Rather, the hospital board makes the decision, generally at the behest of a cadre of executive faculty members (i.e. multiple chiefs of other services in the hospital). This actual scenario provides much less drama and interpersonal competition, however.

3) Yes, indeed, surgical interns sometimes scrub into cases and find themselves merely holding a retractor. However, this task generally finds its way into the category of "things I hate about internship," and does not cause ejaculations of joy and awe as we once again saw from Dr. Grey in this episode. The girl is seriously going to lose her sh*@ when she actually gets to make an incision or close a wound.

4) Every newborn baby has its blood oxygen content checked via pulse oximetry. Cyanotic heart conditions such as Tetralogy of Fallot generally do not just 'slip by,' waiting for the gallant surgical intern to swoop in and save the day.

Well, that's about enough. If I had watched the whole show, I might have had more. And by the way, if my fault-finding becomes annoying, feel free to send me a nasty email or berate me mercilessly in my comments.

-------------------------------------------------------------------

In other news, this and this are pretty cool. It appears the scene in Star Wars in which Luke's severed hand (a lot of talk of severed body parts today, I know) is replaced with a robotic hand may become more fact than fancy in coming years.

What happens when people spend too much time in a dark room

2005-04-02T16:04:00.000-08:00

Every once in a while I stumble upon a medical discovery that renews my hope that one day, we might through our astounding ingenuity finally conquer all human disease and suffering. Indeed, today I feel warmed by the promise of a field of medicine that can teach us that, in fact, the penis assumes a boomerang shape during coitus. Here is the study, in PDF format. May you bask in the radiance of its intellectual triumph.

(Click on the "Begin manual download" button in the center of the screen if the study does not appear.)

Add to that list untonsured

2005-04-01T15:37:00.000-08:00

By the way, I am not only fat and ugly, but my hair is getting out of control. I already have an enormous head, but when I let it become overgrown with a thick matte of sandy-blonde, sprouting profusion, I begin to look rather ridiculous. For those of you who have ever played Goldeneye on Nintendo 64, and who have had the pleasure of entering that code that gives all the characters ultra-large heads, well -- you know just what I look like.

Anyhow, I have had a rather good day as I finally lit upon something about which I actually feel motivated to write -- not for my blog, but for real-life writing. I'm revisiting my college days, when I ran cross country and track and measured my life in weekly miles and pairs of worn out running shoes. I find it quite mentally liberating to re-live my running days in fiction, as my own running career came to a premature end due to injury. Watching fictional characters face the same challenges you did -- and then steering them either to safety or catastrophe -- can be a serviceable antidote for regret.

In other news, interest rates continue to rise, and the very real possibility exists that I will not be able to purchase the house I had decided upon as my home for the next seven years of residency. Ahh, disappointment.

But I'm fat, I'm ugly, I'm unkempt, and things have nowhere to look but up.

When I need motivation

2005-03-31T23:49:00.000-08:00

I AM FAT AND I AM UGLY.

My friend Erik taught me that mantra -- it's the remedy for complacency. Whenever I realize that a part of me thinks I've got this life thing sussed out, I just say, "I am fat and I am ugly." It also serves a dual purpose when one is in a self-deprecative mode.

I AM FAT AND I AM UGLY.

One out of seven deadly sins ain't bad

2005-03-29T23:55:00.000-08:00

This photo of me was taken just moments ago as I reclined in my favorite tree. Seriously, I have become a sloth. I'm sleeping nine hours a night, taking naps in the afternoon, and finding it difficult to mount enough motivation even to perform basic chores such as grocery shopping. Well, I'm drawing the line... I will fight my slothfulness henceforth. So here I am, with my newly discovered will to strive (and, apparently, facility in French):

Painful television

2005-03-27T20:01:00.000-08:00

I will have the dubious distinction of beginning my surgery internship shortly after the beginning of the new ABC program, "Grey's Anatomy," which is about a group of surgical interns. Initially I had high hopes that the program would help to illuminate for the general public what surgical interns actually experience. What a foolish little expectation that was! I only caught the last half hour of the show today, but it was enough for me to grow terribly dissatisfied with the veracity of the plot. First, the interns on this program appear roughly as competent as mediocre third year medical students. Second, at every turn the doctors on the program violated HIPAA standards and residency work hour regulations; please don't watch this show and develop the misapprehension that doctors shout to each other through a crowded elevator doorway the intimate details of a patient case, or that whole teams of interns still work 48 hour shifts before retiring to home! Those things don't happen anymore, thankfully. Also, interns don't salivate over the chance to stand passively in the operating room during a brain surgery -- not scrubbed in -- and then have an orgasm when offered a momentary opportunity to look into the microscope. "It was such a high; I don't know why anybody does drugs," said the main character, the intern Dr. Grey. Aack! Continuing the strong dialogue, the attending neurosurgeon (who also happens to be Grey's love interest -- hey, it's drama, right?) nods like a bobble-head doll and says, "Yeah." Way to contribute to the profundity, there, big guy! So in any event it appears that neurosurgeons don't undergo the longest, most arduous residency and work the most challenging hours in medicine out of a sense of professional duty and committment to their patients; nay, they do it 'cuz it's better than crack!

As for the actual medical content of the show -- well, I won't waste time pointing out the whole host of inaccuracies. Suffice it to say that there were plenty -- more inaccuracies than truths. Painful, painful, painful.

As much as I hate to face this fact, I actually feel compelled to watch "Grey's Anatomy" repeatedly so as to know the extent of the misinformation that will bombard the public during the next several months before the show gets canceled. I can't wait until somebody hears that I'm a surgical intern soon and asks, "Is it really better than drugs?" Yeah, it's like sniffing nose candy all day long. I can't wait -- I'm going to feel like Tony Montana sitting behind a foot-tall heap of yeyo, and I'm going to get paid for it! The world is mine!

What do I do? Oh, well I'm a high school english teacher.

2005-03-24T20:47:00.000-08:00

I haven't even started my neurosurgery training, and already I'm tired of telling people what I'm going to be when I grow up. It seems that the range of responses of which people are capable when hearing the word "neurosurgery" in conversation is actually binary. Either they reply with a 0, which is machine language for "OH MY GOD! A neurosurgeon? You really don't ever want to know your kids do you? You'd better have a very understanding wife. Well, actually, I'm quite sure you'll have several. Man, you seem really well adjusted for a future neurosurgeon. I guess a lot of 'em must start out normal, though -- it must be the training that kills the personality. Well, I guess somebody has to do it. I'm just glad it's not me." Alternatively, they respond with a 1, meaning, "..." (awkward pause, jaw agape), "Wowwwwwwwwwww...that's awesommmmmmmmmmme. That's really hardcore. I can't even imagine what that must be like. So you're going to look at people's brains and stuff? Wowwwwwwwwwwww...that's awesommmmmmmme. Congratulations. Wowwwwwwwww... That's really hardcore."

That's just about all I get. And so far, no groupies. Somebody should have told me ahead of time there weren't going to be any groupies, because that's a bum deal. Come to think of it, though, not even the neurosurgery attendings seem to have much of a following. Even when their legs are soaked to the knee with blood and cerebrospinal fluid, and they're finally getting out of the OR at 9pm, and they're on their way to their office for a teleconference with their attorney about the latest frivolous malpractice suit, they still don't seem to have any fans hanging about, nor even any paparazzi vying for an unobstructed photograph. Hmmm...I guess all the rocket scientists get groupies, though. DANG IT! Too bad I didn't have any rocket science skills.

So anyhow, I'm thinking of renaming my blog, "Not American History," and writing about my imagined life as a high school english teacher. What do you folks think?

An apolitical post about Terry Schiavo's case

2005-03-23T00:38:00.000-08:00

Wow, I can't sleep. I just spent a while reading a blog by a radiologist, who offers his opinion of the Terry Schiavo case. I couldn't resist adding a comment on that site. Meanwhile, I have resisted using this blog as a forum for my personal opinions regarding the case. Honestly, I don't know enough about it, and neither, I believe, do 99% of the people we hear blathering on about it on the news. In any case, I would like to offer some basics of medical ethics -- the ideas upon which this case is founded.

After the horrors committed in Nazi Germany in the first half the 20th century, the international medical community developed four overarching principles of medical ethics to which all physicians must adhere when making medical decisions. These principles are, in no particular order: 1) Beneficence -- the physician must try to help the patient; 2) Non-maleficence -- the physician must not try to harm the patient; 3) Justice -- the physician must consider the impact of the patient's care upon the society, both locally and at large (e.g. using limited resources on exhorbitant treatment for a dying patient is unjust if it deprives other patients of their opportuninity for treatment); 4) Autonomy -- the physician must respect the decision making capacity of the patient, and must not administer treatments against the patient's will. It is this latter ethical principle that comes into play in the Terry Shiavo case. From the standpoint of medical ethics, it doesn't matter if the family wants Terry to live, or if Michael Schiavo wants her not to live. The ONLY issue in question should be, 'What would Terry want for herself?' That is the principle of autonomy in action. We must respect what Terry would have wanted. That is the reason why Michael Schiavo has won every court case to date regarding Terry's treatment: he offers testimony (whether you believe it or not) as to what Terry expressed to him she would want done under such circumstances as she now faces. It's the only thing that matters.

Also, we have this large problem of having to remove a feeding tube in order to allow Terry to pass away. Some people see such an act as tantamount to murder; she was alive, then the doctor did something to her, and then she began to die. However, a well-established precedent exists that the withdrawal of treatment is no different, from a medicolegal and medical ethical standpoint, than never offering treatment in the first place. So taking the feeding tube out -- even 15 years after its placement -- becomes a question of whether or not Terry would have wanted in the first place to undergo an invasive procedure in order to obtain nutrition that would maintain her in her present state. The issue becomes more thorny because the court order Michael Schiavo recently obtained also contains prohibitions against Terry receiving anything by mouth, such as food or even water. I must admit that I'm a bit out of my depth in dealing with that particular issue -- perhaps the family could be allowed to care for her, sans tube, as a compromise that still respects Terry's autonomy? I just dont' know.

In any event, this case has become a terrible conundrum (gee, Ian, thanks for that insight). The take-home point, though, is this: make sure that your loved ones understand your wishes if, God forbid, anything should happen to you. Making clear, illustrative statements such as, "I do not want to have any medical treatment if it means living in a persistent vegetative state," is a good thing. Better yet, capture those wishes in print in the form of a living will that provides guidance for your loved ones. Better still, if you know of an authoritative figure who can make well informed, dispassionate decisions on your behalf, obtain legal documentation to appoint that person as your durable power of attorney should you lose decision making capacity. For example, many physicians have a fellow physician as a proxy decision maker. The idea is that this person would be educated about the pertinent issues and would not let emotion stand in the way of faithfully representing what you would have wanted. Moreover, certain pitfalls associated with a living will can be avoided, because written documentation is by nature static and finite, and cannot delineate exactly how caregivers should act under an infinite number of circumstances. Whatever you do, remember that it's never too early to think about this sort of thing; Terry Schiavo is a prime example.

Okay, I'm sleepy now. Hopefully I kept this post relatively free of opinion, restricting it instead to background info and general advice.

Bored, bored, bored

2005-03-22T22:40:00.000-08:00

A friend of mine who reads my blog (my only non-Internet friend who routinely reads it) was a bit confused by my last post, which is probably because I was not clear about the origin of the poem that I trashed. I think that's understandable, because nobody in his right mind would actually take something he created himself and criticize it so sardnonically, right? Well, sometimes I like to mock myself in order to ensure that I'm not taking myself too seriously. It works for me; I find it difficult to remain in a melancholic mood for any length of time if I consider myself a buffoon who worries himself to death over trifles.

Anyhow, I spent today (well, yesterday, at this point) expressing how completely burned out I've become on my steady diet of medical school this and medical school that. I tried to read a few pages in American Pastoral by Philip Roth, but then I got bored and stopped. So, I moved on to Sons and Lovers by D.H. Lawrence, but then I got REALLY bored and stopped. Next I tried to do some writing, but about two hours and forty words of composition later, I realized that it just was not going to happen today. So, I acquiesced to my urges and drove off to the casinos, where over the course of four hours I succeeded in losing $100 playing limit Hold 'Em. It's no big deal, though -- I just won't eat for a week or so, and I'll make up for that lost money, no sweat. Eating is overrated anyhow.

So is sleeping, by the way.

Esa poema es terrible

2005-03-21T23:59:00.000-08:00

As I remain stricken with intense blogger's block, I decided to post some more old poetry rather than leaving my blog blank for another day. This piece (of ____), written about three years ago, is a particular favorite of mine, as it calls to mind what a room full of chimpanzees might produce if they were provided a typewriter and a thesaurus, and then given abundant time -- oh, say, twenty or thirty minutes. Oh, and they should be nihilistic chimpanzees. With hemorrhoids. Okay, so we're limiting our candidate pool -- one nihilistic chimpanzee with hemorrhoids will do.

This chimp should do.
Originally uploaded by Ian D..

"By the Campfire"

By the side of the fire he lays his head;
The remnants of his dinner still adorn
His plate -- fresh caught fish and canned corn.
He relishes lying where other feet don't tread.
Gazing at the starry night, a wistful thought
Encroaches. Could he stay? Let his absence
Spill and blot out all the words of nonsense
That ruefully define the diction of his lot?
His mind ascends on a blissful gust, as he
Ponders the wonders of a hermetic home
Here, devoid of the paragraphs in the tome
Of his life, written so peremptorily.
Yes, he will stay! O joyous evening away
From the painful truth of his reality among
The Others! Here there is no truth slung
Gravely upon his neck, but only day after day,
And time stretching endlessly before him while
The guileless rain washes off the caked history
Of society and leaves the indelible mystery
Of Nature to curl his wayward lips into a smile.

Then, a baleful epiphany clatters over the hills.
He must return. The firm dictate of a Nature who
Will not have him here: he must wade through
The fetid mire of what he was granted, as God wills.

Wow! Great job, Coco! I particularly like how you threw in that line about the canned corn so as to preserve your simplistic rhyme structure. Nothing says poetry like canned corn. Now, was that creamed or whole-kernal?

Anyhow, Coco, you have done yeoman's work with that thesaurus we gave you. In fact, learning only the vocab words you forced into this little poem would be sufficient to ace the verbal portion of the SAT! And as we all know, the key to good writing is to cram as many inkhorn words in there as can possibly be made to fit. You've really outdone yourself here, Coco. Hey, are you even listening to me? Put down that typewriter -- that's not food! Bad Coco!

P.S. In looking for a picture of a chimpanzee I happened upon this little fellow, who is apparently buggering himself. Somebody actually painstakingly sculpted this thing.
Ahem...what, exactly, is that right hand doing?

P.P.S. Upon further review, it appears that the right hand is actually involved in the wholly innocent endeavor of clutching the right thigh, and that I in my idiocy have mistaken the chimp's foot with his hand. That's not to say he hasn't developed certain talents with his right foot, though.

P.P.P.S. And besides, he's a cute little fella, even if he is abusing himself.

Oh, by the way, I believe it was just last night that I swore off these 2am posts. Just ignore everything I say; it'll be better for all parties.

My mood swings have put me in a bad mood

2005-03-21T00:30:00.000-08:00

"Drying up in conversation
you will be the one who cannot talk"

I've been feeling out of sorts the past few days. I'm not sure if it's because of the recent Match that signifies the impending conclusion of my medical school training (and the inexorable advance of the next seven year phase of my life), because I will likely sign a contract on a ridiculously expensive house tomorrow, or because my girlfriend departed today for her three week trip to India. Whatever the reason, I have felt rather leaden. My blog has suffered, as you can perhaps surmise from my recent uninspired and laconic posts. On the plus side, though, I seem to have installed a new time sink into my life: Blogshares. Somehow becoming a mogul in fake blog stock has struck me as more important than reading or writing anything substantive the past few days. Well, I intend to readjust my priorities tomorrow and spend my time in a more constructive fashion. That's not to say I won't strive to increase my net worth in B$, but I will at least spend a few hours tomorrow writing. Perhaps getting my sleep schedule back in order wouldn't hurt either! (Sorry, no more 2am posts).

Blogger's lassitude

2005-03-19T22:59:00.000-08:00

I could write a nice little blog post this evening. Or I could just sit here and stare at my computer screen, my wall, my feet, and any other random thing that happens to catch my eye. Yeah, I'll do that. G'night all.

Pervasive nausea

2005-03-18T21:55:00.000-08:00

Having mentioned a particular medical supply (heretofore indicated by the initials V.S.) a multitude of times in recent posts, my infernal Google ad bar has become a one-stop-shopping alternative for all your pelvic examination needs. Though I must admit to some curiosity over the extent of the damage done, I cannot gather the guts to run a Google search for a V.S., lest I find that my blog has actually occupied a high station. Ugh. Time for some Zofran.

What? On what?

2005-03-17T23:07:00.000-08:00

Search used to find my blog through Google:
"cystic on man's balls"

Sweet. The search, that is -- not the balls.

Feeling ill

2005-03-15T20:55:00.000-08:00

I just noticed that the Google ad bar I placed on my blog some time ago in a fit of poor judgment has dealt me a formidable blow. Yes, indeed...I am now advertising vaginal specula on my blog. Come one, come all, get yours while they're still cold! Special price for you today! Get your vaginal speculum here!

I must make this feeling of nausea go away, but I'm so dumbfounded that I can't decide whether to use my finger or the back of my toothbrush to gag myself. Any suggestions?

Ch-ch-ch-ch-changes

2005-03-15T20:48:00.000-08:00

Not feeling like writing any content for my blog tonight, I decided instead to fiddle with the sidebars and add two new features. First, I have a column called "My Published Writing," which at present contains the only story I've ever published: one that happens to be published in my school's literary journal, which probably amounts to exactly nothing in terms of the gravity of the accomplishment, but at least it's a start. I hope to add links to more published stories in the near future.

I also borrowed an idea from L and added a drop-down menu with links to some of my earlier posts of significance. If you feel like browsing, these represent my attempt to cull the wheat from the chaff, so to speak, saving you the trouble of having to wade through multitudes of inane posts about online quiz results and the like.

Anyhow, thanks for reading, and to all, a good night.

To this chapter, a conclusion

2005-03-13T21:55:00.000-08:00

Yesterday I finished the second stage of my medical board licensing examination, meaning that I will now be able to practice medicine as an intern come July 1st. More importantly for me in the short term, though, is the fact that I can now go about the practice of life in an unencumbered fashion, reading and writing what I want, when I want. It's a nice feeling. Of course, nagging issues will arise and demand attention, such as ongoing student government duties and the detail of a graduation speech I have to prepare. However, those things will not seem too terribly painful now that my time is my own once again.

The exam was another exercise in attrition. I had to see twelve patients, performing a thorough history and physical exam on each, and then summarize my findings in a medical record note. It wouldn't have been so bad were it not for the unrealistic time constraint imposed upon us: 15 minutes to interview, examine, and counsel the patient, and 10 minutes to write it up. The latter time limit I could handle, but 15 minutes to see a patient borders on absurdity. Oh, sure, doctors do it every day in their clinics (we've all likely been on the receiving end of all-too-brief care, seeing a blur of a white coat move into the room and steamroll us with a mechanical diagnosis and treatment plan), but they do so with the aid of pre-printed patient history forms filled out in the waiting room, saving them the effort of asking about Aunt Clarice's psoriasis and other minute details. Nevermind the fact that practicing physicians have...well, years of practice, which tends to expedite the process of clinic visits. In any case, 15 minutes proved vastly inadequate for me to feel comfortable in creating a quality patient encounter. Yet, that was the scenario presented to me. So, for eight hours total (we had a couple of breaks, hence the failure of the math), I plowed through patient after patient... Oh, wait. I can't really say any more. See, the first rule of the Clinical skills exam is you're not supposed to talk about it. And the second rule of the clinical skills exam is you're not supposed to talk about it. Seriously. I could get in trouble. In fact, I may just burst into a smoldering pile of charred bones in an instant if I divulge any more details. Suffice it to say that I feel tired and worn, but glad to be finished. Now it's time to gather the scraps of my life, and during the next three months, paste them together into such a patchwork that, though it will not likely resemble the real thing, it may serve as a suitable substitute. So bear with me.

And thanks to everyone for persevering during the great Blogger comment famine. My trip to Chicago left me unaware of the turmoil, but I was pleased to find a couple of emails waiting for me upon my return. Thanks to KarbonKountyMoos for the great postcard, and sorry to Extreme Unction for the delay in providing apt medical terminology for toes. It's good to be back.

Sapped of production capacity for tonight

2005-03-09T20:39:00.000-08:00

Initially I felt like writing a decent blog entry tonight, but upon sitting down at my computer I found my mind wandering to stories and themes I would like to explore in depth at a later date; nothing sprang to mind that would suit a quick blog post. Besides, I'm tired from studying and generally overcome with evening lassitude, so here instead is a poem that I wrote about three years ago. I don't write poetry, by the way. Let's just get our excuses out in the open beforehand.

Tender is the breath that blows
The fine powdery dust from the stone;
What words there linger on the slab
That marks a passage to a lasting home?

Carved in the granite, defying the flow
Of time with an ebb of the infinite,
The words bespeak the works and days
Of a tireless body and the soul within it.

Words to sum, words to conclude --
What do they say, those sentinels
Of a singular history? What ink did
This life score in the world's annals?

Ah -- a closer look reveals that
The space for summary remains yet blank;
So still I can choose: what grave words
Will encapsulate me once my corpse is cold and dank?

I'm like a speculum...

2005-03-07T23:28:00.000-08:00

speculum
Originally uploaded by Ian D..

...that's how many medical examinations I have endured. Though, hopefully, most women don't bristle at the sight of me as they do upon glimpsing that bad boy.

Once again, a board examination detracts from my enjoyment of my final months of free time before I begin residency. This coming Saturday I'll take the second part of my USMLE Step II board exam, this one consisting of 12 standardized patient encounters that will demonstrate my proficiency in patient communication and the diagnosis/initial management of some common diseases. Alas, this test pretty much blows, and I am loathe to devote ample time to preparing for it. But I must. So, begrudgingly, I spent a few hours today, and I'll spend the rest of the next three days, studying like the obedient little student I am.

I wrote a long rant about the exam, its premise, and its implementation earlier today; however, I decided against publishing it, both in the interest of avoiding a needless increase in the negative Karmic energy of the world, and in the irrational fear that somebody from the National Board of Medical Examiners would come upon what I wrote and decide to fail me out of spite. Well, the latter is not really a concern for anyone not suffering from a paranoid delusion (thus not a concern for me!?!?), but in any case the rant served its purpose by providing a much needed catharsis. Now it's gone, deleted, and I'll hear no more about it, understood?

Well, I'm off to bed and then back to the books. I'll try to post intermittently for the next few days, then return to our regularly scheduled programming next week.

Me too

2005-03-05T22:43:00.000-08:00

I saw a link to this quiz on The Meat of the Matter, and I ended up getting the exact same result as he did. I guess it's reassuring, somehow.

Your Brain is 33.33% Female, 66.67% Male

You have a total boy brain

Logical and detailed, you tend to look at the facts

And while your emotions do sway you sometimes...

You never like to get feelings too involved

What Gender Is Your Brain?

Lessons from The Jacket

2005-03-05T21:54:00.000-08:00

I watched The Jacket this evening, a new film starring Adrien Brody and Keira Knightley. This is what I learned, whether or not I wanted to learn it (WARNING-- MAY CONTAIN PLOT SPOILERS, especially #7):

1) Time travel may or may not be possible
2) Presenting time travel on film with an internally coherent plot is patently impossible
3) Apparently -- I had never noticed this before -- one's memories actually appear on the retina as if cast forward from a movie projector located (I would guess) somewhere just posterior to the optic canal
4) Keira Knightley's breast development is roughly Tanner Stage III
5) Keira deserves respect for showing us that one need not have 500cc saline bags implanted prior to exposing one's breasts on film
5) Adrien Brody's maxillary teeth are in fine order, whereas his mandibular teeth are all over the place
6) When observing extreme close-ups of the mouth, one gains greater appreciation for Eliot's description, "her teeth were only accidental stars with a talent for squad-drill"
7) Wretched, ill-devised, cruel, medieval psychiatric treatments are not for everyone; side effects may include PTSD, time travel, and -- if one has already sustained a severe scalp laceration leading to profuse hemorrhage -- death from unabated continuation of said hemorrhage

But at least I learned something.

The best laid plans

2005-03-04T19:20:00.000-08:00

For the past couple of years of med school, during which I have studied until my mind was dull, I often thought how fun -- and how easy -- it would be to write. Alas, I rarely found the time to write, as my studies and/or clinical duties demanded my attention anywhere from 10-24 hours per day, but I always thought wistfully of how blissful such a pursuit would be. A recollection came often to my mind of an article I had read which stated that Stephen King, one of the most prolific of contemporary writers, could produce as many as 1500 words(!) per day; yet that total struck me as rather mediocre. I knew that I myself could write 1500 words in a couple of hours, so surely I could produce at least five times that much in a single day! Hmmm...

I'm working on a short story at present, and I must admit that my previous conceptions of the writing life are proving far askance from reality. Don't get me wrong, I've written many a short story before, so the realization of the difficulty of writing comes as somewhat of a shock to me now. Though I cannot say for sure why I have begun to suffer this newfound difficulty, I suspect that my medical training has had a sure influence: whether by instilling in me a greater appreciation for economy (as all medical communication places a priority on being succinct), by making me more intently focused on the quality of my product, or even perhaps by robbing me of some of my basic literary facility, med school has made it exquisitely more painful for me to write. In any event, my goal of writing a novel before beginning my residency on July 1st may prove daunting indeed, and will surely require me to eliminate needless distracions from my daily routine. Hence, I may pass on addictive but time-sucking activities such as Texas Hold'Em. Man, I'm gonna miss Texas Hold 'Em.

Meanwhile, with this resolution fresh in my mind I just spent an hour on my girlfriend's couch watching America's Next Top Model. Way to go, Ian. That's time well spent, buddy.

P.S. More acurately, I spent an hour coughing, sneezing, hacking, wheezing, and generally making the world a snottier place to be, all while watching America's Next Top Model on my girlfriend's couch. I am tormented by millions of organisms that don't even meet the minimum criteria for life. Humbling, indeed.

On receipt of a parking ticket

2005-03-03T23:32:00.000-08:00

A great benevolent

Force

Protects

the

innocents

On even dated Wednesdays

Do not fear

No big surprise here

2005-02-24T23:46:00.000-08:00

I could have predicted this result:

Disorder	Rating
Paranoid:	Moderate
Schizoid:	Low
Schizotypal:	Low
Antisocial:	Low
Borderline:	Low
Histrionic:	Low
Narcissistic:	Moderate
Avoidant:	Low
Dependent:	Low
Obsessive-Compulsive:	Moderate
-- Personality Disorder Test - Take It! --

But really, why am I not asleep?

Great Balls of Fungus

2005-02-24T09:14:00.000-08:00

Following his correct replies to my literary trivia and the receipt of his Kudos, Extreme Unction requested the name of a respiratory infection that could be obtained from living in a damp Irish boarding house. As per that request:

Aspergillus fumigatus is one of the most common spores you might encounter in the environment, and the one most likely to lead to a respiratory infection. Typically it affects individuals with certain predisposing factors, such as immunosuppression, asthma, cystic fibrosis, or previous cavitary lung disease (i.e. TB). The manifestations of the disease differ depending upon the host's status. For instance, if your boarding house resident has asthma, he might become infected with Allergic Bronchopulmonary Aspergillosis (ABPA), involving high fever, cough, hemoptysis (bloody sputum), and general respiratory distress (wheezing, difficulty maintaining oxygen saturation of the blood, etc.). If, on the other hand, your character has a hole in his lung such as from a previous TB infection, he might form an aspergilloma, which is literally a ball of fungus that occupies that lung cavity; the manifestations of this sort of infection would not be as severe as ABPA because the fungus ball remains somewhat isolated in the lung tissue, but symptoms would nonetheless include fever, cough, and bloody sputum -- the latter of which can, in some cases, become massive and life threatening. Finally, if your boarding house resident has some degree of generalized immunosuppression, such as AIDS, neutropenia (reduced white blood cell counts due perhaps to cancer or its treatment), immunosuppressive therapy, or even severe alcoholism, he might suffer from either invasive aspergillosis or chronic necrotizing aspergillosis. The former is a uniformly life-threatening infection involving, as the name implies, an invasion of multiple body tissues after the aspergillus spores make their way into the bloodstream and disseminate broadly. The latter, chronic necrotizing aspergillosis, is a longer-term, less acute infection of the lungs that may mimic various other types of pneumonia and lead to multiple rounds of futile antibiotic treatment. It ultimately can lead to the death (necrosis) of large areas of lung tissue if allowed to progress unchecked.

Anyhow, this may have been more info than you desired, but I wanted to provide a thorough list of clinical scenarios in order to provide the best fodder for your story. It strikes me the aspergilloma is the most fascinating infection, as the fungus sets up shop in its own sequestered micro-environment of the lung, and can remain there for years. A character with this problem might even find himself coughing up the same stuff that's growing on the walls of the damp boarding house room. All he needs in order to be eligible for this fascinating disease is a hole in the lung; if TB isn't glamorous enough, perhaps he could have suffered a gunshot wound to the chest at some point; all of those fungi could crowd themselves around a nice .22 caliber bullet lodged in his right upper lobe. In any case, good luck with the writing.

2005-02-24T00:19:00.000-08:00

Here's a picture of me with my girlfriend at our Senior Medical Students' Dinner, 2005.

2005-02-23T20:17:00.000-08:00

As promised, I offer Kudos to pinhut at Extreme Unction for his rapid, accurate responses to the literary trivia questions in my last post. He gets Bonus Points as well, for what it's worth.

Well now that's done: and I'm glad it's over.

2005-02-22T22:25:00.000-08:00

I took my Step II board exam today. Or rather, it took me. The test endured for a total of nine hours, with eight one-hour blocks of questions and an hour of break (O such overwhelming magnanimity!). During this time, I faced a continuous stream of questions designed not so much to test my knowledge as to break my will and leave me crestfallen. Despite taking four Vivarin (4*200mg of potent, alertness-inducing caffeine), my attention flagged after about two hours into the exam; in fact, to say that my attention flagged is somewhat of an understatement, as even Betsy Ross would envy what this exam created of my meager mental capacity. I struggled, battled, and sweet-talked my mind into finishing the interminable onslaught of questions, but by the end I was suffering even trying to read, much less to discern the proper management of yet another cause of second trimester bleeding (Ob-gyn, my least favorite subject, featured prominently on the exam, as it turned out). All in all, now that I have finished, my brain feels rather like a stadium urinal at the end of the seventh inning stretch: slightly stained, frothy, possessed of a singularly foul odor, and altogether used. Thankfully I have a few months to recover my wits before my surgical internship begins, and patients' lives actually depend upon my clinical acumen.

Well, since completing my exam I have ventured to the local riverboat casino and pissed away $120 into the Mississippi River, then returned home and voraciously consumed a glass of port wine and two bottles of McEwan's Scotch Ale (the best beer on the planet). Now I have about two hundred pages of reading to complete before my Health Administration class at 9:00am. So it goes.

*Kudos to the first person (amongst my substantial readership, ahem...) to recognize the source of the title of this post. No cheating with Google, though!
*Bonus points if you point out the novel in which "So it goes" was utilized as a concise means of recognizing the conclusion of a human life. (I have, of course, abused the term here).

A sad day in the literary world

2005-02-21T13:34:00.000-08:00

Hunter S. Thompson committed suicide today at his home in Aspen, CO. The story is here:
http://news.bbc.co.uk/2/hi/entertainment/4282865.stm

I was a sophomore in college when I read Fear and Loathing, which still stands out as having perhaps the most vivid imagery of any book I've read. Anyhow, this is sad news for anyone familiar with Thompson's work.

The drudgery continues

2005-02-18T21:36:00.000-08:00

Well, this is now my sixth consecutive day of 10-12 hours of studying. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy. All work and no play makes Jack a dull boy.

Anyhow, I have amused myself during my study breaks by going to homestarrunner.com. You see, when I took one of those online quizzes not long ago, "Which website are you?," I learned that I most resemble homestarrunner.com, because I am flashy [sometimes] and funny [again, sometimes], I have a large following [well, not really], I talk funny [hmm...sometimes], and most people don't get me [definitely]. In any case, it turns out that the website provides just the kind of humor I like: a quirky plethora of puerility with an intellectual undertone. I highly recommend it to people who like that sort of thing.

Well, I look forward to spending more guilt-free time blogging once next Tuesday's exam has passed.

Google ascent and a new idea

2005-02-17T19:27:00.000-08:00

I realized recently that many people reaching my blog did so by searching for the term "orgasmic cephalgia" on Google. In fact, my blog attained the fourth rank on Google for this search term -- something I never thought possible. Then, I got to thinking... First, the post containing that search term was rather tongue-in-cheek, and lacking some of the professional detachment befitting somebody who will, in fact, be a real life doctor in a handful of months. Second, the fact that my blog shot up the ranks of Google's ponderous list of websites means that not much info is extant on the Web about orgasmic cephalgia. As a result of these revelations, I have considered starting up a separate blog containing general information about medical topics of interest to myself and anyone who might happen to surf (or search) along and find me. Once I finish my board exam next Tuesday, I'll try to create that blog and post a link to it here, for the two or three of you out there who may be interested.

Meanwhile, here is a small blurb about orgasmic cephalgia, restricted to useful info this time (the previous post has been expurgated from my blog).

Orgasmic cephalgia -- According to The Handbook of Neurosurgery, this disease consists of "a severe, throbbing, sometimes "explosive" H/A with onset just before or at the time of orgasm." Besides the obvious emotional and physical ramifications of having a pronounced headache at the time of orgasm, this disease merits consideration because it is actually relatively benign, yet closely mimics a different, life-threatening illness. Subarachnoid hemorrhage -- acute bleeding into the brain that generally occurs because of the rupture of a weakened arterial wall -- presents similarly, with a sudden-onset headache that frequently can occur during a period of intense exertion (such as during intercourse, at the time of orgasm). Subarachnoid hemorrhage is a medical emergency, and requires prompt consultation by a neurosurgeon. On the other hand, orgasmic cephalgia is transitory, not life-threatening, and essentially avoidable -- though not without significant lifestyle changes.

I'll see what I can dig up on treatment of orgasmic cephalgia, and perhaps post it on my new blog when I have time. Meanwhile, I'm back to the books...

Will they never stop

2005-02-15T23:16:00.000-08:00

As it turns out, I'm a... (picture Uma Thurman as Beatrix Kiddo in Kill Bill Vol. 1, tracing out three sides of a square in the air).

You are a Square. What a weirdo.

What kind of Sixties Person are you?
brought to you by Quizilla

Another blow to my girlfriend's ego, thanks to online quizzes

2005-02-15T19:56:00.000-08:00

Here's what website she would be:

Which Website are You?

Languishing somewhere among Google's top 1,820,000

2005-02-14T07:28:00.000-08:00

I tried a simple Google search of my blog's name this morning, and much to my disappointment learned that my blog does not appear in the top 100 results for "Not rocket science." What does appear (as #100) is a site containing the words, "Penis enlargement is not rocket science." I have taken this finding to mean either that 1) my blog has not been referenced enough to compare favorably with the almost two million other sites that include the words, "not rocket science," or 2) I don't talk enough about penises. In either case, my goal is to one day enter into Google's top 100.

P.S. The actual plural of the word penis is penes, but because that fact is not generally known, the term penises can perhaps be more easily employed in text to humorous effect.

What happens to a Valentine's Day deferred?

2005-02-13T22:21:00.001-08:00

My girlfriend and I, in observance of our rapidly approaching board exams, have decided to postpone Valentine's Day until early March. Which makes me wonder...

What happens to a Valentine's Day deferred?

Does it dry up
like month-old roses in a vase?
Or disseminate like a spore--
And then pepper your face?
Does it stink like too much perfume?
Or crust and sugar over--
like another damn box of chocolates to consume?

Maybe it just sags
like an American ass.

Or does it pass gas?

Wow, that was really lame. I'll have to figure out a reasonable argument as to why I shouldn't have my blogging privileges revoked after that one. My profuse apologies to Langston Hughes.

Oh, and I just learned from the Extreme Unction blog (which is a great read, by the way) that Pagoda Egg Rolls are the key to attracting traffic to one's blog. Apparently, scattering the term Pagoda Egg Rolls into your posts can substantially improve the number of searches that yield your blog's address. There's something magical in those Pagoda Egg Rolls. Mmmm...Pagoda Egg Rolls.

For a good laugh...

2005-02-11T21:10:00.000-08:00

If you've ever found yourself entertained by Snoop Dogg, you should certainly check out Gizoogle. I started cracking up as soon as I saw the o's sporting spinning rims. Then, I translated my own blog and laughed so hard my girlfriend had to leave the room. Good times, good times.

I should be studying for my board exam.

The zero-sum game of knowledge

2005-02-08T21:07:00.000-08:00

Ahh, medical school. The general public hears this term and pictures eager students dissecting cadavers in sterile rooms, pompous professors bloviating before packed auditoriums, and inexperienced, nervous students testing their new skills on a few willing (or unwitting) patients. What the uninitiated do not know, though, is that medical school is, in reality, a highly efficient mechanism for purging intelligence from one's brain. The reason for this fact lies in the simple truth that the brain contains only a finite number of neurons, and each neuron can participate in the recollection of a finite number of memories; thus, memory formation, at its core, remains a zero-sum game. Further, because medical school requires roughly 120 hours of work per week -- leaving 48 for sleeping, eating, defecating, and performing various other vegetative functions -- the world of training to become a physician is an insular one indeed. Once you throw in the monotony of day and night studying followed by unending toil in the hospital, the basics of higher cognitive function begin to deteriorate. In any case, I used to know a decent amount about a lot, and be able to do something with it. Now I know an obscene amount about very little, and I'm highly qualified to do (as yet) essentially nothing.

For the sake of illustration, here is a brief list of pieces of knowledge I used to possess, and the new specialized facts that have supplanted them.

Old: All the presidents of the U.S. --> New: All the diseases one can contract by mowing over a rabbit in the yard
Old: The plots and themes of Shakespeare's plays --> New: The DSM IV diagnoses of Hamlet, Ophelia, Caliban, Othello, Macbeth, Richard III, etc.
Old: Every word of The Wasteland by T.S. Eliot --> New: Every word of First Aid for the USMLE Step I by Vikas Bhushan, Tao Le, and Chirag Amin.
Old: How to program HTML and VbScript --> New: how to digitally disimpact a constipated rectum and use a fiberoptic scope to pick a nose
Old: All the synonyms for the word rigid --> New: All the scientific and colloquial euphemisms for impotence ("I'm making love with a stuffer, not a poker.")

But, you know, I'll be a better doctor for it. Now I just need to train for seven more years so that I can actually reap that reward. Meanwhile, I would recommend that you take your Metamucil -- lest you end up being the means for another med student to forget the basics of web development.

...And more still

2005-02-06T23:20:00.000-08:00

At least the act of taking the quizzes is entertaining.

Which File Extension are You?

It seems that both of these quizzes highlight my flashiness as a common denominator. I'll have to see what my friends think about that.

More minutes I'll never get back

2005-02-06T23:13:00.000-08:00

What the heck is this all about?

Which Website are You?

Blogger's guilt

2005-02-05T23:16:00.000-08:00

Being new to this whole blogging thing, I did not anticipate the existence of such a phenomenon as blogger's guilt. However, after not posting for a week and learning from my site meter that -- wow! -- a couple of people actually visited my site, I felt like an odious little waster of Internet space and browsing time. To think that I allowed a week to pass without providing content for someone gracious enough to care what I have to say! What a selfish bastard I've been! I'll have to schedule some zealous self-flagellation for sometime in the next couple of days. I'll pencil it in, anyhow -- hopefully I can get around to it.

Due to the fact that I recently committed to seven more years in Nelly's hometown (interestingly, also the hometown of Chingy, Murphy Lee, and J-Kwon, for those who care), a search for real estate has elevated itself to priority number one in my life. I have spent about 98% of my free hours in the past week poring over MLS listings, driving through neighborhoods, and viewing properties. Of course, there is one primary reason for my rapt enthusiasm for the new home search: my Step II board exam! As is always the case with fourth year medical students, the exigency of the need to study comes in inverse proportion to the will to complete said studying, and in direct proportion to the passionate desire to occupy oneself with any diversion, however mundane. So despite my looming exam date -- Feb. 22nd -- I will spend all day tomorrow looking at lofts and condos, fretting over whether I want to splurge on a unit with upgraded granite counter tops or stainless steel appliances. Hopefully, though, I'll make time for a little blogging. At least blogging seems a more likely endeavor than studying, which bodes well for my blogger's guilt. (Not so well for my overachiever's guilt).

A paradox discovered in online quizzing

2005-01-30T21:13:00.000-08:00

So I took a few online quizzes today, and I found some interesting results. To begin, I tried the Nerd Quiz. Here I learned that I am, in fact, a "Mid-Rank Nerd," placing in the 77th percentile of nerdiness. Next I tried the Loser Quiz, thinking that my well-established (but not overwhelming) nerdiness would also relegate me to the depths of the loser pack. Quite surprisingly, I learned that I actually rank as "Kinda Cool" -- cooler, as it turns out, than half of people. Hmm. It would appear that mid-level nerdiness does not preclude at least a modicum of coolness. I would like to think that my peculiar set of characteristics suits me well for the field of neurosurgery, which happens to be the coolest field of medicine (an incontrovertible fact), but one that nonetheless demands a redoubtable degree of nerdiness.

Anyhow, I also proceeded to take the Spoiled Rotten Quiz, and learned that I rank at about the 70th percentile of spoiled rottenness. I wasn't aware of having been so spoiled, but that's perhaps because I'm largely surrounded by a gaggle of overeducated, overprivileged medical students in my social circles. Incidentally (and scarily), I had my girlfriend take the Spoiled Rotten Quiz as well...she scored in the 98th percentile, and was told by the website, "You are spoiled, spoiled, spoiled, you brat!" She vehemently denied this assertion, but I have had similar suspicions myself. Good thing she'll be a dermatologist, and can spoil herself rotten as needed.