Device Installed

There is one fire station on the island and it's near the airport. Now, it's only about 1.5 miles mind you, and they are great guys, well trained and equipped, but still only one. And they protect the whole island and the airport too. I suspect that in the event of a real fire at my place, I'm on my own. It'll be gone by the time they get here and start hosing.

Needless to say sometimes worry about my electrical outlets or unattended incense, or that of the other housemates I have, burning the place down. I don't have much to lose, but it would be a shame to lose anything. So today, I installed a fire alarm in my apartment. It's sure to get me up out of a dead sleep, I'm sure.  If not, I can get a quick bit to eat as I'm exiting the flames.

Treachery

While living in Hawaii, I became an avid "boogie board" surfer. I used to drive down to Ho'okipa Beach on the north shore of Maui and dive into the surf with a boogie board (short wide board that you lay on), fins (especially made short fins for the boogie purpose) and a "shortie" wetsuit (enough 1/8 inch protection from the cool waters of the Pacific). After work, it was my sanity, and part of my strong attachment to the island nature around me. I love being near the ocean, being in it, enjoying it...I am an "island boy" at heart.

During that time I encountered sometimes treacherous waters, high waves, strong currents, jelly fish, strong winds, locals bent on hurting haoles...but always took it all in stride. I also developed a strong understanding and appreciation for the power of the ocean. It can be a very dangerous place. The ocean has no emotion, or fear, or hatred...it is an equal opportunity power that will kill you if you don't honor it's power. Every so often that reminder came in the form of a coral cut (as a wave slammed me into it), or in the form of a serious injury or death of another. I honor the power of the ocean and that continues today.

So I swim everyday or other as I can. I love swimming the Caribe on the quiet side of the island ~30 minutes. It's heart pumping, great for the physical, and easy on the mind. It is my aquarium and I don't have to clean the filter. Lately it's been a wonderful sight with the volume of baby fish, jellys, rays, conchs...filled with life, easy on the soul. But it can be dangerous, and I respect that. Not everyone does, nor do they understand it at the level I do.

There is a reason that on most law-suit fearing beaches there are signs, flags, postings warning of dangerous currents. It is, forgive the repetition, dangerous. Unfortunately, the island infrastructure has little fear of law-suits in the Netherlands Antilles, so no flags, no postings, no signs, no lifeguards, no beach patrol...you are on your own. They do have a pretty good human body recovery system though after an event.

Yesterday the current was really strong. Like the sign says, if you doubt don't go out. And for me to say it was strong, it was REALLY strong. From the harbor to the point at the oil terminal is was running strongly at about 5 knots...pulling, no sucking you toward Saba island if you didn't swim it. I swam diagonal toward the harbor catiwhampus (at an angle) to the current and then swam back with the current to get back out at the beach. That's the way you should do it. And you still need to be a strong swimmer to do it. I am. It's invigorating and never a problem for me. I understand and respect the ocean. I plan my swim. I execute my plan (all that fire and police training helped a little in my life).

At the same time two of my classmates also took a swim, but swam out straight from the beach into the cross current. Before everyone knew it they were 100 yards "down current" and almost out of sight. They realized where they were and then began to swim vigorously back to the beach against the current. One was not a swimmer, a smoker and had only a mask he was using for the first time. That is the recipe, for those who don't recognize it, for disaster. I may have been the only one who appreciated that. I saw him swimming and I walked down the beach to get as close as I could without entering the water. I yelled at him, talked to him and watched to see if I was going to have to jump in after him. I hoped his head would continue to bob and make progress toward the shore, but with each stroke he seemed to stand still and with each non stroke he seemed to get further away.

It took what seemed like a longer time than it was, but with persistence he made it back to shore. He stumbled from the water as I talked to him about what had just happened and he said those words..."I didn't realize how strong the current was..." We walked back to our group, and he collapsed on the sand to rest. I was relieved. People die each year in the ocean just this way.

My respect for the ocean has increased that much more.

Block #1 Exams

Het wordt gedaan! It is done. Zij zijn geschiedenis! They are HISTORY!  I did ok, but I could have done better.  Decent grades on exams today and not really shocked by the intensity or the process, but there were some questions that were (to my knowledge) nowhere in our lectures, notes or Powerpoint presentations. I'm sure I'm wrong in that delusion, but I'd like to think the amyloidal deposition of beta pleated sheets (brain plaque) hasn't taken over part of my brain and rendered them inaccessible...whether I've seen the stuff or not. I know that I need to change the way I study #1 and I've got to buddy up with one of the folks that got a high score.

Genetics was one of those that the study, while moderately effective to understanding, was riddled with terminology that I wasn't sure of and process variations that I hadn't anticipated (non standard ELISA, PCR, reading gel plates, template sequence variations, etc). Such is the luck of the study draw. There will be no curves on this one though. A few 100's (grades) were posted. We are unlucky to have 6 transfer students in my class from another Caribe medical school who have had this course before (it's a repeat event) and they nailed this exam and obliterated the class outcome curve. Shucks! BTW, how did "shucks" become an explicative? Just doesn't seem to cover it.

I wish I'd had genetics before this class. Heck, I wish I'd had genetics at all!  I hate to admit this but the field of genetics in medicine wasn't even invented when I went to PA school. When I was in school we had just discovered HIV during my last year of school and if you met a Filipino nurse on the floors, that was exotic. I think that the ship doc on the Nina was the Surgeon General at the time and something Bubonic was amuck in downtown Birmingham.

Alas, I still have to learn Genetics for the now and future. I can tell you that it is unlikely that I'll head  a biochemical genetic research facility in my lifetime. Good thing really :) In any event, first exams are worth 15% of the class grade this term, so there is plenty of room for improvement (85% worth), particularly in Genetics. It's melamine-laced Mik-a-lobe (frontal or parietal?), er, I mean uh Heineken of course  (vergeef me immigratie want ik sinned heb). The Dutch just seems to flow when the stress is off.

Class starts back tomorrow.
Ik zal klaar zijn.  I'll be ready!

Eve of the Assault

It is the eve of the exam assault that will be tomorrow. I don't know if I'm ready, but I've run out of time, and brain space I think. Hopefully my subconscious will have free and open access to the deep recesses unavailable to my conscious mind and pick the right answers. One can dream.  All this studying and thinking thoughts about readiness or not readiness has created a bunch of thoughts about the body mind connections. I've been fascinated by health and thoughts for a long time. I've always known that part of our healing profession is based on the thoughts we plant in our minds and how we think our way through things. Watching a woman survive nearly 3 years with cancer after a 6 month prognosis convinced me that the state of mind we are in can even help us survive longer than the body should permit.  We hear a lot about detoxing our physical bodies today from all the chemicals, bad foods, bacteria, pesticides and stuff in our world.  We know scientifically the connection between the toxins and ill health. Is it possible that our minds work in the same way?  As we have and fill our minds with wrong thoughts, sad thoughts, angry thoughts, frustrated thoughts, hateful thoughts, fearful thoughts...everything categorized as "fight or flight" stressful thoughts...can they too be toxic?  Beyond the illness in our spiritual and emotional life, is there a connection with the body thru our limbic, and autonomic nervous system? Many think so. Proverbs 4:23, "Above all else guard your heart for it affects everything you do." Was that an ancient prescription for health?  Is it possible that we need to detoxify our minds each day with good thoughts and rid ourselves of the bad ones.  Letting go of anger, hurt, disappointment, low self esteem, negative words, negative thoughts, delusions, attitudes, beliefs, prejudices....really cleaning out...might it create a better container to grow health? I'd like to believe that that was a good thought.

Swim-Not An Option

On my what has come to be my daily or at least every other swim, I encounter creatures of the Caribe that are absolutely beautiful and some quite amazing. There are few things I've encountered underwater that are more aggressive though than squirrelfish. The orange and light blue or gray striped fish is an aggressive protector of underwater real estate, hole or ledge. It'll go after almost anything that get's close no matter how much bigger that thing is, including human.

Now they can barely hurt a plankton, no teeth or poisonous appendage, but when the wide eyed striped fish puffs up, spreads it's fins wide, unfurls the yellow tinted dorsal fin and then "shakes"...it's fear inducing. If it actually had jaws/teeth or something poisonous to drive deeply into your nervous system, it would be truly frightful. And when I say shake...I mean it literally convulses it's whole body...as if to say, "I'm really serious; Don't take another step (or stroke) forward !!" The sad, down turned mouth makes it even worse...almost angry. I usually return the greeting by spreading my arms and legs and shaking violently. I'm sure it's hysterical to see from afar.

The swim after first block exams was WONDERFUL, and it has become a compulsory event. Swimming (or running) is not an option. It is part of my sanity so that as people around me say "how can you be doing medical school", I can say, "it's not a problem."

Food and Medicine

I worked briefly with a redneck surgeon. He was a colorful character who's family owned a grocery store in the deep, deep, deep south. It was so deep (how deep was it) that the kudzu covered it completely. It was so deep that that the there was a confederate national guard unit stationed there (his words). Anyway, he told me once that his granddad told him to go into medicine or the grocery business "cuz, vryone haz to eet, and vryone gits sik."  He imitated his grandpa badly, but he was a hell of a surgeon.

Great wisdom in a strange sort of way. As I watch the eating around me on this microcosm of the world, I realize that it is, in some ways, the one that is feeding the other. We are what we eat, and we are generally pretty sick. As we begin to study internal medicine from the inside out (the biochemical nature of life), it is becoming more apparent that health, and disease are intrinsically tied to each other, beyond the commerce of Eastside Grocery.  Exhibit one, the "Triple Bypass Burger" at the Heartattack Cafe. Priceless. I want to be a cardiologist near that greasy spoon.

No Wonder!

It's really not rocket science! A woman in our school is going to graduate with nearly $200,000 of debt, wants to work part time and start a family. Given that foundation for coming to medical school, was I shocked to hear she wanted to be a dermatologist or gastroenterologist or radiologist? No. Then the reasons came tumbling forth, and not a single mention of healing the sick. I hope that she ends up in Gastro and she is allowed to fully reflect on her decision to come to medical school over being anything else when the first projectile, GI bleed vomit hits her :)

Feed the Spirit

Capricorn -You're feeling a bit nostalgic or curious and need to connect with someone who lives (or is temporarily staying) far away. Try to make sure that you're keeping the right attitude toward the endeavor.

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I was flipping thru AM TV, getting ready for the day of study after my run. As is the case on Statia TV, there is plenty of religion to choose from and I sometimes stop and listen to the many assorted programs and teachers on various spiritual topics. As I flipped the channels I saw a familiar vision and stopped. It was Jerusalem.

There have been few happenings in my life more significant than going to Israel, the center of several major religions. And whether you believe in God or not, it is truly amazing what Israel can do to your sense of yourself and of history. It's no secret to those who know me that this is the case with me.

The flashes of scenes from Bethlehem, Jerusalem, the  Judean Desert, Masada, the Dead Sea, the Sea of Galilee, the Golan Heights and the valley below, the Jordan River, the Church of the Holy Sephlecre, and many others bring back strikingly clear memories and sensations. The most profound to me was the scene on TV of the marketplace and surrounding "life" in Jerusalem.

Like a private physiology experiment, the vision stimulated my frontal lobes and my memory centers connected to all of my six, or five (depending on who you read) senses. I could smell the food, hear the noises, feel the air, hear the sounds...Some wonderful memories with the people I love and loved most in the world (some missing). It is those times that fill my spirit, and awaken periodically to put into perspective what it is I'm doing here, on earth and on this island.

And Jerusalem is not a perfect place. It's filled with oxymorons, morons and deep seated hatreds that are completely counter to God's word, but in that and the visions I saw on TV today, there is some hope.

"You are forgiving and good, O Lord, abounding in love to all who call to you" (Psalm 86:5).

It's amazing how spiritual you become after and during significant life events, and during major examinations. I fed my body at breakfast, and fed my spirit...I am ready for the day and for exams, with God's help and the right attitude toward the endeavor...like everything we commit to do. Ok, back to the science of the body...t-minus two days till all day testing. Ugh!

Empathy

Dr. Pauline W. Chen, M.D., wrote an article in the NY Times recently, reporting on a study about docs and empathy and time.  She noted that she always believed that it takes more time to listen and answer empathetically to patients.  But a recent study published in the Archives of Internal Medicine "found that physicians overwhelmingly miss opportunities to express empathy to their patients," partly due to "lack of time," according to the authors. But, based on her own experiences, Dr. Chen argues that "empathy, expressed throughout a patient-doctor encounter, may actually help to alleviate problems with time." She suggests that "too little empathy, or empathy expressed too late in an encounter, may actually result in longer visits."

WHAT A CONCEPT! Actually I've known this for a long time. Time spent, I believe (and this is purely anecdotal, biased and with a p>.05) that spending that time reduced after visit phone calls, revisits for dumb things (additional schedule killer), etc. Empathy as a methodology for time management.  I wonder if I can empathize my way through this weekend to Monday's exams?

Resolution, For Now

It is my firm belief that God does not put anything in your life that he (or she) has not equipped you to deal with. Such are the mini traumas of medical school. I know the reality is my expectations often exceed reality and the possible realities (it's not possible in many cases). I know that the "nerd" in my head is ALWAYS the culprit and that I'll deal with the ups and downs. But today, it took a 50 minute swim in 2 foot rolling seas to get it to sink in. Perhaps it was the bruised head from hitting it earlier on a door frame, or the salt water sinus wash out (I think it may have been gray matter that was expelled from the post nose blow), but I'm ready tackle this now...t-minus 3 days to get ready for block #1 and to the best of my ability, I WILL be ready. The Old Testament talks about a 40 year journey that should have taken about 2 weeks. I won't wander in the sand that long. After all it is about the journey and the character I develop along the way. Nobody said it would be easy. For a moment I deluded myself. "It is not knowledge, but the act of learning, not possession but the act of getting there, which grants the greatest enjoyment." -Carl Friedrich Gauss (1777-1855), Mathematician and astronomer "Forget goals. Value the process." --Jim Bouton, Baseball player

Big Bugs

One fact about rain in the tropics...the more it rains, the larger the bugs. Seems that they are driven from areas they are normally hiding and they breed faster and bigger. Where's my bone marrow suppressing bug spray?

Teaching 101

Don't change the rules. Don't lie deliberately or accidentally. Assume that the students are engaged and listening and pondering on every word in order to find out how to be successful. Create success pathways, and then stick to them. Consider the challenges of medical school in and of themselves, the shear volume of information and the fact that yours is NOT the only class, as much as you would try to think otherwise. Understand that trickery is not education, and that there really is a right way too teach and organize the learning experience, independent from your knowledge of the subject. Try to find out how to do that and stop scoffing at the possibility that you may need to learn to teach.

The rules of engagement changed today in one of the classes. The success pathway, how to do well in this class, and this subject matter were altered today...3 days before the exam. I am so angry right now. I have got to get over this set back, but it changes the rules for Monday significantly and I need to change my tactic for studying for the next 72 hours. I'll figure it out and I'll make it happen, but this was so avoidable. And while accidental, this is a teacher driven world, regardless of their ability to teach, and I'm so tired of us, and THEM operating in this mode. It's counterproductive to learning and retention and demeans the process. But it is what it is...and Monday will come whether I am ready or not...so I'll get ready, and do what I have to do.

Why is it that the further you climb the educational ladder the worse "teaching" gets? Just because you are the expert in any given area or field, doesn't make you a teacher.  Better, lets' just do away with teachers all together, tell me when the exam is, what to read to get there, and I'll go home and teach myself. I don't think Dr. Stead was too far off..."medical school can be done at home." When mandatory attendance becomes a sentence rather than a valuable experience, it's a waste.

AhhhhhhhhNnnnnaaaammmmmmmmmmmmmm....

Conundrum

"Conundrum (noun): Anything that arouses curiosity or perplexes."  The study and care of the human body in health and disease is difficult enough, but throw in ethics, the law, morals, capitalism, human empathy and suffering...sometimes presents the practicing clinician with conundrums. We just want to make it better. It's not that easy.

Recently a study indicated that a commonly used medication may be killing patients. This medication is not illegal. It is approved by the FDA, studied, marketed by the drug companies..."sold" to clinicians to use for good reasons on patients with the right disease. Clinicians have trusted that the medication is working without doing harm.

The study has indicated that drugs for lung disease may increase risk of strokes, heart attacks and death. This drug is widely (mucho sales) used as first line (the first thing to use) in chronic pulmonary lung disease (aka COPD), which it the 3rd or 4th leading cause of death in the U.S. And the most common cause of the disease is smoking. The drugs are inhaled anticholinergic.

   The authors have pointed out that "a larger clinical trial is needed to validate the findings" though. Of course, "pharmaceutical industry spokespeople issued a statement strongly disagreeing with the conclusions of the study."  Shocking eh?

Consider being a clinician. Your patient is a 70 y/o former smoker (40 years, 2 packs a day) with COPD whom you have had on inhaled anticholinerics. He quit smoking since he's been your patient (with your help) and he's breathing better. His quality of life has improved. And then...he has a stroke. Conundrum.

We respond appropriately with the best information we have at any moment in time. We "do no harm" to best extent possible. We use approved drugs and techniques in approved ways. We don't wake up in the morning thinking we are going to hurt people, but wonder each day if we have. Is it any wonder why people don't choose this profession, and maybe more a wonder, why some do.

Retail

My colleagues scoffed when I told them almost 10 years ago that I had seen the construction plans for a Walgreen's with a clinic in it. At the time they laughed but I knew that pharmacists were taking "Physical Diagnosis" classes where I was teaching. I was pretty sure that pharmacists would be staffing outpatient clinics and moving for more scope of practice. Well I wasn't far off.

The 1,000th retail health clinic in America was christened in August, eight years after the first clinic of its kind was unveiled. Walgreen's, CVS, Wal-Mart and others are on the fast train to drive thru medicine mostly staffed by Nurse Practitioners. And I think it's GREAT! Just what we need...a jolt of down home capitalism and competition to try to give what the people want and need. They are attempting to do what the mainstream medical community can't...won't. Good hours, convenient locations, at a great price. If I didn't know better, I would think there was child labor involved.

What is likely to happen as this phenomenon grows is that people will stop going to their own primary care doctors for simple problems...the bread and butter of practices.  Why wait for hours, for an appointment you can't get, when you can walk in and walk out with your antibiotic du jour after you pick up your milk and a pair of shorts on sale? 

  And we are talking about big numbers too. It is estimated that over 3,000,000 patients will be seen at these centers and maybe more. The growth has been staggering. The need was there.  The fee generated by the two largest totaled over $150,000,000. Oh and the 3  people that co-founded one the first, MinuteClinic, sold out to CVS Pharmacy for a cool $170 million in 2006. Hard to ignore the numbers.

Physician groups are keeping an eye on retail clinics. That's what they do best...react, and defend territory. Some forward thinking practices have already begun to compete by offering better hours, quicker access, walk-in appointment, and enhanced locations.  On national association of physicians has a "Retail Health Clinics" pledge", which requires them to limit the scope of their services and to partner with local doctors. The first sign of fear.

The bottom line is likely to drive the future in retail, coupled with the consumer demands for convenience and lower cost...particularly in this day and age of medical insurance mayhem. If you can drive up and get a doctor's visit as easily and as satisfying as a Jiffy Lube oil change (minus the fraud), we are likely to see (and have to compete) with such centers for a long, long time.  In the words of the NP that gave me a free cholesterol screening and 30 minutes of her time in patient education at my local CVS clinic, "We are just doing it better...", and she did.  Great lesson for my future.

Incompatible

Everyone is incompatible. We are different. When difference merges into incompatibility we believe that we need to "get away" from that other person. We are just different and each of us has unique gifts and limitations. I need to spend greater effort to identify those unique gifts in others and learn from others, even as the nerd in my head talks to me about how different they are.

Oil is incompatible with water. A body pH of 6.2 is incompatible with life. Hot chillers peppers from the coast of South American are incompatible with chocolate pudding (I know, I tried). But we are NEVER incompatible with other people until we allow our pride, ego and exaggerated opinion of ourselves.

Presence, real presence, and listening, and being able to fully understand or express understanding of what other are going thru is our greatest gift and what provide the springboard for good work in the healing arts. I need more brokenness in my life. I am not "too good" to share the burden of others. I'd like to believe I'm not incompatible with anyone.

Brokeness

Study suggests physicians may rarely provide empathetic responses to patients' emotional concerns. 

(9/23) USA Today reports that "physicians might be superb at diagnosing and treating diseases, but they could use a lesson or two about how to care for their patients' psyches," according to a study published in the Archives of Internal Medicine.

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I met a local physician the other day...one of the 2-3 active physicians here serving the 3200 or so here. he trained in Holland and is by any estimation "brilliant".  The mainland Netherlands has some of the best medical training in the world, and if I spoke Dutch, it might be a viable professional option to do some training or even live there. I  have a friend who live in Utrecht and I can't get enough of the descriptions of open markets, the dikes, train access to Europe, the medical center...

This physician could practice anywhere, yet he chose (not a loan payback program or punishment for anything)...he chose to be here. We talked about why. He mentioned a "brokeness" he had about himself that allowed him to listen to his "God", and do in spite of what he felt, and about what was right.

Cultivating a spirit to work in medicine is a lifelong process for many. As a firefighter paramedic on the verge of going to PA school, I was filled with excitement about going to school and learning the craft. But it was then, about me. It filled a need in me to be professional successful in the field I enjoyed.

We need more "brokeness" in the world of medicine and use our gifts in a way that serve ourselves less, and serve others more. It certainly is a great hope of mine.  Besides it's much easier to stay above your own personal strife when you are serving others.

Genetics Daily

  It was recently reported that 100,000 tests for breast cancer gene mutations were done...genetic testing of patients to see if they had the "gene" for breast cancer. As I am likely the recipient of the gene from both parents, I was wondering..should testing be performed on young patients as an effort at education and/or prevention?

The current recommendation that little can be done to prevent or screen for breast until adulthood, so testing earlier than that is a wasted effort.  Additionally, they propose, the information may only cause needless worry. Would the knowledge that you had a gene mutation that predisposes you to cancer worry you? Is the worry worth the value of knowing? That may be the $million question in implementation of genetic testing in everyday practice...risk vs. benefit.

This inherited risk could be lowered by taking "anti-estrogen drugs or having [one's] breasts removed. Certainly different to the approach of the disease as practiced clinically now. But that is the key to implementation of genetics in clinical practice. It WILL change the way we approach, and treat disease, or certainly change the options and education of our patients. It is important to begin this discussion as our knowledge of genes in health and disease become more accessible to the clinician.

So if I knew that I had both gene mutations from my mom and dad, what should / would I do with that information?

Roosterus Interuptus

Too funny. The professor just had to stop lecturing because of a interruption by a crowing rooster outside the door of our classroom. Sounded like he was inside the classroom. In all my days, I've never been interrupted or had my professor interrupted by a crowing rooster. Only on Statia.

Inconvenience

"I never feel sorry for the doctor. The sick NEVER inconvenience the well." - Dr. Eugene Stead, Steadisms p.17 #18

I am becoming so sick of hearing of the shortage of physicians in one breath, and hearing all the obstacles gaining more providers in the next breath.  Physician groups lately have loudly proclaimed the problems with "other" providers (recent articles I've read).

There are so many forces in the world of physician leadership that would have the populace feel sorry for them. I understand the business of medicine better than most, although I don't have the answers, but to hear the AMA plead that they are the downtrodden is pathetic and counter to serving the sick.  I know that we all have the potential to fall into that trap. It is possible to buy into the organized control that physicians have on medicine and the outright mythology out there about who should be doing what to whom. Control. That's what it is really all about.

I am hopeful that I will never be inconvenienced in anyway to working for the good of the sick. That extends beyond the daily, physician to patient encounters, and moves into how we conduct ourselves in organized medicine. It is imperative that organizations move together toward the common good and cease the territorial tire-pissing that has become so entrenched. After all, it is all about one thing, access to care. For God's sake, let 'em practice! There are plenty of sick to go around for everyone. I will create no detours or barriers.

More Important Things

FOXBOROUGH, Mass. (AP)—"Fans booed the Patriots. Many left early. The record winning streak of their favorite team was ending with a stunning domination by the lowly Dolphins.  The loss ended the Patriots’ NFL mark of 21 straight regular-season wins that began after a 21-0 loss to the Dolphins on Dec. 10, 2006.  The Dolphins, who lost their first 13 games last year and finished 1-15, won for just the second time in 22 games. It was the first victory for new coach Tony Sparano, and it was a stunner."

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It was stun-ing! For some reason, the Dutch don't put the same value on Miami Dolphin football as some people I know.  I couldn't watch it, but I listened online. It made the rainy, study-filled day a little brighter.  AWESOME! Way to go Fins!! Way to go Ronnie!

How can you be stunning and lowly at the same time?? And how "lowly" could they be if they kicked gluteus maximus, medius and minimus?

Flashback Flashflood

 

It is amazing how quickly it starts raining here. It's dry and slightly overcast one minute and the next, the skies literally open up and drench everything. It's almost like a faucet gets turned on and instantly, it's a monsoon. Florida rains seem to come on more slowly, with less dramatic onset, but I could just be sensitive.

More amazing is how much water can accumulate in a short period of time. I'm about half way down the volcano and the water that comes down the front of the house is truly amazing. It's God's perfect street cleaning system too; Everything up road, ends up down road.  I've seen what it does all the way down the mountain at the shore too. Water can move some sand, quickly. 

Whenever I see and think of moving water, I think of my experience in Maui with the only time I was caught in a flash flood. There are few things more horrific than facing a wall of water from massive rains, running down the side of a mountain.

I was living on a little farm on the north shore of Maui in a small house at the edge of a drainage stream, just down hill from a blacktop road.  Over the stream was a curved aqueduct bridge. I could walk under the bridge from the property. The stream moved small amounts of rainwater from the top of Haleakala Volcano to the sea during the time I was living there. One night it rained, and rained hard. I never gave it much though as I was in a rain forest, but this was different.  It just didn't stop.

Gradually I watched the stream rise to right beside my rental house, and then it happened. The water volume became so big that it exceeded the aqueduct, and moved over the top of the bridge, down the road, and into my steep driveway which led to the carport open garage. I heard the water hitting the back bumper of my Toyota 4-Runner and the underside of the house.

For a few moments, I didn't know what to do, but I knew I had to get out of the house. It was quite possible that the water could lift the house off the cement block stilts and sweep it down stream. I wasn't going to be in the house when that happened. I pulled on my knee high rubber boots (mandatory rain forest garb), grabbed my wallet, my dog (Doberman puppy), the keys and hit the electric breakers off as I bolted thru the door to the truck. The water was up to mid door at that point, and I managed to climb into the truck thru an open window. I threw the puppy into the passenger front seat, and prayed as I started the engine, threw it into reverse 4 WD, and gunned the gas to back out of the carport, up the drive and on to the road's pavement. I made it out of the gully. Whew! I sat for a moments contemplating what I left behind and if I'd see it again. The water continued to rise.

I ended up at a friends house for the night and returned to the house the next day. The yard was spotless clean from the washout it received. The grass was almost combed down in the direction of the water flow. It actually looked nice. No damage beyond my memory, but a night of water I won't ever forget. Until the day he died, I doubt my Doberman ever forgot either.

It is supposed to continue to rain all day on Sunday too.

Genetics Importance

I get it. The human patient has 23 pairs of chromosomes. On those 46 chromosomes is the twisted ladder construction called DNA that houses our 21,500 genes. Those genes hold the code to all of our life processes thru the production of proteins. Proteins govern our lives in sickness and in health. Except for gun shot injury and other trauma, almost every illness has genetic basis.

What's happened in genetics in the last 5 years is profound. The "human genome", the map to those 21,500 genes, has been largely decoded. We understand now 100's of gene variations associated with medical conditions.  There has been identified over 1500 genes linked to disease and better understand the damage that a single gene mutation (change) can cause.

The class I'm taking in genetics was not possible when I attended PA school. It's only been in the last few years that this class has existed at all. It is growing, dynamic and an ever changing target from an educational perspective.  It is probable that in my practice I'll be able to effective use genetics in some manner for treatment. Clearly preventive medicine is an area that will most benefit from this knowledge. Will we be able to ID a possible gene mutation, predict a disease and "reengineer" the gene or in some way, fend off the illness? The possibilities are mind boggling...and likely well beyond the constraints of a single class in medical school. It's exciting! If we don't get better health from this knowledge at least we'll get some really big omelettes.  In the meantime, I'd better figure out my replication forks from my DNA protease...sounds sorta important!

30 Days Recovered

I glance periodically at the countdown clock below this blog.  I was shocked to see 120 days left till the end of the term! No way! A simple error corrected in the HTML and my anxiety lifted...only 90 days.

On a "I got to get some more sleep" side note...The experiment is soon to begin. How much medication does it take to knock out, for more than 24 hours, a yappy Pomeranian mix? I will soon find out. It's not a double blind randomized study...I know what I'm giving him, and there is selection bias. I think the Chinese restaurant is looking for groceries too.

Mnemonics & Descriptors

I've worked mostly in surgery, critical care, trauma, and such.  It's been often fast paced, a bit surreal and sometimes raucous. One of the more edgy elements has been the communications, such as patient mnemonics and descriptors.

There are many, many mnemonics out there in the medical world, like FLK (Funny Looking Kid). There are vast collections of them in many locations.  I've been entertained by the inventiveness of many colleagues along the way in  conversation about their work, and the inability of regular medical terminology to capture the idea completely.  I've heard from ICU professionals about patients that were "CTD" (Circling the Drain), and the patient who was a "GiLSOB" (good looking son of a bitch) from floor nurses. One of my bosses told me he had treated a lacerated a hand from a "UBI" the night before (Unexplained Beer Injury).  Some of my faves; Usually starting with the introduction, "the patient is... or has..." :

• 185 grain Injection - 9mm gunshot wound
• ALS - Absolute Loss of Sanity
• CRS - Can’t Remember Sh*t
• BBL Sign - Belly-button Lint Sign
• BFH - Big F****ing Head
• CATS- Cut all to sh*t (after knife fights usually)
• CBT - Chronic Burger Toxicity
• Chartomegaly - large chart
• CLL - chronic Low Life
• D&D - Divorced and Desperate
• High DBI - Dirt Bag Index
• DRT - Dead Right There
• ETOH - Extremely Trashed or Hammered
• FUBAR - F***ed Up Beyond All Recognition)
• ATS - Acute Thespian Syndrome (faking it)
• GOMER - Get Out of My Emergency Room
• 4F - Fair, fat, female and forty
• GORK - God Only Really Knows
• HIBGIA - Had it before, got it again
• HMS - Hysterical Mother Syndrome
• JAFHA - Just Another Fat Hospital Administrator
• KOKO - Keep on Keeping on
• NARS - Not a rocket scientist (low IQ)
• NQR - Not Quite Right
• OBS - Obvious bullsh*t
• Osteocephaly - boneheaded
• DAFO - Drunk And Fell Over
• PFH - Parent(s) from Hell
• PPP - Piss-Poor Protoplasm
• RBS - Really Bad Shape
• SAS - Sick As Sh*t
• Smurf Sign - patient blue or going blue
• SWAG - Scientific Wild Ass Guess
• TBP - Total body pain
• TTR - Tattoo-to-Tooth Ratio
• WOMBAT - Waste Of Money, Brains And Time
• ZB or Zorro belly - someone with multiple surgeries

An ER nurse called me one night an told me a patient, beyond his amputated finger, was "NFB" (Normal for Birmingham...where we were living at the time).  The same nurse later told me that an order for "Plankton at Beside" was appropriate for a mutual patient who had a BMI of 40 something (The nurse was burned out and later married a PA friend of mine, never to work as a nurse again).  Another nurse described on of my patients as "CNS-lite" referring to his mental challenges and I'll never forget the radiology tech that described a rather large patient as "CBO" (Cheese Burger Overdosed).

I am appalled at  some of the references, but the art of mnemonics in medicine is priceless. While not always in good taste, having a sense of humor about this field can save sanity and might prevent migration to concierge medicine.

Duh

There is a moment in the continuum of learning something brand new that causes a momentary "what the hell" moment. You hear the words, you moderately understand the vocabulary and the concept, but the pieces don't fit, and there seems no way to get to the complete understanding and cross the intellectual abyss to "oh yea, I know that". I was having one of those moments yesterday at the end of genetics. Just couldn't get it to save my soul. So, in my earnest student mode (the one I required of my students), I visited the professor after class.

Now he's a genius at the stuff he teaches. He is clearly on a level that I can't hope to achieve. No I WON'T ever achieve. I'm ok with that. I'd just like to know enough to do some decent counseling in practice and recognize the reasons for all those funny looking kids out there (FLK's). Genetics in primary care is mostly about that. But I know that there is some mandatory minutiael component that I'll have to regurgitate (in all it's backwash glory) to the national board folks.  So I seek his patient tutoring. I was over-expectant.

"It's easy when you know it," he said as he searched for the thickest book on molecular biology I've ever seen. I bit my lip to hide the laughter. Well duh! If I knew it, it WOULD be easy and I wouldn't be sitting here! And then I heard myself say "outloud"...I appreciate that, and I hope that I will find it easier with your help.

Aaaaarrrrrrggggghhhhhh..., I've crossed to the dark side of suck up, apple polisher...striving to become a "pet". No, not really; But I got tickled none the less and felt my lip part into a smirk. I seem to find ways to entertain myself even as I struggle to figure out how knowing the 5 prime end from the 3 prime end of the DNA of a little known, rare disease will help elevate my bedside skills and compassion. I do know one thing, I can ID a FLK from a block away. But can I figure out the disease? Hopefully I will after this class.

Zero Tolerance

How gossip taints reality: So an edict came down via the school web site that the local government officials have started a crackdown on everyone to carry official papers at all times. Somehow that got translated to harassment by the government of students in the populace. Thursday and Friday of last week were filled with side discussions about it, with many wondering aloud about why the government would do that to a group of people (students), and the school, who make up such a large part of the economy of this island psuedo-nation. I have to admit I was almost convinced.

Reality: The island engaged an island wide program involving the police, the Lt. Governor's office, Immigration, airport security, the harbor, marine police and many other departments including the Dutch Navy (evident floating in the harbor...now gone).  The program had been in the works for many months, and was "long overdue" according to the chief of police talking on local cable access TV.  The program was called "Zero Tolerance" and it is and exercise  periodically performed on what is termed "general controls" on the island including drugs, airport security, immigration paperwork, driver/vehicle paperwork etc. It has little to do with students beyond having our papers handy when stopped and being here legally beyond our admissions to school. We have to have permission to be here as students from the government.  This recent effort and actions are likely the reason that some of our classmates were not permitted to return to the island as well.

In all fairness, we've been warned. And I have heeded the warnings. My papers are in order, and I carry them with me.  I get "police action" to keep a preventive posture in the community since I used to be "one" in a previous life. So another rumor dispelled by fact and truth. I wonder how many of the "things" I've heard since I've been here are like that....the truth shrouded by opinion, immaturity, discomfort being on this island, stress, ego and pride. Another reason to just do what I need to do, when I need to do it.

Genetics Emerges

"How simple it is to see that all the worry in the world cannot control the future. How simple it is to see that we can only be happy. And that there will never be a time when it is not now." -- Gerald Jampolsky

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While I really worried about Biochemistry, it turns out to be one of my fave classes so far. I love intertwingling of clinical disease in this course and the links to my real fave, physiology. The combination of the two has great value in my understanding of clinical disease. I get that.

The beast has turned out to be genetics. I am so totally lost in the terminology and verbiage. I wish there was something nice to say about, but I can't think of anything. This will be my "beast", at least this part. I'm trying not to worry and be happy (sounds like a great Reggae song), but it a challenge for my brain to wrap around polymerases, ligand strand substitutions...aaarrgh! Like anything I need more time with the matter. Afterall it's just week 1, but I'm struggling.

This is SUCH an important class though, and I know it.  It is becoming more and more imperative to understand genetics in health and disease. In history taking, and disease counseling it is foundational. I totally get that, but I'm not sure that I'll be able to get thru it without worry. And I'm pretty sure I won't be happy :) Back to reviewing it for the umpteenth time.

NOT the Club Med

It is sometimes easy to believe, even as a student, that medical school in the Caribbean is a vacation, a Club Medicalschool. I have to admit, that waking up and walking out to my front porch overlooking the most beautiful expanse of God's Aquarium is intoxicating . It is no wonder why people retire to places like this. But clearly, the reason for being here for us is study and the goal is collect as much information as humanly possible about the practice of medicine.

That stark reality happened (again) for me late last night, while studying at the open classroom study area at school. One of my colleagues in the 4th term who, like me, has to repeatedly review in order to codify that information into her brain. We are the blighted student who have to actually review, study, read and review again...unlike our much hated brothers and sisters who can read something one time and remember it forever (and quote it with impunity)

This was the note she wrote on the top of my paper (I scanned it in with the content today). She's here to get away from her boyfriend who distracts her from learning. I'm here because the Internet is down at home with no immediate possibility of having it come back up in the near future. For me, the Internet is my library. Beyond my local digital world (what's on my laptop) the Internet is the equalizer. I have access to the greater medical knowledge of the world that every medical school in the world has access too.

I was looking up disulfide bonds on the Internet when the intrusion happened. The glancing eye, the Internet was all that was seen, but I appreciate her attention to my success.  It was a great reminder about the subtle aspects of learning. One simple word, "STUDY", written almost with violence in pencil, woke me to the reality that this is not the Club Med, and exams are in two weeks.

While I've been going to class, reading, reviewing the day's work and studying with some intent...there is a mental shift to this place that has to happen at some point for the ungifted like me. Time with the content. Studying (contraction of the words "student" and "dying". Who knew??

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"There are few more valuable professional commodities than a medical degree." - Unknown

P.S. Just heard from a recently departed (the island) student. He passed USMLE part 1 with flying colors. There is hope :)

Girls

Biochemistry is a collection of individual chemicals and the actions and reactions of those chemicals in the body to create, support and maintain life. Ok, rather simple, but in essence what it's all about. So one of my esteemed colleagues relayed a very important reaction.

I've known for a long time that girls were "icky". When I was 7, I drew big "CP" on the back of my hand with pen so that the powers of "cootie protection" would be envelope me against the ickiness that girls are capable of. It worked for some time, but I believe that immunity wore off and I lost all value of "herd immunity" just before I proposed to my ex-wife.

The chemical equation is simple.

Step 1 of the reaction ->Girls = time x money (it is simply amazing how much time and money girls require; and in most cases there is no connectivity with successful bonding with them. Disulfide bonds in peptides are stronger). Time is a multiplication function of time and money.

Step 2: Everyone knows that time = money. This fact has been repeated to me regularly since birth. It must be knowledge (ex post facto).

Step 3: money x money = (money)2...money squared; This is a simple math rule. Nothing fancy or contrived. So then girls = (money)2...girls = money squared

Step 4: "Money is the root of all evil." - This rule has been part of the knowledge of man since the book of Genesis. It is a law of nature, again, passed down thru the ages. Thus you can replace money with evil as appropriate in the equation. Then girls = (root of evil)2

Step 5: Solving for the right side of the equation,

girls = evil

The application of math, science, biology and biochemistry in one lesson. I've seen the light! I was right all along. I'm going down to the tattoo shop today and get that "CP" permanently engraved on the back of both hands. Oh, and I'm going to start walking around with crossed fingers and toes too. Can't be too careful.

Dang Gee

"SHCA confirms six dengue fever cases; Residents urged to take measures to continue to prevent mosquito breeding" - Thursday, 11 September 2008
St. Maarten – Sector Health Care Affairs (SHCA) Dengue Action Response Team (DART) confirmed on Thursday that there are six laboratory confirmed cases of dengue fever for the month of August which is more than what is usually reported. On average two cases are reported per month.

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Who knew there was a DART team for this disease.  Dengue hemorrhagic (bleeding) fever (DHF) comes from a virus spread by a mosquito that feeds during the day. Yum!Living on an island is bad enough. Having mosquitos is an annoyance for the most part, but they are here and getting deathly ill or dying is what this trek was about.

To prevent the spread of dengue fever, you must first prevent the breeding of its vector, the Aedes mosquito. The Aedes mosquito is easily identifiable by its distinctive black and white stripes on their body. It prefers to breed in clean, stagnant water easily found in our homes. You can get rid of the Aedes mosquito by frequently checking and removing stagnant water on your premises. But what about the stagnant water down the street? There is no mosquito control on Statia, or anywhere in the NA that I am aware of and public health is unheard of.

I heard someone talking about a striped mosquito the other day at school. Marvelous! Where's my island deodorant (insect spray)??

Pray Hard

The feeling increases with me every time a storm approaches land.  16 years ago Andrew hit South Florida.  Ike will be coming a shore near Galveston TX. The wave of water that will hit the coast as a Cat 2 or maybe three is going to be huge. The storm covers almost the entire real-estate footprint of the Gulf of Mexico. With it comes the wave of water it "sucks" behind it. The coast is drenched, and low. Pray.