Friday, October 31, 2008

Happy Halloween!

Believe it or not, Halloween is a HUGE event on Statia. There are multiple parties and such around the island imageand it should be a nice temporary diversion. I've got plenty to study, so It'll just be a few hours, end of Friday before a long study weekend.

Halloween has become increasingly popular in The Netherlands and always has been in the islands. Trick-or-treating is highly uncommon here though. I'll miss that at home. I was the "door goblin" at my house for many years while the girls went out. Somebody else has that job now.

Back to the biochem. So many lipids, so little time.

Thursday, October 30, 2008

St. Eustatius

I never really took the time to research the name of our fine island. But there was a quiet celebration here at the end of September and became curious.  When Christopher Columbus named this place I'm sure he didn't conceive of a medical school here, but the saint of hunting, Eustatius, is with us as we "hunt" for our next lives as healthcare professionals.

St. Eustatius is also known as Eustace. This man was named Placidus by his parents in Rome and we celebrate his "memorial" in September (Western) and November (Eastern) each year.

Placidus began life as a pagan and became a Roman general in the army of the emperor Trajan. He was converted to Christianity following a hunting trip during which he saw a glowing cross between the antlers of a stag, after which he received a prophecy that he would suffer for Christ. He was baptized with his wife and two sons, and given the name Eustachius.  In Rome he was denounced as a Christian, he lost his property, was reduced to abject poverty, and Roman authorities took his wife and children. However, being a capable general, he was recalled to duty by Trajan to [Saint Eustachius]help repel barbarians from Rome, which he did. He and his family were reunited with the expectation by Roman authority, that they (Placidus and his family) would sacrifice to idols in thanks for a military victory.

When they refused, an enraged Trajan ordered them thrown to the lions; the big cats played like kittens around them, so they were martyred together by being cooked to death in a bronze bull in the year 188.

Eustachius is one of the Fourteen Holy Helpers and represents also patronage against fire, against torture difficult situations, and torture victims. How fitting then that the name of our school and our island is St. Eustatius. Perhaps we should add patronage of fired upon, tortured medical students in difficult situations?

Wednesday, October 29, 2008

Why Be a Doctor?

image1. Because you get to see everyone in those funny, backless gowns (this is also the number one reason why it's not good to be a doctor).

2. Because you can park your car on the sidewalk [or speed] without getting a ticket. [as a cop, I tried to give a OB/Gyn going to deliver a baby a ticket...LOL]

3. Because it's the best excuse for illegible handwriting.


4. Because there's no beat like a heartbeat. It's easy to dance to.

5. Because after working with patients you realize that you are not as neurotic as you thought you might have been.

6. Because you get to meet so many interesting people. For example, lawyers and lawyers and lawyers…[nurse reviewers, medical board investigators, hospital administrators,...]

7. Because lots of people are dying to see you.

8. Because you can put your entire family on Valium.


9. Because even if no one sends you a Christmas present, the pharmaceutical companies certainly will [if you like coffee mugs, pens and sticky notes].

10. Because the market is always booming. Even if we were eventually to run out of diseases, we could still rely on traffic, [skydiving, snake handlers, lawn mowers and firearms].

*Mostly excerpted from Mangione: Physical Diagnosis Secrets, 2nd Edition 2008

Genotype v Phenotype

As we get deeper into the realm of genetics, the full implications of it are become clearer, and muddier. It's so much and has implications on nearly everything in clinical medicine. If your genes (genotype) don't cause the disease, it certainly provides the environment for disease to surface or be encouraged. Likewise the genes set up our milieu for health. But it is increasingly becoming the reality for me that the front line, primary care physician, from presentation alone, cannot possibly use this information easily in practice beyond just ordering a gene test first.

Gene Testing Results Panel

Dr. David Ledbetter, Ph.D., in the New England Journal of Medicine recently stated that the clinical implications of modern genotype technology and the understanding of even small changes (called micro-deletions) that can affect a patient..."The total number of disorders is now far too large for a pediatrician, or even a pediatric geneticist, to make a specific clinical diagnosis before genetic testing." When you consider the programmed responses of our genes to foods, drugs, and other environmental "assaults", the need for knowing the genes (and not guessing) becomes really evident.

We now know that given a specific drug, that it is probably that each person reacts differently based on how their genes are programmed. Can you "see" this clinically. No. It is nearly impossible to guess how somebody will react to anything we impose upon them.

So when we order screening laboratories in the near future, it is like that part of the standard panels for disease diagnosis will include routine genetic testing. The implication of that, are significant. If you think about it, we will then begin to obtain information about the genetic makeup, and environments created by those genes, in the patient well before disease (or health) become apparent clinically. Ponder the ramifications of that for a moment.

Tuesday, October 28, 2008


Medical Licensing - An Obstacle to Affordable, Quality Care - by Shirley Svorny - Cato Institute Policy Anaysis; No. 621 September 17, 2008

Executive Summary - "In the United States, the authority to regulate medical professionals lies with the states. To practice within a state, clinicians must obtain a license from that state’s government.  State statutes dictate standards for licensing and disciplining medical professionals.  They also list tasks clinicians are allowed to perform. One view is that state licensing of medical professionals assures quality. In contrast, I argue here that licensure not only fails to protect consumers from incompetent physicians, but, by raising barriers to entry, makes health care more expensive and less accessible.  Institutional oversight and a sophisticated network of private accrediting and certification organizations, all motivated by the need to protect reputations and avoid legal liability, offer whatever consumer protections exist today. 

Consumers would benefit were states to eliminate professional licensing in medicine and leave education, credentialing, and scope-of-practice decisions entirely to the private sector and the courts.  If eliminating licensing is politically infeasible, some preliminary steps might be generally acceptable.  States could increase workforce mobility by recognizing licenses issued by other states. At the very least, state legislators should be alert to the self-interest of medical professional organizations that may lie behind the licensing proposals brought to the legislature for approval."


Are consumers protected by education, licensing and other processes administered by political appointed bodies at the state level?  Are patients being served well in the US when there is greater import of foreign trained physicians than the capacity willingness of US medical schools to train US citizens for those rolls? Does the system truly protect the consumer?

Monday, October 27, 2008

Steams of Consciousness


It is amazing how streams of thought get started. In biochemistry we are discussion lipid metabolism and got to talking a bit about conversion of sugars to fats and fat deposition at the molecular level. I am totally fascinated by the diseases, issues and concerns surrounding obesity and have been for a long time. I was really lucky to have had the opportunity to work with some wonderful minds in this area back at the Diabetes Hospital in the "Halls of Kudzu" and gained great insight into the role that obesity played in this disease. Even way back then,  as Galen discovered the cell, obesity was understood to be a core player in diabetes.  Goes to show that with a good "teacher" you remember stuff. They were great teachers.

My mind wandered to the present as my current professor talked.  And then I read this mini article that came thru my email alert service:

Study links higher body mass index to arthritis in hips, knees. (Los Angeles Times, 10/25 as presented at the American College of Rheumatology) "The first and largest study examining the association between overweight, body mass, and osteoarthritis...found that overweight people are more likely to suffer the pain of arthritis in their hips and knees as they age... increased weight accelerates "the progressive damage done to the cartilage around joints," which "can lead to fluid accumulation, bony overgrowth, and loosening and weakness of muscles and tendons around the joints."

My mind streamed to my last job, first assisting in orthopedic surgery; A position that required me to "hold" and manipulate a lot of legs for total hip and imageknee surgery. A LOT of BIG legs. The article was no shock to me and I have the biceps to prove it. I can't remember we operated on a skinny total joint patient. Obesity has become a central focus on disease development, and the culprits (sugar, overeating, sedentary lives) keep on culpritting.

And how about the cost? $25,000 and up! With peripheral costs, as high as $75,000 in one study.$100,000+ if you have to go on and get the "other" one done. This is not cheap. Can you imagine the health spa, exercise facility experience that could be created with that money to keep people thin?

But in the words of that wonderful professor, years ago walking the halls of the hospital, teaching me extraordinary things...American medicine is predicated on people doing things to themselves. If everyone stayed healthy and actually did something about those preventable things in their lives, there wouldn't be the demand for the 200,000 projected physician shortfall in the next decade. So, for my sake and that sake of my colleagues...keep eating America. It's good business. Don't "step away from the chicken!"


Sunday, October 26, 2008

Choose Life


There is a big controversy on when life begins. In many traditions, the fetus is not considered viable until it graduates from medical school.

Student Physician Speaks

I'm catching up on my reading and I just finished the last edition of the journal Student Physician from the American Medical Student Association (AMSA). The list of challenges in this issue was tremendous. As I read everything I took note...from the ads, letters to the editors, article content, and side bars:

Aging population, soaring costs in healthcare, millions of uninsured and underinsured, staggering nurse shortages, medical professional depression, lack of business savvy teaching in medical school, medical school debt, lack of ability to recruit and retain rural health physicians, undisclosed payments to researchers by drug companies (at Harvard, to the tune of a $million), conflict of interest in research, accepting gifts from pharmaceutical companies and integrity, Medicare payment shortfalls, paperwork increases in the office...

imageI must be nuts! Why would anybody want to enter this arena of work? How is it possible that I still have the passion to be a physician, elevate my knowledge, serve people in unique ways and focus my career in this way? I think sustaining this momentum is the key. But I would love to pick up a journal dedicated to medical studies or practice and read about the more positive aspects of being a student and the field that I study. Is that really too much to ask? We've heard enough of the problems. How about the solutions? I don't know enough to propose solutions, but hope to be part of them. But I challenge writers of the world of medicine to find solutions oriented topics and disseminate them with the same vim and vigor (I wish I knew what that was) as they do the problems.

Friday, October 24, 2008

Turn Here

I went hiking today. I was supposed to meet some folks to join on the hike. One of them just said "meet us at the big stone." I was embarrassed to say that even though I thought I know my way around pretty well, I didn't know where she meant. She proceeded to give me detailed directions to the road the "stone" was on. I asked "how will I know the stone?" She said, "you are a medical student; You'll figure it out. I finally did.

Big Stone

Thursday, October 23, 2008

How Viagra Works

The magic of sildenofil (5-[2-ethoxy-5- (4-methylpiperazin-1- ylsulfonyl) phenyl]-1- methyl-3-propyl-1,6-dihydro-7H-pyrazolo [4,3-d] pyrimidin-7-one) better known as its citrate salt, Viagra, revealed itself today as an aside discussion about nitrous oxide. 

Seems it interferes with an enzyme called phosphodiesterase-5 located in the smooth muscle of the arteries that supply blood to the penis. This action prolongs the action of nitrous oxide to trigger the relaxation of the smooth muscle that lines the arteries and cause erection to stay longer than usual.  Prolonged erection can be dangerous however.

If the light stays on for more  than 4 hours, please call the electrician.


Wednesday, October 22, 2008

New Rationale

Ok, I admit it. I went to medical school to fend off Oldtimers. The cat's out of the bag now and I feel much better. I'm not Italian but I am brain damaged. And, I am totally convinced that this process, and particularly the testing challenges, have protected me for life. What a great rationale for going to medical school. It's not for achievement, future accomplishment, stepping up to the challenge or even giving something back to the planet. I'm doing it to keep from losing my mind....


Demanding Job, Less Memory Decline

Think hard and it may protect your brain from Alzheimer’s disease. A new study finds those with more education and more mentally demanding jobs may have protection against the memory loss that precedes Alzheimer’s disease, Italian researchers have concluded - Neurology, 2008

Tuesday, October 21, 2008

Used to be Beach!


At the southwestern edge of the Caribbean side, is an area known as Smoke Alley. Along side it, with a  beautiful view of Saba and the terminal was a gray-black sand beach that stretched nearly to the end of the stone wall ahead. It's all gone. No more beach. Worse, the waves of the storm who shall not be mentioned, set up a stone wall break about 20 yards offshore. The result? Sand will not easily return to this, the only real beach on Statia. It is very sad, and very difficult to gain access for swimming. Easy come, easy go. In Florida, I suspect they'd be ordering up a $million dredging operation to put sand back on the beach. Pipe dream here.


Ceramics found - click for bigger picWalking along what's left of the beach (and there is not much) I found some interesting Dutch, Spanish and English pieces of ceramics and pottery. Some of the design and texture was amazing...little works of art. I'm sure that some of them may be 100's of years old.  Sorry that the gold bullion wreck didn't wash up to (but I'm Ceramics found - click for bigger picstill looking).  The hurricane literally raked the bottom of the Caribbean floor and deposited it very close to and on shore along with damaging many of the beautiful diving sites around here.  It's not surprising that this stuff washed up during the storm since Statia was a free trade port for the world, and a smugglers haven for stolen goods. It was also "kept" by several countries over the years. A tumultuous history of plundering, pillaging and trade. Ceramics found - click for bigger picAnyway, just thought I'd share some of the more interesting ones. I don't have them anymore though, ...threw 'em back into the ocean on my swim...where they rightfully belong. Although, I'm sure the local historical society might take exception to that. I suspect that there is at least one PhD candidate in archeology that needed one of them to complete her dissertation. I may have thrown away a million dollar fortune...that one piece missing from completing a full collection of Statia Ceramic Parts and Pieces, I think now "showing" at the Museum of History in Amsterdam. But my police mind said, these might be stolen. I certainly wouldn't want to be arrested for aiding and abetting a pirate Blue Beads of Statiawould I? How would that look on my application for residency?  I'm still looking for the ever elusive blue bead though.

Monday, October 20, 2008

Midterm Exam Day

This has just been a weird week. Everyone seems a bit off kilter in the class. The hurricane messed people up I think. Not in the physical sense (it did little damage up the mountain where most of us live), but emotionally, psychologically... It changed our study schedules abruptly, and interrupted that normal flow, crescendo pattern, to the exam during the week before.  I can't really explain it, but you can certainly feel it. I too feel more tired, more nervous, more under-prepared this time.

0903 AM - The fever blister I had started this morning is  at bay for the moment. Dousing with alcohol is a time tested wives tale method for me...and it seems to have worked again for the moment. I don't remember being this stressed by exams before. I felt moderately ready for every other exam series, but not today. I just walked out of cardiac phys and feel pretty good about imagehow I did there, but I have had working experience in that area, so I should have done well. Not as well as I would have liked (never do), but ok for the format and content. I was dismayed to find many errors in both the root and answers. Example: stroke volume of the heart is measured in cc's or ml (milliliters) not cc/min or ml/min...that's cardiac output. So #1 is over..on to the beast..#2 biochem. This is the one that we are all worried about...

 10:43 AM - I guess I shouldn't be surprised that my PA experience actually can help me. It did. This biochem test could have been a disaster - It covered sooooo much stuff....all of carbohydrate digestion and metabolism Just one of the many (Kreb's cycle etc) and all the disease entities of carb metabolism and storage (McArdle's, Von Gierke, Pompe, etc) plus everything you always wanted to know about enzymes. It's the minutia that kills me, and always has (since organic chemistry "days of disaster"). But the prof was kind. I liked him before. I like him even more now. Is it appropriate to kiss a professor? There was more gross overview content, disease specific presentations that I could identify by key presentation features and reason from my knowledge of anatomy/phys, physical diagnosis and laboratory studies. Again, I didn't set the curve, but I did OK..."NAGAIWHL" (my phrase for life: "not as good as I would have liked") but good fine for this phase of my education. One more to go...genetics and molecular biology. I wish my brother was here to take this exam...he knows his "funny looking kid" stuff and genetics.

1:15 PM - It is done. Genetics kicked my butt. I think I got an environmentally stimulated 22 p deletion! Besides being the most difficult, it was the last.  The last one was the most difficult and the one most draining. I really don't have much energy left, particularly after a long night of study. I'm sure there is devastation in the wake in terms of exam failures but, for the moment, I'm not one of them. Time for a nap. And I think it's a holiday tomorrow.

Sunday, October 19, 2008


I've just been reading the latest medical news in a break as I cram last minute information for exams in the AM. I hope for a prosperous next 24 hours..."Bismillah". I don’t know what it means, but it must mean something about educational success or it's a mnemonic for the TCA Cycle. I've been hearing it a lot around here lately.

  So the news is lamenting about the medical system in the U.S., how little attention it is getting in the election discussion, and how failed the medical school system is. That caught my eye.  Why does the United States import physicians from foreign countries instead of training our own?  Why do US Medical schools graduate imageonly 16,000 medical students each year when we have a need for at least twice that number of physicians each year?  Why do US Medical Schools refuse to accept well qualified applicants forcing many would be physicians to go abroad for their training? Why do you need 4 years of undergraduate work in college before applying to medical school (the rest of the world knows that's not important)? Why is it that each year we deny a medical school [postgraduate] education to some 16,000 well-qualified American college graduates?   Why do we then remedy this shortfall by importing 16,000 foreign docs? Oh wait, I am one :)

Ok, so I'm all questions and no answers. Actually I've got a few and maybe I'll figure out how to institute them shortly, but for the moment, I'm wrestling with the Cori Cycle, gluconeo-something, and base sequence repeats. Makes you hair curl doesn't it? It is, what it is. I'm hopeful about tomorrow.

Saturday, October 18, 2008


I don't like generalizations, but some of us were talking at lunch today about common features on medical students here. We arrived at some conclusions that are fascinating to me although I realize not universal.  Eating tends to fuel such discussions. So what did the lunch brain trust decide?

We seek affirmation in our work and others around us. We are go getters, and have very high standards for ourselves and others around us. We sometimes fail to meet our own expectations, and then often beat ourselves up for that. We are assumed to be confident by those around us, until we break. Mostly people think us self-confident and sometimes even cocky. We know that our self esteem is not as strong as they think though.

Good enough!We tend to bite off more than we can chew in life. We have a general inability to hold steady overall satisfaction as the quest for external approval and accomplishment continues.  Our feelings often tank when things go poorly or soar when success is in our grasp.  At some point though, acceptance is the clear goal and we are proven eventually to be good enough...there is nothing to prove, except that we have the tenacity and heart to do this work with morality, care, and the attention it deserves.

Friday, October 17, 2008


I miss comforts. I miss my little girl. I miss Halloween. I miss my family. I miss fall in the NC mountains. I miss Coldstone. I think I need a hug. But I digress...

Losing more weight hasn't helped, but I think I'm developing blisters and hard calluses on my ever increasingly superficial ischial tuberosities...those bony landmarks that support our entire weight when we sit in front of computer screens, notes and textbooks for hours at a time without realizing we have been. I usually imageget up and stretch, eat, socialize, make up things to say with others when I feel that first blood clot forming in my legs (another symptom of sitting too long without moving - deep vein thrombosis). I've been sitting for long periods of time lately getting ready for midterms. I've got 3 full days until round of torture is over. I'm sure I'll "B"ready for them, in a manner of speaking.  Ah, no more grades starting this term, so I'll "P"ready.

It's funny how you "am ready" when you walk in the room. Actually that is not a statement of preparedness (as you are physically walking into the room to test), but more of resignation. More acceptance of the fate really. imageI'm sure that William Wallace (Scotland) and Joan of Arc felt much the same way. Rather than by hanging or fire, mine will be by computer assisted testing software, covering 4 subjects in 3 courses from 8 AM until 12 noon. I hope to maximize the information retention portions of my cerebral gyri by then. I wish Moses was here to "part" the beta pleated sheets of my brain. It's all about retention. A good thing if we are talking about the bladder, but impossible for the brain at times.

I'm sitting at school, ready for post hurricane roll call (our disaster management system). Hopefully some study here and then home or other study spots I've staked out since arriving that have access to the only pre-reqs: food, water, bathroom, Internet, electricity...not necessarily in that order. With the weather clearing some (still raining) after Omar's visit, it's time to get that rhythm back. Sleep, eat, study, swim, repeat. This weekend, that before a major exam, is made for that. Butt cushion anyone??


Thursday, October 16, 2008

The Day After



There is a set of stairs on the lower town road that leads down to a vast expanse of sand at my Stairs to the Sea...Where's the Beachfave swimming beach. The beach is gone, and the water (the day after) is lashing about 1/2 way up the stairs. The seas appear to be at last 4-5 feet elevated this morning, but it looks like it was much higher. There is significant debris, from the ocean, on the road. Conch shells are everywhere. The sea has combed the bottom from way out, and deposited a lot of it on the lower town road. Clean up has begun.

We appear to have survived the storm in great shape, but the true effects are yet to be felt. Not much damage to buildings, trees and such. It was loud, with conch shells everywhereoccasional gusts of wind and very heavy rain from about 1 AM until about 330 AM...tapering off very quickly. Came and went pretty fast actually. I got a little water thru the windows and thru the walls at the addition seam (where kitchen and main room join), but it wasn't bad. A little mop up, little towelage, and it was done. Electricity was off from midnight until about 930 this morning which worked out fine. We'll likely find  out that GEBE, the electric company, actually turned it off on purpose to avoid injury, system damage and fire.

Surf is still up, lashing at the hotels and harbor still The biggest effect was felt on lower town with the seas, some are saying now, as high as 15-20 feet.  They are down now, but the waves are still lashing the back of the hotels and businesses down there. The hotel Catering Manager, "M", looks disgusted. Business owners are talking about water inside, whole beaches being washed away, debris covering the road, and worst of all, damage to the harbor port. 

imageThat could be the effect that keeps on giving. The harbor, is our lifeline to supplies, water, everything really. Again, we'll see how that plays out over the next few days and weeks as the harbor begins to get going again. I've got 35 liters of water :) I think I'll be ok for now. Right now, everything is closed down there until the seas chill out a bit. They are still pretty high.

Statia Harbor...Lots of Damage

So all in all, I got a good amount of study done yesterday, will do so again today and have begun the push to midterms. I think we did pretty good but I'm sure that this was a wake up call to many who have never experienced the strangely scary feeling of a hurricane. It was  gentle reminder of days, storms gone by for me and now, the name "Omar" is fresh in my mind. That sux.

Bed Time Prayer

Now I lay me down to sleep. I hope that Omar doesn't...oh he probably will. It's Omar!image

Wednesday, October 15, 2008

Swimming Anyone?

Water EverywhereI am about as ready as can be for this thing called Omar. The irony still has me smile every time I hear or say the name. We started in class this morning, but school just closed and is no longer an option. Electricity may stay on at school, but Internet is off, and doors are locked up tight. We don't have to be back until Friday morning, so Thursday will be in the house study day for sure.

It is officially at Cat 1 storm and will pass just to the east of PR and west of us. You'd hardly know it from what I see about preparation. It is lack luster at best.  It is no wonder that when a Cat III or higher hits the islands there is so much damage, injury and death. There is debris, potential "missiles" everywhere.  They are saying words like "hard hit" as a Cat 2 for this one and with an excess of 10 inches of rain. Should be interesting. The weather channel just said something about St. Kitts getting "walloped" so that means us too.

So home it is, or where ever my little legs can carry me. I can see the Caribe and the path of the incoming storm, so it should start knocking on my front window in the next 12 hours or so. I've got 36 liters of water, gas for the stove and all the peanuts I can eat. I can make it for a long time on those provisions. My candles are out on the table, my back up battery and power supply is charged for the laptop and fridge if I really need it. And I've printed out the content for class and exams just in case. I am worried about blowing rain under the door, thru the jalousie windows. Yes, I said jalousie.

I heard we were the last Caribe med school to close, but that is hardly a surprise. We do things different on Statia. I think it's time for a swim. :) Just kidding Mom.

"Other" Island

"Hurricane Omar taking aim at Caribbean islands - MIAMI — Hurricane Omar is slowly moving northeast, a day after drenching islands in the southeastern Caribbean. Hurricane warnings have been issued for the U.S. Virgin islands, Puerto Rico's Vieques and Culebra islands and other islands in the region."

We am those "other islands". It's coming in the next 24 hours. This will really test our strength and stress the week before midterms exams. Thursday 2AM is the hit time, but the it is dreary out now. The winds and rain will pick up today and school may be canceled later. I've got plenty of supplies and feel as ready as I can be, but these wood shutters are not exactly the aluminum ones I had back on the mainland.

It is what it is on the "other" islands.

Tuesday, October 14, 2008

Omar, and tigers and bears, OH MY!

Tropical Storm Omar nears hurricane strength in the south central Caribbean. Omar is now taking a more northeasterly track, and a Hurricane Watch is now in effect for Sint Eustatius, indicating that hurricane conditions are expected within the next 36 hours, with weather conditions expected to deteriorate in advance of that time and tropical storm conditions being likely. A further advisory will be posted in the morning. Caution is advised in relation to this rapidly developing weather system, noting its unusual track....moving north and east. What?

Omar is Coming!

Ok this one is going to come close....OMAR! For those who know me, there is some irony here somewhere. Looks like about 50 mph winds now, but should get a bit more blowzy by Thurs at 2 AM when it scoots just west of us. No wonder the seas were up a bit during my swim today :) It was good swim in the rain though. Anyway, that would explain all the rain we've been having lately. Really hard, and muddy runoff too.


Printer-instability Syndrome

I think I've been patient. I know that I've got an "American service mentality" (one local calls it ASM), but I've not been able to use the school printers since May (5 months). In the scope of a 2 year experience, when is enough enough. I've done all the right things. I've consulted IT and done everything they've said to do...several times. I've loaded, downloaded, reconfigured...all the things I was supposed to do, to get the benefits that I've contracted with the school to do related to printing. Still nothing, until yesterday.

Printer hell! Now this is no small problem in the week before exams.  While some don't feel the same, I really need print capability to study the way I need to study. It's just me. I've not completely graduated into the world of paperless, but I've come a long way. And I've done everything I was supposed to do to make that happen. But this system is not right. And while I understand the challenges, and the issues at large (too many to deal with here), the simple fact is that me, simple student, can't print. It is such a bad problem that part of the platform in our student government elections of the presidential candidates was their promise to fix the print situation. Sad really.

Yesterday I lost it. I'm sick (fever this morning), I am behind, I am totally stressed out by tests coming that I'm not ready for, and I couldn't print. In no uncertain terms I described in vivid, pungent detail to the IT professional (and I use that term loosely) why this was such a problem and pleaded, begged, groveled, prayed aloud, and ranted about doing whatever we needed to do to fix it today. I can now print. Amazing what can happen.

There is a feeling on this island that we students are just visitors and need to put up with everything thrown at us. That somehow we need to suck up, digest and absorb every little thing that we are subject too without a whimper. I've done that, but there are some things, however seemingly unimportant to the outside world, that students just "need" to help make this experience manageable and bearable and (dare I) successful.

I'll put up with sharks and jellyfish, killer bees, mosquitos the size of aircraft with Denge', unbearable heat, food supplies that rival most 3rd world countries (I said most), high prices, alcoholic drifters barricading the lab door, surly locals serving me with attitude when I shop their stores, water from a cistern, roaches larger than my shoes...but I need to print. For the moment, I can, and I'm happy although sick. But I need to go apologize to the IT guys. It's not their fault. They are just a symptom of what this experience is. Good gosh, I just want to be a doctor. Printer heaven...

Monday, October 13, 2008

Smelling Health

"Fat people are fat because they are more comfortable that way. The day is easier being obese than suffering from the discomforts of not eating." - Steadism #28, p19

The medical student association sponsored a community event this weekend. Students took blood pressures and stabbed finger to assess glucose (sugar) levels. About 15 folks, out of about 3200, from the community came to have this free service performed and most of them were from the surrounding area (around school) or directly associated with the school. Sad really. A free, healthcare event, with very few active "takers" to come out from the community. I wasn't really surprised. I've been involved with these types of events before.

image A member of the local medical community was also in attendance and shared some local demographic information that is truly phenomenal. Over 50% of this community has hypertension (high blood pressure) and/or acquired diabetes. Whoa! 1/2 of the population had disease processes that are known to be genetically and or environmentally induced related to insulin resistance, and vascular damage. Our understanding of metabolic syndrome...induced insulin increasing daily.

I have no NIH grant and didn't do a study that would be approved by my peers, but I could have predicted that level of disease. I'll call this "COA", community observational assessment. And what do we see? Obesity, lousy food choices, alcohol abuse, and the smell. The smell.

As I walk to school each day, and walk home for lunch, and walk home after school, it is the smell that is most telling of the health of this community. On an island, imageeach day, the Caribe breezes blow away the tell tale signs of lingering smells, so what I smell each day is what is happening at that moment in time. It is, a olfactory snapshot of the community. And what do I smell? Cooking grease...the heavy, permeating smell of grease. The smell of a McDonald's uniform after a full shift of cooking french fries.  It's almost as diagnostic as the smell of cigarette smoke on a patients person as they emphatically tell you that they don't smoke.  You can almost feel the fat caking the lining of the arteries, making them thick, non-compliant, and causing intimal (wall) inflammation. I can hear the screams of the pancreas islet cells as they labor to produce enough insulin to overcome the fatty tissue deposited around organs and various appendages.

The food choices on this island, and the food preparation techniques, are not atypical of many communities around the world.  And the rampant insulin resistance, peripheral vascular disease and associated sign, symptoms and health (or lack thereof) is not shocking at all.

Oh, I won one of the raffles at the health event. What did I win? An order of fries from the local eatery. I wish I was making this stuff up. I'm not. Life is more entertaining than fiction.


American diet seen as key factor driving up U.S. healthcare costs. - In an essay in the the NY Times, 10/12,..."one of the biggest, and perhaps most tractable," reasons for increasing healthcare costs "is the cost to the system of preventable chronic diseases. Four of the top 10 killers in America today are chronic diseases linked to diet: heart disease, stroke, type 2 diabetes, and cancer.

Friday, October 10, 2008

Right in Front


You're thinking big and might be focusing on the future to the exclusion of everything and everyone in front of you now. That's as it should be, but make sure to swing back to the present occasionally.


It's so easy to cycle into the daily grind of school, and the long term goal thoughts of finishing. The focus on the future, and the ultimate goal is the "raison d'etre", but the real gems are found in focusing on the day to day learning, interaction, and focus on what's happens every single day. I'm learning how to do that more and more each day.

Physiology today was freakin' wonderful! I love clinical applications of the concepts  of basic medical science. And in that, buried in my frustration of waiting for so long to do this, is the knowledge that I actually know what I'm talking about.  Those amazing, local, immediate "EUREKA" experiences are priceless. Seeing it in others is even more amazing. See what happens when swinging to the present occasionally?


Thursday, October 9, 2008

Don't Eat the Fish

Eating Local Fish in the Caribbean - WARNING

It was bound to happen. Someone got sick from eating the local fish at the gala on Saturday night. I ate safe and ate only the "HOT" chicken.  The reality is that fish and shellfish ingestion accounts for much of the food-borne illness in the islands of the Caribbean. She got one of the seafood-borne neurotoxins. The bad thing is that they are thermo-stable and unaffected and cannot be detoxified by cooking, freezing, or salting.


The worst is Domoic acid (works in the brain) from shellfish who have ingested harmful algae.  is a central neurotoxin which causes amnesic shellfish poisoning.  Tetrodotoxin is a potent peripheral neurotoxin from the pufferfish, porcupinefish, ocean sunfish (mola), triggerfish, Blue-ringed TriggerfishOctopus, and the Rough-skinned newt...also the product of certain bacteria they eat.  Saxitoxin produced by bacteria and flagellates and concentrated in clams.  Brevetoxin is also known as Neurotoxic Shellfish Poisoning. One common one is Ciguatera found in barracudas, moray eels, parrotPufferfish fishes, groupers, trigger fishes and amberjacks. are most likely to cause ciguatera poisoning, but it has been found in other species.  Scombroid-related histamine toxicity , a histamine mediated allergic like reaction, is most commonly in tuna, mahi-mahi, bonito, sardines, anchovies, and related species that are inappropriately handled, stored or process from inadequate refrigeration or preservation after being caught.

Just add that to one of the hazards of attending medical school in the Caribe. Resolution: I don't eat the fish unless it is out of a can or pouch produced in a major country that is friendly to U.S. passports.

Wednesday, October 8, 2008


Lurking deep down inside of every single one of us is a psychotic, antisocial maniac just ready to pounce on others, or ourselves.

I watched a small, demure little female medical student, who I thought was the definition of stable and quiet resolve, completely "lose it" the other day on someone else. Fortunately no blood was shed, but it clearly drove home the point that we all have battles and challenges in our lives, and we never ever know when it'll come out. She told me today that she has never done that in her life.

Keeping vigilant...with real awareness, and a constancy of inner strength certainly is a great goal, but it is a great challenge under stress. Never know when our lurking psychotic will come out.

Tuesday, October 7, 2008

PharmFree NOW

Experts Conclude Pfizer Manipulated Studies By STEPHANIE SAUL; Published: October 8, 2008 - The drug maker Pfizer earlier this decade manipulated the publication of scientific studies to bolster the use of its epilepsy drug Neurontin for other disorders, while suppressing research that did not support those uses, according to experts who reviewed thousands of company documents for plaintiffs in a lawsuit against the company.  Pfizer's tactics included delaying the publication of studies that had found no evidence the drug worked for some other disorders, "spinning" negative data to place it in a more positive light, and bundling negative findings with positive studies to neutralize the results, according to written reports by the experts, who analyzed the documents at the request of the plaintiffs' lawyers.

I feel terrible. I have been such a drug company whore over the years. I've eaten the dinners. I've been an "expert" speaker for a failed drug that caused heart problems, I've traveled to cities to "learn" on the drug company tab. I have so many drug company pens that I've not bought a pen in nearly 20 years. The fact is, I've bought into this notion that the companies and the drugs they represent were above and beyond being affected by the market and financial pressures to perform. I've lied to myself in order to get the perks.

Beyond the headlines, I've been "convicted" to act. I've officially joined PharmaFree, a program by the American Medical Student Association. The concept is really quite simple, and the results could help fee the vision that there may be a day "when pharmaceutical companies are able to dedicate their resources to creating drugs that physicians choose to use because they are effective in treating disease, not because they are effectively marketed."

I don't want patients wondering where my loyalties lie.  There are serious professional, ethical and practical complications from any relationship a clinician has with pharmaceutical company representatives. It's about integrity, honesty and real education based on solid, third party research and the elimination of biased information provided by unwitting "experts" paid to be delivering that education.

imageIt's PharmaFree Week coming up and I think this is a great cause for my future. I will certainly miss the drug company meals, and I may have to break down and buy a pen or two, but in the end it's just the right thing to do.

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Monday, October 6, 2008

Unstuck / Stuck


"'s like watching your friends put their tongue on a cold, metal pool in winter. Looks like great fun and tremendously exciting at the time. Then you do it, and your are stuck." Unless of course you get unstuck and realize that you are free. Now that's exciting. And  you likely will never put your tongue on a cold pole again. But you might encourage others to do it, just for the entertainment value :)

A very good  and old friend of mine asked me today if he should get married (again). Fact is, he's been on the pole once already. But I certainly could use the entertainment. Isn't that what friends are for?

Sunday, October 5, 2008


Capricorn - Something you've been working on comes to completion today -- and you can tell it's a winner! You may see the results instantly, or they may come later, but you've definitely pulled it off.


This past weekend was a fundraiser for a local boy with cerebral palsy. I donated my time on Friday, Saturday and Sunday for the set up, event and cleanup. What an amazing event with amazing people. With this money, he'll be able to have care he might have never had here in the middle of the Caribe.

In serving someone else, you forget about yourself...and that is a good thing. We are exhausted, and one member of the "crew" was hospitalized for dehydration or related post event malady, but we raised almost $8000. That's going to buy a lot of trips to the care he needs.


Saturday, October 4, 2008


Seems like this conversation comes up pretty regularly lately. The one where two people, whos' ages total 100 or more, talk about how they feel relative to how they are in chronology. I know I look older, but I feel like I'm still that kid that was running around in South Florida in his '65 F85 Olds with the Kenwood 8-track tape player and dual JVC speakers playing Jethro Tull ("Aqualung"), Deep Purple ("Machine Head") and Pink Floyd.  And others in my age bracket here seem to agree or at least we commiserate. Ok I get it. The strata I'm from is old.  I'm on the edge of baby booming. When I was 20 something I thought people my age were old. Why should I think they'll believe anything more or less of me? But does God have to continue to remind me?!

I'm doing my regular run to the water cooler in between classes the other day. It's a bit of a hike from our downstairs classroom (not really, I'm just old). There, I run into one of the new term 20 something students (20ss) and ask how she is doing with class and island life? She's cordial and tells me about missing home (somewhere in the "great white north") and her struggles in Anatomy...and asks about my struggles. I passively, and briefly tell her about Genetics, a "course that wasn't even invented when I graduated PA school in the mid 1980's." Then I caught myself and paused...

Now I get that I set myself up. I totally take responsibility for allowing her the opportunity to remind me, yet again, that I'm surrounded by humans that are young enough to be my kids if I was responsible enough to have them when I was 20 something (I wasn't).

She says, "Wow, I wasn't even born then."

UGH! I hope she fails anatomy. And she didn't even know who Deep Purple was.