Vacation + Books = It's been a while

-book-worm-

 

Latest shipment from internet purchases....well done me - it's better than trendy tops, but come on.....nerd. Really though, I am excited to read these; have already gotten through most of the "Kill as Few Patients as Possible" - excellent book. I am reading them in order from bottom to top....stay tuned for reviews. In the meantime:

"A clear understanding of how much I don't know about medicine is one of my greatest strengths."

Dr. Oscar London - Kill as Few Patients as Possible

An Ode to A Patient...

 So I woke up at eight twenty four

with my alarm clock thrown down on the floor.

I sat for a sec

then I hopped to the deck

"It's too light out to be 6:44!!!"

My first patient at a half past eight,

I was already horribly late.

So I called to the nurses,

as I spat heinous curses;

What a fabulous day this would create.

After popping in and out of the shower

I gave my mirror image a glower

"Why'd you have to sleep in?

Is that a zit on your chin?"

It seems over my body I have no power.

So I rushed through the streets of my town,

giving those driving slowly a frown.

"I'm an ass." I confess,

and I'm still just half dressed

I look like some bedridden clown.

When to the hospital I finally arrive,

I run breathless, just trying to survive.

by the time I'm in clinic,

I'm a rushed, breathless cynic,

And I look like I'm barely alive.

Colleagues stare, saying "are you okay?"

concerned looks are all aimed my way.

I find what rooms I'm in,

grab a chart to begin,

"please don't be a train-wreck" I pray.

So my first patient is understanding and kind,

and I thank heavens that to me she's assigned.

She has just one complaint,

She's a real clinic saint.

A sore back; but then what did I find?

Point tenderness on the bones in her neck.

I go back to her history to check...

Cancer of the breast

which she'd beat by each test.

But now this exam; what the heck?!

Back to the oncologist she must go,

to see what further testing might show.

So my nurse I did ask

to help me with the task

Of scheduling a date with a doc who's a pro.

I head back to my patient, and I tell

of the worries that now make my head swell.

"We must now further check

on this pain in your neck."

And it was then that my poor patient's face fell.

"Is it back?" she asks with a worried gaze.

What to say? I felt a bit in a daze.

"There's a chance; I don't know.

We'll see what more tests show.

But I'm here for you through these stressful days."

I tell her that the pain in her spine

could be something completely benign.

But with her recent woes

From the cancerous foes

Pose the thought that all may not be fine.

I tell of what could possibly be,

Though that diagnosis won't be up to me.

I am honest and strait

About how she must wait.

A long road was something I could foresee.

Then my nurse popped her head in the room

I hoped to say the appointment was soon.

"Dr. T, could you please,"

With no hint of unease...

Make note: do not ever assume.

"There's only one oncology group in town,

and I'm afraid her insurance has been turned down.

She can switch to a plan

so her coverage can span

this appointment." And then came the frown.

"As it seems with this new plan there's a catch,

in that with us her insurance won't match."

"See them or see us?"

 I blurt out, with a cuss

This poor woman's really hit a rough patch.

How's this fair to a woman of twenty-nine,

Who, until twenty-four, was just fine.

Then a lump was discovered, 

And the word 'Cancer' hovered.

The rest of her life had been redefined.

Her blood showed that she had certain genes,

That when present, they usually mean,

That cancer of the breast

Could possibly be expressed.

Female relatives with this curse she had seen.

So she had both her breasts then removed,

To the cancer she hoped she could prove,

No disease could take charge,

In her body enlarge,

Unless she herself had first approved.

She was cured, all the tests had said so.

Were the lymph nodes involved? Tests said no.

Her health had a clean bill,

Her wish had been fulfilled.

Now to face this possibly - what a blow.

I sat down with her, and told her the truth,

That with this history in her youth

She needed them more than me,

It was clear, we could see.

They were the ones to help fight nail and tooth.

So this patient, not mine anymore,

Turned to me as she walked out of the door.

"Thank you maam," with a smile,

"I'll be back in a while."

But the fear in her face, I couldn't ignore.

I stayed back in the room for a bit,

Thinking of this woman, her dealt cards had been shit.

Would she be okay?

Would I see her one day?

If only fate could be kind, and permit.

Then I thought of the morning I'd had,

And how I thought that my day was bad.

She'd had courage and poise,

Through life's loud background noise.

At myself, this did make me quite mad.

She taught me to take all life in stride,

dodge the rocks that get flung on life's ride.

You can't have full control,

But that's what makes life whole.

Let the challenges you face be your guide.

Don't get down, or dwell on the mishaps,

Cause sometimes life can just turn to crap.

Pick yourself off the ground,

Note the strength you have found.

And give hard times and strife a good slap.

When you're dealt a bad hand, it's not fair.

But do you think that fate really does care?

It's your job to endure.

That's what makes us mature,

And able to handle despair.

Every patient has a lesson to teach,

Your encounters have wisdom to preach.

So pay real close attention,

And wade through all the tension.

Hang on to each word from their speech.

You will find that when you are mildly reflective,

And see things from someone else's perspective,

It could always be worse,

No matter what is your curse.

Enjoying the good times should be your main objective.

That's my ode to my patient that day,

The moral, I hope that I've helped convey.

Keep your patients in mind,

And humility you'll find.

Your life could be in much worse disarray.

The Top 10 Things I HATE About Ageing...

-frenemies-

Well a very happy birthday it was..... Another year older - Check! Another year wiser - one would hope. Being in residency alone makes me feel like I've aged 9 years in the past 9 months, and not all for the worser (or whatever the opposite of better is); I do feel weathered, and tired, and out of shape...but I also feel like I've learned more about my field in the past 9 months than I ever thought possible. I owe it to my fellow goats, my seniors, my attendings, my nurses, my administration, and mostly my patients. So thanks. And thank you to all those who have supported me through this ageing process - again, my fellow goats, my seniors, my attendings, my nurses, my administration, my patients, and more than anything, my friends and family; never could have done it without any of you.

As I sit here, wishing that Coppola never invented such a delicious bottle of Malbec, I reflect on the things that truly make me feel old....at a ripe age of 31 (I know for all those older than me that I should quit my bitching, but lets be honest here - if you've never been in my position, you have no idea, and if you have been in my position, you know where I'm coming from.) As plush and delightful as my program may be, there are things that I wish the years did not bring me, and there are things about my younger years that I wish I could regain. Alas, the human body and the wonders of life have in store for us something that none of us want (that would be the whole ageing thing again), yet I long to embrace. So here's to another year older, and another year wiser....again, one would hope ;-)

My list of the top 10 things I absolutely despise about getting older (and I'm sure many can commiserate with me...for those with no idea, get ready, get set, cause game on!)

1. I'm Tired - As you age, you may get tired (and to those of you who don't....well....stuff you (j/k)!! Being tired is soooooo common a complaint among patients, and it is so non-specific (caused by many different things), that there's often no way to figure out what's causing it. We can check your thyroid, iron, hemoglobin and vitamin D levels (I find myself wishing that I have a thyroid problem, a vitamin D deficiency, whatever it may be that I can fix with the wonders of supplementation), but sometimes it's just getting older, not getting proper sleep, not eating right, not getting proper exercise, etc, etc, etc. I want to say that I'm tired all the time. It doesn't matter if I get a full 8 hours (a full what now??!), and even when I get 12-16 in a row (once in a blue moon)....I feel like I am always ready for a nap. As a resident, I'm just not getting enough sleep. It's not cause I work too much to sleep - for the most part, I almost never work 14-16 hours in a day, but on the days that I do, it's not like I come home and head strait to bed. I want to hang out, watch some Southpark, chill out and wind down. Which brings me (usually) to midnight or one in the morning, at which point I set my alarm to 6 or 6:30 (if I'm lucky enough), and try to lay down, wondering if I will wake up to said alarm. I've had a real problem lately with this, too often sleeping through it, or waking up in my sleep to turn it off.....bottom line, I can't decide if it's ageing or residency (or the accelerated former due to the latter) that makes me tired, but whichever way you cut it, I feel weathered....sleepy....exhausted....and I just want to stop and sleep for a month.

2. I'm Creaky and Stiff and Sore  - I'm only 31, but for whatever reason, I seem to wake up all sore and creaky in the mornings. And that's not the only time - on occasion my knees hurt when climbing the stairs, my feet hurt at the end of the day, I get stiff while reclining on my couch in the evenings. What did I do to deserve this? Oh yeah - years of not thinking it would ever happen to me. I've broken my share of bones (a couple wrists, a couple ankles, a knee, a couple metatarsals) - blame rugby, snowboarding and running on that, but I never thought that I would have any sort of arthritis this young. Well I do. I actually creak, and pop, and crackle....it's like a favorite breakfast cereal in my joints on a regular basis. The reason I hate this so much is that it's now come to the point that I can no longer run long distances (something I really did love to do.) What a fabulous way to release stress, by running though a lovely park, with some fabulous music flowing through my ipod, people watching and getting lost in my thoughts. I can only run a few kilometers (that's only a couple miles, for my American brethren) before I start to feel the pain. So I'm stuck cycling, ellipticalling, swimming, yogaing....nothing that I love as much as running, and nothing as easy as grabbing my shoes and running out the door. Oh how I wish I could be 16 and back on Vancouver Island running through the back-woods behind school once again..... So as you age, the wear an tear on your joints takes a toll on the cartilage within it; cartilage acts like a cushion, so to speak, between your joints. It prevents the oh-so-painful bone-on-bone feeling that you would have forever. It has your joints moving smoothly, and as you age, injury, wear and tear (like high-impact activity), and general inflammation around areas with cartilage will cause degeneration of it over time. When this happens, you get less and less cushion, until eventually your joints aren't moving so smoothly. You creak, crackle, get stiff and sore. See the back-pain section for further explanation for the lower body creaks. Supplementation may be in order - Boswellia, Glucosamine, Glycominoglycans.

3. My Back Hurts - Said to be the most common complaint in doctor's offices, a sore back can have many different causes. As you age, many things can affect your back, some of which are preventable. Here are a couple of my faves....

1. So remember those shoes that you love which have no arch support, and when you wear them you have sore feet at the end of the day? Well, they may inevitably cause a sore back one day! When you wear shoes that don't support your feet properly, your ankle joints don't align quite properly, or your knees, or your hips, and....yup, you guessed it - your back! Your body is designed to line up with itself, so that all your joints sit in a certain position; when you screw with one of those joints, you can cause pain in all the joints above it, and since there are so many joints below the back, it can end up in pain from any misalignment in the feet, ankles, knees or hips. Moral - get good shoes that have support specific to your foot type - if you're flat footed, get arch support, if you've got high arches, watch out for too much arch support. If you are a runner, go to one of those stores that lets you try on shoes, and then films your feet as you run - you can actually see the alignment of your step change with different shoes, and this can help you find shoes that will support and protect all your joints!

2. As you age, the cells in your body are just not as strong as they used to be. That combined with activity can lead to damage in the support system of the back itself; your back is a series of vertebral bones that are stacked on each other, with cushiony discs in between them to absorb shock. The discs can get worn down, so you lose that shock absorber, so any sort of 'shock' is absorbed by the vertebral bones themselves (degenerative disk disease); these bones are not designed to do this so when this happens, they can weaken and collapse on themselves, although this usually happens after some sort of  injury, and is more common in the much-more-elderly-than-myself....it can happen though, so don't pretend you're invincible. The disks between the bones can absorb enough shock that you can get a bulging, or even a herniated disc; your discs are like a jelly doughnut, except that the jelly is supposed to stay in...if it gets squeezed towards the outside of the doughnut, you may get a bulging disk, which can cause pain when that bulge pushes on nerves, and if the jelly gets squeezed out all over the place, you can end up in a world of pain where you have lots of pressure on the large nerves of the spinal  cord (ever heard of sciatica? Ouchie). Bulging discs can be quite common, and since they don't always cause pain, they are often found incidentally....ruptured/herniated discs, not commonly painless, and nerve pain sucks cause there's little you can do to stop it - you have to stop what is causing it. Stretch, take calcium-vitamin D supplements, exercise, eat a healthy diet. All the basics here... Booerns back pain, booerns.

3. When you think of what your back's job is, it is to hold up your body, and when that body has lots of extra pounds on it to hold up, you're going to end up with back pain. This can lead to what would seem like a catch-22 for many people, because they say they can't work out cause of back pain (and some will ask for disability and pain meds.....I want to hand them a salad and a swimsuit), but their back pain would be relieved if they would just work out and lose those pounds! Well, working out does not have to equal jogging. Go for a brisk walk , go swimming, do intensive yoga, whatever it is that will get your heart rate up for a half-an-hour several times a week (nudge, nudge, wink, wink), and that's a great start. I mean really, if the people on the biggest loser can go from panting while walking on the treadmill to running a marathon, I'm sure you can go for a swim. Supplementation in order - fruits, vegetables, lean protein, and less crap.

4. I'm Fat - Likely the part of ageing that I despise the most, cause my whole life I have struggled with my weight. Every now and then I will get to a healthy weight (usually for some goal....like a wedding for instance), and then something will snap, I will stop exercising, and start eating crap again. I remember back in the day when I could start working out, and within about a week I would start feeling great, start seeing results, and feel like my workouts were taking me somewhere. These days I do not feel so lucky, and there are several reasons for this (my lazy, fat-ass attitude one of them, but I am not going to go there.) As you age, your basal metabolism slows down it's pace. As well, in general, the amount of lean muscle that you have on your body decreases, so this even further decreases your metabolism; lean muscle increases your metabolism by increasing the number of little 'power stations' in your body that are using up your fuel (fat). Fat is just storage - no power stations there! So it makes sense that more lean muscle = more fat burned, even at rest. For whatever reason, my mind seems to be very 'black or white' on the subject of diet and exercise, and I either go at it like a madwoman, keeping the strictest diet ever, and working out like it's my job, or I eat anything I want and I sit on my couch. With all honesty, it's just easier to sit on my couch and eat crap food during residency. I've tried waking up early to work out (cause let me tell you the motivation and energy factor after a long day is nil), but I can talk myself out of this so easily....or sleepy-me just sabotages all efforts and turns off the alarm at 5am, for me only to wake up 5 minutes before clinic (see #1). So as you age, one of the most frustrating things that happens is your metabolism just sloooooooows doooooooown, which means that it takes longer to burn off that doughnut you had for breakfast, so think quick and put it down. Have a banana instead. Without your metabolism burning off the calories/fat you're eating, you're just going to end up with a muffin-top.

5. I'm Hungover - Well this one might only be relevant on certain days,  (note: I downed a couple glasses of wine last night to celebrate/commiserate my new older year, and feel like I drank a whole bottle of tequila) but nonetheless, I cannot help but notice that I cannot recover in the same ways I used to be able to after a couple of libations. Now I don't want to say I was a big partier, but I remember the days when I was working as a waitress at a little breakfast joint that opened at 6:45, when I could go out all night long, and still make it to work, manage to work efficiently, and look and feel great doing so. These days I find a glass of wine will have me waking up feeling like I got hit by a bus. My ability to recover has dwindled (and luckily so has my desire to put myself in the situation to need to recover in the first place.) As I mentioned above, your metabolism slows down as you age...now 'metabolism' goes not just refer to that which makes you fat or thin - it's all the chemical interactions and processes that are happening at the smallest level in the body, all required to keep you alive. Well, metabolizing alcohol is one of those little chemical equations; the process takes alcohol and works it through a couple enzymes (proteins that in this case change alcohol into other compounds, via a couple of reactions). The intermediate compounds (ones in the middle of the equation between alcohol, and fully metabolized alcohol) are toxic and can contribute to hangover symptoms (dehydration, alcohol-induced nausea, and other factors also contribute). When your metabolism slows down, so does the conversion of these compounds, and you can get a back-up of toxic chemicals (more than when you were younger). So voila, your body slowing down helps you have that headache that makes you physically slow down. I feel kinda sabotaged by myself. Water, anti-oxidants (vitamin C, vitamin B1, fruits and veggies in general) can help prevent these, and you'll definitely want to, for more than just hangover prevention - the 'oxidants' that the anti-oxidants are anti-ing do more damage than just the hangover headache.

6. I'm Wrinkly - I've aged. I can tell when I look in the mirror. Those creases in my forehead don't go away when I relax anymore. The crows feet in the corner's of my eyes can be seen in the light of day. I don't really have anything against wrinkles, or at least the ones that you've earned and that tell a happy story of your life....laugh lines, crows feet, cheek creases from smiling...I think they are a testament to how much you smile. But the ones that bother me are the ones on my forehead - the ones that I've gotten from furrowing my brow. They remind me of the hours in my life that I have spent bent over books, charts, EMR's (electronic medical records). And these creases are getting deep quick! I can't even tell you how many different wrinkle creams, refinishing serums, collagen masks and retinoid solutions I have purchased over the past 5 years....it's kinda ridiculous. Wrinkles are formed as you age due to skin, muscles, connective tissues (shocking surprise) getting weaker, more flaccid, less tense. Skin sags, creases form....sunlight, repetitive facial expressions, smoking, pollution, dehydration - these all contribute to wrinkles. There is more money put into wrinkle research every year than into cancer research (which is not such a shocking surprise, since sadly there is money in wrinkles, and none in Cancer....sad reality). The good news is that you can prevent wrinkles by drinking lots of fluids, eating healthily, exercising, using sunscreen, taking care of your skin, and quitting smoking. I'm feeling repetitive here...which makes me furrow my brow....

7. Cellulite - I love how people how to justify cellulite saying that "movie stars have it too!!" I don't care who all has it....I flipping hate it! Cottage-cheese thighs, orange-peel skin**....No thanks. It is true though that it is a relatively "normal" part of ageing (people are predisposed obviously, and the amount of fat you have can play a role in the development.) Cellulite is what it is because subcutaneous fat pushes through the fibrous connective tissue that lays over top of it; when you're young, that fibrous tissue is tight and fresh, but thanks to genes, body type, sex, race, inflammation, weight (the list goes on), those fibers get weak and flimsy, not being able to hold back the impending outpouches of fatty tissue. ....I vividly remember the first time I realized this in The Talented Mr. Ryan, a shot of Gwenyth Paltrow in a bathing suit where you see the back of her thighs, and she too (in her ever-perfect physique), had cellulite. This, of course, was before I developed mine...oh the naivety of it all, the unknowing of what wonders the years would bring me. Now sadly, there is no cure for cellulite...yes there are things to help smooth, firm, plump, etc, etc, etc. But nothing is every really going to tighten up that fibrous tissue again. Best bet (assuming you don't have too many of the genes, body-type, race points against you), is to exercise and eat well so that you can decrease the amount of fat that you're letting be there to poke through (yes...you are in-fact usually not blameless in this....admitting you have a problem is the first step towards recovery.) There is no pill, no cream, no smoothing serum, roller device, coffee mask, slimming wrap that will do more for you than diet, exercise and a healthy lifestyle. And I plan on implementing one of these just as soon as I get back from vacation (just over a weeks time....recently purchased "Metamorphosis....the body transformation system" via infomercial. Should make for an entertaining month of night float.)

(**sidenote - is it coincidence that we use food-related descriptions when describing body imperfections due to fat? Cottage-cheese thighs, orange-peel skin, jelly-belly, muffin-top...)

8. Everyone's Having Babies but Me - Residency is tough enough as it is, that I have no idea how people do it while getting pregnant and raising kids....I can't even keep a couple of house plants alive (Plants - 0, Me - 5). Props to you guys. That being said, my body YEARNS to have one for myself. I feel like every time I log onto facebook, I see yet another ultrasound pic, a baby belly or another picture of a brand new baby. Most of me is ecstatic for people, and the other part of me wants to....I'm not going to finish that sentence, cause no matter how I cut it, I sound like a horrible person. Really, I am happy for all of you, and it's not as if 'age' is getting in my way of having kids right now; it's the 1824 miles between Hubbs and I for the next 460 days (of course I have a countdown!) But it's ageing that makes our post-residency options narrow; I want to be a young Mum (yeah, I know...missed that boat, but I'm trying to prevent it from getting any more of a head-start than it already has.) I'm not saying there is anything wrong with having kids in your thirties (there are obviously more risks involved, but it's not like my eggs are shriveled up and useless), it's just not what I planned for myself. Honestly, I wanted to have at least one by now, but plans change. Med school happened later than originally planned, and I wouldn't have done anything differently, I just wish I could do it all at once (or do I when I think of the craziness??) I worry that since I already have to deal with numbers 1, 2, 3, 4, and 7 at age 31, what is adding pregnancy going to do to me a couple years from now? Yeah, yeah, I need to listen to my own advice about getting off my couch, exercising more, drinking more water, eating more healthily....but that bacon at the hospital is just so crispy and delicious....every morning. Again, "Metamorphosis"  ;-)

9. My Memory - Really this point should really be called "The Lack Thereof." Again, yeah....I'm only 31, but MAN has my memory declined since I was a teenager! Hubbs jokes about it, how I have early-onset dementia, and obviously he's kidding (obviously, right love?!), but there is no doubt in my mind that either my brain is full and every time I put something new in there, something else falls out, or as I age, some of the memories are fading. Take today as an example. I am (ever so clearly, eh?) a Canadian, so to live and work here, I have a green-card (yes older-sissy, now it's on the blog, so Mum and Dad will know that I am in fact still dealing with myself...at least I have the excuse of a busy life these days!!) So being the good Kiwi-Canadian that I am, I settled in for an episode of The Flight of the Conchords last night (S2E1 - Femodent Commercial), when Bret and Jemaine get into a pickle regarding getting paid for their recent work; up comes the topic of word-visas, green-cards, etc. So I think to myself (at 2am, post birthday-wine) "wait a moment...when does my green-card expire? I think the end of April some time." Having a feeling in the pit of my stomach, I hop out of bed, find my card and see "Expiry: April 6, 2012." Oh swizzle-sticks. So this flung me into a flurry of printing off forms, gathering bank statements, writing affidavits....luckily I have friends on Nightfloat to guide me through the ridiculous that is me, and luckily I remembered today, and not next week - I could have been deported! And do you know how many times I've thought to myself that I should check on that date and make sure I'm 'on top of things?' Too many times to count, but never at a time when I was anywhere near my card, and never did I write it down again in my daytimer (I actually had written it down for a couple months ago, and the page has so many scribbles and crossed out errands, it's a wonder I get anything done at all! So it's come to this....if I don't write it down, I could get totally screwed. I need a personal scribe to follow me around and remind me of things I think, and I don't even think Siri could help me here, cause she'd be constantly reminding me of things that I would just have her remind me of later. As I get older, these scatterbrained moments are becoming more common, but thanks to the horse-shoe I seem to have up my rear, I've managed to make it this far. Knock on wood that the good times keep on coming....

10. Real Life - Now not that I don't love doing what I'm doing....I really do! But don't you ever wish you could be like 6 or 7 again, where your 'job' in life was to go to school, play with toys and friends, go to camp in the summer, watch cartoons on Saturday mornings. I mean come on - doesn't that sound delightful? Have you ever seen a kid entertained by something like bubble wrap? Or if they're young enough, a box? Imagine being that easily entertained, and that happy about something so simple? A time when you didn't have to worry about work, bills, gas prices, insurance, diet, homework, laundry....I really could go on. Real life and being all growed up is fun, but man does it get old sometimes. I even miss the days when I was a waitress/bartender, and my 'work' was getting dressed up, serving food, entertaining people for 45 mins to a couple of hours, and charming every penny out of them that I could. It was great money, and when I was done work, I was done work. No charting about diners, pages about kitchen emergencies, consults on dishes. At most I had to learn what wines went with what dishes, and this was research and studying I was into! Being a responsible adult is great and all, but sometimes I long for the days when blowing bubbles, or remembering what kind of toast table 4 wanted with their eggs was the hardest thing I had to do in my day.

So there it is. Ageing can be great because you get to live like a big-person, having real money, your own apartment, whatever bed-time you want. But living like a big-person can suck, as 1-10 may demonstrate. I don't mean to complain, but it's been a long day.....I'm tired, creaky, dimpled, wrinkly, fat, with a sore back, a bad memory, a hangover, no baby, and the reality of a 'Real Life' awaiting me in the morning. Good night :-)

Happy Birthday to Me :-)

Drinking a bottle of wine tonight means I'm researching blogging about how old I'm going to feel tomorrow....true story :-) Stay tuned for tomorrow's topic - "The Top 10 Things I CANNOT STAND About Ageing."

The sense you are unaware of till it's gone

 

-my-favorite-is-the-nose-

Proprioception. For those of you who are not familiar with what this means, it is one of the senses in the body (true story - there are really more than five!) Proprioception is your brain's sense of where your body is in space, and without it, simple tasks (like standing or sitting even) are difficult or even impossible. When I learned about proprioception, I truly never realized quite how important it was, or what a life would be like without it....this is until I heard the story of a man who had lost this sense forever.

A couple years ago while in studying on the rock, I got into the habit of watching documentaries about medical topics, and I found this one most fascinating - The Man Who Lost His Body. Now that I am in residency, I find myself with my TV-watching hours not coordinating with normal prime-time TV, so I've gone back to the docs, and I re-watched this one again. It is a BBC documentary about this guy who was working in a butcher shop at the age of 19, when he came down with some viral illness. During this illness, he slowly lost the ability to feel anything below the neck, and along with this, he lost his sense of proprioception. The man could not feel where his limbs were in space, and he lost all control of his body. He is one of only a few people in the world who have suffered from this 'disease,' and he is (or at least was when the documentary was made) the only one who is able to walk.

The human brain is a truly amazing organ; my favorite part of the body to learn about, and the part of the body we will know the least about. One interesting feature of the brain is that it is plastic (not in the rubber, made of plastic sense, but in a whole other way). When I say that the brain is plastic, I mean that it has the ability to change and adapt to our environments, our behaviors, and our conditions - this is called Neuroplasticity. It's how the body responds to injury; when something happens to one neural pathway, your brain will find another one. 

"If you are driving from here to Milwaukee and the main bridge goes out, first you are paralyzed. Then you take old secondary roads through the farmland. Then you use these roads more; you find shorter paths to use to get where you want to go, and you start to get there faster. These "secondary" neural pathways are "unmasked" or exposed and strengthened as they are used. The "unmasking" process is generally thought to be one of the principal ways in which the plastic brain reorganizes itself." 

-Bach-y-Rita, one of the people who first studied plasticity

In the case of the man in the story, as he built these new pathways in order to walk, by consciously telling his muscles what to do, his brain eventually adapted to his inability to feel and control his body. All these movements that were originally unconscious, which then had to be conscious, again became (in part) unconscious; as he had to create/find new pathways for making himself move, they got stronger and faster until they were nearly as strong as the original pathways. He was able to walk (as long as he could watch his legs doing their thing)....and this is really the key - if he can see his body move he has control, but if he can't he does not. This opens up the ability for a very cruel joke if this guy's in a room with no windows - turn of the lights and he'll slump to a pile on the ground! 

As we have all heard "you can't teach an old dog new tricks," and this does seem to be one of the limitations to neuroplasticity - it's more effective in younger people, and older brains have had more difficulty adapting to injury and change than younger ones (have you ever tried to watch your grandma/grandpa/any 80-year-old try to send an email? It's like a whole ridiculous process for them! Yet my 6 year old nephew seems to have the concept down pat.) In short, one of the reasons the man in the documentary was likely able to get himself walking again, was because he had to relearn how to use his body at 19, when his brain was still very plastic and pliable. Most (or even all) others afflicted with this weird condition have not been so lucky, so (as you can see in the opening scene of the documentary), they can barely crawl.....sad :-(

We take for granted the fact that our brain allows us to move, walk, grab, and make all other movements without having to think about all that is involved in these actions. We do not have to tell certain leg muscles to contract while others relax in order to take a step. We do not have to control the hundreds of muscle fibers in our hand when grabbing our cups of coffee. Our body just does these things when we tell our brain it's what we want to do. Well, this is something that you lose when you lose your proprioception. If you think of an example - imagine you have no feeling in your body, so hypothetically, you would not be able to feel the bottoms of your feet standing on the ground; if you can't feel your feet on the ground, then your brain wouldn't know they were there and so it could not tell all the big (and little) stabilizing muscles in your legs, hips, buttocks, back, and abdomen what to do in order to keep you upright. In short, you would just fall into a pile on the floor. The man in the story would tell his brain he wanted to lift his arm, but he could not. He just lay there....for weeks. And after laying there for weeks, he eventually got tired of his inability to do anything (and his desire to just die), and he taught himself to control his body.

Slowly, muscle by muscle, he was able to start moving. It was difficult at first - he would have to tell one muscle to contract while making sure another one would stay relaxed, and he had to do this all consciously. Over time, he was able to lift his arms, and move his body, but the key was that he had to be able to see these parts of his body to do so (remember, no feeling in your body means not being able to feel where they are, and if you can't feel where they are, you can't know what to tell them to do.) At the time that this documentary was made (1997) there were less than 10 similar reported cases, and this man was the only one who could walk....through hours, days, weeks and months, he trained his brain over and over and over again, what he had to do in able to take those steps. Now keep in mind that there is more involved that just telling his muscles that they have to contract or relax - he needed to be able to tell them how much to contract or relax. He had to be able to look at things he was picking up (for example), and guess how much force it would take to do so, otherwise he either wouldn't be able to pick it up, or he'd be flinging it across the room! The perseverance and determination that this must have taken, in order to get to a (semi) normal way of functioning is truly mind-boggling to me.

Anyways, here are the links to the video

via you tube (better quality, but in 5 parts):

part one

part two

part three

part four

part five

via random website (fuzzy quality, in 1 part):

The Man Who Lost His Body

Residency Lesson of the Day...

Never, ever, ever try to argue or correct an old lady who has self-diagnosed 

"Obama-induced Hypertension" 

....as in, Obama physically gave her an elevated blood pressure through his own magical means. You will only waste an hour of your life and end up late for subsequent clinic patients. It's better just to smile and nod at the crazy lady :-/

There is no reasoning with some people... On a brighter note:

-spring-has-sprung-

Quote of the week...

"So I thought I had hemoptysis the other day....turns out I had just eaten a jelly-bean and then fallen asleep."

- Dr. ND

CLEAR!!!!

Today we had a lady who was in atrial flutter (a heart arrhythmia where the top chambers of the heart are beating at a faster rate than the bottom chambers of the heart), and after doing a quick transesophageal echocardiogram (sticking a probe down her throat to get a look at the heart through the esophagus to make sure there were no clots in there) we hooked her up to defibrillator and.....CLEAR!!!! She was fixed....

Before:

 -flutterbug-

During: (see far right for the shock)

 

-electrifying-

After:

-normal-sinus-rhythm-

It's amazing how a little jolt of electricity can just reset your beat...and they say white girls ain't got no rhythm ;-)

 I heart Cardiology

I hate medicare

-fancy-shoes-

I have a clinic patient who had a stroke years ago - it left them with a little bit of right sided weakness, but otherwise they are pretty functional. They came to me a few weeks ago as a new patient, their son at their side, for a general check-up. The only medical issues that they reported to me was hypertension and dementia; they were told a while back that they had Alzheimer's, and now were on Donepezil, an Alzheimer's medication. As I spoke with my patient and their son about the dementia, they told me it was mild. My patient was still living on their own, and their son thought this was not a problem, as he and his siblings would come and help pay bills, clean up and shop as needed; overall though, he reported, my patient was pretty self-sufficient. Sounded like pretty mild dementia to me. They'd had a recent CT from the doctor's office they'd switched from, and it showed that little areas of micro-infarcts; these are little areas in the brain that have been left without oxygen for enough time that the brain cells were damaged. As we continued talking, the son told me that his parent's slow decline was not happening gradually, but instead was happening in a step-wise fashion, and every few months they would all of a sudden have a bit of a worsened memory. This did not sound like Alzheimer's, it sounded like vascular dementia.

Vascular dementia is a type of dementia that is caused by, as their CT showed, little micro-infarcts in the brain. This can be caused by hypertension leading to tiny little bleeds, ischemia from a lack of blood flow (often due to narrowing of arteries or little clots.) In comparison, Alzheimer's is due to 'plaques' of random, mis-folded proteins that accumulate in the brain, disrupting the flow between neurons. I decided to do a work-up on my patient....

I wanted to order an echocardiogram (where we ultrasound the heart so they can get a good look at the valves, the chambers, the wall-motion, etc), a carotid ultrasound (where we look at the vessels in the neck to see if there is any narrowing that could potentially cause a stroke), an EKG (where we look at the electrical activity of the heart to make sure there is no abnormal rhythms that could be causing clots to form), and some blood tests to check cholesterol levels. The echo and EKG were easy to order, because the patient has hypertension, but the carotid study posed me more problems....

Now as I have previously ranted, the ICD-9 is the master and controller of all that is done in the office - if you want something done, you have to code it properly, or it will not be approved, or paid for, by insurance...Medicare is the biggest pain in my rear when it comes to making sure I am coding things absolutely perfectly in the ridonculous world that is Medicare's justification system. Unfortunately (and ridiculously), there is no code for 'History of stroke.' There are 'family history of stroke,' 'acute stroke,' 'known cerebrovascular disease' codes, but nothing that you might type in to order a SCREENING carotid ultrasound. I did not know what kind of dementia my patient has, so I couldn't code that it WAS due to anything in the carotids. In all honesty, I didn't even think that there was necessarily anything going on in the carotids (the micro-infarcts were, in my mind, more likely due to  hypertension that I was pretty sure wasn't all that well controlled - their BP in my office was 150/96, but that's not the point.) I had no documented screening carotid ultrasound in this 79 year old patient, and I felt that they needed one. So I ordered it under 'Dementia, unspecified,' thinking that this was an okay code - the patient has dementia, I'm not sure why. It is therefore unspecified.

Well, as it turns out, Medicare would not approve this. I got a message from the clinic saying that I had to call the scheduling office to come up with a new code. When I called the lady, she read off all of the codes that would work - among others that didn't apply to this patient.....


'Occlusion and stenosis of pre-cerebral arteries' (pre-cerebral, as in the carotids) - I wouldn't know this without an ultrasound or other study, now would I?

'Transient ischemic attack': they had not had one of these, so I can't just go about lying

'Acute cerebrovascular disease': nope...nothing acute going on here

'Occlusion of cerebral arteries': couldn't know this one either without a MUCH more expensive study, that I'm sure medicare would find some way out of paying.

So all I could code for this SCREENING test, were codes that were applicable to conditions that could have been caught by screening. Are you kidding me? Medicare sucks! I was on the phone with the scheduling lady for a good 20 minutes trying to come up with a code, and in the end, I just diagnosed the patient with 'Vascular Dementia' to get the test.

Medicare is supposed to be in place to help people. What is the point of a screening test if you have to have a stroke in order to have the test that can help prevent a stroke? Who come's up with these crap rules? I'm willing to bet that they aren't doctors, and their only worries are the money that goes into, and comes out of this system. I don't hope bad things upon people at all, but I feel like it will take every person in the upper-levels of Medicare to have a family member who gets screwed by Medicare, in order to change the stupid rules that are in place preventing people from getting the full level of care that they need, and deserve! I will definitely say that there is a lot of money that is wasted in the healthcare system, but I do not feel like this is any reason to hold back care from those people who are elderly/disabled/whatever and actually NEED the help from the government. It's ridiculous. So ridiculous in fact, that I plan a much more detailed rant into this 'secretly socialized' healthcare system that the US has....you heard me - I said the s word:

Socialized 

Eek!!! Stay tuned...

The Frenemies of my Residency Life...

Work aside, these are the top four things that make my life difficult right now..... needless to say, work makes my life more difficult than all four of these combined, but still...

 

-evil-deliciousness-

-i-never-want-to-leave-

-not-even-friends-just-enemies-

-thank-god-i'm-not-lactose-intolerant-

Life Lessons from the Cath Lab

-tortuous-

Now for those of you who are not familiar with what Cardiac Catheterization is, it is a procedure where we (as in the cardiologist/interventional radiologists....I say we cause I'm on their service this month) go through the femoral artery (in the groin, where your leg meets your torso) with a cateter (hollow tube with a wire in it), and up through the Aorta (big artery that comes from your heart), to the heart itself. Once up there, using flouroscopy (like a real-time x-ray) we can look at how the heart and vessels of the heart are filling (or not filling) with blood. It allows us to identify any abnormal filling or movement of the heart, as well as any blockages in the coronary arteries (which cause angina and heart attacks). After we see blockages in the vessels, we can do a couple different things...

a) Balloon Angioplasty - this is where a tiny catheter with a deflated balloon on the end us sent up to the blockage, and then when within the blockage, the balloon is inflated and the plaque buildup is pushed aside against the walls of the vessel, opening it up

b) Coronary Stenting - like the Balloon-thingamajig, but instead we sent a catheter that has a stent (a cylindrical mesh support-thingy that holds open the vessel), and the stent is opened up on the plaque, thereby clearing the blockage.

c) Identify areas that aren't candidates for A or B, but could be candidates for bypass surgery: This is where you take a vessel from another part of the body and attach it in front of and just past the blockage, bypassing the interruption of flow. This is major surgery with very real risks, so don't just think it's an easy fix.

I am currently working with a cardiologist who is a well known genius, and all-round cool guy....I don't know if he started this, but I know him as the-guy-who-wears-a-sport-coat-with-scrubs....complete with elbow patches and everything. It seems like lots of the surgeons/cardiologists are doing this as well.  He's awesome to follow around (no, I am not a puppy), and I feel like I should just be scribbling down every enlightening thing he's saying, cause the man is like an encyclopedia of cardiology knowledge....I'm truly in awe. 

Today we 'cathed' a couple people, and here are some amazing before and after shots of what can come of such a procedure...

 -do-not-pass-go-

Before: You will note in the center of the page is a blockage in the LAD (left anterior descending) artery...it's the main artery supplying the left heart, which supplies the left ventricle (the outflow to the body), and is a common place for blockages. If you don't see it, it's in the middle of the picture...the break in the blackness (the blood-flow)...

-flow-baby-flow-

After: No more blockage! This lucky patient went from about 98% occlusion, to clean-as-a-whistle!! Not bad, considering that in this particular patient, this was an incidental finding, and there was no previous evidence of this blockage even being there.....lucky barely cuts it, since had this not been fixed, it would have surely led to a heart attack in the very near future.

Now the moral of the story today is this...

Everyone (I'm going to go out on a limb and add "in western culture") begins developing the startings of plaques as a child...not necessarily in the coronary arteries, but this is where the progression heads. Eating fast/fatty foods, smoking, not exercising, being overweight, drinking alcohol, etc can all contribute to this, and as some of the less fortunate patients that we cathed today now know(who had blockages that were beyond repair), you should work on getting these problems fixed before you have a problem.

How can you do this?

Well, I'm going to go ahead and assume (from the 'average' age of my facebook friends/readers) that you are young and you haven't gotten such blockages yet. So here's what to do - put down the burgers and pick up a salad!! For the love of Pete, put on some running shoes and go for a brisk walk (or some other sort of cardiovascular work-out....remember - cardiovascular = heart and vessels!!) Lose weight! Let go of the "I'm big boned," "I'm husky," and the "I'm trying to set an healthy example for the kids of today." Yes, curves are lovely, but when we say it's important to be in shape, keep in mind that 'round' is not the shape we're talking about. Quit smoking, once and for all. Stop drinking like your 18 years old (unless you ARE 18 years old, in which case enjoy for a couple years, then settle down).

One of our patients today was a 72 year-old gentleman who was recently found to have bladder cancer, and his oncologist sent him for a cath so that they could make sure he was safe for the surgery that would help treat his cancer (ie. removing the bladder and cancer completely). His blockages were so severe, that it was decided he was not a candidate for angioplasty, stenting, or even bypass surgery. I watched as Dr. Brilliance-McMastermind told him that the surgery to fix his heart would likely kill him, so his options for cancer treatment were going to be limited to radiation and chemotherapy. The look on this mans face was so sad....he tried to  be strong in front of his wife and daughter, and then muttered today's quote of the day...

"I should have quit smoking years ago when they told me to." 

Yeah....you should have. The man had smoked 2 packs a day for 55 years....mind-boggling. And preventable. Not to mention that he, his wife, and his daughter were all morbidly obese (BMI of roughly 40-45....that's big), so I'm guessing he wasn't exactly watching his diet. Again, preventable. 

The future of medicine is in prevention. Prevent disease by exercising, eating well, and generally taking care of your body, and you can stay healthy (I say can, and not will because the reality of the situation is that not ALL disease is necessarily preventable, but of the top 10 causes of death in the western world, 7 are (usually) preventable (with the exception of the very small proportion of these killers that are caused by messed up genes/DNA) - Chronic Obstructive Pulmonary Disease (smoking), Diabetes (type II - eating crap, not exercising, obesity), Colorectal Cancer (eating crap, obesity, smoking, not exercising), Lung Cancer (smoking), Stroke and Cerebrovascular (brain-vessel) Disease (eating crap, smoking, alcohol, not exercising), Hypertensive Heart Disease (eating crap, smoking, alcohol, obesity, and not exercising), and the number one killer (and reason that we cath people), Ischemic Heart Disease (eating crap, smoking, alcohol, obesity, and not exercising). Pattern recognition much?

So here is the bottom line...

1. Quit Smoking. Cigarettes don't just cause lung cancers, but is linked to so many types of cancer - bladder, cervical, mouth, esophageal, nasal, pharyngeal and laryngeal (throat), stomach, colon, kidney, pancreatic, and even AML (a type of leukemia). Plus you end up smelling disgusting, getting all wrinkly at an early age (these are the 60 year olds who look 90), and getting addicted to a habit that is more addictive than cocaine or heroin.

2. Add more fruits and veggies to your diet, cut down on fatty and high-sugar/high-glycemic-index foods, decrease the amount of red meat in your diet. Remember - you are what you eat...literally. This does not mean you have to say goodbye to all those foods that are delicious (and lets admit, a krispy creme donut in all it's crack-like ways is WAY more delicious than any salad....admit it); the key is moderation.

3. Exercise...this doesn't mean you have to join a gym and pump iron 7 days a week. We recommend 30 minutes of getting your heart-rate up 5 times a week....that could be a brisk walk if you want it to. Hypertension (high blood pressure) is one of those diseases that can actually kill you with it's effects, and studies show that it's incredibly responsive to exercise.

4. Cut down the alcohol. Now I say cut down, because you don't have to quit (believe me...you don't). The risk of all these diseases starts when you have more than 1 drink per day. That does not mean you can have 7 drinks once a week and be fine, but keep the binge drinking to a minimum. Again, if you aren't 18, wake up to yourself and grow up. An occasional night of getting liquored up isn't going to impact your health that much, but if you're doing it even once a month, you may have a problem. A glass of red wine a night has been shown to actually POSITIVELY impact your cardiovascular health; I'm not going to go into how, but this is a practice I will happily follow :-)

5. Lose weight if your BMI is more than 25**. Doing number 2 and number three will help this, and losing weight can help prevent and treat Diabetes, Hypertension, Ischemic Heart Disease, Stroke and Cerebrovascular Disease, and many types of cancer. Plus, you'll feel better, sleep better, look better and improve your self image (hopefully....if that's something that you need). Studies show that obesity doesn't just impact your health, it can impact your relationships, your sex-life, your ability to play with your kids/grand-kids, and even can prevent you from getting a job (some employers discriminate against obese individuals because they fear a decreased productivity, increased risk of sick-days, and the fact that not taking pride in one's body can equal not taking pride in ones work....this practice is not right, but it exists. We've all heard that obesity is the next big epidemic, and believe me it is - nothing is sadder than having to tell the parent of a 5-year-old that they are overweight and need to lose weight....kids should be fit so they can have oreos and chocolate milk! I feel the obesity rant may translate into another post on another day....

Your health is very much in your hands, and believe me when I say that although doctors sympathize with your diseases, we also don't feel that sorry for you when you are doing it to yourself. True story. There's no magic pill, it takes work, both to get there and maintain. Now get off your computer and get your ass in gear!!

**To calculate your BMI, click here. Now keep in mind this is not always accurate, as people with lots of muscle will appear to be overweight. This does not mean that if you calculate to be overweight that you can get away with that gut cause you've been beefing up with the weights. Be realistic.