Happy Leap Year ‘07

So I’m going through some receipts that have been languishing on my desk, awaiting entry into either Quicken or the trash can, when I ran across this gem:

Apparently some vendors in Mexico celebrated leap year already! And people thought the daylight savings time bruhaha would be a fiasco…

The Blogging Thymus

I primarily use ecto on my Mac(s) to compose blog entries. I’m not writing about the program (though it’s best strength IMO is its customizability when you want to get under-the-hood of the markup code) per se, but one thing that always surprises me when I fire it up, thinking of a new topic to post about, is the sheer amount of drafts waiting to be completed. There is an unmistakable, lopsided ratio of drafts:posts.

Part of the problem is that I get interrupted. A lot. With a 10-month-old, this should come as no surprise. Another problem, and perhaps more relevant, is that I’ll get all fired up about something, scribble down a good bit, but know it’s not polished for public posting. It’s definitely comprehensible, not just stream-of-consciousness babble, but my standards for publishing are high (even annoying myself), so I put it aside and look forward to returning with fresh eyes. That might be as much as a few days later; meanwhile, the interest in the topic has waned, I’m now thinking on other things (perhaps opening new drafts!) and a thin film of dust–barely perceptible but unmistakably there–begins to accumulate on the website. I don’t read other sites with hardly a critical eye at all, and I certainly don’t think that others come here with a “BlanketyBlank Manual of Style,” complain that I use parentheses too much (I do!), and leave in a huff. So what gives?

As I’m reviewing microbiology in general, and specifically immunology since I have a love/hate relationship with this topic (so much so, I volunteered to do the painful task of coming up with clinical vignette questions on this dense topic for a study group), I have come to the realization my blog drafts are like immature T cells coming to me, Thymus Rex, to mature, grow, and develop. I nurture them, hoping to one day post them to the world, each one a unique combination of words with its own meaning and potential. If at any point, however, I see something I don’t like or know that there is no way that a given post will ever make it out there on its own, I just flag it for deletion (apoptosis). There is a code, a standard. Sometime that standard is too high, and the blog-rot that ensues is visible to all. At least I’m not as bad as a real thymus: less than 5% of the original pre-T cells in real life make it out as mature, functional T lymphocytes. Talk about a blogging complex if that were true!

I was writing to a surgeon blogger friend about this the other day when this idea first struck me (I won’t mention names, but his initials are Sid Schwab), and he replied in not so many words, “Thank God I don’t have to worry about the specifics of T-cells anymore.” For now though, I still have to, and since I’m pretty much always thinking about some aspect of medicine, science, computing or music, weird combinations like blogging and T-cell maturation make these inexplicable connections. It took 10x as long to write down than it did to think about, but I hope this entertains somebody out there.

Perhaps this draft should have been nixed. Uh oh, now my blog is going to get some autoimmune disease…dammit!

Grand Rounds 3:26

Appropriately themed with Sir William Osler, this week’s Grand Rounds is hosted by Dr. Samuel Blackman at Blog, MD. My post being mentioned aside, I really love it when the host–as is with this week’s edition–comments a bit on the article and the author from their perspective. It’s nice to have a context before you go read the linked article, and the personalization of each link also speaks about the host as well as the given author. (pre-rounds)

Studying for USMLE Step 0.1

Due to the brain trusts at Kaplan, we have a week off because the left hand didn’t know what the right hand was doing. We were supposed to be getting physio lectures this week, but the incoming prof didn’t know we had already covered that material with someone else. So, in the interest of fairness to the class since he wouldn’t have had sufficient prep time, Kaplan decided that classes would be cancelled for this week. Exqueeze me? I don’t know if cardio, respiratory, or GI was next (we don’t have that detail in the schedule), but you can’t tell me a PhD or MD-level lecturer can’t “wing it” with lectures aimed at 2nd year med students. Please. Something else has to be up, especially since this is the second such “crisis” of a prof’s/class’ unavailability that’s changed our schedule and even cost students some money as they had to scramble to change plane tickets.

So for the first time that I was actually WANTING class to be in session to take me out of my funk to ensure something got accomplished from 9-3 or so, this happens. Now I have the whole day to play with–a dangerous thing indeed. On a completely different but related note, it’s starting to get really warm for parts of the day here now, probably close to about 89-90 degrees. The problem is that the day starts out at about 45 degrees, which means there’s a 45-degree temperature swing from 7am until about 2-3pm. That’s frickin’ crazy!! It’s wreaking havoc with my sinuses–the spring flowers, temperature swings, pollution (ever-present, but worth mentioning). Since the upstairs is so much warmer than downstairs, I moved my laptop, desklamp and books to the kitchen table where it’s cooler due to much more ventilation from downstairs windows. The problem is now the street noise coupled with the fact that I feel weird with all this open space around me instead of my little study cove upstairs means that my chi is off. Feng-shui has something to say about this, I’m sure–perhaps there is too much “yang” down here interfering with my studies. What does the I-Ching say about a good swift kick in the ass?

I know, offer me some cheese with my whine (it’s OK–I’m not on an MAO inhibitor, ha!), but this trend of not being able to get it the fuck together is wearing thin. I need to be cooking with gas, blazing new trails, seeing the lightbulbs go off above my head as I delve deep into the material and say, “OH! That’s what Dr. BarelySpeaksEnglish meant two years ago! Why didn’t he just say that in the first place?” If you look above my head, in true cartoon fashion, you’d instead see a bulb with a thin, pathetic filament, barely glowing with the effort of trying to memorize micro right now.

What physician (non ID-research, obviously) gives a rat’s ass about what media to select for growth? I thought by Kaplan Step 1 time, such microbiology trivia would have been stuck down in favor of, oh I don’t know–pathogenesis maybe? I swear to Christ, if in the coming years I ever have to walk a culture swab back to a lab and remember to pull out chocolate or McConkey agar because I suspect this bug or that bug in a patient (because ALL doctors do all the lab work themselves, just like on “House, MD”)–that’s the day ladies and gentlemen, that I’ll inoculate myself with the culture sample.

5/4

Mother Nature’s calling card is symmetry. Even Father Physics can’t fool Mother Nature (remember the old “Parkay” margarine commercials? Ok, I’m dating myself…), because entropy and chaos/fractal theory still render patterns of inexplicable symmetrical complexity. Music is no exception. The symmetrical time signatures of 4/4 (most things), 2/4 (polkas, marches), and 6/8 (usually two groups of 3, such as a jig) are so natural one doesn’t even think of the meter. (The bottom number simply refers to what kind of note gets the beat: 4=quarter note, 8=eighth note. It has no bearing on the “feel” of the rhythm, just how it’s written and mathematically subdivided)

Even a waltz, which is an odd number of 3 is really 1, not three individual beats. Think of a pair dancing in a Victorian ballroom, the bodies really actually move on the 1 downbeat: 1-2-3 1-2-3 1-2-3. What was an odd number is, in physical human expression, one fluid motion that happens to be divided in three subdivisions. (I’m ignoring some musically famous but undanceable “waltzes” of late Romantic and 20th century composers where, while technically a waltz, a ferret on crack couldn’t keep up with dancing it.)

I am alone once again, my wife and daughter back in the USA, trying to get some order back into my life. My now quiet home is both a peaceful sanctuary to study and a prison of solitude. Our parting was exactly what I didn’t want–stressful, agitated, unfulfilled. I miss my daughter terribly–her sweet, gummy smile when she sees me. It’s so hard to study with her innocent noise, yet the empty rooms distract me with their silent cacophony.

What about 5? Oooh. Now there’s a problem. Not really anything fits into 5, being a totally disjointed number of beats between a natural 4 and an easily divisible 6. Even in visual terms, a pentagon has no real axis of symmetry while a square, hexagon and triangle all do.  The simple act of walking with a 5-beat in your head is like being on the verge of stumbling.

So too I feel like I’m stumbling along, not really sure where to put my feet, wondering if at any minute I’m going to fall. In general, I often feel unnatural, unconventional, like I don’t exactly fit in. As a med student, I stand out on so many levels: I’m way overweight, I’m in my mid-30s, it’s hard to find common ground with the young 20-somethings in class. I’m outspoken yet reserved. I seek camaraderie while at the same time knowing I can be hard to approach. My thoughts are vastly complex, but my needs as a person are rather simple. 5 takes extra time to figure out.

So what does one do with such an unnatural meter? Divide it, of course! Music in 5 naturally gets subdivided in either a 3+2 or a 2+3 pattern. Nature doesn’t have a problem with 2 or 3, so 5 can exist without seeming totally aberrant. Now It wouldn’t be right for me to make all these musical allusions and metaphors without sharing some actual music.

With all the selections below, count “1-2-3-4-5, 1-2-3-4-5, etc.” in your head, flip your fingers, whatever you need to count, so you can get a real feel of what’s going on rhythmically:

1. Dave Brubeck’s “Take 5″ (excerpt): Probably the most famous 5-meter piece to modern ears and a proud start to this list, it was a classic the day it was released. My dad has the original LP and although this is the title selection, the whole album is gold. A crystal clear example of a 3+2 meter (1-2-3-4-5, 1-2-3-4-5…)

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2. Tchaikovsky-”Pathetique” Symphony (No. 6), 2nd movment (excerpt): This is a twist on a twist, since this has all the right elements of that elegant ballroom depicted above, but now the graceful waltzing pair has suddenly turned into a horrific example of one person with a 5-inch-heeled orthotic shoe and the other with a cerebellar lesion. It feels this way because Tchaikovsky wrote a 3+2 / 2+3 dual pattern (ie, two measures make a single rhythmical mirror-image), but only a genius as he could have pulled off this aberration with such elegance and grace. Everything should be “wrong” here, but it’s so masterfully written, all that is perceived is beauty. Counting is “1-2-3-4-5 1-2-3-4-5, 1-2-3-4-5 1-2-3-4-5….” (it might be easier to count “1-2-3-1-2 1-2-1-2-3, 1-2-3-1-2 1-2-1-2-3….”)

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3. Holst-”Mars, The Bringer of War” (from “The Planets”) If you think you’ve heard this before and you do not listen to classical music, that’s because John Williams (“Star Wars”), Hans Zimmer (“Gladiator”), and virtually every modern film composer has shamefully stolen motifs from this work written in 1916. I left the whole piece here for listening because it’s just such a bad-ass work. While the melodic motifs are mostly a 3+2 pattern, the real driving force is a straight 5 meter relentless ostinato rhythm. It’s first established in the beginning, softly and ominously with the timpani and the strings marked col legno in the score (Italian, “with the wood”) meaning to percussively hit the strings with the wood of the bow–that’s the light “clacking” noise. As the war machine moves menacingly forward, this rhythm ends up in the hands of the entire percussion battery and high brass towards the end at 4:22. Fasten your seat belt!

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Maybe it’s not so bad in 5-land. 3 was always my favorite number growing up, but I’m older now, so maybe 5 suits me better. I am unique. I am creative. I am full of surprises and can vary my step, depending. I might be awkward, but like the Tchaikovsky movement, there is no less beauty there just because I’m different. I can chill out if I let myself, or I can be a relentless juggernaut driving towards whatever goal I have in my sights. I am who I am, and regardless of the fact that I am different in 5, I keep moving forward nonetheless.

Grand Rounds 3:25

Grand Rounds goes overseas at ScienceRoll, (pre-rounds) run by a Hungarian medical student. I’ve communicated with Bertalan by email before, and he is truly trying to make a robust science-centric blog, not just a medical one. One of my posts from last week got included, but I’m in much bigger company. Go read!

The cheapest baby food/pacifier EVER

Ok, we’ve turned totally Mexican now. Mom, if you’re reading this, turn away.

When people think of Mexican food and what accompanies it, the first thing that pops into peoples’ heads is tortillas. For the most part that’s true, for those dishes that it goes with, but for far more versatility, Mexicans go for good old bread, just like most of the world. For those not familiar with true Mexican food, traditional white bread are made in small loaves, about 8 inches (20 cm) long, called bolillos (pronounced “bowl-EE-ohs”). Depending on the region and other factors I’m not familiar with, it could be called birote, or if scored in thirds instead of lengthwise, telera (perfect for Cuban sandwiches).

Growing up on the border, I was used to a bolillo that was almost indistinguishable from a mini-French baguette: a firm, chewy but thin crust, and soft/pillowy on the inside. Coming to Guadalajara, I was met with oblong pieces of rock suitable for loading into a torpedo tube, which, after hammering a good two hours, one might get something edible at the very center. I would ask a clerk if these were day (nay, month) old breads, and he assured me, almost insulted, that they were put out that very morning. The thing is, here preservatives are never used for staple foods since people go to the market constantly. Bread lasts maybe a couple of days sealed; fresh corn tortillas might be coaxed into living 4 or so days with Ziplocs and the fridge. It’s not that they go rotten, they just get hard. Tortillas, bolillos, etc. are things that, especially for a family of any real size, are bought and/or delivered daily. Packaged, sliced bread in the supermarkets are different, of course, and they are identical to what Americans would be used to. We’re talking the real food of the Mexican table here, not the supermarket version. In spite of my making fun above, few things are as satisfying to the soul as a good, fresh, still-warm bolillo.

So what do you give a teething, fussy, hungry baby? Day old bolillos!!! Cut an end-piece of that hard bread in a chunk sized way too big to fit in her mouth completely, and you have 1) a nutritious food (no preservatives, just water, flour, leavening and a touch of salt), 2) a solid, organic object for her to rub her gums better than any plastic teething ring, and 3) something that is light enough that she can hold with one hand (unlike many of the teething rings) and gain coordination and independence. The 3 gallons of saliva she produces in one hour is just the right amount to slowly but surely soften the bread into minute bits that she can easily handle.

For about a peso per bolillo (literally a dime), I’d say we’ve hit paydirt!! The little one doesn’t care about the value or benefits–she just says, “Keep ‘em coming!”

P.S. The picture above is funny because trying to cut a hard bolillo with a butter knife as shown is about as futile an act as I can think of. That’s why it’s still there, embedded, like Excalibur waiting to be freed. (Okay, I went a little too far there, sorry.)

P.P.S. The word bolillo is also be used as a derogatory term for a gringo or “White Man,” since obviously it refers to white bread.

Grand Rounds & Change of Shift

GruntDoc Hosts Grand Rounds for the 4th time since its inception–a new record! (pre-rounds) Yes, this went up yesterday, but as usual, I’m late to the party.

Also, the nursing blogfest, Change of Shift, is up at Emergiblog where it all began.

Stumped by the simplest things

This community medicine rotation was a little different than the previous ones. For the first time, I actually felt I might have something to offer. Having completed my pre-clinical coursework, prepping for Step I, I felt equipped to at least handle some basic office-based cases–not on my own, but certainly with some basic supervision.

I quickly realized that I don’t know squat, or at least not practically, anyway. I never had the idea that I was in any way special beyond my training, but I was a bit shocked to have it hit me how useless I seem to be (at least in my own head) when confronted with a real patient thinking of differentials in real-time. The brains of end-of-2nd-year students are chock full of information from all sorts of sources, and obviously, individual knowledge will vary on all sorts of factors, but what’s common to all in “traditional” schools at this point are three main things: 1) almost all information has come from books/lectures, and as such, has focused on “classical” or typical presentation of diseases, 2) no class has really extended beyond itself to intentionally integrate other subjects, and 3) a vast majority of the space occupying our brains (especially owing to the first two points) is really not useful at all in the real-world practice of most aspects of medicine.

Regarding point #1, we all have the idealized patient in our heads when we think of a particular disease. The reality is that not only do disease presentations not obey such standards (how dare they!), but we are taught in such a way that stresses the “bullet points” of disease facts on paper, with no focus about the actual person. How many diseases have I learned in which there was no picture of a patient suffering from it? Or maybe there was one, but it was a histological slide of the basement membrane of their such-and-such epithelium–you get the drift. Even if there was a picture, there was ONE picture, and anything deviating significantly from that is new territory.

Regarding point #2, every professor thinks their basic science subject is the foundation of medicine. How can you know medicine if you don’t know your anatomy? How can you understand the body’s response to disease if you don’t understand the intricacies of immunology, or for that matter the pathogens that cause them (microbiology)? Well, all of that is dependent on your understanding of basic physiology isn’t it? ….  The message here is that each course focused on itself and only itself, and as a result, so too did our studying. Whether it was memorizing tables of interleukins for immuno or which inhibitory interneuron modulated which thalamic nucleus, each subject demanded its own narcissistic world view.

Fast forward, and here I am in front of a 9-month-old girl with what looks like mosquito bites all over her torso, some on her hips, a couple on her right knee, and one or two on each arm. I keep thinking bug bites over and over, since it looks rather obvious, follows no real pattern, and the small, reddened welts are neither fluid-filled nor crusted. But can I be sure? I strain my brain for my micro knowledge, thinking “Could there be a virus that could be the cause here?” I come up empty, but that means nothing in my case. There is no fever. The mother says they have no pets other than some chickens outside which the girl doesn’t play with. Bug bites. The mother says that she’s the only child in the house that has them. Uh oh–not looking good for me. I ask if she’s been to anyone else’s house for any period of time, the mother says no.

Now I’m feeling like the guy at the poker table holding two pairs and the guy across from me just raised the pot with way too much enthusiasm. I’m out of my league. I want to fold the cards and defer to the doctor there, only to suffer the humiliation of not being able to suggest simple topical hydrocortisone for some mosquito bites if that’s the case. (At the same time, I laugh to myself at the prospect of being a real dermatologist and saying, “Let’s get a biopsy to be $ure” LOL)

Honestly, at this point I’m just waiting for the night shift to go from the community clinic to the Red Cross so I can suture, splint–DO SOMETHING WITH MY HANDS FOR GOD’S SAKE–instead of all this fucking mental masturbation. Perhaps it was that I actually came with some expectation to be able to help, to offer something for a change other than be total scut monkey or a useless shadow in the corner, observing.  Perhaps it’s just me wanting to flee to do something far more simple and focused with immediate reward than constantly face my own inadequacies.

We pre-clinical students are almost universally dying for a chance to “get our hands dirty.” We disdain all the histories, all of the vitals-taking, all of the throats/abodmens/etc. exams that by now we are adept at performing. Performing, not necessarily interpreting. And I guess the take home point here is that it finally hit me that there’s a wealth of information that is easy to overlook because it seems boring, mundane, or repetitive. I am always excited, scared, and humbled by how much there is to learn, but I also know that I chose this profession in part because of that very fact.

Community medicine, once again

Only this time I’m in Chapala, Jalisco. That city, and the neighboring city, Ajijic (pronounced “ah-hee-HEEK”), might be familiar to some because there are a huge number of retirees from the US and Canada that have decided to spend their twilight years in this area of eternal spring. For the first time in my experience here in Mexico, it’s regularly assumed that you don’t speak Spanish and get attended to in English (as best as possible). In fact, much of this area feels more like some retirement community in Florida, except with much prettier scenery and better weather. For example, we are staying at a bed-and-breakfast place called El Sueño that is owned by a Canadian lady. I’ve never met a rude/mean Canadian, so I figure we’d be in good hands. I was right. Claudia and baby came along for a mini-vacation while I slave away at the Red Cross (hence the B&B–we’re in “Suite Three” if you look at the pictures on the website).

Anyway, as usual, I’ll have lots of pictures and stories to share when I get settled back. I worked into the wee hours so I could have Sunday off to enjoy the day with family, so I’ll do exactly that before getting back home to the same old grind.