Boreal B[l]og

After the second long flight on the trip, from Tokyo to Singapore, we arrived in the Lion City about 1 a.m.  Fortunately, we had booked a hotel at the airport, and all we had to do was find it.

Biologically, it was about 10 a.m. the next day for me, and I had not slept well on the plane.  I seldom do.  Usually, my head flops over and wakes me up, and I couldn’t find a way to rest it elsewhere that worked.  Yet, I felt surprisingly sharp, as we walked through the terminal.  The terminal wasn’t quiet; indeed, the world isn’t quiet, even when it ought to be.

I wasn’t sharp,  although I didn’t realize it.  I had trouble finding the right tram, and the “T2” sign didn’t click with me as meaning “Terminal 2.”  I thought it meant “Tram 2.”  Nevertheless, we got to the hotel and slept a little.

The next morning, I realized how much clearer I was after even 5 hours of sleep.  There was so much I had missed in the airport the prior night.  I didn’t realize the shortness of the tram and the various shops present.  It wasn’t like I was totally stupid the night before, but I thought I had been functioning well, and instead I had acted like I was mildly drunk.

Exactly.

Being sleep deprived for 24 hours is akin to being drunk.

When I learned German online, I was often teaching English to people all over the world.  I was amazed at the hours when they were awake.  No, not the hours in my time zone, but hours in theirs.  People were up at 2,3 or 4 a.m.  I can’t fathom this.  I have often wondered if the one of the big problems in the world is that a good share of humanity is functioning half or fully drunk because they aren’t sleeping enough.  It sure would explain a lot of the world’s problems.

If I am separated from the felines who live with me, like when I take a canoe trip, I find I sleep even more than the 7 hours I usually get, although eventually I return to that number.

I knew sleep deprivation was bad when I was a physician.  I felt awful, the telephone’s ringing jarred me, I occasionally dozed, and I often sat writing a note on a patient, only to realize I was staring at the paper and nothing was appearing on it.  Had I been drinking and practicing medicine, I would have been thrown off the hospital staff.  Instead, they tolerated me for years functioning at a sub-optimal level, called “not enough sleep,” and actually expected it.  My partners did, my colleagues did, my teachers did, for the “giants” of medicine, those who in my view made the mess American medicine is, were purportedly able to function without eating, sleeping, or vacations.  They were held up as paragons of medical virtue.

The only bad evaluation I received as a medical student was when I gave the wrong order at midnight and fell back asleep.  The next day, the patient needed a ventilator.  I felt badly, for good doctors give the right order any time day or night.  I obviously was not good.

Eventually, medical programs recognized the need for doctors in training to get enough sleep.  Pilots have known about sleep deprivation for a lot longer.  The airline disasters in the Marianas and Colombia were in large part due to pilot fatigue.  Pilots take brief naps on long haul flights, for a nap has been shown to improve performance.  I wonder sometimes how many errors I made because I was too tired.  We all gave orders over the phone at night and had in the future to sign off our phone orders.  There were always orders I gave at say 3:27 a.m. that I had no recollection of  giving.  No recollection.  That’s scary.

More than one has teased me for the brief 10 minute afternoon nap I often take and have taken for years.  Because I have animals, I am up at 5.  I am in bed by 9, when most I know go to bed a lot later.  Indeed, I often wonder if they go to bed at all.  There appears to be a gap between 2 and 5 in the afternoon on the US West Coast, when the rest of the world is quieter.  Three hours.  Then in the evening the messages start, and when I awaken at 5, there are often messages sent to me at 1,2,3 a.m. as if I were awake at those hours.

Nope.  I’m not.  I can’t function awake at 24 hours.  Nobody can.  Oh, people can be awake that long, but they are kidding themselves if they think they can function.  They are missing things in life, because we just aren’t able to function normally.

One Saturday night early in my internship, I was called to the cardiology floor to evaluate a patient with a fast pulse.  I walked into the room, today still able to remember what room and which bed he was in.  The man’s heart rate was about 150, and while he was tolerating it, he needed to have something done.  I hooked up an EKG, both confirming the rapid pulse rate and the diagnosis, atrial flutter, with 2:1 block, so the atrial rate was 300 contractions a minute and half of them were getting through to the ventricles.  Back then, before the anti-arrhythmic drugs we have today, massaging the carotid artery was one way to stimulate vagal tone and slow the heart rate.  Thinking I could see the EKG well, I started massaging the patient’s right carotid artery.

I can still see the patient as he had a seizure about twenty seconds later.  I took my finger off the carotid and he quickly woke up.  I looked more closely at what I thought I had been watching.  The vagal tone I stimulated was so strong that I blocked all atrial conduction, no longer 2:1 but rather 300:0, so that not one beat passed through the atrioventricular node to the ventricle.  I had put him into cardiac arrest.  Great job, Doc.  No pumping, no blood.  No blood, no brain function.  When the brain suddenly gets no blood, one of two things may happen: coma, which is the most common, or a sudden burst of electrical activity, a seizure. I once seized when I fainted.  A lot of “near death” experiences may be due to excessive brain stimulation due to severe hypoxia.

The attending showed up an hour later, looked at the patient, then the EKG, and finally me.  He held up the EKG, looked down his glasses, and quietly said, in a British accent,  “Are you the author of this?”  I was embarrassed beyond belief.  The patient was moved to ICU and fortunately made an uneventful recovery.

My misadventure with a patient’s neck was the butt of many jokes for the rest of my internship. For days afterward, every one of my fellow interns, when they saw me, would rub the side of their neck. Even today, I would be willing to bet money if one of the interns I knew saw me, the first thing he would do is put his hand on the right side of his neck and act like he was rubbing it.  He did that every time he saw me for the rest of the year.

The first few times it was tolerable.  Then, it became annoying and finally hurtful.  I admit it.  I screwed up.  Do I have to be reminded of it every time you see me?  What do you want?  Should I admit to being the worst doctor in existence?  Would that help?  Should I quit? Would that help?  Why are you doing this to me?  Have you never made a mistake?

Later, in practice, I saw a psych patient whom I was convinced didn’t have anything neurological going on.  A nurse disagreed, and she was proven right; the CT scan I ordered showed a large, benign brain tumor, which had caused the person’s problems.  I might add while this is always a consideration, I only saw twice a benign tumor causing psychosis in all the years I practiced.  Oh, I diagnosed the other tumor.  For years afterward, the nurse reminded me of my mistake.  Stuff like that hurts.  It starts to eat away at a person.  OK, I missed a tumor.  I am a bad person, a bad diagnostician, a bad doctor, and on and on up the ladder of inference.  Do you continue to  have to remind me?  Does anybody remind me, I wondered back then, about the diagnoses I did make correctly, the patients I did help, the times I was right and others were wrong?  What about the case of Wilson’s Disease that I diagnosed on the first visit in the office?

Teasing is toxic.  Maybe in small doses, it is fine, but only in small doses.  Let the individual poke fun at himself or herself.  And perhaps that is why I behaved the way I did last February 2, when the hike leader gave me a stuffed toy of a groundhog and told me quietly to start hiking before everybody else and put the groundhog on the trail somewhere where it could be seen.  About fifteen minutes up the trail, I stopped and placed the groundhog on the edge in the sun, because frankly I wanted six more weeks of winter.  I like rain; I haven’t seen enough of it in decades.

I waited, and when the first group of hikers arrived, one looked at the groundhog and pulled out his camera.  He was dead serious.  “Wow, a groundhog is up here!”

I thought he was kidding.  He had to be.  But the furry thing did look kind of real.  I quietly walked over and put my hand down on the stuffed animal.

“Oh my God,” the hiker said. “I fell for that.  I can’t believe it!!”  I didn’t say anything.

And I haven’t since.  The individual has mentioned the groundhog event to several people, but I have stayed quiet.  Sure, I could have teased him about it, but a long time ago, I learned what I should have known all along:  a good deal of teasing is toxic.  It hurts, and it isn’t appreciated, no matter what people say.  “Can’t you take a little teasing?” I heard as a kid.  I should have replied, “Can’t you take a little poison?”

It did me good to read that Finnish skier Eero Mäntyranta’s success in winning seven Olympic medals in cross country skiing was likely due to a genetic mutation that increased his oxygen carrying capacity 25-50%.  He wasn’t the only Finn who was this fortunate.  I wondered at the time why Americans never were on the podium in those events.

It also did me good when I read in Outside about a man who could hold his breath six minutes—yes, six minutes— and used that skill to dive to tag threatened hammerhead sharks.  A comment was even made by Laird Hamilton that this man was unique.

Hamilton, one of the great big wave surfers, is unique, too.

It did me good to read that virtually every Track and Field star has the 577R allele in some form, enabling them to do things that the rest of us can’t.  It isn’t a matter of training harder, as some have told us, or “mental toughness”; nope, it’s genetics.  Now, that doesn’t mean one can’t train and improve.  There was evidence that Lance Armstrong improved his muscle performance 8 per cent through training.  Unfortunately for the sport, he improved it another smidgin by taking drugs, although he was far from alone.  All Tour de France riders are genetically exceptional, and at the top of the top, a fraction of a per cent advantage matters.  Some argue that genetic mutations don’t make for a level playing field. Well, we aren’t all created equal.

For years, reading about all these guys and gals who could do everything from surf to big wall climbing made me feel inadequate, despite my wondering that these skills were genetic.  Now it’s clear.  You either are born that way or you aren’t.  Nurture is essential, mind you, but nature creates a few special people every generation.  I am not one of them and never will be.  On the other case, I’ve never taken performance-enhancing drugs.  I was drug-free.  Maybe there is a genetic mutation for that, too.  Or maybe good nurturing teaches one not to cheat.

For most of my life, I tried to play sports well.  I am competitive.  But I have a modest ceiling.  My medal in 1966 for the third place 400 yard freestyle relay at the Delaware state swimming championships was my being a moderate size fish in a puddle, since Delaware, besides being the first state, is the second smallest.  I played baseball but never thought to try out for the team.  Basketball? I played third string in the city league, although one fabulous day I hit 20 free throws in a row at a schoolyard.

In cycling I was in the top 14% of the El Tour de Tucson 109 mile finishers.  That meant I placed about #736.  I trained long hours and had done all the right things; my result wasn’t bad, but hardly noteworthy.  In only one sport—skiing—was I good, and that was because I started young, took lessons, and had a lot of days on snow.  I was an excellent technical skier, but I couldn’t race well.  As a kid, I dreamt of being a pro baseball player; I never once dreamed of being a top skier. I was neither.

I feel better knowing that when I watch a track meet, or a good basketball game, I am watching people with chromosomal genetic code that I and nearly all others do not have.  More importantly, I understand the pain of those who train and train and train, but they didn’t have the right 577R allele to be part of the U.S. Olympic Team.

I feel better knowing that I was right when I argued with my cycling friends that it was genetics that made top riders.  All the training I did made me better and faster, but I reached a low asymptote.  I do believe I have a slight genetic advantage for endurance. I did a 200 mile bike ride once in just over 12 hours. In the 2002 Cochise County Classic, I was part of a small group that had our own support, and from mile 100 to mile 160, the end, I was pulling at the front two-thirds of the time, stamping out a solid pace, seven riders in my slip stream,  as we finished in about 8 hours, averaging 20 mph.

I was sixth out of 20 finishers.  Not even podium.

I was right when I argued that if I could be a top cyclist by training, anybody could multiply three digit numbers in their head, the way I do, simply by training.  That stopped most arguments, because people knew then that my skills were genetic.  Sure, I practiced math a lot, but I had this stuff in my genetic code from day 1, just like Yo-Yo Ma and cello;  Laird Hamilton in big wave surfing, Chris Froome in cycling, or Stephan Curry in basketball.

We should celebrate these people, and we do, paying them good money and cheering for the the ones we like to succeed.  No doubt they eat right, they train right, they do everything they can to reach their potential.  Some do it better than others, and they are household names.

I no longer feel inadequate when I read about these people who grace the articles in Outside, Sports Illustrated or Golf Digest.  I am reading about genetics, what how random mutations can positively affect performance, and—I think—to a lesser extent what training does.  Training is what we can control, and allows us to do reasonably well, be it learning a language or hiking up a mountain.  None of us will be noteworthy except maybe in our small group.  Nope, it is the mutations who make the stars, the names we know.  They work hard, to be sure, to separate themselves from other stars, but they are in a league of their own.

Now all we need is a mutation that leads to idea generation that would fix the rest of the human race, so we wouldn’t trash the planet and drive ourselves to the brink of extinction, which we will.

Maybe it’s time for better nurture.