Boreal B[l]og

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.

I travel all the time but have not paid the $100 for the TSA pre-check. However, I get selected for this line in LGA more often than not. I think that they (Delta) know the frequency that I travel and do not consider me a risk. I will tell you that it ticks off the people on my team that have paid for the service.

This was a recent Facebook post from one who was randomly chosen to use the TSA pre-check line. TSA does this to encourage more to be pre-screened.  It cost me $84 to get mine, and I had to drive to Roseburg to be fingerprinted, but the few times I fly,  I don’t wait in line.  I am at an age when convenience is worth a lot, even if I can’t attach a dollar value to it.

“It ticks off the people on my team that have paid for the service.”  In other words, somebody got something for nothing, They had to pay for it, IT IS NOT FAIR, IT IS WRONG, AND IT MUST BE CHANGED.

Fairness is an American obsession.  Many want to end Food Stamps, now SNAP, Supplemental Nutrition Assistance Program, because a few have abused it to buy things they shouldn’t have. Food Stamps is one of the least abused, most useful of all federal programs.  Still, any unfairness bothers people.  In Kentucky, able-bodied adults between 18 and 50 with no dependents must work, volunteer, or take classes for 20 hours a week for SNAP.  Heaven forbid somebody get something for nothing.  Many can’t find jobs, and I know first hand the difficulty to find volunteer opportunities. If we want “must work programs” let’s have mandatory national service for the young and able-bodied on welfare with an organized list of thousands of jobs, thousands of supervisors, so that we can fix infrastructure and support the three gifts America gave the world: liberty (military service), the national parks (build trails, fix the backlog of jobs), and public education (help in the schools).  Then let’s pay them by giving them a reasonable stipend followed by four years of education in a field of their choice after completion of their duty.  Such work gives people dignity, and I can’t attach a dollar value to dignity, either.

Because somebody cheats on welfare, many want to disband it. One should pull himself up by his own bootstraps, by golly.  This is difficult if one doesn’t have shoes, let alone boots. If we tried to enhance family planning, rather than trying to destroy it, we would have fewer children, less poverty, and require fewer jobs.  Freeloaders are employers who come to a city lured by tax breaks, not single women with children on welfare.  Every corporation that skirts IRS laws is a freeloader.

In college, I discovered for the first time in my life that hard work didn’t bring success and good grades.  It wasn’t fair, but life isn’t. When asked whether it was fair to call Reservists up for duty in Vietnam, JFK replied, “There is always inequity in life. Some men are killed in a war and some men are wounded, and some men never leave the country, and some men are stationed in the Antarctic and some are stationed in San Francisco. It’s very hard in military or in personal life to assure complete equality. Life is unfair.”

Want to know something that wasn’t fair?  Read Paul Kalanithi’s “My Last Day as a Surgeon” or “How long do I have left?”  He was, the past tense a sad way to refer to a remarkable human being, a neurosurgical resident, diagnosed during his training as having Stage IV non-small cell lung cancer.  He died two years later at 37.  As a resident, he was a skilled communicator and physician.  He learned in his last two years of life to enjoy the simple things as realizing his reassurance of a patient mattered.  He was a physician-scientist who could have been a writer, too.  It wasn’t fair that he died so young.  He quoted his chances of getting his disease: 0.00012%

As a physician, a lot of my stress was seeing people who had medical problems that weren’t fair.  I saw the 55 year-old at 2 a.m. with a sudden onset of a Grade V (the worst) subarachnoid hemorrhage, who was going to die. Not fair.  I saw a colleague develop a glioblastoma multiforme, which killed him at age 52. Not fair.  Or the 41 year-old man who in the ED at midnight, with a big stroke, whose wife said, “He’s going to die,” and I remained silent, because I knew she was right.  Not fair.  The 25 year-old woman devastated by MS.  Not fair.  The 28 year-old who broke his tibia, who coded one night at 3 a.m.  He didn’t make it.  I can still see the ugly, huge pulmonary embolus at his autopsy.  A gifted classmate, hiking by a Colorado river, falling, hitting his head and drowning.  He was 27.  Not fair. Notice that four of these were sudden.

This is life, or maybe death.  Bad things happen.  Some we can prevent, and some we haven’t a clue how to prevent.  I try to think that I must make each day count in some way, because we don’t have forever, and time is passing.  Atrial fibrillation was my game changer.  My probability of having a stroke has significantly increased.  Not fair that I inherited some bad genes, but biology doesn’t really care how I feel.  It just is. I’m moving on. The clock is really ticking now.

One question we must address as a society is how much unfairness is…for lack of a better word…fair.  The other is how to treat people fairly.

The tax code is unfair and could be changed.  It is not a malignancy.  I don’t think it is either fair or appropriate to pay women less who do the same work as men.  I don’t think it is fair for a child to die of a preventable disease because the parents didn’t believe in vaccination. I don’t think it is fair that people should go bankrupt because they had a medical condition that nobody could have foreseen.

We aren’t born equal, we don’t have equal opportunities and life will never be fair.  We can, however, treat people fairly who end up on the wrong side of the luck scale.  Any of us could be one of them.

Any time.

“Everything is going to be OK, Mr. Roberts!”  the young man ran in to the hospital room where I was examining Mr. Roberts and just as quickly left.

My first thought was, “Who was that guy?”  My second thought was that Mr. Roberts was most assuredly not going to be “OK” for the near future, maybe never.  I was just an intern, years ago, and had to evaluate the unfortunate man who had a large stroke involving the dominant hemisphere, middle cerebral artery territory, affecting expressive and receptive speech and paralyzing his right side.  At least Mr. Roberts didn’t understand the optimistic words.

The “intruder” was a physician’s assistant for a well-known local internist and was busy writing orders when I returned to the nursing station.  Because he worked for a senior physician, he made himself important by association.  Stripes are what nautical and airline officers wear on their sleeves or shoulders. Stripes should not be transferrable, but a lot of people think they are.

I stayed quiet that day; as an intern, I was at the bottom of the hospital pecking order, and the PA was “wearing the stripes” of the doctor for whom he worked.  My training was more than his, I was working longer hours than he (nobody worked longer hours than interns in those days), but length of training, knowledge and hours worked stood little chance against a forceful, sure of himself individual.  I would see that in spades with the surgeons with whom I would deal.  There was no way I would have told the PA that Mr. Roberts had a long, difficult road ahead of him.

A month later, that longest year of my life, I found that the OR Nurse for cardiac surgery wore the stripes of the two cardiac surgeons for whom she worked.  Every intern had to spend time on the cardiac surgery service. The pair made my 24 day rotation hell.  The two fed off each other, driving me to tears on one occasion, classic physician behavior back then that is slowly dying out as the old guard finally moves on.  I was a physician, not yet licensed to be sure, but I didn’t deserve to be treated as the “hired help,” either.  The two were equal opportunity nasty to everybody; they threw instruments, hit me on the wrist with an instrument if I weren’t holding it properly, demanded I hold a retractor better, when I couldn’t see what I was doing, and thanked me only 5 times on the 12 multi-hour cases which I helped them.  I found I could fight back with my intellect, because I was able to correctly answer every anatomy question they posed during a case, often with a bored tone of voice that was my passive-aggressive way to say, “Can’t you do better than that?”

One day, I finally had one of those rare moments in life where I said exactly the right words at the right time, the “Perfect Squelch.”  I was holding a hemostat, a clamp, and my thumb was too far through the handle.  “SMITTY!” the senior surgeon shouted.  (I hated that name).  “DON’T HOLD YOUR INSTRUMENTS LIKE THAT!!! YOU DON’T HOLD YOUR SILVERWARE LIKE THAT, DO YOU?”

I quietly replied, “Dr. Maloney, I don’t use silverware.  I eat with my fingers.”  Other than Dr. Maloney’s unsuccessful attempt to comment, the room remained silent the rest of the case.

Their nurse treated me as the hired help, too.  While I didn’t like how she looked at me, her mannerisms or her tone of voice. I just told myself that my time as an intern wouldn’t last forever.  Every day was another 0.27% gone.  I wonder how she was treated by the surgeons themselves.  One subsequently had a nervous breakdown, and I actually felt sorry for him.  He was an arrogant jerk, but his life was going south and mine was not.

Wearing the stripes literally came to pass the following two years, when I was in the Navy.  The concept of the wife of the Captain being in charge of the other wives was “wearing his stripes.” Some women used their power well, however, perhaps supporting a pregnant wife of a Navy Ensign, her officer-husband overseas for 8 months, and needing help.  Others tended to act as their husbands, only that backfired if a wife was a professional with her own career and quite capable of living independently from her husband if she had to.  Like mine.

Over the years, I have seen others wearing the stripes.  I’ve seen them on the face or heard it in the voice of an Executive Secretary or a doctor’s nurse.  It was a very clear, “my boss has a lot of power, so therefore I have it, too.”  Had I more interpersonal skills, I would have learned to cultivate these people so that they would look forward to hearing from me and do things that I wanted.  Alas, I did not have such skills.  I called things as I saw them, and that wasn’t always popular.

I came by my attitudes honestly.  My father was once superintendent of schools, responsible for everything in the district. Not everything he did was popular; indeed, we frequently got phone calls at various hours, since our number was in the directory.  One night, I heard my mother on the phone in my parents’ bedroom, a place I never went.  Sound travels, however, and I couldn’t help but overhear her say something along the lines of “That’s not my job, and I am not going to listen to your tone of voice any longer.  Good-by.”  She hung up.  When she left the bedroom, she saw me.  I don’t remember the look on her face, but I never forgot her words.

“Your father is getting paid to do this.  I’m not.”

She might easily have said, “He can wear his own goddamn stripes.”