Monday, September 28, 2009

The Right Tail

Born in a motherless home where authoritarian controls over individual actions were exercised hourly, he was limited to his thoughts. Undeterred in his lonely invisible cage, amongst the escapades he imagined, one was to live in a different world. The penitent of  real life released into his fluid and vivid dreams. What the world did not disclose to him under the crossed eyes and stern rejections, he accomplished in his daily escapes into the cloistered world of peace and tranquility where life belonged to him and him alone.

His birth had been traumatic leaving him with a deformity of the spine, kyphosis they called it. He countered this with the flair of certitude in his dealings at school. The in-room quiet nights with the low wattage bulb lamp next to his bed so as not to disturb nor raise the ire of his father was his sanctuary. The pale and pasty complexion gave him the sickly look and made him the butt of his schoolmate jokes. This dual battle of repression strengthened his resolve to commit his life from an imagined into a true reality.

The marathon of constant struggle was the tempest of his vigorous and fertile mind. He devoted his studies to mathematics and from there he undertook physics and biology and then through esoteric subjects he one day descended on software programming. Even though for the next decade the programming was a means to make payments on a modest home and food on the table. His time at home was devoted to the use of the programming skills for purposes entirely his own. Logic.

The numbers of patents he filed always exceeded his age. One day after his thirty-second birthday he decided to write a sentence a day that would describe the day ahead. By his fortieth birthday he had written 8 books on far reaching issues. From as diverse topics as evolutionary biology to the more mathematically inclined probability functions. The diversity of subjects was fodder to his imagination. He opined, the publishers published and experts attacked him for his heretical, iconoclastic condemnation of business as usual. Most of his writings were proven correct and because of the evoked controversy, his works became known worldwide. 

He was well on his way to amassing a fortune that he did not desire, but life had other plans. It was the afternoon of his fortieth birthday when he was taken ill to the hospital. He had fever, a cough and some shortness of breath. After the medical deliberations were over the verdict was not good.

“That was 22 years ago. Really. They had me dead and buried. I still remember the doctor, a serious looking guy with reading glasses would not take his eyes off the chart while he told me I had Mesothelioma.” He put down the glass of water and resumed, “I mean come on man! Talk to me. Tell me my odds. I am no dimwit dummy crawling under the blanket of fear. I can take it. But no, he just dragged out his monotone and after five minutes of monologue he exited the room. What kind of crap is that?” The memories from two decades ago came flooding in with the anger and frustration.
“Maybe he wasn’t comfortable with delivering bad news.”
“Like it was his neck in the gallows.” He said peering over his thick-rimmed blue tinted reading glasses. "He was more interested in how I got it. I told him it was from working in the shipyard as a teenager.  That was it, he was done with the interview."
“Terrible approach.”
“So I decided then and there that I was going to make my own decisions based on the evidence at hand. One of my fields of research as you know is Conditional Probability. So when the initial fog rolled out, I read some articles on Mesothelioma and the overall survival rates.” He pointed to a filing cabinet next to his cherry wood desk, indicating that was where the data was buried.

“And what was your discovery.”
“I am here, aren’t I?”
"I found out it is extremely slow growing. If you smoke with it the chances of having cancer is higher and that treatment is mostly surgical removal of the lining of the lung initially. However given the slowness of the illness one's survival is prolonged."
"As yours turned out to be."
“I do see the problem with the medical people it is not that they are dumb or anything remote to that. They are dedicated and smart otherwise they could not possibly be where they are. But they are illiterate in the field of statistics. The statisticians make up the numbers, coddle the data, invoke some mysterious law and variance test and then deliver percentages to suit what the investigator wants to say. All that is scientifically packaged with graphs and tables and all the hoopla of a true scientific literary presentation. The editors also schooled similarly look to their experts for the mathematical models proposed in the paper and having found no problems publish it. That seals the deal.” He picks up the sheaf of papers sitting on the end side table under a glass half filled with water. “I’ll show you. Now look at this nice Bell shaped curve.” He holds out a Normal Distribution Curve image. "This Bell shaped diagram is based on the Gaussian Function." (Figure to the right).
“Yeah, what about it?”
“What do you see in it?”
“The mean, and a 2 standard deviation from that mean showing a 95 confidence interval stating that majority of the population with this disease will die within 5 months to a 19 month.”
“True. So what would you tell your patients?”
“Just that.”
“Exactly my point. Look at the tails on the right side of this curve. The tail which is mathematically called kurtosis is fairly long isn’t it? The perfect bell curve we all are shown is not the normal as everyone will have us believe. There are always distributions of events on the left and the right side giving out left and right tails or widening and flattening the graphic function based on the events    observed. Not all of life flies on the strict aerodynamic principles of an airplane wing, some fly the circuitous and topsy turvy flight path of a broom handle as in Harry Potter movies."
“Yeah, you're right, I guess.”
“So what about the people in this tail who can live out longer?” (Figure below).
“But only a minority is in that tail.”
“True, but tell that to the individual. If I had resigned myself to the verdict, I got 22 years ago, I could have unwittingly given up all hope, lost interest in life, become unproductive and essentially dug up the ground with my own mental shovel and deposited myself with the worms. You would not be here and we would not be having a conversation today.” He said with a note of exasperation on his brow arching the wrinkle on his forehead into a deeper furrow.” I chose to understand the logic of medicine and defined my own terms. Not that I was the lucky one to be in that right tail of the curve, but lucky enough to understand the meaning of the right tail and take my chances. Whether my mental energies or the immune surveillance or just being to damn dumb about the whole thing made me live this long with that hope, I don’t know. But here I am.” Exhausted with the expressive monologue, he fell quiet.

The choices we make, make us. The linearity of time follows a circuitous path with many forks in the road. Our peregrinations when recorded show us what we have become. All the learning, looking, grasping at ideas, reading the written and understanding that which is not continues to evolve us onto a fate that we choose. This is the finality of purpose of a human life. Life is a spirit striving to understand and then drawing from that understanding devolves itself to live that time with a purpose.

Monday, September 21, 2009

The Perfect Note

The golden hue from the west stoked the fire in the underbelly of the fair weather cumulus in the sky. The azure color deepened as the sun slipped slowly behind the rooftops. The beach was deserted. The crowds had all but left, save for a loner looking for treasure with his metal finder as he scanned the white sand. Footprints devolved into softened craters where the sand had partially refilled the hollowed spots forming tracks of behavior of the various visitors. Some small going in circles of happy independent and uninhibited thoughts, while others more determined created a purposeful linear line, some showed deviation from their linear trance to cluster nearer to the water presumably lone fishermen exploiting the ambience of the quiet and the rush of the ocean waves for a quick catch of the day.
His path was of a quiet, slow determination, the hollowed craters were deeper and each step measured. It was a remarkable frame of reference; his rhytmic steps to the persistent roll of the waves over the sandy beach, both in tandem with life’s rituals. With every third step the slow rolling wave would crest and then crash onto the beach, withdrawing in a series of bubbles, leaving behind artifacts from the days of yore. There was a rhythm to this human-nature dance, unplanned, unrehearsed and unnoticed by the players.
“This is life.” He says with a slow rise of his arms. With both palms facing the sky and the wisdom of his age lit by the departing sun, it felt like Moses at the Red Sea. But there was none of that of course, just a memorable unconscious act caught in memory.
“Yes it is.”
“You know,” he paused with his right hand caressing his weathered chin, “I don’t know a better time then this for a little music.”

The house was an architectural triumph. The large windows overlooked the ocean. The entire room scaled the breathed of the house. It appeared to have been built around this magnificent viewing room. It was immaculate in its whiteness. The only pieces of furniture; a lamp next to a large soft-leathered armchair perched against the window overlooking the ocean. Next to that was a concert grand piano, a Steinway in all its pristine glory, in a place all to itself. The lid was opened to reveal the enormous acoustic chamber and the complex arrangements of the strings. The ceiling had sound enhancing ceiling tiles. It was a musical chamber.

As the first felt covered hammer hit the string and made it vibrate, the flood of sound erupted in the room. The ambience changed somehow. The trickle of light from the fading sun briefly intensified and then all was rhapsodic, moving, exploding governance of the mind. The rhythmical flow of his hands over the keyboard was magical, swaying like branches of a tree to the whims of the breeze, barely touching yet eliciting a pluck on the heartstring with every note. Beethoven’s Fur Elise the first classical lesson to any student of piano music was being unleashed as a symphonic masterpiece under his fingers. The room and everything within it became one with the sound and the piano enlarged to encase the space and time. He changed from A minor to C major to a G major key through the 4-minute musical interlude. The echoes still remained long after the last key had struck the string. He was pleased with the silence that followed, for he sat there for a while.
“Thank you," he said in quiet modesty. Then he reached inside the lid of the piano and with a felt covered hammer he tapped away at the interior, plink-plink-plink as the string took the hurt. “A little off,” he said. Pressing one of the black keys in concert with the hammering. “Now that sounds better.” As if what had just been played had not.
“You know that is how I knew something was wrong with me. I could feel the change inside of me. The melody changed and I knew something was amiss.”
“Yup. The body is like a finely tuned instrument. Any instrument, if it is out of tune you’ll know it.” He shrugged his shoulders as if it was a well-known matter-of-fact commonly visited issue of life.
“I have never heard Fur Elise any better than today and yet you felt a note was off slightly.”
“In my shoes any inharmonic plays out louder. It stands out.”
“I guess you’re ears are trained to hear any imperfection. But how did you know something was wrong inside of you?”
“Harmony is not only in sound but in your body too. It gives signals from time to time. I remember sitting in a cinema theater when I was 10 years old and my heart changed its rhythm. It happened several times and then it stopped when I got older. Oh it would happen again once in a great while after drinking coffee and all. That is when I started to listen to my body. Not in some paranoid, self absorbed, hypochondriac sort of way. I just knew when things were not in sync.”
“Any special symptoms.”
“Not really. A little tired maybe and the emotional rise from the music was muted. The stars were crossed. The alignment was off a little. This might sound weird but I felt disembodied.” He said and the width of both his hands hit the first few chords of Beethoven’s 5th. It was his way of saying enough about that with the flare of a concert pianist. Later the ride back to reality was filled with sounds and melodies reverberating in space. The story of his illness was an art form in self-diagnosis.

Two years ago, It was a sunny summers day. He had just come back from jogging. With sweat pouring and a hunger for air, he quenched his thirst with cold water but for some reason he could not get enough air. He felt unsteady on his feet a little. The hunger for air lingered ever so imperceptibly that another person would ignore and move on. His vision perfect for his contact lens eyes seemed just a hair off in acuity. That day he went for a physical. After all the tests had been run, he was granted a congratulatory “in perfect health” word banner. But something still was not quite right in his world. His conviction resisted the desire to agree. So he decided to challenge his physician, looking for a malady that would answer the infinitesimal discord in his body’s metronome. After further testing and much searching a small colon tumor the size of a walnut was found which was subsequently removed by minimally invasive surgery and voila all his symptoms abated. Harmony was restored.
The concert of life is played out in all the keys. The inharmonic key will stand out for the fixing if we learn to look for it. Listen to the melody.

Friday, September 11, 2009

The Consummate Connoisseur

On a verdant strip of land splitting a forest of pine trees and ripples of river water, nestled within the green and surrounded by nature’s gifts of smell and sight is a modest cottage with blue shuttered windows dressed with white window planters overflowing with impatience, lives a man of extra ordinary talents. His vision of life is gifted through the lilacs, daisies, chrysanthemums and streaming irises. There are sweet smelling honeysuckle and colorful lavender. Here is the rainbow’s end, the elusive pot of gold.
And deep in the very heart of this beautiful garden are the yellow narcissus surrounded by two varieties of the aloe vera plants to soften the sharp angles of the shingled home. He loves his little heaven. The morning ritual of caressing and talking with his colorful friends that blossom for him their delight and inner sanctums of love. Yes, this place is heavenly. When you walk towards the entrance on the cobblestone path barely wide enough to fit the train of a newly wedded bride, the flowers and leaves brush against you like the whimpering house cat. Unlike the feline friend these caresses are all about giving. You are in Eden or very close to what could be Eden. The temptation to pick any flower does not rise in one’s thoughts because the grandeur and majesty of the whole would be lost but for the one.
He opens the door dressed in a white shirt and gray pants. His ample being pressed by the strained leather belt, belies his love for food. The thick grey moustache covering the upper lip with rosy cheeks filling the sides while his lower lip moves slightly when he says hello. One could charge him with a jovial and devil may care personality but one would be wrong. The care given to nature around his abode speaks volumes of his tome.
“Thanks for coming. Come in, come in!” His open welcome gives you ease of being with family and loved ones. “How are you?” and “You look good.” All of that comes naturally to him. None is casual, all with depth of desire to know and share. You feel at ease with him, like being in an embrace with a long lost friend.
“How are you John?”
“Great. Today.” He says as he heads into the clean and sparsely decorated living room. “Come sit down and we will enjoy a piece of that pie I made this morning.”
“Sure. Would love to.”
“You know, I was at a bistro four blocks from here this past Saturday and I had this Crème Brulee.” He smacked his lips and you could just see the end of his tongue glide over the lower lip. “There was something about it?” His face cocked at an angle and his eyes turned sideways as thoughts rushed in to fill the vacuum. “Ah, I have known, perfection!” He exclaimed. “The surface was a deep brown, like stilled molten gold, hard enough that you could tap it with the spoon and it would not give. It yielded to the edge of the spoon, the crust slowly cracking under the weight, slowly at first and then rapidly. The soft velvety interior enveloped the spoon.” Again the thoughts flooded in his head to give his voice a pause and his tongue to lick his lips – the after taste of a stolen adventure. “The first bite was like heaven. The crunch mixed with the soft smooth delicate interior just melted in the mouth in a slow rush of juices. The tongue the inside of the cheeks and teeth all merged into a wild tempestuous party. That was most delicious. Most heavenly! I can taste it every time I think of it.” His face turned a shade redder then before.
“You’re making me hungry.”
“Let me get that blueberry pie I promised you,” and with that off he went into the adjacent room where the refrigerator hummed its coolness.
“Now try this,” he said as he offered the plate with a generous slice of the pie, “in its own right it is good. I made it from scratch.” Like a proud father he beamed.
“This is great!”
“I knew you would like it.” His delight was obvious in his words, not from the compliment but the joy of seeing another enjoy the richness of life. “The blueberries are aged just right. I picked them from the market. There is very little sugar in there. All that flavor comes form nature.” He swiped the plate with his finger and licked the last of the essence of this confectionary delight.
“Are you ready for tomorrow?” Tomorrow was his time with destiny. The inch sized malignant tumor in his lung was to be removed. But the tumor location evaded a direct assault at it. John wanted it out in spite of the thoracic surgeon’s slight hesitancy. This was a pact between two experts in their craft, with no repercussions should the after math be an open and close scenario. The gardener wanted the root cause eliminated as much as the surgeon, for that, the chance had to be taken. The weed killer was the surgical scalpel and John knew of none other better option.
“Is one ever?”
“I know, but are you okay.”
“As I’ll ever be.. Will you be there?”
It was an ugly imperfection to see him with tubes exiting his chest, nose and throat and others entering his arms. He had just had his right lung lobe removed for the malignant tumor. He wafted in and out of consciousness for a better part of the afternoon. The experts made dire predictions, predicated on his diabetes, weight and complexity of the surgery in the chart. His, was a malignancy in its infancy stage, now dissected, excised, reviewed and eliminated. The only shadows that might remain were invisible to the naked eye.
The next morning his head propped up on the pillows his eyes held the joy of life again. Unable to speak he motioned for a pen and paper.
How did I do? He wrote in squiggly capital letters.
His eyes scrunched with a ‘yeah?’ as if in disbelief.
“Really. You did well. They removed that little lump of sugar in your Crème Brulee.”
He smiled and then wrote, ‘perfect again?’
“Pretty much.”
‘Please check on my garden.’ He wrote on the pad with searching eyes. It almost looked like a cry of help expressed through the blue-grey interior to his soul.
The next day was overcast and gloomy. The happy dialogue of the birds was missing. The roses seemed to droop a little as if the stalks could not contain the weight of their worry. They seemed to fall away from the cobblestone path, some slightly wilted while others had turned their inner glow off. There was an emergent sadness in this garden. Even though the smell of a moist earth filled the air from the automatic sprinkling system, all was not well with the garden.
Ten days after his surgery and a day after his return home he sat in his wheelchair looking over his ‘children’ as he called the plants. The foliage once again caressed the cobblestone path walkers. The droop from the roses was gone. The spirit had returned and spread from flower to flower and plant to plant with osmotic delight. The garden once again was ablaze with color and perfume.
“I never asked this question before. So I will now. How did I get it? I do not smoke and there is no family history so what happened? Don’t tell me its food because I wont listen.” He let his hands fall to his side. “So there.”
“Unfortunately there are genetic mutations that occur at random. It might have been a weak gene structure and in the process of cell division it might have picked up the wrong signal. Two parts never meant to join, joined or a part was deleted, one never knows. Time will tell. This is a theoretical conjecture, with a lot of ‘might’s’. The truth has still to reveal itself.”
“Philosophy eh?” He smiled.
“Just kidding. I am thrilled not contemplating the remaining time on writing my own obituary. Maybe I’ll eat a little less and lose some weight and then maybe I wont. Or maybe I’ll walk a little more. Maybe!” He clapped his hands in a gesture of finality. “Next week we go to that Bistro for the Crème Brulee.” He was back in step with life. The march to his norm had begun. Promises. Promises.
Some times fate favors the lovers. United again the garden smiles brighter stoked by the whispers of the consummate connoisseur gardener. The lover of life.

Tuesday, September 8, 2009

An Ode to Freedom

“O’ Horrible, O’ Horrible, Most Horrible.” The ghostly echo rises from the slain Dane reaching across centuries to cry the injustice of times. There is a time to mark and it is now.
Darkness enshrouds. Trees and bushes conjure images of ghosts and goblins. The sleepy, creepy fog floats, caressing the foliage. It’s tongue licking nature’s bounty. Not a stirring this late hour can be heard, except the lone headlights of the car coursing its way on a highway. This exterior is bottled outside from the inner sanctums of the car where the lilting, lolling, cadence of Beethoven’s 9th. confronts the anger, happiness, resignation and finally acceptance of life is playing center stage. “Ode to Freedom” that it is, is the essence of the violins. Life expressed in D minor. The cold and mocking air outside slams and presses against the doors but cannot find a way inside this musical realm. It is a winter’s night. Humanity is calling for help and neither cold nor dark will win.
The muted hum of the Operating Room with its bright lights and day-like ambience caters to the needs of the unfortunate. The two nurses with their slightly wrinkled uniforms are chatting, trying to find equilibrium. Their eyes speak volumes. The clarity that brought them in is disjointed by the grief of the day. And there is always a teaspoonful of that elixir to swallow on a daily basis. Human suffering is never a timely event.
“Haven’t seen you in a while?” The statement morphs into a question with the raised decibel at the end.
“Yeah. It is every other weekend and every third week on coverage.”
“Not bad. This place is a second home for me.” He says twisting the ends of the paper overalls he is wearing. His eyes are screwed into a mess of wrinkles with deep pockets of circles accentuating the lower eyelids. The scorn and fear combine to create the unflattering troubled image in the face of a healthy thirty-five year old.
“Not quite, I still have the paper work to finish and speak to the family outside.” He said with a hint of exasperation.
“Hey, did you watch the game last night. It was unbelievable.”
“No, I fell asleep on the couch. I was tired. I am beginning to see that I am not a whole lot of fun these days.” His hands open in total resignation.
“Catch the next one then.”
“Yeah.” He says again his head bobs a little in muted defiance against the gods.
“Everything okay?”
“Long story.”
“I have time. My case is delayed pending approval.”
“That is exactly what I am talking about!” he slaps his hands on the bench besides him. The color of his face reemerges. The frustration boils the anger out in bubbles of expression.
“What about?”
“Those approvals!”
“What about them?”
“What the hell are we doing here? I get called on an emergent appendicitis. I am scrubbing and they tell me that the approvals are not authorized yet. So finish scrubbing and get gowned and ready and the company wants to talk with me. What the hell!” Disbelief in his eyes tells the tale. The face is contorted with muscles contracted in different phases give him an eerie look. His voice takes on a higher pitch. “ What do they think, I am doing, performing an appendectomy on a normal appendix at 2 AM for fun?”
“Its getting tough.”
“I did the case anyway. The patient was prepped and ready. The appendix was blown up like a balloon ready to burst. It was a mess in there.” His hands clasping and unclasping, “Now the admin tells me that they are not going to get paid because of the pre-approval issue.”
“Did you speak to the company?”
“Not yet, but I will. You know how much time it takes to get to their doctors. The last one wasn’t even a surgeon who had to give the approval for a lysis of adhesion. He was embarrassed himself for taking on the approval issue.”
“The whole concept is wrong.”
“It is!” He cries.
“The problem is that the whole medical industry is a 1.9 trillion dollar enterprise. It forms 16% of the GDP so the insurers are trying to figure out cuts where ever they can.”
“That would be so if they were not paying astronomical compensations. Like that CEO of United Health Care Company got 2 billion dollars in stock and options. That is obscene.” He shakes his head with frustration.
“It is, especially when they vilify the doctors and deny compensation. I am a supply side person. If the demand is there the supply must command the right to charge for the service. It is the way of our country. If you change the model then universality of choice is lost and mediocrity of performance is gained. Tit–for-Tat. There are no free lunches.”
“You know if I did not love what I do, I would have done what my friend did.” He launches into an argument inside his head.
“What’s that?”
“He started a small chicken and egg business in Seattle. He is happy dong that. He has hung his shingle up for good after only five years in practice and is happier now then he ever was the past 14 years learning medicine and doctoring.” He stops thinks about it for a moment. “That may not be a bad idea.”
“What, setting up a chick and egg business?”
“No something other then medicine.” He betrays his soul.
“But you are so good at it.”
“Good for what? Being questioned on my decisions, my judgment, my knowledge and understanding of the disease. No! based on the questioning, I am good for nothing!”
“Easy there. This just a bad night and you are tired. The day will bring a different perspective after you have had some sleep.”
“Oh, this might help. An excerpt from my fourteen year-olds’ essay. Even the kids know the score.”
“Well, they see us haggard always saying no to their demands and complaining about a work that once was pleasure now with every bureaucratic finger in the pot it has become a nightmare.” He opens the folded paper and reads.
Somewhere in that conversation the cries of humanity are being stifled, they will rise and command the theater one day.
The lined paper unfolded trembles in his hands.
When tough choices become tougher. The social, peer and legal pressures continue to burden the system. The latter is where the prospective judgment of the physician is questioned by retrospective reviews. The public and peer pressure to use the new technology and then to deride the physicians or even impose penalties against them for using these tools is lunacy at best. There is a steep cost of excellence in medical care, but this cost is self-imposed. We sing praises for the newest accomplishments, cures, latest biotechnological products, tools such as the use of CT scans, MRI and PET scanner machines. But we cry foul when the cost of using this technology has to be borne. The duality of thought has to be reprocessed. One cannot have it both ways. These impositions have allowed their pressures to mount over the past decade and now the regulatory concepts are framing the same argument. As if paperwork leads to excellence in human care. Stitching a sentence of demand and then to devilishly imbue it with the scent of purity of purpose is not the genius of sanity nor does it guarantee safety of the patient. It is the human intellect, experience and knowledge that guides the domain of caring. ‘Feeling’ is an emotion expressed by the outsiders, the lookers-on and the rubbernecking crowd. That is not who helps the person in need. No amount of on-lookers on the highway can help the accident victim. It is the police, the paramedics at the scene and the physician and his team of experts in the waiting hospital. All others are wearing the pretend white lab coats of observers. Let experience prevail. The messages of clarity from yesterday are no longer understood in the precincts of this dubious realm of today. Failure was not an option then. Now success is decried.

The fading echoes from the ghostly apparition smother the morning sun. The dew shall not form on the dry leaves and the spiders shall not spin their magic into a web. The birds chirp their dissonant chirps and the instructive words of the imagined past echo again.
“Pity me not, but lend thy serious hearing.”

Saturday, September 5, 2009

Resource Management Cockpit - The Brain

The altimeter read thirty-five thousand feet. There was the constant sound of energies being liberated and consumed. The dials and flicker-free glass monitors that weighed each and every aspect of the domain were in harmony, happily displaying their digital world in bright color. The view in front was that of a serene sky with overhead cirrus layer that was flying by. All was well, controlled, conformal, quiet and routine.

At first there was a single beep and an amber light blinked then faded. It was nothing, the pilot guessed, probably a gremlin in the power grid or a lone photon high jacking the LED, or just a plain irritating oddity. Another blink of the same LED and now the pilot gave it careful attention. Still nothing. Seconds later all hell broke loose. Multiple alarms suddenly blared. The howl of the Master alarm sounded with the red caution light blinking furiously. Before the pilot or his co-pilot could do anything the aircraft pitched down 20 degrees and started a steep descent. The sounds grew menacingly and the cockpit became a cavern of sirens. Immigrant Rivers of uncertain thoughts flooded the pilot’s brain as his hands tried with futility to regain control of the aircraft pulling mightily on the yoke, the relentless free dive continued. The lower layered clouds now began to appear in front gradually enlarging as the screaming chaos of uncertainty reigned.

The pilot felt the sting of disaster looming and large streams of sweat broke out, some coursing their way down his spine while others perched precariously on his brow. The hands remained steady analyzing the swift descent and the potential of recovery, the prospects of which seemed to diminish with each passing moment. His voice from the fine thin crisp controlled pitch turned husky, rough and weighted with the sudden burden. He barked out orders to his co-pilot who repeated the order and performed the necessary action. Still nothing. No change in the arrest of this calamitous fall. Something had to give. Hope and despair lurked like two thieves ready to sap the energies of the brain leaving it soft and rudderless.  There was no time for either of these charlatans. The checklists and manuals fell from their respective holders strewing paper on the cockpit floor. A glass of water tipped over and wetted the papers. Among this contusion of confused thoughts the pilot steadied his nerves and called out, “Pull the Autopilot, auto-throttle circuit-breakers.” The co-pilot acknowledged the command and then with deliberate measure the pilot eased the throttle to idle and gently pulled the yoke. The altitude now read twelve thousand five hundred and rapidly decreasing. The tens of feet indicator unwound swiftly jumping ahead to keep up with the steeply falling outside pressure differential. At nine thousand feet the pilot had managed to slow the descent to less than a thousand feet per minute from eight thousand feet per minute. The view outside was limited to thick grayish dark clouds whooshing past. There was nothing to be gained from outside view. Success and failure lay quietly in the cockpit ready to be awakened. As the altimeter slowed its rate of descent the pilot leveled the aircraft at seven thousand feet. He then radioed his orders for emergency landing to the Air traffic Controller and resumed control.

Later the pilot and the instructor revisited the entirety of this event to fathom the time element and fashion the probability of speeding up the thought process. If this had been a real aircraft there would not have been enough time for rosaries. Panic and cries of help would have echoed in the passenger compartment. This was simulator training.

Every six months airline pilots are placed in the simulators to fashion their thinking through one or multiple disasters. This “ride” is what keeps them in sync with their abilities. Proficiency combined with experience allows flying to be the safest mode of travel.

Back outside the Operating Room two men sit in the waiting room chairs. One drenched with sweat, the other getting ready to operate.

“What happened?”

“I don’t really know. I was clamping the regional blood vessel for the colon resection when the sudden gush of blood completely obliterated the field of view.”


“Yeah! It didn’t take more than a fifteen seconds. I asked the nurse to pull on the retractor and she was shell-shocked with the view herself. So I had to yell to get her to listen.”

“Did she?”

“She did. Meanwhile the anesthesiologist yelled the pressure is dropping. And I asked him to increase the intravenous flow rate.”

“So things stabilized?”

“Kind of.”

“What do you mean?”

“The blood pressure did stabilize but then the resident called out that the arterial blood looked a little darker then usual.”

“A newbie?”

“No this one is pretty astute.”

“So then what?”

“I saw it too and called out to the anesthesiologist. The patient was not getting enough oxygen and the saturation had dropped down quite a bit.”


“Yeah.” He said that his scrubs all wet with perspiration and the front covered with a splatter of blood. “Yeah, it poured today.”

“I’m glad not to be in your shoes. How did the family take it?”

“They did well.”


“Sure the patient is in recovery and doing well.”

“That is great! What miracle did you pull off this time?””

“Actually three years ago I had a similar event. My assistant located the anomalous blood vessel and stopped the bleed.”

“Not rare enough for you.”

“Similar rarity twice visited makes me an expert.”

“Good for you! What of this anomaly? Where is it located?” The two heads convene over a piece of paper as one pencils a cartoon of where and what of the human anatomy. Both know that the human body is not the plastic mold of “Operation Game” by Hasbro for children. Embryology and genetics conspire to vary the locations of things inside the human body.

“Hah.” He said loudly with an air of satisfaction to no one in particular, victorious, he now headed to the Recovery Room. All was well at this hour.

The drama of life unfolds in different venues but retains its capacity to unnerve, confuse and detach our senses. As humans we conspire to understand the demons and potential hardships and tuck them away as “maybe not”. Yet the risks are ever present. Risks are defined as probabilities of adverse outcomes. We strive to learn so that we may mitigate the risks in venues that harm no one but teach us our own reactions. However where risk mitigation is not possible, we accept the risks and learn from nature’s curveballs and previous experiences. Sometimes, if we are lucky we learn from others’ knowledge. If lady luck is visiting elsewhere then we become the test pilots.

Both worlds exist in a single frame of reference. The drama of plunging from the sky onto certain annihilation to the reality of an accidental hemo-dynamic compromise of a life, are threads from the same fabric. Fashioning an event out of probabilities creates the illusion of a practiced possibility. The phantom that leaps out like an exuberant flame can douse itself with a sudden sigh through the aegis of experience. It is the unprepared, undocumented mind that freezes on the most unwanted of frames where answers fail and calamity visits.

We organize our lives with decisions, some with days or months of pre-thoughts and other times we intuit and spew at the spur of the moment. Both may lead to good or bad outcomes, but the decisions are always correct as long as they are based on experience and knowledge. Sometimes we base our successes and failures on attribution bias rather then on good decision making skills. It is not the outcome that proffers the way to success but the diligence of the decision making process.

Human frailty is the conspiracy of the DNA. The strength of the mind is via the evolutionary process of experience. Life teaches us. Nature roils and boils and bubbles its surprises at us. We in turn learn, respect and strategize our defenses. The battles continue. 

Thursday, September 3, 2009

The Crooked Stick

Was it sand or stone? It is difficult to remember the seat of the argument. But I believe it must have been the sand. He was seated on a rock with a crooked stick in his hand drawing on the sand. Even though the answers that followed on the sand were as nebulous as clouds constantly changing from cats to dinosaurs and back to a wisp. The moderate breeze blew the sand and erased his answers. The weaving in and out of reality was a constant waking to an image and sleeping to a nightmare. Time spent with him was the flux of thought riddled with distant memory – all a dream.

He was elderly by the standards of the 21st century man in appearance but youngish in intellectual thought. His face marked with the battle scars and frustration of time. His eyes close set protected under deep brows with overhanging dense white hair. The hair on his head long and thick hung straight to merge with those of his flowing white beard. He was an image of Santa Claus without the stuffed pillows or the rosy cheeks. The brown garment he wore made him look like an 18th century Bedouin. An MIT graduate, having given up the comforts of life and lost to the world of fiscal productivity, he was engulfed in the mental den of numbers. He was one with his soul. He could evaluate, manipulate, extrapolate and calculate any mathematical argument. Some say he might have been the first to solve Fermat’s Theorem on torn pieces of paper that he carried around for a while. But he would deny it vociferously.  All the same, folklore did not begin without a kernel of truth somewhere.

“Numbers,” he would say with the throaty, croaky voice of his, “are the basis of our existence and that of this universe.” His explanation was simple; “You can put a number to explain any thing, the velocity of a car, mass of an airplane, tonnage of a ship.” If you got him going he would divulge more of these simple facts.

“We now calculate the surface area and camber of the proposed aircraft wing to determine the lift it would produce to haul the planned weight of the entire aircraft under development. No longer the Wrights Brothers dilemma of experiment, cross check, crash and retool, now one goes right from the computed data to manufacturing.’’ His crooked stick began writing the formula then erased it halfway through, as if not applicable. “And what of the orbit of the earth around the sun? It was calculated by Johannes Kepler (1571-1630) to within 5% error with mathematics long before all the fancy infrared telescopes. Kepler's third law was used to measure distances between planets and the sun. To make that leap of faith, Kepler jumped on Brahe and Copernicus’ ideas to formulate his mathematical intercession. It is always the same one mathematical mind transcends another as Einstein’s Special Relativity was based on Lorentz’s Transformation, which was derived from Galilean relativity. The march to understanding reality is always based on one giant standing on the shoulders of another!” The stick drew three ellipses all interlinked in a gravitational dance and then hovered as this giant sat quietly and analyzed the products of the past. He loved to pass along his learned objectives for others to use as springboard.

“So math can answer all questions?”

“Depends.” He would say.

“On what?”

“On the question.” The smirk remained hidden under the ample beard and moustache.

“Well let’s talk about medical facts.”

“Facts whether they are medical or otherwise are facts. It is how you fashion the argument with them.” He would pause for a long moment and you knew he was going to throw something deep and heavy in your direction.

“Give me an example.”

“Okay,” he paused, “assume you have two baskets of apples. There are 3 bad apples out of ten in one basket and 4 bad out of 10 in the other. How you express that makes the sale. If you say that the first basket has 15% lesser number of bad apples then the other basket you make it look good. But if you say that it has one less bad apple than the other, the argument is less compelling. The higher number makes it sound like a better basket.” The numbers on the sand appeared and disappeared as his thought completed their ritual imagery. This was not hot nor was it heavy.

“But that is simple.”

“It is but how many times the TV or the newspaper or the magazines will make something better or worse than the reality. Real numbers do not hide the truth but relative numbers, fractions and percentages all are modifiers that play to the tune of the piper.”

“Any examples in medicine?”

“Sure the best one is about the effects of the cholesterol medications. The benefits are expressed in relative risk reduction while the toxicity as you people are prone to say is expressed in absolute numbers. That is like apples and oranges.” He again wrote 38 and a 2 on the sand and then erased them wielding the crooked stick.

“What do those numbers stand for?”

“Relative Risk reduction and Absolute Risk.” The crooked stick made an exclamation mark.

“But those data are provided by the statisticians, the gurus, not by doctors.”

“Yes, but the arbiter of reality in expressing the truth is the author of the scientific expedition. If the results are not charming, the journal will not print. And if the print is not there the promoter of the argument will not reap the rewards. The argument is circular to a degree. You manipulate to publish and publish to manipulate.”

“So if I am writing a paper, I can…”

“Let me stop you there. Before you even start writing the paper you have done the experiment. And even before you have done the experiment you have a premise you want to explore. That is where the problem begins.” His voice had a quiver of disdain in it.

“You are referring to ‘observer bias’ aren’t you?”


“Meaning, I am prejudiced in my experiment therefore I will manipulate the events, to suit the desired end result.”

“Bingo.” The “o” in the bingo whistled into a sonorous echo.

“But that is easily verified.”

“By the real numbers and never by the percentages. And also by the events placed in the experiment. If you delete the events that go against your initial premise citing non-compliance, or lack of eligibility in your criteria then those numbers fall out. For example if you do a study where there are more women in one arm of the study then the other arm, and you know that the outcome of women in a certain disease is better than men, you have prejudiced the outcome in your favor slanting the opinion to benefit the experimental drug.”

“But that is easy to see.”

“That is just an example. Another one would be to have a larger number of fair skinned red heads in one arm and dark Irish in the other and expose them to sun tanning. Obviously the red heads would be more at risk to get sunburn. If now you give the group with the larger number of dark Irish a product that protects against sun burn and the other a placebo, you have brought in prejudice and destroyed the validity of that study.”

“I see.”

“Always look at the real numbers. They tell the tale. See how they are matched. See how the events are stacked and then make your own assumptions and not necessarily rely on those of the author.” He looked from beneath his thick eyebrows, scrutinizing the impact and then wrapped it all with the sweep of, “ all probabilities are a game of chance AND never theorize before data otherwise you twist the facts to suit the theories.” The emphasis on “and” was quite forceful. He was silent while his crooked stick continued to doodle on the sandy slate.

Genius does not come in a pinstriped suit nor in a cotton shirt and baggy pants, it comes in all shapes and sizes. It is in our desire to galvanize that spirit of learning and acquire knowledge from anyone even if he is the spitting image of Santa on a diet.

Tuesday, September 1, 2009


The leaves having washed off their impurities from the morning rain glisten with pride. The birds twitter with delight at the prospects of the grub from the softened moist soil, while the insects recently incarnated from their cocoons buzz around looking for life to feed on. The earth is alive with the predatory instincts of survival. The glory of this moistened renewal hides the evolutionary instincts of living. Man and beast both are beset by similar sets of harvested needs. These need grow and multiply in packets of desire. These needs however change with the changing of the seasons of life. Summer changing to fall mutes the unquenchable wants of desire  and converts it to the daily desires for comfort. The need to grow gives way to the hope to preserve. This life cycle continues unabated through generations. As age looks back at youth and sees the frivolity of the desire, the backdrop of history becomes the fore prop of thought. And life goes on. Predation ends and survival begins.


Basking in this ritual of renewal under the bright sunlight day is a lone figure. Age has come slowly upon her. Quiet like a church mouse slowly eating away at the scattered crumbs of life- the eyes too shaded to see, the ears too dampened to hear and the hands too gnarled to work. She stands almost erect but for the slight hump just below her neck. This, her body hides beneath the colored display of chiffon and cotton. Her face is lit with a smile, more of amusement then pure delight. The crow’s feet around her eyes deep with intent and her mouth slight pouting at her attempt to complete her chore soften a little as the birds alight from the trees flying towards her. She stands affixed amongst this array of nature’s bounty. Slowly as the rising flag on the flagpole her arm flexes her hand into an open palm. There are breadcrumbs there. Within minutes she becomes an aviary of frolic and fun. The birds singing and twittering to each other flying around her eventually with their wings flapping rest on her hand and partake in the feast. Different colored ones of different shapes and sizes all circle and wait their turn.


With the hand empty of food, the lady slowly lowers her hand. Her smile fades as she turns to take a step back to her house. Her foot catches on a muddy mound tilting her form. Gravity pulls and yanks at the fulcrum of her being and she falls. The air rushes out of her mouth and a deep groan escapes her lips that no one can hear. She lies on the wet ground. Her left arm held hostage to the weight of her body while her right arm appears angulated into dysfunction –bruised or worse broken.


She tries to move, kicking at the mound that brought her down only to realize that such movement causes more pain. She tries to roll over only to find that the arms that push and pull are held hostage. She tries to yell for help but there is no ear within earshot – thus no sound is emitted if none is heard. The tragedy of a momentary lapse in gait plays out from seconds into minutes. She finally rocks herself from side to side and rolls over on her face. With one hand released to function she puts her weight on that hand to lift herself up, but the tortured hand with weakened sinews, atrophied muscles and arthritic joints cannot hold together the weight of her body. With Herculean effort she pushes with her left leg and is finally able to bring her knee up. Finally, an hour later, muddied and bruised from the battle she gets up and limps along the graveled driveway to her house.


Her strength eludes her and she collapses on to the chair in the balcony,nursing the bruised and bloody skin from a lonesome ordeal invisible to all but her.

“Hi.” A little girl stands with a lollipop in her hand. She is nearing her fifth year. She is wearing a red polka dot dress as she straddles her white bicycle. Her hair is neatly pulled back in a ponytail tied with a large red ribbon.

“Hello sweetie.” The older woman replies.

“My name is Kathleen.” She says.

“Nice to meet you Kathleen. Does you mommy know you are here?”

“No. I am just riding my bike.”

“Would you like to have some cookies?”

“Yes, please.” She answers in the most adorable way.

As the lady weakened from her fall tries to get up, the girl cries out, “You are hurt.”

“I am alright.” The lady protests.

“No you re hurt. Look at all the boo-boos.” She looks alarmed.

“Just a little hurt. I’ll be alright.”

“No, I am going to get my mommy.” With that she peddles away furiously.


The night falls and after an examination by the doctor who finds only bruises and scratches on her skin and a torn ligament in her right arm that now is hammocked in a sling, she rests comfortably in her bed. The husband, wife and the beautiful little girl say their goodbyes. Kathleen promises to visit and share a cookie with her the next day. The world with all its disjointed sarcasm still manages with all the snubs, rubs, fright and spite, to foster goodness. Human kindness creates a wealthy network of resource. What Kathleen will learn from the experiences and wisdom of the old lady is what cannot ever be learnt from the books. What the old lady gets from Kathleen is a priceless companionship. A little girl in a ponytail with a heart of gold, a gift of love and a touch of an angel, flowers the world of an older woman, is the tincture of medicine the world needs to survive beyond tomorrow.