Sunday, August 30, 2009

Across the Genetic Divide

 

There is something about cloudy days and a visit to the zoo. The overcast clouds are pleated and wrinkled from horizon to horizon. The turgidity makes them stoop down onto the earth encasing tall towers in their grey interior. The earth is still, breached only by the sounds of the inhabitants. The chimps playful in their cages dangle from bars while the orangutans quietly ignore the passersby and are immersed in the grooming of their young, carefully de-licing and nitpicking.

Two teens kicking a ball around the walkway come to rest and look at the chimps. One is nudging the other. The chimp closest to them shows interest in their behavior. The chimpanzee starts to mimic their actions to the great delight of the teens. The interactive theater of mutual thrills continues for a while then the chimp seems to bore and look for other action. The teens continue to observe while surveying their surroundings.

“Hey Mister. Did you see that?”

“Yes.”

“These are some smart monkeys.” The taller skinnier of them says.

“Looks like it.”

“I wonder what they think?” He asks.

“We know they have limited intelligence. But they are able to understand how to express their needs. They are also playful as you just saw. Very little difference between us and them.”

“You an animal expert or something?”

“Me, no just curious.”

“What? I should hope there is more difference between and that monkey.”

“As a matter of fact they have 98% of the same gene code as us.”

“Really?”

“The only difference is that we have elements of thinking, understanding and cognition due to our larger brains that they don’t. But those Orangutans do have a capacity to learn. There was a naturalist named Jane Goodall who researched this and made it her life’s ambition.”

“Oh.” Josh’s thoughts had drifted elsewhere.

At this time the other teen turns around for the first time. He has a pasty complexion, wide set eyes, a flattened bridge of his nose, thick lips and a capacious mouth. His head is supported on a wide neckline topped with a thinned black hair.

“Hi.” He says in a thick voice.

“Hello.”

“This is my friend Cag, and I am Josh.” The other one extends his hand in friendship.

The conversation continues. Josh and Cag have been friends since childhood. Both are next-door neighbors. Cag is slow and deliberate. Josh carries the mantle of their conversation. Josh finally asks, “Are you a doctor or something?”

“Yes.”

“Tell me then about my friend Cag.” Then after a moment of reflection he volunteers, “Oh he doesn’t mind too much. Besides I want to be a doctor too so that I can take care of Cag. We are best buddies and always will be.” He squeezes his friend’s shoulder. “Cag and I have no secrets.”

“So tell me about Cag.”

“Google the words Trisomy 21, and ask me any questions you have tomorrow morning here at the same time.”

Theirs is a journey with unequal distances. This thriving friendship will be tested and will have moments of sheer delight and a handful of heartaches. These moments will revel themselves at the appointed time. But their friendship will see both of them through. The contrasting desire to learn in one equals the visually empathic style of the other creating a strong link. The knots of these small differences help them climb this braided rope. Both enjoy the value of the other. The concern of one is equaled by the unapologetic loyalty of the other. As they move away in their quest to gather more insights into the animal kingdom of the zoo, Cag bends down to pick up something and shows it to Josh. They both view it with interest and then Cag with a wave of his hand lets the little insect fly away. The history of their friendship sealed in that moment, like Geppetto breathing life into wood each such moment breathes life into their friendship.

The next morning the sun is ablaze with possibilities. The animals are at a fever pitch in their cages enjoying nature’s bounty.

“Where’s Cag?”

“He had to go with his parents.” Josh replies. But I do have questions for you.”

“Okay.”

“Why do the chromosomes not split?”

“No one knows. This seems to occur in older women when the germ cells divide, the 21st chromosome fails to separate (Non-disjunction) and when the father’s separated chromosomes on division of the germ cell merges with the mother’s two undivided chromosomes the result is three of the 21st chromosomes instead of a pair. This trisomy as its called leads to developmental defects in the baby.”

“The chromosome is full of genes?” He looked at his feet trying to visualize the entity. “Isn’t three better than two.”

“The answer to the first is yes. It is the DNA, which consists of two spaghetti like strands zippered together. There are 30,000 genes in the entire human DNA library. Answer to the second is, when areas that govern different function mix inadvertently, there are unintended consequences, unfortunately it is not additive.”

“What about Cag’s chances of being normal?”

“Unfortunately Josh, that is impossible. His arrested development in both features and brain also affects his mental development. This varies from complete helplessness to a functioning person. Fortunately for Cag he has a functional life.”

“The internet suggested that there is a high possibility of infections and other disease that go along with this. Why?”

“Well, the genetic disturbance can affect other areas that govern a human’s daily life. The kids with Down Syndrome as it is called can develop infections and other ailments over time.” This knowledge causes a concern on Josh’s face. “But with modern medicine that can easily be handled.” His face relaxes.

“Why do they call it Down Syndrome?”

“Named after the scientist, Langdon Down, who described it in the late 1800s.”

“Oh.”

The conversation continues in a question and answer format. When Josh can find no further questions to ask he claims with undisputed desire, “I want to be a research doctor.”

The desires of an individual thrive in the pockets of human affection. Countless scientists, researchers, brilliant game-changers have embarked on a field to find answers to difficult questions not for the glory but for the sake of a loved one, a friend or unquenchable curiosity. Most, with this relentless desire that pushes its invisible force, will find the recipe to the cocktail of success. The discovery ultimately serves all of humanity. Josh will be one of those few with that desire.

Thursday, August 27, 2009

High Tea

In the dark of the twilight there lit a blue shimmer of nocilucent cloud high above the earth brightening the ambient light. The summer rains had ended and the sky was an obsidian blue glass but for the shimmer. The cicadas were in full guttural pitch announcing the oncoming fall and the return of the yellow school buses filled with children headed for school. It meant an end to the fun and frolic of the easy days of laze and haze. Across the valley an old Victorian house stood still against the sky. The haunt of the light had thrown many a children into a state of panic on a “dare.”

The lonely occupant of this house was an old lady known vaguely to her neighbors. To the children she had powers beyond those of a normal human being. She could transfix you in a stupor so that only pee on the pant legs was a reminder of the magic. She could also make the bats suddenly come out of the house gables and swarm over you – one bat maybe. The myth of the magic powers escalated to such a degree that transgression onto the lady’s property became a source of “hazing ritual.” amongst children. A little boy too young to be involved was egged on by his seniors, did just that and fell as his foot caught on the uneven ground.

“I am so sorry about your son’s injury.” The old lady with her gnarled hands lost in a sea of tremors barely able to hold the pot of tea in her hands apologized.

“I see the children playing outside all the time and I let them enjoy their little games.” She said with a loud whisper that had a deep undulating tone like that of Katherine Hepburn. It made her sound as if her voice was an analog recording on a warped old 78-RPM vinyl record.

“Would you like some sugar dear?” She asked.

“No thank you.”

“Good for you. It causes diabetes anyway.” She stated bluntly. "Look at me. I have been living with this for five years now. My doctors tell me I may have to move out of the house and live in assisted living.”

 “I am sorry to hear that.”

“I have lived all of my 75 years in this house. “ Her voice lowered to a whisper. The cloudy eyes shimmered with emotion but the dignity of her past helped her through the moment. “I don’t know if I could do it.”

“These sandwiches are great.”

“Why thank you.”

“Did you make them?”

“I make them every day.” She paused a moment and without regret or thought she referenced a natural event, “In the old days if no one visited, I would eat them myself, but now I feed them to the birds.” Here she looked out of the window. A glint of smile touched the corners of her once delicate mouth. “See!”

Between the sheer curtains and the dusty windowpanes four little birds sat perched on the banister of the balcony, twittering away, awaiting their gourmet meal.
“I feed them out of my hand.” She said with a sense of pride and joy.

“They give you company?”

“They do.”

“Don’t you have a family?”

“I do.” Her eyes brightened a bit and then the stare of solitude overwhelmed the eyelids. “But they live far from here in different States. Besides they have their own families and I would not want to burden them.” Her hands now folded on her lap as the bony fingers harvested comfort in their clasp.

“I am sure you would not be a burden to anyone.”

“Why bless you for saying that.” The little joy in the sea of wilderness seemed to raise her spirits. “But I want to leave my three sons and their children and theirs all that I have.” The wistful look of resignation crossed her eyes again. “The well-meaning people from the State keep coming and telling me that it would be in my interest to move. Sell the house and that can pay for me to stay in the assisted living.” Her voice raised a decibel, “What do they know about my life and my wants?” With her fingers now untied from the clasp, she gestured by approximating the finger and thumb of her right hand, squeezing the air between, “They know nothing.”

“Yes but you do have to look after yourself too.”

The ornate small teacup was empty of its content.

“May I pour you some more?”

“No thank you. That was just wonderful.”

“The world has changed. We don’t live for one another anymore.” She answered. It was so truthful and symbolic of times. “I am sure your parents are proud of you. You spend all this time listening to an old lady and her complaints.” She said as she cleared the table of the food and plates onto a tray. She talked some more and then growing tired she grew silent.

“It has been my pleasure. Maybe you can visit our house next door and you can show your magical powers to my kids.”

She laughed quietly as she slowly lifted the tray off the table. Refusing all help and with her slow determined yet quiet dignity carried it to the kitchen. 

The next afternoon as the tree shadows shortened and the bright light of the sun burnt the fog of the still Sunday afternoon, a police car drove over to the old Victorian house. Moments later an ambulance arrived without any fanfare of lights or sound. The only sound was that of rubber tires on the gravel driveway. The house that had never looked empty was made empty now. It was now devoid of its fortune - an elegant lady who made tea one late Saturday afternoon for a stranger. The birds still flew and the occasional raven still crowed and the family of chipmunks making a haven in the old oak tree still playfully ran up and down its trunk, but the earth stood still for a brief moment.

She had diabetes. This was the curse of an indulged civilization. The sugar molecules converting into fat created Insulin resistance. She had said losing weight in her later years had only helped defer the ultimate damage to her body. The slow deterioration from aging had been accelerated many-fold by diabetes. Her eyesight had weakened to requiring a magnifying glass for reading and her heart would go into a state of “pitter-patter” as she called it. Her hearing was limited and her legs had scars of poorly healed sores. The doctors had told her kidneys were failing. All this she had said with a stoicism of a wounded veteran. She lived the ruin but never dwelled or looked for sympathy. Her only concern in her conversation was what she had lived for – her family, that they would not be deprived of her limited bounty – her house and property. It was her silent chant of “Don’t cry for me, but learn from me.”

Her non-verbal cry was a simple one, “Avoid the road I have taken. Take the fork to better self-care, health and prosperity. You can live as long or longer but without the indignity of infirmity."

Wednesday, August 26, 2009

The Iconoclast

 

At five feet seven he walked amongst the sea of average. Slight of structure, fair of skin and possessing of a warm smile that would melt inches of snow off the rooftops in the winter. His eyes were set wide apart with a flattened bridge in between. He was a modest man but could distill the sweet drop of understanding from the nebulous cloud of information. “Always dig deep. Deeper than you can dig.” Was his mantra. In his own self-effacing way he would light the desire of learning. He was a chemist by trade, a √©migr√© from Thailand, spoke impeccable English and his interests lay in a field where he possessed very little expertise - medicine. He could not practice the craft but there lay within him a deep understanding of the causality of disease. This passion had been kindled after the premature death of his father from a sudden heart attack. He had left his lucrative job to work in a restaurant. He loved to cook and creating “something out of raw material,” gave him ultimate satisfaction. Even though his salary was meager in relative terms, he was content. There were no financial pressures on him, no demands. He was single.         

“So what do you think?” he would ask.

“About what?”

“About heart disease.”

“It has hereditary roots, it is amplified by diet and cigarette smoking and is the number one killer.”

“No, I mean how does it start?” He would probe.

“I guess, high cholesterol, stress, high blood pressure and bad genes.”

“See you came up with all this information just by asking the same question twice.” He would rub his hands as if getting ready to handle the prize he had sought.

“Okay, lets look a this cholesterol myth for starters. Do you think that just by raising the cholesterol the arteries would start clogging. If that were true then every artery would be evenly clogged?”

“I suppose.”

“No really, think. There must be a mechanism that must precede the event.” He said his voice getting softer in tone but the force behind his conviction flowing stronger.

“Well if you throw a lot of sludge through PVC pipes they ultimately get crud in them. Once the first layer settles then sedimentation follows due to uneven surface created by the initial sediment, and voila the clogged pipe!”

“Right, but certain kind of crud has to line the inner part of the pipes, right?” His voice raised a touch with an impassioned concern of sorts.

“So lets look at where the crud can get deposited first probably where the pipe hinges are and at where it bends and where it forks, Right?” His eyes now wild with passion, seeking comfort in his knowledge and a confirmation from the “medicine man.”

“Yup.”

“And if the inside of the pipe is smooth then that crud would not be able to stick to the inner surface either, unless the flow rate slows down. Right?”

“True.”

“So then there must be a trigger mechanism that causes the inner surface to allow for the crud to accumulate and slow the flow rate down. So far you’re with me?”

“Yes but…the pumping heart is a violent organ that dispenses a tsunami of blood through the vessels. Wouldn’t this force create the necessary damage to the innards of the blood vessel and create the soil for deposition?”

“True, good observation, that is why the blood vessels branch in such fractals. This branching (arborization) and the muscular walls dampen the forceful trauma into a docile continuous flow. He paused a moment for the image to sink in, “Agreed?”

“Pretty much.”

“Now lets find the trigger mechanism for the cholesterol to stick to the walls. Which brings me to the next question. Is this cholesterol stuff inside the lining of the wall or just lies on top of the inner side of the artery?”

“It lies under the inner lining.”

“Okay so now this crud or cholesterol has to somehow, pressured by the flow of blood separate from the rest of the blood (loss of linearity) and seep into the inner lining of the blood vessel?” There was silence for a minute as the question sank through the pores of understanding. “Now we are assuming multiple occurrences without a cause.”

‘Okay,” after the minute he allowed for contemplation, “So what would be the trigger?”

“Slow rate?”

“No, assuming the rate of flow remains constant until the trigger mechanism is turned on.” A little edge of dissatisfaction lingered at the edge of his tone.

“How about, Inflammation?”

“Bingo. And what causes inflammation?”

“Infection?”

“So 90% of all arterial plaques have Chlamydia antigens present according to one study.” He states with unadulterated but quiet repose. He had just slammed the royal flush on the table. To the victor belonged the spoils. Hooray. A brilliant cook had toppled the mountain of illogic.

“Serious?”

“Yes, I read it in one of your journals. A very comprehensive article but little mentioned by the rest of the medical crowd.”

“What about the genes?”

“Oh they make the cholesterol go up and all but without the trigger mechanism nothing can happen. The Macrophages or Foam Cells without the inflammatory irritation will not be desirous to pick up the Very Low Density Lipoprotein or VLDL. Hence the argument.” He rubs his hands together in his mental victory lap, all the while the smile never leaving the corners of his mouth.

“Remember the cholesterol is a very intricate part of what makes the brain function, the hormones that guide cellular networks in the body and what gives us the gender bias after the XY and the XX chromosome party is over.”

“Brilliant, so the body itself manufactures the product for its own function and need.” He slapped his hand on the glass table, rattling the half full glass of water. The agitated liquid laid testimony to his claim. “If this was bad for humanity, then evolutionary powers would have changed the game for the species perpetuation.” Taking a breath to collect his thoughts he continued, “Heart disease causes early deaths and that would prevent humanity to continue to prosper.” He nodded in assertion. That also made sense.

It was a Sunday afternoon after a heavy lunch when he was admitted to the hospital with abdominal pains. His diagnosis was acute bacterial diverticulitis. After his bout with antibiotics and the change of diet he was back home and again playing thought experiments. Sitting in the armchair he seemed subdued a bit. The visit was shorter then usual and there was a nagging sensation of “chance,” lingering in the room. Chance at what had happened to him, chance that he was where he was at this time, chance as the counter-intuitive physics of today would have you believe that life was mere a perception and reality restored only upon observation. But he did not. In a low whisper as if in deep thought he said he would take time off from the restaurant and visit the States of his adopted country. “See the real world, “ as he put it.

He seemed to disappear from the scene for a few months, which he was wont to from time to time. Never one to make long term plans nor spend time on the phone, his disappearance was a mark of his free spirit. But this time when he reappeared he had lost more weight and his appearance had a haggard look to it. The clothes seem to hang from him, not refining him but defining him. His demeanor was the same but there was the curse of knowledge that caressed his brow now.

“It was that darn colonic infection that was the trigger to my heart attack.” He said quietly. “You know, my genes were a little off from the beginning. But this infectious diverticulitis was not in the plans.” He shudders just a little, reflecting a bit and then continues his thought, “I survived this because of being forewarned and taking care of my nutrition and exercising this temple,” pointing to his belly. “Things would have gone along fine, absent the infection.”

We elevate our understanding to a higher plane but cede to the lower cause that we have uncovered. Life plays tricks. A quantum dynamic of observation causes reality to emerge. The singer and not the song is the victim. The drama of our lives plays out over linear time with sudden and abrupt Stop signs or forks in the road hidden just beyond the falling terrain. Life moves on unconcerned for the one. It favors health, information and fitness for propagation. 

Tuesday, August 25, 2009

The Circle of Life

 

She was soaked to the skin with the anguish and pain of a loneliness she could not fully comprehend. The days were filled with work and conversations. The underlying emptiness growled within throughout the smiles and the conversations. The nights were sheer torture. The feeling would come over her like a blanket, covering everything. She had moments of suffocating feelings that made her sit upright in her bed at night clammy with the sensation of the rivulets of sweat running down her spine. She would feel the comforting hand of her husband on her arm for he knew the turmoil and chaos within in her. Things he could not quell with words or embrace. Things that needed to work their way out on their own. A purging of sorts had to occur.

This was the seventh year of their marriage. This was the seventh month since the last attempt at having a baby- another unsuccessful trial. “It will happen one day.” People would say with knowing looks and genuine warmth. They would tell their side of the story of many miscarriages and then success. The stories were the same all meant to make her torment tolerable. But to her they remained void of meaning.

She had several short-lived pregnancies, never carrying to term or much less past the first trimester. The psychological trauma of this deficiency chided her soul. She was determined to have a baby and she and her husband had agreed to this pact. She would have their baby and not contemplate adoption as others had proposed. Her determination was strong even though nature kept thwarting her attempts. No way was she capitulating to this alternate mentality

The prejudice that guides conception hides in little molecules of the germ cells. The fitness grade of each cell must pass muster before any progeny is allowed to hold the reins of life. Life is a self-propagating phenomenon. The very code that resides within the cell conspires to conjugate with the most eligible of counter-part. If either side has a weakness then propagation will be thwarted. These weaknesses can occur as potential damage to the genetic code of the germ cell itself occurring during replication or after. The damage can be at a very basic level which when mixed with the DNA of the counter-part (a spouse) the resulting fetus may have cellular un-differentiation, a protean defect or protein malformation that would lead to a miscarriage. The body evaluates the product of conception and only if “Inspector 12,” grants the certification then the pregnancy is allowed to full term. This “Inspector 12,” is in the form of multiple genetic triggers that assess the appropriate cellular function and form. Finding any defect in the basic mechanistic mode, the suicide genes are activated that abort the fetus. It is a fail-safe operation, purely for the propagation of the fittest species. 

“I don’t know what to do.” She cries softly rocking her self gently in her bed. It is midnight and all the fireflies of human inventions have been extinguished.

“Honey. We will go to the Fertility doctors tomorrow.” He assures her.

“But we tried that already.”

Yes, but there is a new technique that they have.”

“We don’t have the money.”

“I’ll take a loan. Don’t worry. This is the most important thing in our lives.”

“You sure?” She asks as tears stream down her face.

“Never more.”

It is the fifth month of the eighth year, after a speedy labor, the couple beam with delight as they behold their first-born, a healthy boy. Funny the tears of joy taste different then the ones she had been crying before. The world is a happier place. The lights are brighter and every nuance brings laughter. 

The mating of the germ cells is a small miracle. Two dissimilar cells merge to combine their genetic material. From this union and after all the reviews and checks are completed within and the go-ahead signal is received for the fused cell to go-forth-and-multiply life begins. The initial process is done. This cell divides at a geometrical pace. The rapid growth and the constant genetic surveillance of the product for any errant phenomenon proceeds quickly and quietly as the mother’s belly slowly stretches to behold the greatest triumph of human endeavor. The preparation of the “soil,” called the placenta where the growing fetus derives its food supply and the sac that holds the “water,” the amniotic fluid is all encompassing of the many “triggers” that need to be in the right position at the right time. And yet a birth happens every half a second somewhere on this planet. It is the remarkable machinery - the human body- that carries the mantle of such an impressive feat. Not only that the merger of the two disparate genetic material that carry the histories of two dissimilar family trees are brought together in this rendering. It is a Michael Angelo’s “Creation of Adam,” on the Sistine Chapel. It is the greatest gift.

Another chapter gets written at each birth unbeknownst to us. That is the slow subsurface evolutionary writing on the genetic code. The merger of disparate genetic material also allows for gain of access to stronger sets of genes that may help thwart a disease manifest in the population as Sickle cell for Malaria with just one amino acid variation in the genetic code. It can also harbor as “junk DNA,” in the genome some material grafted in the man or the women via exposure to viruses. These can strengthen or weaken some codes that can help immunity. The previous exposures to viruses can also help alert the immune system of the baby against any unwanted attacks from the external world. There is a matter of cooperation or deception that continuously goes on inside of us. Sometimes the viral world wins with its deceptive ways and other times it cooperates with the body to serve it’s own purpose of survival thus helping humanity. Oh there is a whole carnival of activity going on inside of us. The genome continues to better itself with each generation. Most time it succeeds. It is a quest for perfection.

She holds the baby close to her. Both sets of eyes locked on each other. One overflowing with love and the other helpless but comforted and secure. The baby coos and melts his mother’s heart. A single tear of joy runs down the mother’s cheek and onto the baby’s face. Permanence is established. The husband gently caresses both his loves. The world is complete. Humanity is once again saved from extinction.

Sunday, August 23, 2009

The Perfect Circle

 

Alone on the sandy white beach he sits, while the clouds overhead shield the warmth of the sun. The beach is deserted save his mother who sits in a beach chair under an umbrella reading a book. She keeps a weary eye on him. He is not yet seven years old. Fair of skin with a face charmed with bright blue eyes, a small nose and a crop of blonde hair bleached from the sun, dripping down his face in locks, that he periodically blows away from his face with a pursed pair of lips. He is a cute one by standards of any passerby. From a distance he would appear to be engrossed with his pail building a sand castle that, if you took the time to observe never materializes. The pail sits by this child and the sand waits.

He seems to be deep in thought, quiet yet with a gentle rocking motion to his manner, a comforting rhythm to his inner clock. Something is adrift in the inner sanctums of his mind. It is a damaged offering from an innocent past. Might it be a solar flare in collusion with Martian Dust in space creating subatomic muonic-quarky hell that drives through the body at blinding speed to create villainy of sorts on the structure of the DNA – deleting, duplicating or inverting chromosomal pieces thus affecting the brain development. Or is it man at his most intellectual self, creating disorder by trying to prevent disease. Or is it the chemicals that man uses to keep crops from being engulfed with disease to save humanity from starvation. Or, is it just a chance mutation causing the brain trust of neuronal circuitry to find inherent loops within smaller compartments and not seek the advice and consent of the rest of the imaged experiential self. This loop fosters a genius in a single application at the risk of losing comfort from the rest of the society leading to an undesired ostracism.

But there he is now drawing a circle in the sand and then erasing it. Over and over again he draws the circle and then comes the erasure as if the entire future of the world depends on the perfect circle.  To any one else it would be near perfection, but to these pairs of perfectly created ocean blue eyes there is always a hint of distortion, imperfection, not quite good yet that forces another attempt. Maybe better next time. Maybe the radius is not equal in all quadrants or maybe it has not equaled the measure of his keen stare. As he erases each circle to make room for the next rendition there is no emotions of frustration or anger, just a peaceful transition into the next attempt.

A man with dyed blonde hair approaches the mother. “How’s he doing?”

“Fine.” She replies. “He is playing happily. Don’t bother him.”

“What’s going to happen when he grows up?”

“We’ll take one day at a time.” She closes her book.

“Yeah, I know but he is never going to be able to get married, have kids and all that –live a life you know?”

“And I wont have an empty nest syndrome.” She laughs.

“No seriously.”

“I am serious too. I love our little child and I would not trade for another.”

“I love him too, but look what he is going to miss.”

“What he does not know won’t hurt him,” she says firmly. “And who knows what the future holds for him. Someone could fall in love with him as a person. Not every girl is looking for the muscle bound steroid dripping male you see on TV.” ending the conversation.

“Six out of a thousand eh? Why couldn’t he have been one of the 994?” He mutters.

They remain quiet, observing their offspring nearby as he continues to rock to his inner beat perfecting the near perfect circle.

“Who knows that we all may not have a little bit of him in us?” The mother says whimsically.

“What do you mean?” Her husband replies defiantly.

“Lets see,” she stretches open her hand to count down the frailties, “You go through your rituals every morning. The towels have to be in the same spot. You use the same shaving cream and place the razor in the same place. Your golf shirts are hung in color-sequenced order. The militant neatness may be a small part of the whole picture. So don’t be in a hurry to throw stones.” She cautions him gently.

The little boy ceases his rocking motion briefly and grunts loudly. The mother looks at him. He grunts again and rocks a little more forcefully still in perfect rhythm. The mother slowly gets up and walks towards her child, while the father remains engrossed with the ocean view paying little attention to the two. His wife calls out to him in an urgent whisper and he walks up to them. An involuntary whistle escapes out between his lips.

“Wow that is a perfect circle.”

“Oh honey that is wonderful!” as the mother cuddles her only child not quite knowing the significance but intuitively knowing something has happened -  a game changer.

The father kisses his child on the cheek and the child allows the comfort. A brief encounter with reality occurs as a synaptic electrical current flows in the boy’s self-referential system, unbeknownst to the parents. Yet they are aware of the significance instinctively. An unremitting disorder has shown weakness in its’ relentless pathological drive.

We all live in the blank slate of the white sandy beaches where the perfect circle can be drawn. Most lives are lived in quiet desperation drawing imperfect circles with perfect tools. Some achieve perfection without them. There are moments of profound joy that spring from the littlest of human endeavors while some minor accomplishments sometimes take monumental work. Both share the commonality of endeavor. Both signify humanity at work. Both signify achievement. And both need oceans of love and support. We fight as we work and sometimes winning one battle at a time eventually wins the war. Patience, kindness and love sometimes accomplish a tenor of health and a victory against disease that medicine cannot.

 

Saturday, August 22, 2009

Disorderly conduct

Isn’t life strange? The whole continuum unfolds one decision at a time. Each day, each hour and minute we take the fork in the road and what follows is life. Change is continuous always clamoring to add that delicate spice to make the whole better. Parallel universes aside the linearity of events dictate the outcome, from each cell to the entire organism.  Origins are the possibilities of endless quests and endless desires. The road to these quests, collapse the possibilities into realities. It is as if sitting in your living room you decide to take a walk instead of fill the empty bowl with ice cream and resume watching television. One probability collapses while another one becomes real. A living cell continues on the same path of probabilities, constantly being barraged by a slew of inputs. The greatest input or the largest collections of similar inputs force the cell to proceed in its course of action. Does the cell have memory? A question you can only ask if you have one too. Of course the cell has memory. It resides in the matrix of a complex interior. Like the Immune modulatory cell remembers the vulgar attacks of an allergen, stimulated, it releases its cast of characters in the blood stream for the body to fight off the offending agent. Sometimes the cell is forced by external or internal inflicted damages to commit suicide to save the rest of the body.  And other times the body cannot tolerate this selfless act and the whole body goes into a dangerous state of flux. The brain functions on a similar plane. Weeding out the tall grass to keep the surface smooth and even.

Life takes turns from roads well traveled to those less traveled and vice versa. Decisions manufactured in the mind create the impetus for the direction. These decisions arise as a consequence of the entire brain at play. The pre-frontal cortex is the arbiter of such directives. The question being mulled in the brain continues to swirl between the temporal lobes (located under the temples) and the frontal lobes, coursing the highway between the to two sides of the brain called the corpus collusum. After such contemplative issues have been hashed the pros and cons weighed then the judgment comes down from the pre-frontal cortex. The weighing of such decisions are balanced with the fears and anger, hopes and desires, submission and extroversion, past and the potential future information residing in various niches of the brain, before the pre-frontal cortex visits the decision well. In spite of such a collective force of thought, the decisions are not always perfect. The fudge factors are always at play, for knowledge and information is never complete. That is what makes us humans. This imperfection of sorts, this final turn of the roulette wheel is how we become who we are. Perfection is only in the mind. Actions reek of imperfection. Overall though a properly functioning mind will see the road of it's desire and plunge headlong. Yet sometimes these desires are drowned by elements out of human control.

It was a Monday, the day that awakens with much hope and desire. The morning had slowly slipped into finding the sun fully ablaze overhead. The usual bustle of the day-shift nurses mulling in the cafeteria to discuss their personal problems or that of their wards in the hospital made quite a buzz. Cell phones on mute vibrated their owners of incoming calls making them leave the table amidst juicy conversation. The culture of this environment feeds on its participants. The stories, some exaggerated, some real, some perceived all blended are those that finally make it out of the environment for further mixing and churning outside. The constant obsession by the outside over this environment within remains a subject of journals, newspapers, books, television and the big screen, challenges the mind. To the outside it is a microcosm of the world itself. Life, death and all in between hashed out on paper or digital 1 and 0. This coveted sanctuary is the hospital.

A sudden crash of silverware silenced the cacophony. All eyes diverted to the direction of the sound. A pile of scrubs lay on the floor covered with the remains of her lunch. Some spaghetti strewn across the floor made the housekeepers scamper to this person’s aid.

After much ado and deliberation the stricken woman got up with bewildered unfocused eyes. She stumbled but managed to keep her station intact. After a moment of sway she seemed to conquer her sudden loss of stride. Her gait now steadied she continued to walk with her soiled tray and placed it in front of the cashier, who looked at her with confusion. The lady stood there as confusion mounted on both sides. The cashier asked politely, “Can I help you?”

“Yes. I’ll pay.”

“But you have nothing on this tray.” Cried the cashier.

“I do. See all this." the lady said and pointed to her tray. "I don’t want to jip you.” 

“But there is nothing on this tray, except some left over sauce covered spaghetti?”

“Oh. Oh. I, I can’t think... I have a head...” With that she collapsed under her own weight. She could not concentrate on the act of concentration. The smooth graph lines of her brain function had suddenly turned chaotic. Order had morphed into disorder. While this riot of the mind continued to unfold the outside world, efficiently and quickly, marshaled it’s collective insight to help her. A slew of barked orders and someone had taken charge.

There were many witnesses to the event. The diagnostician, a neurologist determined after an MRI that the lady had suffered a cerebral bleed –a stroke. The cause was a small berry aneurysm located near the parieto-temporal region on the right side. In those few minutes was manifested a complete picture of the brain in a state of disarray. Confusion preceded indecision, which was followed by a disaffected action. Was confusion the driving force or was it the warbled messaging that entered the pre-frontal cortical cells. Her confusion and the resulting actions were disproportionate to the moment. The brain cells (neurons) inundated with a flood of blood fired, misfired or simply quit and the highways of orderly flow in the axonal (neuronal fibers) bundles sent misguided messages adding to the disorderly state. Confusion therefore had followed disorder.

The lady, a nurse, recovered fully. She was lucky to have been in an environment suited to care for such an occurrence. Medicine had subsumed another calamity. Another life had been helped. And another mind was cleansed to make real decision based on life-lived experiences.

 

Thursday, August 20, 2009

Trilogy: On being a Physician. Part II Resident.


 Sometimes those nights where monsters leap out from nowhere and fill in the screen of imagination make for a restless sleep. The waking moments are spent resolving the subconscious errors of the mind and its firing neurons. What does that dream mean? What bearing will it have on life? Is it a future told in a dreamscape? Is it a harbinger of things to come? Or is it just the manifestations of fears and desires coming together in an idle mind at rest trying to create a reality? No one knows except may be the dream readers or merchants of psychic persuasion.

Yet there are those who have this blend of fancy occurring during the day. It manifests itself as reality. It is termed a hallucination. Rightfully or not it is that same desire of the brain to fill in extraneous, out-of-left-field experiences with some modicum of reality. Many drugs illustrate that power. These compounds or hallucinogens hold the power to disassemble the framework of normalcy, distort, bend and violate the fabric of reality into phantasmagorical images of the bizarre.

When this occurs suddenly and without known reason, the puzzle assemblage begins. Piece by piece the detective work of the physician is categorized in his mind as tests are made and deciphered. Somewhere in the deep recesses a thought emerges and manifests itself as a possibility. A spent afternoon in the library or “something from the blue,” lays the seed of what it could be – a diagnosis.

On a bright afternoon in the middle of summer while tanning at the beach this young woman was brought in to the Emergency Room after she started scratching herself bloody. Her eyes crazed to the world, wide with terror and her head bent sideways looking over her shoulder as if trying to stave off an attack from a predator. Her husband recalled no such previous occurrences. “No,” he said categorically, “that drugs were not an issue and she had not taken any medications either.” Her core temperature was slightly high but signs of fear and flight manifested in her being. Her husband was holding a fictional novel about Vampires; he claimed that she had been reading.

Minutes later when she had been sedated and all the tests were run, the answer remained elusive. Puzzling over this set of disparate facts Joe called his friend Jack a continent away on the West Coast.

“So what’s going on?”

“I’ve got an interesting one.” Joe said.

“Yeah well I have my handful of them.”

“No seriously.” And before Jack could answer, Joe started his monologue of the recent events.

“ What does the MRI show?” Jack asked.

“Negative.”

“Get a T2 weighted TSE MRI.”

“What?”

“Stands for T2 weighted Turbo-spine echo MRI which is computer algorithm generated view and picks up extremely small lesions. In a denovo occurrence like this without previous history in a youngish person suspect a brain pathology.”

“Thanks. But where did you get that?”

“Wasting my time in the library since no girl wants to go out with me.”

“Fly down here and I can fix that.”

“Oh yeah, like Shirley. My supposed date that became magnetized by you.”

 

Three months later a knock on the open door and in walks Jack.

“Hey, man good to see you?” Joe looks up from his sofa where he is sprawled.

“You look like hell!” Jack surveys the room. “I was in the neighborhood. Thought I’d drop in. Not getting any sleep?”

“Questions! Questions! The simple answer is that those advertised eight-hour shifts end up as 12-14 hours by the time the paperwork and handover of cases and all that. You know? This residency thing isn’t as glamorous as television makes it.”

"You certainly don't look like Dr. McDreamy." Jack turns towards the desk strewn with piles of journals.

“Hey, Joe I have been meaning to call you about that case you called a few weeks ago?”

“Huh!” Sudden change in thought and question is Jack’s forte; always inquiring.

“Oh yeah, that one, she had an Astro grade III. This brilliant neuro-surgical fellow figured it out. He enhanced the MRI imaged films and found the tiny little sucker was perched in the temporal lobe. Just like you said. It took them three hours to remove it and voila she is fine. No residuals. No more hallucinations.” With those few words and hand-arm gestures the ordeal of one life has been catalogued. A hidden scar beneath the hair serve as the remains of a troubled, deranged moments in that patient's life.

“Good to hear.” Jack says opening up the refrigerator. “What no beer?”

“Fresh out. You still haven’t told me what are you doing here?”

“Interview.” Jack looks back with his muted smirk.

“Any place I know?”

“Yeah the place next to your hospital.”

“Serious! That is great! Man that is a world-renowned institution. You’ll make a good professor”

“We’ll see I haven’t made up my mind yet.”

“Lets go out and celebrate anyway.”

Medicine is a lived life. Never separate from one’s being. It conquers the mind and becomes one with your being. You live it. You walk down the street and your mind floats in a sea of diagnoses as you pass by people. You stop and help those in need and feel the joy in little victories and when you are unable to help, suffer through the defeats against nature only to emerge stronger for battles that lie ahead. Like jabs in the sides, these pricks of conscience deflate while the puffs of small miracles inflate the soul. Medicine is like a friendship; both thrive in the giving.  

Monday, August 17, 2009

The Measure of Efficiency

It was a cold dark autumn night. The trees were undressed into their skeletal remains silhouetting against the dark skies. The ambulance siren from far away echoed through the still chilly air. It was a quiet night when he was wheeled in.

He wore horizontally striped Pajamas. There were scribbles of ink over the stripes above his knees, as if he had thought of something and sketched it for fear of leaving it to the vagaries of his memory. The ink spots were partially washed out but the essence remained. His body was a frail metaphor to the winter of his years. He spoke fluent French in a Parisian dialect, in an environment where English was the norm. Nurses eyed him with inquisitiveness smiling to his minimal complaints offered in this language for lovers.

He was weak and barely able to stitch a few words into a sentence. The breath that eluded him seemed to come in short bursts where he could whisper his minimal requests. “I am cold.” Or “I need a pen.” Simple requests when granted afforded him great joy expressed in an affable smile.

“I wish I had more time.” He would say frequently. In his late seventies according to the actuarial charts he had met the median for males of the 21st Century. But he was in need of more time. And time was running out. His once healthy heart skipped more beats in a minute than it once produced. A pacemaker to pace the heart was suggested and placed within him but to little avail. His heart muscles weakened by the lack of blood flow  over years became reluctant to the demands. His heart was like a boxer battered and bloodied barely able to hold up his arms in victory 

“I don’t know what to do!” he would reflect at this calamity of misfortune. His desire to live was at odds when face to face with the limits of survival. One battle would be lost another won.

The arguments of throwing more resources at this aging man seem destined for failure. No matter what, time was knocking at the door and ready to extract its vengeance. Placing him on an artificial pump was considered but he was not a candidate for a heart transplant. So after many of his low voiced urgings, he was begun on an experimental regimen.

On the fourth night the midnight shift nurses reported that he had kept his room light on all night against their entreaties. The following morning he was sitting up in his bed, propped up by pillows around him. There were ink stains on his fingers and pieces of paper strewn on the floor. He clutched to one piece of paper in his left hand straining the angio-catheter. His face appeared content. 

“How are you feeling today?”

“Great.” He replied.

“No shortness of breath?”

“Oh yes, of course.” He replied with a smile. He looked at the monitor for confirmation, but 40 beats a minute is not the answer that corroborated his statement.

“You seem comfortable today?”

“ Un peu." "A little.” he translated

“Anything I can do for you?”

“Another day.”

“Pardon me?”

“I need another day." He expressed. Then whispered in French, "J'ai besoin d'un autre jour”

“You might get a lot more based on your improvement.”

“Oui?” He smiled weakly and closed his eyes.

Meanwhile the arguments at the resource optimization committee kept getting louder as this man begged for a few days of living. The voices drowned any medical logic and calls for “nature to take its course,” came from various agencies documenting physical data and potential survivability. Yet doggedly, something in this man’s yearning was so deep and so desirous of an outcome that, the cacophony of irritated voices drowned in their own frustration.

“Merci.” He said the following morning, raising his hand at the wrist while the weakness anchored his arm on the bed. His bony hand delivered the pieces of paper he was holding and said, “Please, to my son,” he said barely above a whisper, “When he comes.” With that he closed his eyes and drifted softly to sleep to dream the dreams.

His son a tall replica of his aging father wept by his father’s side. His face seemed to light up upon receiving the pieces of paper.

“My dad worked for this all his life.” He said in perfect Midwestern American accent.

A year later the newspaper carried an article of a physicist who had figured out the Specific Impulse to improve efficiency of the high by-pass jet engine that would revolutionize air travel and reduce costs by a third to a half.

The man who wanted more time had finally won his place in history. He had extracted more efficiency from a jet engine using lesser resource in fuel, giving millions of travelers the cost effective means of seeing faraway places and family members.  This physicist had toiled after this intellectual treasure most of his life and found it in the gasps at the end of his life. It all happened in that “One more day.”

Life is strange and sometimes invisibly cruel that while his heroic attempt was transpiring in those waning hours of that night before his last, the “life managers” were arguing about the efficient use of resources to grant him that extension.

Sometimes the temper of times has to be wisely matched with the temper of humanity. One never knows where the next fountain will spout from in the deserted landscape or oil will gush from which muddy soil. But life always dictates as time recedes.

Sunday, August 16, 2009

The elegant Pebble


I was walking on the boardwalk, kicking the pebble “up the road” and found that it danced to its own beat. Each kick revealed a different path, a different bounce in a different direction. Sometimes it would turn right and then as easily with the clatter of stone on wood it would turn left to regain the center. It was weird. There was no apparent rhyme or reason to its motion. Or was there? So I, on spotting another pebble, kicked that one and discovered that it bounced on a different path.  Apparently the kick and the contours of the pebble dictated the motion.

 

Later that day I met a man in the mid years of life. He was robust from all outward impressions. Talkative and well traveled from the confluence of languages that worked their way into his way of communicating. It was natural to him. He knew the world that surrounded him. He was passionate about it and the feeling it imbued in him. He expressed these feelings without reservation, about the delight of seeing the first morning light and the enshrouding fog or the mossy hill, were each a wonder to him in their own right.  Once in conversation he seemed to grow silent and later remarked that the hum of the fan and the twittering birds outside created a melody worth listening. Strange one would think, but not if you happened to meet him and listen to his internal clock of reference.

 

He was incarcerated from his living in the confines of a white hospital room. Dethroned from the elegance of his world’s stage to one poaching the nectar from afar through cracks in the window or the whispers of the nurses from a partially opened door.

 

The diagnosis was grave and discussions with him about life and survival were taken in the same vein as “what would you like for breakfast?” request. Every encounter was measured quietly and thoughtfully. There was no rise of emotions or a crashing thud of realism that made him wallow in the wake of chaos.

 

“Speaking about…” he would bring the subject to wood carving a hobby of his. He loved the essence of wood and the manner it could distill itself under the hands of an experienced carver to the beauty within. He mentioned the many wood statuettes he had marveled at by the great masters of the art. He talked about contours and curves with such pleasure that listening to him one could easily wander into a parallel universe.

 

“So what is your opinion of my problem?” He asked.  His eyes direct as if looking at the depths of one’s understanding. One could not build walls of statistics around him to scale. No he could see right through their fragile scaffoldings. He never addressed his disease as anything other than a "problem."

“Well…” and he would cut you off.

“I understand.” He would interject. Not wishing to know the answer that he already had a sense of. Then he would once again launch into another segment of his life of adventure.

“If you want to see magic, you should go to the Amazon Forest. There are so many species of animals and plants that every where you look something new pops up.”

“I have heard.” I replied meekly.

“Did you know that the Amazon flowed westward initially?" He said with wide-eyed reflection.

“How can that be?”

“Millions of years ago, the Amazon River flowed west.” he began, and then clearing his throat he continued on a journey of his mind, “ When the tectonic plates of the South American continent and the Nazca plate of the African Continent, the Andes were born. That created a dam for the Amazon River and an inland sea was born. After the sea waters receded the gradient from the Andes made the Amazon flow Eastward. The marshy uninhabitable area was a relative sanctuary for the biodiversity of the gene pool of these animals and plants. For instance there are several species of Stingrays that match those found in the Pacific Ocean.” His eyes were now beaming with the thoughts that raced through his mind. “And for you guys in the medical field it has enormous implications. The discoveries of newer medications from plants and animal life are astronomical.” His eyes twinkled with excitement. He went on this historical journey leaving some details for me to work out for my self. He was a teacher in his own right. He made me open a geography atlas, a history book of the Peruvian Andes, learn about the Machu-Picchu culture and beyond.

 

The following day he went home with a smile on his face and a quiet goodbye. Missing him was difficult but remembering him was easy. He was a treasure trove of information. It was like getting an education in geography, history and humanity all encompassed in one. 

 

Several weeks later a package arrived. Within the package was a one-line note, “Thank you for listening.” There was a wood carved pen of such exquisite detail that holding it the thumb and the fingers rested perfectly on the contours.

 

We try to erect taller ladders to scale the walls of someone’s intellectual castle so that we can impose our will and understanding. But a voice dear to my soul once said giving the gift of listening creates a better bond of understanding.

 

Medicine heals one person at a time. Listening to the patient makes the road to healing easier. Sometimes comfort is all that is required. Sometimes more, but that is in the art of medicine.

 

He was a pebble with very elegant contours that scaled the boardwalk of life.

Friday, August 14, 2009

Is life Infinite?

Or is it finite?

 

The short answer is yes and no. From the very early beginnings when the four forces converged to create the earth and the first stirrings of life wrestled with survival in the primordial soup, life has continuously evolved into a fascinating gallery of species. It is a continuum of discontinuous gatherings of life forms. Most fail to survive and display their remains as fossils, carbon-dated in time. There are estimates of 1.5 billion species having perished at the rate of 3 an hour.  So, since the beginning of earth time around 3.9 billion years ago the planet has played host to life. If the unmoving mover – time – elects to push life forward from the pool of mucous to it’s ultimate achievement the human kind then the word infinite fits.

 

But then each individual life is finite also. No traces are left over time except artifacts and skeletal remains that lift the pointed finger to the past. You might just about now ask the question, what has this to do with medicine/medical care? Patience dear reader, for it does.

 

You might be hanging on tightly to the finely braided rope of hope of immortality watching it fray against the sharp edged precipice of  reality. You watch the dark abyss of reality staring back from the depths and the roots of the tree where your rope is anchored loosening its grip on the earth. Immortality is not a human event. So those tyrants and sociopaths of society better heed to the mortality of life. Doing harm to others in hopes of being immortal is fraught with ignorance. One-day time will extract its pound of flesh. You see, the two soft, slippery, delicate spaghetti like strands intertwined into a double helix called DNA has it’s life’s limit built within.

 

Leonard Hayflick in 1968 discovered that cells divide for a finite period of time and then die. This limit in humans is about 50 +/- 10. The limit is based on the tail end of the chromosome called Telomere. This tail can be imagined to have indented pieces attached end on end. So if the cell has 50 pieces, then for each division the cell loses a piece until all are gone and then the cell dies. There are also other factors including the Free Radical damage (nascent oxygen radicals liberated by the cells-as a consequence of injury or infection- causing damage to the mitochondria the energy producing factory within the cell) that may hasten the cellular proliferation and thus diminish Telomere content. So, finite is written on the very sacred document of humanity called DNA. You are born and there written in your DNA script is roughly when you will be pushing daisies, give or take a few Telomeres. The only cells that do not subscribe to the Hayflick limit are the stem cells. These few stalwarts are hidden in niches difficult to find. However if DNA damage hits any of these cells to the tune of creating a malignancy then survival is short-circuited immensely.

 

But within this interesting piece of spaghetti-like DNA are the remains of evolution. The DNA collects data as it comes in contact with various other species. Viruses are clever strategists; they unfold and insinuate their own material into ours for their own propagation. This transference leads to mechanistic changes in our DNA, which is then faced with the onslaught of improper gene regulation or improper protein production. Improper gene regulation can be the p53 gene mutation expression causing various cancers (Li-Fraumeni Syndrome) or in improper protein production as in ADA deficiency with immune modulatory dysfunction. One species is hitching a ride for its propagation to the detriment of its host, the latter suffers from the formers parasitic behavior. Not all genetic changes however are harmful though. Some actually are beneficial. For example the Sickle Cell Anemia gene mutation actually was a protection against malaria in the African Subcontinent. And some suspect that the Diabetes Mellitus gene gone awry may be a body’s defense against cold weather, whereby the sugar reduces the temperature for the water in the cells from crystallizing to prevent cellular damage or outright rupture in cold weather. Before you go telling people that remember we are not talking about the Type II, which occurs as a result of too many Twinkies.

 

This is how the infinite/finite life propagates. One life form domesticating the other for it’s own needs. Both, knowingly or unknowingly perpetuating each other’s survival. A breathtaking musical interlude, unfolding as the chorus merges with voices to create the symphonic masterpiece much like Beethoven’s 9th.

 

So we have a draw. Life is finite when seen through the eyes of a human but an overarching visual from above of the entire spectrum of life in this space-time continuum shows us that it is infinite as long as the earth remains the planetary ball with resources to feed its inhabitants. If the earth moves more in the direction of Mars, aliens may be looking for “canaliculi” from afar with their telescopes on a barren landscape.

Wednesday, August 12, 2009

Trilogy: On becoming a Physician. Part One: Student

It is that mysterious wide-eyed look. It corrals the expectant father look, the deer in head light gaze and the wonderment of an adventure to come. Medical students are not really anymore studious then the rest. They just are constantly at it. A lapse in the knowledge of an appendix is forgettable but not the heart. Yet all things intertwined by the sinews of life are inter-dependent. Well not the appendix you say. To the contrary my dear Watson in disease those two are related. I can see someone opening the book to figure out that connection.

 

Jack was a beanstalk climber, trying to unravel the mysteries of the human body. His curiosity was exceeded only by his fear of a lack of knowledge. He would wander into the library at all odd hours of the day and night opening books and journals whose spines had not been tested or paper not yet dog-eared by human hands. He was on a mission to understand the mechanism of life before he knew how to decipher the afflictions of disease. But there was a problem with Jack. Things and differential diagnoses would roll off his tongue in class, to the amazement of his peers and sometimes even to his professors. Yet given the simplest of cases he would wind himself around the bark of this metaphorical tree of bookish knowledge tracing the ridges and failing to see the obvious.

 

In his final year Joe befriended him. Now Joe was street smart and could see with clarity the whole picture in a single piece of puzzle. He had the common sense built into his collected knowledge. His problem was that he could never look nor find the doors to the library. "Why spend time shuffling papers when you can get the info from others. When stumped he would prod Jack to come up with the litany of what it could be and Joe would arrive at the right answer of what it was. That’s how the two got together as good friends. Little by little they arrived at an understanding best suited for each. It happened on a bedside conference with the professor.

 

The patient was jaundiced and lay supine in bed unable to answer any of the questions. After each student had had a chance to interview and examine the patient the professor, a fifty-something with a graying goatee assembled the gang in the conference room.

“Alright then,” he proclaimed, “Jack let’s hear your answer?” The professor would always ask him after the rest of the class and before Joe had his say.

 

And Jack as usual started with his laundry list of possibilities, not quite committing. But when it came to Joe, he simply answered, “My friend Jack has the answer. We can take his number three possibility and add number seven to it which will give us cirrhosis of the liver with hepatic encephalitis as the diagnosis.”  He was correct.

 

“You know Jack if you and Joe got together half and half will make a great whole.” The professor counseled them. 

 They became best of friends and through that friendship of collaboration, they graduated first and second on top of the class. Each learning from the other and each prodding the other for more. Knowledge, they realized is to be shared with give and take and each old and new paradigm polished and shifted to a newer orbit of understanding. That is what takes knowledge to a new frontier.

Physicians who become good at their art share their knowledge, keep an open mind, limit the one sided arguments in their heads and collate information for a healthier patient. 

The rigors of these four years as students were barely contained within a week's worth of the interns’ life that was yet to come for Jack and Joe.

Monday, August 10, 2009

The Little Girl with Bruises

She was 15 years old with a set of green eyes that would stop you in your tracks. Her pony-tailed blonde hair streaming down her shoulders- a picture of health and beauty. Her face however belied some anguish. There were the unmistakable tracks below her eyes of partially wiped off tears from an unwashed face. There was concern and frustration all measured in the deep sigh that escaped her lips. She looked up from her world into the present and started to cry. The Whys came as an endless river flooded from the recent rains, in torrents of forceful velocities. After a while when the Whys could not be easily answered, disheartened she asked the How.

Shey had noted bruising a few weeks ago. Initially ascribed to activity. She was a skate boarder and falling is a pre-requisite to learning of that sport. But as the bruising multiplied and became visible to her mother, medical help had been sought. Then the nosebleeds started and panic led to her hospitalization.

Her anguish as she lay there was palpable. “I am not going to be able to have a boyfriend? This was more a question mark than a statement. “Am I going to die?” That one got the nursing staff in a bundle. How could this little girl with nary a chance at a bad deed suffer the ignominy of a fair world.

Yes she would have many a boyfriends, because her person would command that and no she was not going to die were the answers. “But I want just one boy friend.” She cried. “Then you shall have the one you want.” Even with that reply she eyed everyone with skepticism.

“What do I have?” she asked finally. The medical diagnosis, although startling in terminology, nevertheless registered little in her limited vocabulary.  “And what is that?” Well it is where your body is creating antibodies against its own cells.

“What!”

“Yes and it does so as a self protective phenomenon.”

“That doesn’t make sense. It’s protecting me but hurting me at the same time?” You knew from the look in her eyes that she was nobody’s fool. She was ahead of the curve in her class and well ahead in the land of inquisitiveness.

“You called it ITP?” she asked.

“Yes that is the diagnosis.”

“What is it?”

“The I in the ITP stands for Idiopathic, which means we don’t know. But the body destroys these cells called platelets which protect us from bleeding. The theory is that exposure to some virus or agent can cause the body's overwhelming response with antibodies meant to destroy the virus or agent and in so doing it trips its own cells. The ultimate nature's mimicry to hide against the defences”

"Stupid, huh."

"Kind of like friendly fire."

She nodded to that one, “But you can treat huh?”

“Yes.”

“That would be like -how?”

“Previous successful experimentation.”

“I am not a Guinea Pig!”

“No, others before you have sacrificed their fears to find relief, so you don’t have to.” 

“Ok.”

Six months later she walked in for her monthly blood test and her results were normal. Her face a little swollen from medications and she had gained a little weight as a consequence of her therapy, but in spite of this she had found her boyfriend, or more appropriately the boy had snagged the prize. She was smiling now without a skin blemish. Restored to her almost natural state of beauty. The future was bright with possibilities.

“Thank you.” She said as she bounced her blonde hair out of the door.

The Cancer Cell

What drives a change in a person's attitude? Is it inherent behavior? Is it coded neuronal traffic in the brain? Or is it just a random process, unbeknownst, unpredicted and totally without reason? Those are the same questions of a wayward cell. A perfectly functioning cell in the family of cells that somehow changes it's very nature, its very drive and out of this change a monster is born. This monster cell, a renegade of totally different mentality runs amuck without care, without need, without concern, conspiring, stealing, usurping other's rights while planning its own survival to the detriment of others. Like a tyrant, unconcerned with the welfare of the people it constantly satiates its voracious appetite while allowing others to starve. This is a cancer cell!

The life of a normal cell is like a controlled machine. Born from genetic pressures and regulated by the evolutionary demands of its neighbors, the cell evolves into a functioning paradigm of efficiency. It may do any of its various function depending on which organ the gene code organized its predictable behavior. For instance the liver cell would work hard at metabolism, a brain cell would traffic electrical stimuli via chemical means and help through protein modulation to store memory or a heart cell would dance to the beat of a drummer (the AV node) at a constant unexcited rate of 72 beats a minute. These virtues of predictable behavior give life a fighting chance. This is who we as humans are, a pulsing virtue of predictability and stability.

The cancer cell is born of a genetic code gone awry. This may happen due to several dislocations in the orderly business of living. The code can be disrupted by a set of "jumping genes." You see the human body is an exemplary machine that evolves when pressures are applied to it. 

These "jumping genes" are constantly flying off of one chromosome and landing on a another. The purpose is to strengthen the DNA so as to forestall any disruptions from the environment. In so doing sometimes it creates untoward changes. Such changes lead to damage to the individual but are rarely duplicated since they are not recorded in the DNA of future generations. 

The DNA (a central processing unit that constitutes all the codes of cellular behavior in its various configurations of just four nucleic acids - Adenine, Tyrosine, Cytosine and Guanine) is constantly at war with the environment. It takes about 10,000 hits a day. These hits come from the solar radiation, from the food we eat, from the beverages we drink. The cell repair mechanism - also under the genetic umbrella called the miss match repair gene - helps thwart those attacks. If the attacks exceed the limit then trouble starts brewing. Even so this problem can be arrested by other mechanisms at the cell duplication factory where when a cancer cell appears due to its miss coded genetics the guardian of the genome a p53 protein will isolate it and push it towards destruction and recycling. The process is orderly until the "hits" start exceeding the limits of the assembly line. Much like the "I love Lucy" episode of the chocolate assembly line. Lucy could not wrap the chocolates fast enough so she started eating them. With her mouth and her hands full, ultimately chaos ruled.

There are other factors at play here too. Although at base level we are at the mercy of a system that quietly regulates us by lassoing the wayward cell we can be preemptive in our daily lives to help the process of weeding these bad influences. Remember your fathers and grandfathers, they never seem to take stress the way we do. They worked hard, walked daily, ate regularly in moderation and consumed alcohol in limited quantities. True many smoked, which was through lack of knowledge and want for conformity with society but overall they lived good lives. It is better to live a life of quiet understanding than one of seething desperation.

There are several other vistas of cellular behavior we will uncover in subsequent musings. But uncovering the knowledge of the cellular behavior is fascinating. Dealing with cigarette smoking, alcohol, drugs and stress that form the constituents of present lives will be an interesting journey. How the mechanisms alluded above create the change in the cell and others not yet mentioned and still others not yet fathomed. The story has to be told.


Saturday, August 8, 2009

The Power of the Mind

It was in the fall of a year with a long autumn. The sun never baked but blushed gently and the breezes never whined but rustled the colored leaves. Time to this tall and burly man, clean shaven with the friendliest of smiles meant nothing. He was limited to his last autumn and winter. This would be the last time to hear the Christmas Carols, the Jingle Bells and the Ho,Ho, Ho.

He had a highly malignant Lymphoma that seems to show a relentless power over the talents and knowledge of his physicians. The illogic of this disease seem to find its own logic for survival by destroying its host. He had tried his latest grueling attempt at triumph with therapies only to be rebuked by nature. He was dying slowly and the flicker of recognition sat despondently on his brow. Left to his own devises in a private room where all bravado and smiles are washed away, he would curl up in his bed and listen to the softest of melodies and peace would surround him. It was truly a wonder of the human mind, of its many interiors, imprisoning the harsh within the softness of art. 

The day before he was released from the hospital was the twelfth day before Christmas, he asked if he would make it to New Year. And as all scientist tend to wear the cloak of realism and statistics he was told "most probably." The weak smile faded from his face and within those few fragments of time where his brain's interior collated his desires to the reality, a defiance rose on the edges of his green eyes. The brows raised and the crows feet multiplied in a state of determination and then moments later it was gone.

It was the spring from hell the next year and a daily flood of rain mushed the grass into muddy puddles. The sun now hiding behind the gray and desolate clouds, barely registered itself. He was readmitted to the hospital weakened and emaciated from the fight against an enemy he could not fathom. His demeanor unchanged but a vestige of a smile still lingered on the corner of his mouth. He had beaten the time alloted to him. There was no rejoicing nor contempt, just a flicker of defiance on his brow. After the comfort and care had been given to him, he went home again, this time he was told for good.

Yet as the summer sun began to part the clouds and heal the wounds of a frightful spring, he was readmitted frail as before, a little more of the little less of a body on him but a lot more of the defiance in him. His brow was set in permanence now into what had been fleeting and on demand before. He still wanted to sit up in bed without help and minimized the agony that only his face would betray but never his voice. 

It was the twelfth day in June in the morning and he lay in bed, dressed in a suit that betrayed the thinned, bony form of his being. He wore a blue tie against a starch white shirt. His face was all smiles from end to end. The wrinkles of a fallen face and the gravity drained flesh disappeared to a face of a youth. it was a remarkable transformation. His eyes and mouth was pinned to the sides in a constant smile. He joked and shook hands with his physicians and nurses. A thank you of sorts for their endeavors.

At around 3:30 PM he was wheeled into the hospital chapel. His only daughter was married there a half hour later by the priest. After the ceremony the family went back to his private room. He kissed his daughter and his new son-in-law and wished them a safe journey on their honeymoon. 

It was 6:00 PM  the same evening when his loving wife came to the nursing desk and wept longingly.

Against all odds known to man and medicine the power of the mind reigns supreme.

Friday, August 7, 2009

The Patient

Confused and boiling with a conflict of emotions, he steps inside the sanctuary of help -a physician's office. It is like stepping into a dark cave, he can see at a distance the glint of treasure and shafts of bright light but before him is a dark abyss. He cautiously steps forward and feels the edge of the precipice, as the echo of a pebble falling below reveals the depth. His mind reels, he finds his footing and figures out ways to cross the abyss to the promised future, but confusion prevents a resolute decision. 

Illness is dark, an embodiment of things gone awry. It collapses the horizon of productive possibilities into a narrow focus for survival. The patient walks in to see the physician and lays out his dilemma recollecting historical signs and symptom. After the evaluation is complete he sits and waits. The internal riot of his mind scrambling for answers and help. His eyes wide with anticipation, his throat dry from fear and his hands shaking in fine tremor staring at an empty void where future resides. 

The patient hears the diagnosis - a verdict of the trained professional - and his eyes remain in a blank stare. The words just seem to flow past his ears. No impact. His lips quiver holding back the deluge of anger, frustration and resignation - emotions of self preservation. 
The physician leans over and lays a hand of comfort, measuring reality of favored odds against the sea of troubles. He comforts with words and outlines a plan of action to circumnavigate the dark abyss. It is that quiver of smile the physician seeks, an understanding from his patient that all being said will be done for him and that optimism laced with reality will ease the passage to those distant shafts of light. The physician is patient and repeats the calming words until the glimmer of hope resettles on the anguished face of his patient. The taut muscles relax and the wide eyed glare dissolves into an understanding look.

Modern medicine maybe embroiled in a cascading sea of newer chemicals to ward off the darkness of disease but the archaic medicine of comfort, care and nurture allows the fragmented mind and tortured soul of the patient to accept that treatment successfully. This is the recipe for success. Another triumph in the making!

Thursday, August 6, 2009

The Remarkable Machine

It is the most prolific version of a machine that evolves with time, fixes itself, self-replicates, grows to encompass the world around itself. It compensates for errors, uses logic to understand and makes predictions for the future. It makes and breaks things and creates structures of great dimension. It soars to heights and dives to greater depths unfathomable to any other species. This is the human machine.

We are blessed to take this ride of life in this container. How we choose to take care of ourselves is personal. There are a few simple but magical self-care cards that we can extract from our sleeves. Basic of all is moderation.

Moderation remains the best defense against disease. Limit caloric intake to 25-30% below the daily requirement. Ample data of mice and men suggest that a 75% dietary intake leads to a 20% increase in longevity. Ok one may not want to live to be too old. Yet the living that can be done is healthier with less disease. Besides food, there are other consumables such as alcohol, drugs that must be kept to a minimum. 

Human society feeds on two very important staples that when consumed in excess cause a large percentage of diseases: Salt and Sugar. From Hypertension, heart attacks and strokes to Diabetes Mellitus and its related complications of heart disease, vascular compromise, kidney disease and nerve damage to a whole slew of damages that are inflicted on this wonderful machine. Limiting excesses of these two will reduce the body's stressors.

The modern world has evolved around a pace that prevents proper rest. The only relaxation is the one week dash to the beaches of luxurious resorts. Here one tries to have compressed fun like jamming a fist through the keyhole. Relaxation must be a state of mind, evolved trough the steady pace of living, not a rush job.

We are slowly growing into a comfortable, entitled culture of little is more. With remote controls and computer games the youth spend hours sitting rather than playing. Over time this leads to obesity. Children must be allowed to be children, allowed to explore and understand the world around them and not coddled into complacency and comfort. Exercise remains the mainstay for good health of the body and the brain. Those who exercise live healthier and more productive lives. They carry a larger share of utilizable information in their heads. And information is key to success and happiness.

Health is self propagated. Health is effort. Health is care of the human machine. 

Wednesday, August 5, 2009

The Right Stuff

Like drooping leaves on a willow tree his flesh seemed  to flow down to the earth by gravity. The shoulders like wiry coat hangers stuck out from under the shirt. His uncomfortable 145 pounds of mostly bones wrestled with shifting positions to find the elusive comfort.
He was accompanied by his two strapping forty something sons and a 17 year old grandson who seemed joined at the hip. They were in the office on a dare - the grandson's dare.

Mr. K once strapping 6 foot 4 inches man of 250 pounds, an executive with a construction company had been reduced to this currency of dependancy by the anomalies of his genetics. He had developed Prostate cancer some 9 months ago and persuaded by the folk-lore of the ever-present media invested his energies in therapeutic measures that promised the world but had failed to deliver. Why they were sitting in front of me was because of a "eenie, meenie, minee,moe" on the yellow pages. His grandson's fingers had done the walking. Apparently the index finger had rested on my name when the counting was done.

He eyes remained reluctant and hesitant to accept any words of a future, reeling from the loss of time and the abyss of fate staring squarely at him. His grandson's hand gently tightened on his left arm and Mr. K's body seemed to relax. The older son standing behind his chair engrossed by the patterns on the wall diverted his attention to the conversation. My suggestions were being ignored. I could see Mr. K's eyes in blank stare not registering my words. So I decided to communicate with his grandson about his future. Mr. K's eyes narrowed and focused on the conversation. His grandson's desires were known to him but apparently never expressed in words. The monologue of the 17 year old barely registered for a few minutes but a wave of understanding breached the fortified beach of resistance in Mr. K's mind.
Some 30 visits and 8 years later Mr. K came back the other day with his grandson, the latter now a graduate from the a prestigious school ready to take on the world of finance. His grandfather now equal in stature, the hunch of his spine gone, the skin filled out smoothing the folds, both beaming with desire to continue enriching their lives. They were taking a trip to Montana to go fly-fishing.

There were no miracles delivered. There was only an "aha moment." He accepted the therapy offered in good faith which he received in equal measure and the results were another small medical triumph.

You see the art of medicine is a mysterious fluid that flows slowly pulled by the gravitational gradient, over rocks and crevices, filling small pools as it gently navigates to the deeper senses of understanding. The science is constantly being written in the books.