Sunday, November 27, 2011

A Blogger's Web

The breeze lifted the leaves from their reverie. Morning had broken and aside from the gentle caress of the air it was quiet. Between the two branches of this acacia plant there was an industrious little fellow hard at work ministering to his needs. His little spinnerets worked their magic as the silk glands ejected the silky fluid. He hung from the top of one branch till he made contact with the other branch and then through a mixture of sequential cadence, fine workmanship and hard labor he created a masterpiece called a web. Having finished, he quietly migrated to its strong epicenter and waited.

Curious though as it was, it made me think about Blogging. When we Blog, we do pretty much the same thing. Don’t we? Find out the location that allows us the freedom to express our thoughts. Having done that, the litany of words gets laid down “concretely” on the page and then with time we add to that litany, word-by-word and page-by-page. We spend all this effort for what? To draw other’s attention of course! Just like the spider waits for its prey. We wait for others to see the web we have cast.

It is a strange ritual and yet so beguiling in its curious attraction. The desire to express is innate in humans. The desire to express a viewpoint and have it acknowledged is a privilege for the writer. Why, we think. someone actually sees this while I sit in my family room and another sits or stands wherever he may have access to the mobile connected device is “insane,” to say the least. My word is incurring a thought in another’s brain. Wow! (Or maybe putting him or her to sleep – better than a sedative anyway.)

What once was the purview of the Ivory Towers inhabitants, the form of written expression has reached mere mortals. The question, “You mean, I can do it too?” is answered by a simple, “Yes!”

Time marches and the soapbox changes from lectern to dais to a promontory from where such pronouncement of deep or shallow expressions becomes available. Today it is as simple as a digital word that can move mountains, change a country’s fortunes, expose untruths, cross the seas, build a better skyscraper, flood a famished land or turn white a landscape with snow. Human is capable of achieving great things and now with collaborations from minds in distant lands with nothing more then a few digitized words, the world is changing.

The spider in us all wants to weave a web so others can be attracted to it, not as a predator but as a willing accomplice to share and create a better future. The digital word is to create, to spread cheer, to harmonize with nature and with each other or just merely to express a thought. The world watches as each thought is rendered and then it changes.

So what should we blog about? People will say, anything your heart desires. Really? I mean let us think through that answer for a minute. Anything means any momentary thought you have, anything means well anything. So in a moment of anger you will have digitized your anger for everyone to read and that goes for moments of happiness, sadness, overjoyed state, depression and frustration. In fact you could exploit the entire range of emotions and lay it out for every home chair psychiatrist to analyze. That may attract some but, no, I think the world is better served with expression of ideas rather then the self-absorbed harangue of discontent. Or we can write about the “Magnetic Cows,” but then, maybe not. Maybe leave that one for another day, that information, you see is more of a “scientific study” worthy of finding grant money and print paper.

Jeez! what a cynic, I’ve turned into. I’ll stop now.

Welcome to my web!

Next up: Diaphanous frippery in Science!


Tuesday, November 22, 2011

Happy Thanksgiving

I am Thankful...

For my family -they make me who I am
For my friends -they show me who I could be
For my acquaintances -they give me ideas
For my health -makes me look outside of myself
For my love -makes me whole
For my curiosity -makes me want to learn
For my desire -fills me with understanding
For my knowledge -makes me question
For my senses -gives me the ability to feel nature
For my happiness -fills me with joy
For my fears -keeps me alert
For my anger -teaches me forgiveness
For my impatience -teaches me patience
For my being -to help humanity
For my past -it shapes my present
For my present -helps me shape the future

Monday, November 21, 2011

End of Life ~Caring

Metaphysics of Decision Making

Oh no! OH NO! That little sparrow perched on that tiny branch visible outside the window, brushed by the sudden breeze, tumbled over. I mean TUMBLED and fell to the ground – lifeless.

Well, and this is a long pause - well. If I were to really dig deep, some bizarre thought configurations emerged for both the sparrow and what lay before me. For instance the conflicting emotions that ensued seemed to come from nowhere. Poof! They just burst onto my inner reality.

Maybe Maxwell’s little tiny demonic gate opened up in between my right and left brain and started pouring particles of thought, all the while picking and choosing trying to create that loophole in the second law of my thermodynamically heated brain. Although the linear flowing mathematical concepts (particles) must exist independently and remain segregated from the cool collective analytics of the nebulous and colorful right brain. Yep! sure. That damn Demon was up to some mischief. Not only was it messing with my thought flow, but it also seemed to understand neuro-trafficking, confusion states and how to manipulate them. And this was happening all in a moment when the sum-total of my energies was needed to focus on a life and death decision.

So now with this bottleneck of two independent and totally dissimilar concepts floating around in their Brownian dance within my brain, strange but quite evocative thoughts began to crystallize.

You know that saying, Uh huh, that very one, about security in the insecurity of life, that says imagine it, for there is no other. That one got under my skin. If I were to ascribe to the Copenhagen Interpretation of the Heisenberg’s Uncertainty Principle and the multiple potentialities or multi-verses or what have you, where the moment, I was going to commit to an action would change the future for this patient and mine by my doing – a heady thought but true, you would understand the pressures that come to bear on me as a  physician. 
Heisenberg's Uncertainty Principle Formula

Yes, you got that right! We are dealing with a human life here. You see, as I sat there with the patient chart in my hands, looking at the weakened body and the shallow movement of the chest and the diaphragmatic breathing of this once beautiful soul, the three universes began to emerge. Each distinct and different from the other and with the same present, each future exploded like a three-pronged projection, if you will, going forward.

Dimension #1

The first one; If I were to consider any interventional treatment there was a potential that she, the patient, would once again be able to understand her environment, maybe even speak full sentences without a cough, eat that bread pudding that remained untouched on her tray, smile or at least acknowledge another’s presence. But the statistics seem so oddly against such an eventuality. The odds were low, very low. On the fly statistics in my head gave that option less then 10% chance. Now where did that number come from? No data existed in any of the medical literature relating directly to this patient. 


So where? 


“No that is hardly scientific,” I thought. “What, then, have I fallen into the trap of masquerading as an elite scientist with facts and figures at the tips of my fingers.” 


That wasn’t the case either. But there it was 10% or less. Smack, dab stuck in the recesses of my brain. The number stared back within me, unmoving, frozen and recalcitrant, so I played with it a while, “How about 25% or 30%?” But no! It kind of just hung there, uncomfortably still. “Must be heeding to the Pauli’s Exclusion Principle or something.” I thought. 

You know that principle in physics that states, that two entities (fermions/bosons) cannot exist in the same place at the same time except with opposing spins. Well there was no spin here so other then the <10% no other number would fit, period. But <10% was still <10%. Life was life and in the best of times sometimes there are the worst of times. We have to make them better, don’t we? Should I subject this tortured vessel to more inhumanity for the sake of offering a delay to the inevitable given such horrible odds? The dilemma was absolutely shredding my already fragmented thinking.

Dimension #2 

And as easily as the first universe thought took a back seat, the second one opened and spread its wings too, This potential was to provide comfort and if her body gained the necessary momentum, then, and maybe then conceivably intervening with further treatment would be an option.

Really? and subjecting her to a similar delayed fate? 

Maybe not! or then again Maybe!

Even the use of a monoclonal antibody to help reduce the tumor burden was a possibility leading to maybe an extension of survival?  That universe had me thinking about her gradually gaining weight, wheeling herself around and then walking with a walker smiling as she went by. Her thinned hair fully grown again and her sallow cheeks filled with color.

“Heerre’s Johnny,” Ed McMohan’s voice suddenly came into my head from nowhere, introducing Johnny Carson.

“Jeez, What the…”

With the image of Johnny holding the closed envelope against his temple, 

“The Great Carnac says… nadda.” his voice echoed softly. 

Now how in the world did that thought arise at such a serious, solemn and contemplative juncture? That damn Maxwell and his demonic monkey must be throwing a wrench in it. “But 0% chance of that possibility?” I said out loud to my own surprise. I shook my head and looked up at the thin frame lying on the bed barely able to keep the virus of the soul contained within it. Yeah maybe The Great Carnac was right about this one after all. “Ok, shake it off!” I chided myself. The solemnity of the situation crowded all such frivolous mental expositions.

Dimension #3 

The third dimension seemed quite blissful and swept in with all the airiness of a summer breeze. To just provide comfort and allow the soul to depart quietly along with the dignity it had arrived in. However the soul departs and enters that undiscovered country, my job would be to let it with total serenity. I could imagine it. Suddenly my brain was awash with the clarity of purpose. The phase transition from the mathematical linearity of numbers to the nebulous grace of quiet certitude was complete and within it all the nuances of comfort, dignity and relief burst out within me.

Yes that is the right course of action. 

That was the right course of action.

It was peaceful, 

          the slow shallow breathing and then... 


There is special providence in 
the fall of a sparrow. If it be now, 'tis not to come; if it be not to
 come, it will be now; if it be not now, yet it will come—the
 readiness is all. Since no man, of aught he leaves, knows what is 
to leave betimes, let be ~ William Shakespeare

Wednesday, November 16, 2011

Tapestry of Disaster - An Aviation Accident Story

Often, in his most reflective moments, he would extol the many virtues of flying; the splendor of sights, of new places but mostly of its freedom.  He was 60 on his last birthday, a Vietnam veteran with an artificial leg flying with a 2nd class medical certificate and a Statement of Demonstrated Ability (SODA).
He flew with precision, dedicated to his hobby and mode of transportation.  Every flight was enriching to him.  He carried his task of flying with zeal, from checklist to checklist, double-checking while motoring one to two miles above terra firma.
Soon that cold, rainy night in October, when I got the news of his plane crash, it scared me, then chilled me, and finally numbed me.  He was, in my mind, going to be an old pilot, for he was never bold.  He flew this immaculately dressed Mooney 201.  But the crashed plane was a Cherokee Six.
He apparently flew it with the gust locks still attached!
The plane had taken-off, gained 500 feet and then, predictably, plowed into the woods.  This man, in life a stickler for checklists, in death was now the object of a storm of controversy and was leaving a legacy of stuff that he would not have been proud of.
They tried to piece together the shattered dreams of his mind and the associated features of the ill-fated flight on that chilled rainy night in October. 'Accidents don't just happen,' said the aviation counselor from the FAA, 'Planes don't just fall out of the sky.'  There is some truth to this, if you were to evaluate the cumulative vapor trail that eventually condenses into the big splash, multiplicity of factors have been involved.
Let's look at the so-called 10-17 percent catastrophic engine failures in piston aircraft.  I am not a betting man, but I can wager that most, or all of them, gave plenty of warning signals and hence, could have been averted.  The gremlins may have shown up in a previous flight, in the pre-flight, or in the intuitive feel.  The oil analysis may have revealed the chewed metal in the filter, maybe the need for more oil, a blob of oil on the ground, or discordant magnetos.  In flight, it may have been a change of the aircraft's behavior, in its speed, sound, dynamics, the hum, and all of the subtle noises that we are attuned to in the cockpit.  This subtle vapor trail of metal, sound, feel, and dynamics is there for us to recognize.

When we commit an error it is generally an isolated one, and we get away with it.  This 'getting away' mentality, unfortunately, reinforces the behavior as being okay - it sets up a confirmation bias. But start stitching a series of these scenarios together, and a tapestry of disaster unfolds.
Imagine a series of cards with random holes in it reflecting the error-prone deficiencies of human beings.  Each little hole reflects an act of omission or commission (failing to check the trim, or the fuel quantity, and so on; you get the point).  Once in an unfortunate while, when those holes line up in sequence, an accident occurs.

The first priority to safety remains trying to patch the holes in each of those successive cards.  Learning the art of flying, practicing it, constructing a practical checklist for all possibilities, and never taking flying for granted.  For instance, every time before I fly into an airport, I look at its layout to see on departure where a straight-in engine out on take-off or landing would save my bacon.  Not much but it keeps your guard up.

Consider the big boys who dream of flying Mooney's but are stuck with the Boeings.  They, too, can have a bad day.  The flapless take-off in Detroit, Michigan, led to hundreds dead - a minor mistake that led to a major tragedy.  A Continental aircraft was about to land gear-up at the Newark airport until advised by an American pilot on the ground to put the wheels down.  Mistakes from shoddy cockpit behavior, taking things for granted, or having the attitude that 'I am the greatest' will bite.

Flying in low overcast without the prerequisite experience or attempting a crosswind landing beyond your abilities speaks volumes of the male gender.  Some of the newly minted and even long-time pilots with little weather experience who venture into the gray unknown of an overcast day just for a rush or, better, stupidity.  How can you justify that with anything but the remark, 'idiots?'
The former is not flying with adequate charts, plates, or lack of their utility, etc.  The latter is when your instinct tells you, 'It is not good to go even on severe clear and a million,' so heed it.
There are preconditions for these unsafe acts [as per the Office of Aerospace Medicine's technical report, The Human Factors Analysis and Classification System (Shappell & Wiegmann, 2000)]:

  • Substandard Conditions of Operators
  • Adverse mental states
  • Psychological states
  • Physical and mental limitations
  • Substandard Practices of Operators
  • Cockpit Resource Management and Personal Readiness
Now, I'll get back to the story.  My veteran aviator would occasionally drink beer but cognizant of the regulations, he would wait eight hours before flying.  He mostly flew his Mooney, where his checklist was always dangling from the mixture control knob and he never allowed himself to rush.
On that fateful night, our 60 year-old pilot had consumed alcohol nine hours before, but he also had taken an over-the-counter medication for allergies, which it turns out, decreases the alcohol metabolism in the body (slows the breakdown of alcohol, hence the effects of alcohol are prolonged in the body).  He was flying an aircraft that he was not totally familiar with, and all his tell-tale readiness checklists were not present to help him where they usually presented themselves before flight, and he was in a rush to pick up his friend from an airport only 20 miles away before a line of thunderstorms came through (that friend owned the Cherokee).
A careful, analytic mind reduced in alacrity, unencumbered by the weight of his previous knowledge through the harmful effect of persistent alcohol in his body, failed to see the cues of impending disaster.  Having found none of the patterned elements that had kept him safe for 60 years, 4 months and 3 days, his clouded brain edged him on that evening and sought to play its own game of chance.
There are many lessons to learn from this story.  My own guidelines are as follows; add on to them as you please:
  • Know your limits
  • Observe those limits
  • Develop good habits - use checklists
  • Follow those habits
  • Rectify a 'getting away' scenario; do not amplify it
  • Be constructively critical of each flight
  • Even the best pilots make mistakes - minimize the number and break the chain
  • Always think about where is the possible error
  • If intuition tells you something is wrong, prove the intuition to be wrong before proceeding.  Intuition is mostly right (Intuition arises from more then your six senses. It originates from the plethora of sensory input including skin, joints, muscles etc) - Read the book "User Illusion."
  • Alcohol, with or without medicines, is dangerous - Affects the brain function directly through euphoria (I can do anything) and then depression (head in the toilet bowl).
  • Ground yourself voluntarily if you need to for any medical reason.  Death is not an option.
  • Improve technique; periodically practice safe flight with an instructor - Proficiency is the name of the game - gives you clarity of purpose and a skill set to achieve it.
  • If flying a different aircraft, become thoroughly familiarized with it before flight
  • Do not violate the rules; they are the products of previous tragedies!

Good decisions are born of good judgments, and good judgments are born of prepared, rested, and alert minds.  Fly safe - always.

Published previously in FAA Aviation News  and Federal Air Surgeon's Bulletin

Sunday, November 13, 2011

World's mine Oyster

I was walking on the boardwalk the other day and came across a pebble. It seemed to catch my right foot in perfect stride. Off it went on a flight, appeared to float in weightlessness as it rotated in the breeze, seemingly unaffected by gravity, rising sharply to its zenith and then in a parabolic decline it landed back onto the wooden planks of the board-walk. The rattling sound was a noticeable “plunk,” and then a non-rhythmic clatter. The pebble finding the wood traveled in a random motion, this way and that, aimless and quite directionless as it deviated from right to left and then seemed to find a contact point that made it careen to the right, coming to rest against the guard-rail.

And I thought about our thoughts. How many of them are against guardrails waiting for a kick-start again and again. An idea, a thought, a concept is a pebble that needs a periodic force of will to move it along until it finds the perfect landscape of a defined architecture.

Maybe that pebble never left the guard-rail or then again maybe the street-sweeper gathered it in its brush-wheel and deposited it in the collected trash. Maybe the trash was emptied into a stone separator and the pebble washed through a bed of water, now sits in its clean splendor sold to a newly constructed home and its beautiful garden where a child will gather it in his or her hands and throw it once again. Maybe he or she will throw it into a pond or lake and the ripples created will burn in his or her memory for a later endeavor that will spread through humanity with exponential charm and change the course of human history.

Oh! I wish it would be so!

Don’t you?

…I think it will be so!

Why then the world's mine oyster,
Which I with sword will open.
 ~William Shakespeare

Friday, November 11, 2011

Thought Experiment on PRDM (Just Thinking)

Thought Experiment #1

PRDM9 micro-satellites involved with human diversity by modulating the hotspots on the DNA. The PRDM (Positive Regulatory Domain Modulator) gene encodes for a protein which is a Zinc Finger transcriptor and this resides within the nucleus to modulate transcription into the DNA of the cell and modulate the proliferation of the cell with the variance to encode diversity – genetic for propagation and cellular to withstand stressors.

PRDM 16 on Chromosome 1

Interesting that PRDM16 is involved in a similar pathway but one of the known issues with PRDM16 is that in a t(1:3) (p36-q21) a subsets of MDS (Myelodysplastic Syndrome) and AML (Acute Myeloid Leukemia) cases have been identified.
Further viral infections lead to over-expression of the PRDM16 gene.
Question: DO sometimes clustering of Acute Leukemia cases represent a viral infection and the subsequent translocations through the PRDM genetic gateway?

Reference: Nature Genetics September 2010.

Just so we are clear, there are PRDMs protein that range from 1-16. 8,12,13 for instance and some are involved in neurogenesis both in the brain and the spinal cord also

Again adding the thought experiment to this subset, consider during the fetal developmental state, or embryogenesis, over expressions can create some functional changes with the brain development too or maybe not. But that is for another day.


Prdm Proto-Oncogene Transcription Factor Family Expression and Interaction with the Notch-Hes Pathway in Mouse Neurogenesis. Kinameri E, Inoue T, Aruga J, Imayoshi I, Kageyama R, et al. 2008 Prdm Proto-Oncogene Transcription Factor Family Expression and Interaction with the Notch-Hes Pathway in Mouse Neurogenesis. PLoS ONE 3(12): e3859. doi:10.1371/journal.pone.0003859

PRDM activity in the Neural Crest (above) and the Spinal Cord (to the right)

Tuesday, November 8, 2011

Occupy Our Health

I saw the fog rolling in. No! no, it was not rolling in as much as it was just embracing the foliage. The trees, far away, first disappeared slowly in the midst of this moisture and then as the visibility decreased, the fields in front of me began to recede into this peaceful quiet of the grey goo –a slow occupation. As I watched the mist overtake, I could see the Hibiscuses and the daffodils in their colorful beds strain to reach for that ray of sunshine hiding behind the clouds.  Straining equally in my mind, I realized how, with such simplicity and grace, a single idea can adorn and then overtake a thought. I mean, how from a nuance, an idea or a dream is born and equally from nothing emerges the kind of thinking that catapults a single thought into the mainstream of society to transform it- like the straining daffodils through the mist of fog, looking for answers find it in the sunshine.  Healthcare is ripe for the occupation by intelligent thought, replete with reason and depleted from diversions.

It may have happened just recently. It started as a slow rumble and grew to the current white noise everywhere. Medicine and its practice is changing as we speak. There is a cacophony of disparate voices clamoring for expression and delving through the cyber universe of hash-tags and ampersands and their collective spirit seems to be emerging to “fix” a badly wounded entity. Medicine lies bleeding at the altar of bureaucracy and on the pyre of finger-pointing and anger. It is being defanged against the viciousness of disease. It has been de-clawed against the predatory advances of fiscal motives and dethroned from the nobility of its purpose; from what should be done to what ought to be done.

Somehow there exists an irony in all this, the irony of reticence and broken expressions of a fragmented society that seems to pervade the medical atmosphere today. Medicine is in the throes of loud voices of self-proclaimed experts, pushing and pulling the torque tubes of momentum for their own self-satisfying needs.  Everyone, it seems has an axe to grind. For that fifteen-minute of fame they will sell their souls and be damned, and not care. And as always from the days of the “Snake-Oilmen” who, still abound today with only their hats and long coats changed to slick hair and pin-striped suits, the selfish motives remain as their pervading mental flotsam. Their expressions are disguised to beguile. Meanwhile the doctors inundated with answering to the needs of patients and monitoring the regulatory burden of this and that and keeping up with the daily advances in the field of medicine are left whimpering as to what is real. So what is real? Do we know? Is there an answer to all these pleadings of help? Or are we just prey to the predation of the slick and the slippery? Is truth the scarce commodity of today?

To find that truth, first we must find the root-cause and then try and fix. Nowadays, the rational thought is disguised in some artifact of graphs and tables, reason is bled from the real and transferred into some fog of probability that leads the essence of patient care to confusion. The despair although palpable in our souls is restricted and confined by the corporeal bounds of our being. We must fight the urge to languish in this despair. We must teach ourselves the concepts that help and not detract from helping people in need. We must question the new concepts if they are steeped in some form of snake-oil slipperiness. We must start to question the very essence of all dictates that try to modify or mollify, not because of the potential of a change but because of the underlying motive. And if the motive and change weave together into a common thread of betterment for all humanity then we must understand and stand by such progress. Calling something “progress” is not always progress. True progress is the cumulative and positive effect of an action. It is the outcome of a motive. It is the endgame of all plays. It is for the better for all of humanity- that is progress! Marie Curie, Louis Pasteur and Watson and Crick come to mind.

And yet as time ticks away, often the purchase of frustration grows, as does the restlessness and the anger. Today, such intemperance finds itself in the form of cyber-chats. Minds full of ideas, disparate or similar find an expressive outlet to jointly grow the foundations of resuscitating the nobility of this profession. Yes, that time has come.

Patients, doctors and nurses all seem to have come to find the common ground for a cause to serve themselves and the future generations, the care and comforts that human dignity deserves. It is not the wail or the cry of want but the distinct and precise nature of the care giving to benefit the individual in need. Realizing that medicine is not all about monetary benefits but about the rewards of seeing the sick get better and those doomed to death finding life in this care, for that, we must strive for the better angels in us all. As physicians we strive for wisdom of knowledge and patients equally need to be understanding of personal responsibility as well. Consumption or over-utilization of limited resources will hamper care for all and this applies equally to physicians as well. We must educate the people about self-governance. Teach them that responsibility of moderation and prevention far exceeds the benefits of retrospective emergent/non-emergent care. We are in this together, all of us.  We are at the threshold of such a moment once again in history. Let us be firm in our resolve and confident in our future. Medicine and self-responsibility are all we have between life and death- keep truth in the former and desire in the latter.