Saturday, January 28, 2012


I bought a lamp the other day. What was interesting about this lamp was that it had, had multiple owners before. It is absolutely beautiful. The dark metal base has four “feet” each splayed out like those of a baby elephant. The stem has a bulbous sort of a transparent appearance that shines through with a greenish hue when the lamp is lit and the shade is an old tiffany style with multicolored leaded glasses glued together that sends a beautiful kaleidoscopic rainbow of colors on to the wall. The real treasure lies under the base, a most telling feature of this lamp, an inscribed signature dated 1901. The date checks out with the antique market makers.

Why this lamp?

As it so happens it reminds me of my grandmother’s house. And in that stitched together confetti of a history is a remembrance of a frail man that came to the house. He had a lamp just like this one, or so I think. It was beautiful. The man, a salesman, would not sell it. The more he was pressured to sell, the more he resisted. He would point out to other things that were for sale, but always held on to the lamp. The mystery was too much for my grandparents. So the cajoling and the sweetness and the invites began. He became a frequent guest to the house. Soon the lamp was forgotten and a great friendship evolved. A few years later the man passed away. Shortly thereafter the lamp appeared in a large brown box via a courier. The sadness that followed by its mere appearance was enough to give my grandmother the “vapors” as she would call them. The lamp took a cherished place in the house, in the foyer. It was perfect there on the table against the wall with a bouquet of fresh flowers that filled the vase daily. It was a meaningless object but oh, so filled with meaning. On the base of that lamp, I remember, was an etched date “1901.”

The lamp, I bought sits on my desk at home. It is a reminder of a reminder. A past, so long ago that time would forbid the removal of the key that opens the door to that remembrance. And yet here it is. And it does bring back a cataract of those yesteryears.

I was asked the other day why do I cherish it so? I replied, “Because it takes me to a life that once might have been.” Yes, I chose those words wisely, I think. You see what remains of that time is nothing more than a nuance, a whisper but it has been embellished over time to form a beautiful memory. Did it happen, exactly as I remember it, I dare say, I don’t know?  It did happen and now with all the holes covered over by my mind’s fuzzy logic a beautiful endurance resides, called back at the sight of this lamp.

Memories (cartoon) by JediPD

Life is funny that way. There are things that would not have any meaning to a 6-year-old, that become etched without reason into the wall of memories only to find relief later when you run your fingers across that wall. Yes, this is one inconsequential memory buried deep that so alights onto my consciousness through the shallows of a tiffany lamp. The salesman lives and so do my grandparents. Maybe that is why some of us have trinkets that we cherish, not for their material worth but so we can hold on to the fading memories of the people and time gone by.

Life is a lonely sport enjoyed through the prism of reflection. Through it all as we build the scaffolding of the edifice of our being, filling in the “fill-ins” of our imagination, we objectify them for reference,  we hold them for reverence and cherish them for who we have become!

Or maybe, I am getting too darn sentimental!

Thursday, January 26, 2012

Hands on the Skin

Exit the Diagnostician

It is the best of times when the psyche is geared towards the health and welfare of each individual. Yes we discuss, we promulgate policies with a philosophical bent, we climb up on soapboxes and advocate altruistic motives, we decry other’s utterances, we subsume the world of thought into an arbitrary morass of chaotic thinking and hold ourselves high as the pillars of societal paragons. It is all good intent. But the results seem tempered with ambiguity at every level. Something is amiss. We have the computing power, oh yes! We have terabytes of storage memory and petaflops of throughput. We have the answers to most of the questions or so we think. We are delighted as we see the light refracted in the color of our viewing. We are educated and well rounded in our grasp of things, after all we carry the domain of science and philosophy and all that is to know in the palm of our hands, don’t we? We are blessed! Yes indeed it is the best of times! Or is it?

Why did I start this offering with such a distasteful paragraph? Why, you ask? Therein lies a short story:

It was the better of days, the sun was in full bloom and the clouds had parted to reveal the blue beyond. Everything seemed in sync with the time of his mental tide. He had just finished his review of cases. He happened to be the Attending and his ward was a second year Resident. This second year resident was “spiffed up” in his faded jeans, an open collar shirt and a short white lab coat with an array of pens in the front pocket. The attending was in a long lab coat with “Medicine” embroidered on his lapel. Beneath his lab coat was a freshly laundered shirt with stiff collars and a handsome blue and red colored tie.

“So what is your impression?” the attending asked.

The resident went into a discourse of the medical background, which mostly was composed of lab and X-Ray data. There was mention of a negative family history and also something about previous admissions. All in all, the resident was able to convey a historical and current status of the patient from his point of view fairly well.
“So it seems that Mr. G is in reasonable good health. He came in with mild congestive heart failure and that based on your assessment is resolved, Correct?” The attending inquired.
“Yes sir.” The resident replied. This attending, it was known in the training circles, wanted to be addressed as “sir”. He was the “old school” who had been nicknamed “Dr. Dinosaur.”

They walked down the corridor towards Mr. G’s room. The resident flicking digital pages on his iPad, expanding and contracting images to make sure he had covered all bases.
“What about that elevated LDH that remains high, what do you make of that?”
“The Lactate Dehydrogenase, sir half-life delays its resolution compared to the CHF symptoms.” The resident answered quietly, he had to know all the answers or reasonable understanding of the potential questions, for he knew that Dr. Dinosaur’s recommendation was a necessary requisite and carried weight when it came to obtaining a fellowship.
“And what about that slightly elevated Uric Acid?” The attending frowned just a smidgen, as if in thought.
“Well sir his renal function is also minimally impaired but getting better from the pre-renal event, preceding the CHF, that would account for it” The resident replied.
“I see.” The Attending stroked his chin gently and eyes narrowed under the frown. If you were able to see his pupils they were in full dilation of thought.

They walked into the room,

The resident stood in the corner as Dr. Dinosaur started examining the patient. He kept talking with the patient as he examined him. Asking questions, nodding to the answers elicited and moving on to more questions. The dialogue was barely audible over the din of the air-conditioning unit that was at medium blast. 
Star Trek's Tricorder

The resident was thumbing through the digital universe looking for any loopholes in his presentation that might be under review. He noticed that Dr. Dinosaur displayed a calmness and thoroughness about the way he proceeded through the half-an-hour or so of examination. After he was done, they walked out of the room.

The resident kept scanning his iPad for information that the attending might need.
“So what is your final diagnosis?”
“CHF sir.”
Okay, did you examine Mr. G?”
“Yes sir.”
“I asked about any issues that he had. I did listen to his lungs for crepitus to confirm the resolving CHF.”
“There were some basilar crackles, but all in all his lungs were clear.”
“Uh huh.” Dr. Dinosaur rubbed his right temple with his fingers. The grey hair stuck out in stark relief against his reddened skin.
“Please go back and reexamine Mr. G and come back and report your findings to me in my office…in about a half an hour. Okay?”
“Yes Sir!”

Half an hour later the resident reported. “His examination was negative sir.”
“Now go back and check his right neck area and ask him about his smoking history, there is a golf-ball sized lump that you wont miss. It is just below the clavicle in the supra-clavicular region. That lymph node is about 2 by 2 centimeter. Also bring in the real films from the X-Ray department and lets look at his Chest X-Rays together. He might need a CT scan of the chest. Ask a consult with the surgical specialty for a needle biopsy of the node and then we will take it from there.”

The resident turned pale and then the color of blush warmed over his face, as if he had seen a ghost and recognized it. He stood there for a moment longer then necessary wishing his body to move, to obey the command that it resisted. Finally he turned and walked out.

Enter the Diagnostician.

With a pair of hands, a gentle touch, a few whisperings of questions and acknowledgements the mind can comprehend more than all the digitized words in the Library of Congress. On paper the patient is doing fine, in health he may not. What is it we hope to seek? What is it we hope to convey? What is it we wish to fix? What is our ultimate aim? Are we to hope for a better future filtering the patient through the refractive lenses of a digital world or with physical contact? If we cannot bridge the gap towards the “real-digital” future this indeed will be the worst of times.
Nanobots in the blood stream

There will come a day, when a hologram will diagnose the problem through a virtual scanner and a nano-labeled fluorescent diagnostic tool floating around in the blood stream of humans will diagnose all the maladies that afflict us and in so doing that nanobots will inject us with the required antidotes of all current and future problems? Unfortunately the time is not ripe for that just yet. Our today’s digitally astute students are living under the premise of that hologram society, today, unfortunately without the necessary available tools in this present and minus the clinical acumen of the Dr. Dinosaur. The promise of that “beautiful life” is just that, a promise.
Star Trek's Holodoc

Until then, we still need the “hands on the skin.”

Sunday, January 22, 2012

BIAS and the Information Asymmetry

Where is the Life we have lost in living? Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?
~T.S Elliot

Leonardo's Vitruvian Man

Life is a constant whirl of motion, the day into night, the passing clouds and the blue sky, the rain turning into snow and the parachuting seed of a dandelion blowing over the meadow to populate. If not for that there would be stillness.

This discourse is not about Stiglitz’ Information asymmetry of economics, where one party is handicapped with lower information value in a two person contract. Nor is this about Hustler and Galusky’s architectural asymmetry of the left and right plastic brain that is in constant state of evolution, No, this is asymmetry of knowledge and the underpinnings of personal hard-boiled bias based on recalcitrant thought.

We are victims to our internal stillness. Our inward prejudices, have the magnetic pull to align the mental filings to our biased polarity, holding them in place – in stillness.

We can without introspection, turn into large bodies of water, without ingress or egress of fresh supply, where the sulphites grow and the Fenton’s Reaction depletes the oxygen turning it into reservoirs of stagnancy, not allowing any life or new forms to prosper, much like ideas, thoughts and new concepts.

This bias resolves itself in the most meaningful and hardened beliefs over time that remain firewalled against all common and new sense. The belief if not reviewed, sinks into the depths of that mental Dead Sea in whose darkness, life and thought are at a standstill.

The foregoing is a tale of that woe.

The cantankerous nature of this balding elderly man who had claimed several prizes in his field of study was evident as he began his monologue. He vociferously defended the concept he had developed and lectured about for years and was doing the same to the thousand or so gathered in the large auditorium. Hands were furiously taking notes, eyes were peeled, ears on full alert and everyone seemed intent on catching the golden dew drops that floated in the ether from the speakers magnified voice. Yes there was energy, crackling at the edges, The lecture ended shortly into a thunderous applause from the converts and the converted. The elderly man basked in the now brightly illuminated auditorium, then slowly walked off the stage. The younger individual who followed him reached the podium as many of the audience were in the process of exiting the auditorium. The lights had started to dim. Not many wanted to hear any upstarts. They had just been blessed with wisdom.

“I am afraid what you just heard although elegant and descriptive is curiously contrary to the experimental evidence we have.”

A pandemonium of hushed voices, chairs clanking against one another and the sound of bottoms placing their burden on the metal chairs took over. Yes controversy was in the air and nothing invites the vultures then the smell of a road-kill. The paradigm was about to change, maybe, but the comment certainly aroused a sense of anticipation amongst the audience. The old shackles had rusted and turned fragile in their hold and were breaking loose. A new sheriff was in town, maybe. Time would tell, but he had injected new blood in the sludge of yesterday.

Wright Brother's Replica

Unfortunately information asymmetry proliferates amongst us all, the baubles of yesteryears are just that, old and discarded. Information changes, ebbs and flows like water, gaining sediment from here and depositing it there, changing direction and drying out beds here whilst watering a new birthing ground of flowers there. It is in this flow, this remarkable understanding that we process and progress. The old is not necessarily bad, but a stepping-stone to cross the stream, a shoulder to climb on and see the next horizon. Clutching it with a death grip is, well…death of a dream!

Burt Rutan's Composite Asymmetrical Twin Engine

Burt Rutan's Space Ship One and the White Knight

Too easily we fall into the traps of our own built in biases and become blind to the changing facts. This then is the interrupted loop of information symmetry that sinks many a seasoned, seafaring ship, fall many a skyscraper of knowledge and blind many a discerning eye. The success of today is only a guarantee for another advancement tomorrow, no less no more. The past success is not to be worshipped, but revered for its being. Clinging to the past is a failure to take the next step and we all know what that means.
Celtic Knot

Information is being manufactured every millisecond. Grasp it, accept it and learn from it to put your thoughts into action. Failing which the burden of entropy leads to a heavy collapse of ideas, thoughts and concepts into the venerable black hole of oblivion.

It is through constant sifting of information, tagging that which tugs at our neuronal strings and that which repels where real symmetry and understanding lies. A jaundiced eye sees the same information but interprets it through the refractive prism of personal bias. An open mind sees that for what it is.

Persian Rug Symmetry

Thus information asymmetry is the prejudice, the bias that lurks in us all for our own accomplishments. Hardened to our internal bias, firm in our resolve to disprove any new advance, we become blinded to the next move. The symmetry ends.

This then is the fall from grace.
This then is implosive reminder of bias.
This then is failure to keep learning.
This then is death of understanding.
This then is information asymmetry. 

Friday, January 20, 2012


“Only those who will risk going too far can possibly find out how far it is possible to go.”T.S. Eliot

Ever seen a four-year-old do “Rockford’s” in a three-wheeler? It was very instructive. After about his tenth attempt to do a 180-degree spin back where he succeeded in about a 110-degree turn, he pushed the limit. He sped up, braked hard with the handlebars fully deflected on his eleventh try, but this time a loose pebble was in the way. The right rear wheel temporarily arrested allowed the forces of physics to lift the left wheel off the pavement and the result was red conjunctivae, tear-stained reddened cheeks and a heavily bruised ego. What happened? ~ Is a few minutes of mental traffic through the ligatures of his and the rest of our offenses.

Loss of control! Why does it happen and how can we prevent it? Or can it be prevented at all? Given that humans freewheel through life most of the time. We all have moments when driving a distance from A to Z, we forget points E thru M. Why? We are as we say “on autopilot.”

Okay, delving into the psyche of the human mind for a non-psychologist is like a neurosurgeon changing the bicycle tire, but there are issues, we can all agree, are easy to grasp for the rest of us– myself included.

Kahneman and his Systems 1 and 2:

Kahneman, the Nobel laureate of the Kahneman and Tversky fame speaks of two systems, 1 and 2. System 1, per his definition is the autopilot, freewheeling, off the cuff, any-thing-goes, and intuitive, instantaneous response to any quandary. Like for instance, if I ask the question what are 2+2 and your answer would be…? Right, no thought required. And to add one more question what color is the sky? Yup, you got it… right!

So now let us look at System 2. This is the detail-oriented, evaluation driven, intensely-contemplative, goal-oriented, nitpick-ingly, and accurate to the nth degree mode. This system requires hard work. A question posed here would be like multiply 23 and 79 and divide the result by 2 all without a calculator and paper and pencil. Uh huh, makes you stop and pause. It makes you multiply each number separately, carry-overs and all, then keep them resident in the mind then add them up and subject the final number to a division, where more carry-overs are needed and so on. Believe me most would give up the dilated pupils of intense thought and all to ease the mental burden, pick up a smart phone (As Ariel would say. “I got Gadgets and Gizmos aplenty”) and voila!

So now what has that preamble got to do with loss of control? As a matter of fact, everything! It is not to say that risk-taking is all failure-prone. It is in the cautious role of an experimenter, risk-taker that true progress is made, but it is done with the knowledge and risk mitigation of most known hazards. Although it is true, that progress in life is made mostly by the “unreasonable person,” the risk taker, for it is he that boldly goes where no other has ventured before, is well-versed with the “lands” he is setting out to conquer. For the others who propose to follow that path without the necessary precaution, understanding, diligent research and think-through the landscape is a veritable minefield adjudicated by System 1.

Etihad Airlines Boeing 777 (brand new) drives into the hanger ~ total loss (Real Picture)

Did I mention that System 1 is also the premier manager in anger management issues and in people with no filters in place during social conversation? In other words (as if they are needed) if one would spend just a minute more before uttering (words that bite us in the derriere) our lives would not be spent un-complicating the complexity so created.

Flight Scenario employing the two Systems:

Loss of control in an aircraft is an event similar to that of the little boy, I described in the beginning. Imagine yourself in this awe-inspiring flight above a solid under-cast of bubbly clouds and the sun peaking just above the clouds as it reaches for its twilight nap, spreading its golden sprinkles on the top of the cloud-bubbles. Got the image. Now imagine in your joy of this beautiful landscape, you decide to do some heavy maneuvers, because you can and because a little thrill is tapping at your knees, (just like the one Chris Matthews of MSNBC had). So off you go banking into a 45-degree bank that proceeds to a 60 degree and then into an accidental wing over, completely unexpected. The plane noses downwards towards the soft cushion-less clouds below. Your System 1 is operational. You react with the “yank” and then try to undo the bank. The clouds now seem to draw nearer, then the blue sky shows up but doesn’t last long and the windshield once again fills in with the white clouds. System 1 calls in more of its instinctive, intuitive, illogically driven self-protective inputss and a full-dress rehearsal of panic takes over. The expletives escape in between hisses through your teeth. The sweat glands are on full-bore expressing the thrill of sympathetic neural response drenching your back and bottom.

Runway over-run

Now this scenario can continue to its ultimate graveyard spiral adding to the gobs of data for the NTSB (and they will investigate this). In the end the accident would be determined as a “pilot error.” But what would create a restless conundrum in their minds would be why did the radar track show the initial departure from a straight and level flight? Why would someone of previously good discipline and a spotless historical background voluntarily do something sooo stoooopid? Ah but we know don’t we? That human gene of sudden urges and thrill might have played the part.

Potential for Survival?

Could you have survived this? Well of course you would have. There were multiple levels of disconnect with this scenario. Stop at number 1 would have been not to fool around in a VFR on top flight under IFR rules with the urge to do 360s. So now not responding to that plea, had you done that and gone wing over anyway, because you are the greatest living “bold(but stupid)pilot” in your walnut-sized universe, you could have employed System 2 to bail you out. It is that startle of insight, the press and push for information, the dogged determination that rides past the wispy entrails of intuition and settles on the firmness of objectivity. That System 2 would have saved your can!

System 1 Failure:

How you ask? Elementary! My dear, elementary! What happened? As you are all too familiar by now is that you placed the aircraft past its aerodynamic limit and it stalled. (Unless you have a different definition of the word “limit” it still means intransigent and inviolable boundary.~ You get the message) Having experienced such appalling failure of reference and resorting to the demands of self-preservation through the dictates of the lowly System 1, leads to pulling on the yoke, further exaggerating the stall, progressing it to a spin and the rest shall we say, is, well permanent “rest.”

System 2 dictates:

Break the stall.
Push the yoke forward! (Be counterintuitive!)
Level the wings,
Stop the Yaw with the opposite rudder (press on the ball) and
Reduce power to prevent over speed through Vne (Never exceed velocity). 
The aircraft would have recovered and with all the expressed sweat and other material soiling your garments, you would have apologized for the deviation to the Air traffic Controller and gone on your merry way, promising yourself never to do it again and would live to tell the hanger “Mother of all Tales.”

Pilot Error:

Loss of control manifests as a result of pilot induced reasons mostly about 70% to be exact. This can happen at any altitude, attitude or speed. Exceeding aircraft aerodynamic limits is a “No…no.” Exceeding your own, sorry to say is a human trait. Psychologists Jennifer Whitson and Adam Galinsky proposed in an issue of Science "when individuals are unable to gain a sense of control objectively, they will try to gain it perceptually." And since we know that perception is reality, you have just made one such reality right out of the frontal cortex of your brain and created an aerodynamic conundrum.

Attitude Correction needed

Illusions, Delusions and the Weather Conditions:

Most common circumstances related to loss of control are weather-related; a VFR pilot ventures into IFR realm, Of course a thunderstorm can toss you and your cookies up too and put you into a real unusual attitude (Remember in turbulent weather slow down to maneuvering speed, maintain the attitude and forget the altitude, since updrafts and downdrafts in storms can lift and hurl at a ferocity of 6000 feet per minute) and thirdly at night time on moonless nights when different visual illusions can create many different ghosts, goblins and not to mention gremlins to appear in your mind’s eye leading to spatial disorientation and a temporary disconnect with reality ~ What images may come staggers the mind and dislodges the context with reality. All these ghostly images and more conspire to make you temporarily perspire.

Flight Control Surface Issues:
Jimmy Leeward's modified P-51 (Note loss of aileron right wing)

Other reasons, not in pilot control include flight control surface related events. For instance, rapid maneuvers at high speeds can cause aero-elastic flutter in the elevators or ailerons, which can through weakness of linkages depart, leading to uncontrolled and unrecoverable departures from creating lift and continuation of flight. Case in point: Jimmy Leeward's P-51 Reno Air Race accident of 2011.

Jimmy Leeward's Loss of Control

Where then can these clashes of uncertainty reveal their ugly heads? Based on the NTSB data ~ anytime. Of all the stall-spin accidents that happen, majorities occur between 1000 feet and terra firma. Now why would that be? Maybe the long urge of the human spirit incapable of flight on its own wishes to be on the ground quickly. But I digress, so save me.

Approach to Landing Stall:

These approach to landing stalls usually happen due to low-speeds on base-to-final tight turns, maneuvering to impress the opposite sex looking up with her/his happy face and outstretched waving arms, stretching a glide with fuel exhaustion or starvation (Oh, we pilots can do some real dumb things), Distractions on the airport (a deer, cattle or rickshaw crossing) or within the aircraft (Are we there yet?) can lead to wrong inputs at the absolute wrong time ~ Keep a sterile cockpit on departures and arrivals!

Departure Stall:

Loss of control can happen at takeoff also, called euphemistically as “departure stall” and can be as a result of insufficient speed, a yank on the yoke, brakes remaining deployed, cross-control in cross-wind environment with wind shear and premature liftoff via the instinctive System 1, leading the NTSB to the scene of the accident.

A word of caution here seems a must: Stalling the aircraft close to the ground is usually unrecoverable and impacting the ground at any velocity is usually fatal (as in, dead as a doornail)
Icing related accident


Now before you get your mind and all those aeronautical charts in a bunch, let me brief you on another possibility, Icing. An aircraft certified in icing condition flying on autopilot in icing conditions can lead to a runaway trim to maintain the altitude as lift degrades due to ice accretion on the wing surfaces, until it stalls the aircraft. Given the “Time Critical Scenario” if the pilot’s response is predicated on System 1 commands then all will be lost. Even flying manually with the autopilot disengaged arriving at an airport it is important (System 2 is commanding) not to put flaps down since doing so will increase drag and the ice covered wings and empennage (airfoils) will be further deprived of lift through air-separation from the wing surface and will not be able to hold the aircraft in the air. Hence crunch ~ QED. As System 2 would say, “Get out of the Icing condition,” “Never get into icing condition if possible and if you do, make sure the deicing system is fully functional.” “Remembering that the quickest way out of icing is 2000 feet above or below the altitude you are flying and of course out of visible moisture (clouds)”. And “if you are carrying ice into the approach, keep going, (aka If you are going through hell, keep going) keep the speed up (power as needed), no flaps and plan to land long”.

Colgan Air Flight 3047
Instrument Flight Rule Approach Plate (Red mark denotes site of accident)

During the flight and continuing through the plane's landing approach, the crew had been flying on autopilot The de-icing system was turned on, minutes into the flight by the crew, who had discussed significant ice buildup on the aircraft's wings and windscreen shortly before the crash. Following this, the pilots extended the aircraft's flaps and landing gear for landing. According to the NTSB's official report, after the landing gear and flaps had been extended, the flight data recorder (FDR) indicated that the airspeed had decayed to 145 knots (269 km/h). The captain, who was the pilot flying, then called for the flaps to be set at the 15-degree position. As the flaps transitioned past the 10-degree mark, the FDR indicated that the airspeed had further slowed to 135 knots (250 km/h). Six seconds later, the aircraft's stick shaker a device intended to provide aural and tactile awareness of a low speed condition, sounded. At this time the cockpit voice recorder (CVR) recorded the autopilot disengaging. The FDR now indicated that the aircraft's speed was a dangerously slow 131 knots (243 km/h). Unfortunately, instead of following the established stall recovery procedure of adding full power and lowering the nose to prevent the stall, the captain only added about 75% power and continued applying nose-up inputs. As the aircraft came even closer to stalling the stick pusher activated ("The Q400 stick pusher applies an airplane-nose-down control column input to decrease the wing angle-of-attack [AOA] after an aerodynamic stall"). The captain overrode the pusher and continued pulling on the control yoke resulting in the upset and subsequent loss of control.  The plane pitched up at an angle of 31 degrees in its final moments, before pitching down at 45 degrees. It then rolled to the left at 46 degrees and snapped back to the right at 105 degrees. Occupants aboard experienced forces estimated at nearly twice that of gravity. Witnesses on the ground claimed to have heard the engines sputter just before the crash.(NTSB data)

Don’t you landlubbers think that you are above all this aviation accident fray? Think again! It is statistically safer to fly from the Atlantic Coast to the Pacific Coast then to drive to the airport. Be careful out there!

O’ the stories we have to weave
To lure you away from the creep
The faith towards which you must leap
And find rewards that you can reap!

Loss of Control Reasons:
1.    Stall
2.    Flight Control Surfaces
3.    Spatial Disorientation
4.    Icing
5.    Weather related
6.    Maneuvering flights
7.    Night Illusions and distractions

Need I say more. My mentor

Loss of Control Prevention:
1.    Stall recognition training
2.    Spin recovery Training
3.    Upset Recovery
4.    Simulator training Scenarios
5.    Didactic education
6.    Non-Reliance on System 1
7.    Beefing up System 2

In October 1996, the NTSB issued a formal Safety Recommendation (A-96-120), which requested the FAA to require all airlines to provide simulator training for flight crews, which would enable them to recognize and recover from "unusual attitudes and upset maneuvers, including upsets that occur while the aircraft is being controlled by automatic flight control systems, and unusual attitudes that result from flight control malfunctions and uncommanded flight control surface movements.

And, not forgetting that cherub on the three-wheeler, remember the one at the beginning of this post, well, he made his 180-degree spin on the very next try after making sure there were no other debris on the pavement. Instead of the frown and tears there was ear-to-ear smile and fist pumping. Yay! System 2 had operated as predicted.

PDara MD, FACP, 
Airline Transport Pilot, 
Master Certified Flight Instructor, 
Advanced Ground Instructor
FAA Safety Team Representative (PHL)

Friday, January 13, 2012

Undressing the Matryoshka Doll

Or... Down the Rabbit hole in Cancer

Charmed magic encasements, opening on the foam of perilous seas, in faery lands forlorn. ~John Keats

The tautological descent into evidence is like an onion peel, each layer brings out another and another. The Matryoska Dolls open and reveal a tinier version within until the infant appears as a single last piece. From Nuclear Physics and the discovery of Atom, which was once considered indivisible now come Leptons, Muons, Quarks and Neutrinos, all arising from ever enlarging circumferences of the Particle Accelerators. The knowledge today is undergoing constant evolution as revolutions of thought and study continue to evolve. We reach the infant in side the Matryoshka Doll and find that it is not! While curiosity uncloaks the strange, imagination delves deeper into the shape of the peculiar.

Those damn fluorescent tube lights kept flickering. It was the 27 year-old young man who solved the problem. He was not an electrician although many had been paid handsomely to fix the problem several times. This youth with a cheerful face, easy demeanor, a shock of dark brown hair, thick eyebrows that were overshadowed by a smile that would not quit, an athletic body and a fecund mind that would run circles around any subject or field of endeavor was a gem. Yup, that just about describes him to a tee.

“So what do you think?” He asked with his open-faced hands on his knees and with a slight knit to the eyebrows. The inquiry required an intelligent response.
“It is a cancer of the testicles.” The words tumbled out from my mouth. “It is called a seminoma.”
‘How’d I get it?” That hundred-and-twenty-four-thousand-dollar-question.
“Its difficult to say.”
“Come on doc. There is always a cause and effect. Right?” His eyes curious and now his hands were in play as he let them wave with emotive expression.
“You are right.” I said. “We don’t really know the proximate cause for each cancer. But we have some clues.”
“Ok. Try me.”
“We know that when it is hereditary or familial then a mutated gene may be the culprit.”
“So any family with that gene would be decimated right.” He inquired.
“Well not exactly.” I replied. Now we were walking down a pathway that forked and each pathway divided like a ancient deciduous oak tree.
“So then something else is at play. Right?”

The screws of this conversation had a long way to drive to reach sufficient understanding. Only the superficial drywall of this invisible frontier had been pierced.

Open the Sarafin dressed Orange colored Doll ~ The First Undress

“Yes.” I said. I thought for a moment and tried to ascertain how far down the rabbit hole to go with him. “For instance in some diseases a bad gene may exist only on one arm of the chromosome and the other happy fully functional gene may forestall and prevent the cancer from ever forming.”
“So in other words, that would work for instance with smokers, if they happen to have a bad gene then smoking can kill the other side and they develop cancer. For I know everyone who smokes does not get it. My uncle died at age 96 and he was a chain smoker.” He interjected.
Wow he was a smart one. His eyes were lit up from this discovery and the shadow of his own disease encased by an invisible wall not allowed to venture into his mind just yet.
“So how exactly would that happen in my case, since smoking is not a cause from what I have read?” Uh oh, here we go, I thought. Down we go the rabbit hole for that pitcher of the special elixir.

“In Seminoma there is a genetic predilection with a mutated gene, but it is not a 100%.” I looked at him and decided to ask a question before proceeding, “You read about chromosomes, right?”
“Well there are studies that show anomalies on the short arm of Chromosome 12 or 12p as it is called. Additionally there are some mutations noted in the c-kit gene, which also may have a promoter effect leading to spread. Not everyone has it, but not everyone has been tested. So to speak.” I looked at him and he sat there without any quizzical look about him as though the flood of understanding was washing on his shores. “There is a possibility that since your right testicle was in your belly till after puberty when they hooked it down.”
“Orchipexy, you mean?” Medical terms and all, this young man was beginning to impress me big time.
“Yes and that delay might have increased the risk of testicular cancer.”
“Ok so supposing there is no genetic basis and the testicles in the belly did not influence this, what else could cause it?”

We lay down the premise and expose the random residues of thought only to find that these are but, the best laid plans, that they are subject to scrutiny, to exposing unintended consequences like swarms of bees flying out of the hive stinging every thing in their path denying accuracy.

The cream colored doll opened. ~ The Second Undress

“There is this Sporadic issue where the researchers feel that a hit on the cell deranges the genetic structure and that propagates the cell growth.” I figured with his intellect, why not give it to him in his lexicon.
“You mean like kick-it-into-action?”
“Something like that.” I replied.
“What’s a hit?”
“You know our bodies are bathed in gamma rays, right?” I replied.
“Yeah. I read that in physics.”
“You also know that there is radio-active Radon gas that is the radioactive decay product from Uranium and Thorium, which are resident in the earth and this Radon gas permeates through the ground, right?” I looked at him. He was, all ears, focused. “And you also may have heard that Radon exposure is linked to Lung cancer. Right?”
“Uh huh!” His eyes bubbled over, wide as saucers, I had ventured into his territory somewhere.
“Ok. Well there is a belief that our DNA gets about 10,000 hits every day on every cell.”
GRB (Gamma Ray Burst)

“Wow!” he paused, “Go on doc.”
“Most of those hits are repaired by the evolutionary survival kit we all have called, DNA Mismatch Repair mechanism. This weeds out the cells that have taken a hit, by fixing them or throwing them into the junk pile for recirculation of the material contained within.”
“And if the cell is not repaired…?”

Now the generalizations were generating new and complex responses that might create an embargo on optimism. Confidence seems concerned as it stands at the threshold of a vast open space.

The pink colored doll opened. ~ The Third Undress 
Mismatch Repair Concept

“The cell still has other mechanisms that can prevent it from becoming cancer.” I replied.
“What’s that?”
“It’s called the p53 gene and protein product, which prevents bad cells from multiplying and termed the “Guardian of the Genome.”
“So then I might have taken multiple hits from the gamma rays, My DNA mismatch went out to lunch and the p53 was sleeping?”
“Maybe. This is all conjecture, based on known science. None of this, some of this or all of this could be the case, we can never know, only postulate.”
“What other reason could there be?”

Speculations grow, through division without reference to rule. Only the well-devised and validated experiment could be grasped in the simple fractal that makes the whole mosaic of this complex field of cancer seem elusive.

The dark maroon doll opened. ~ The Fourth Undress

“There are these “jumping genes” and micro-RNA that have unfolded a whole new molecular aspect of science that can be the causative agents. For instance the Transposons or "jumping genes” as they are called, jump indiscriminately around the DNA linking with other genes that they can in turn, enhance or promote like for instance the cancer producing gene, or suppresses the activity of a tumor suppressor gene both events can lead to unmitigated cell growth.” It was interesting to see his eyes reach out into the far reaches of his mind. He would look upwards and to the right when dealt with an onslaught of new information.
“What is the function of these jumping genes?” He asked quizzically, transformed into a student eager to learn, absorb and digest.
“Evolution.” I replied.
“How so?”

The theoretical nuance that underlies each current of thought ebbs and flows to the very premise of unity, the singularity where all dimensions coalesce. Can we then reach the promise land of all singular truth?

The blue colored doll opened. ~ The Fifth Undress

Senescence has no function--it is the subversion of function. ~ Alex Comfort.

“The evolutionary function is to keep modifying the genome to transform and protect the individual carrier (person) from maladies.”
“Oh the Soma Theory.” He said quietly.
“You know about that?” He nodded. “Something like that, only in Soma Theory the premise of Weissman and Kirkwood was that constant repair to protect and promote health leads to the disposability of the living body via senescence, but for our discussion, the purpose is that the DNA is a built in laboratory that experiments on a steady basis. It keeps trying through generations to come up with protective barriers against invading agents like viruses, for instance some African Americans are born with a disease called Sickle Cell Disease,” He nodded with knowledge, “That was a DNA mutation to stave off the attack from Malaria.”
“I read about Sickle cell disease and Malaria in biology, but didn’t know the connection. Wow!”
“Good for you.”

The panorama that unfolds is but the childish dream of idylls. We venture, we express, we learn and yet even with all the approximations of our accuracy we remain innocent of the real truth.

The little grey doll opened. ~ The Sixth Undress

“This is good doc. Can I ask you just a few more questions?” The nurse peeked in the door, placing her index finger on her wrist where her watch should have been, informing me about delays for the other patients, who were waiting.
“Sure.” I said, this was fun for the both of us and waved off the nurse with a acquiescing nod.
“What,” he asked and then held his words in that silent pregnant momentary pause of thought, “makes it spread, as in my case, to the abdomen? There is no direct connection?”
“In your case via the lymphatics. These are…”
“I know those channels that drain lymph. Yes I read that.” He paused again, “Aren’t there mechanisms that prevent that?
“Actually there are. The cancer cell to spread has to go through a lot of hoops to get there/”
“Like what?”

We live on an orb yet we approximate everything in triangles, rectangles, squares and cubes. We devise mechanisms to study the orb yet always seem to add more digits to the pi in a never ceasing battle to conquer- 3.141 goes on for trillions of units towards infinity, wherever that is. Knowledge never ends, understanding does.

The littler green doll opened. ~ The Seventh Undress
Cancer Cell

“Like, the cancer cell has to spread towards a lymphatic channel or a blood vessel. And to do that it needs nutrition. So it throws out chemicals that make the blood vessels come to it. Then it has to circumvent the local machinery of tissue cells and turn them into “turn-coats” using a mechanism of EMT (a phase-transition) that leads to liberation of more chemicals from these “turn-coat cells”. These chemicals poke a hole into the network of normal tissue cells, breach the wall of the blood vessels and the cancer cell motors through.”
Cancer cell acquiring blood via VEGFs

“So then it can go any where and set up shop. Right?”
“Pretty much, but here’s the caveat. It isn’t that easy. The cell has to find a safe harbor. It has to attach itself to the inside wall of the vessel and then poke a hole there to get out and start the process anew. There are many chemicals that come into play secreted by many different cells under command by the cancer cells.” I stopped to find a metaphor. “Did you see Die Hard part 4?”
“Yeah. I loved it.”
“The bad guys taking over the command center to do their mischief. Same story here.”
“I got it.” His awareness was self-evident.
"But the good guys are ever vigilant!" I finished, leaving a trail of scent for him to sniff.
"Who are the good guys?"
"The Immune cells. These are the bread and butter of our defenses after the genetic machinery has failed. We are endowed with the liberty to enhance our own immunity with exercising good health or conversely diminishing it with confrontations like; stress, smoking, drinking, obesity and other chronic diseases. The choice is always ours to fight the good fight with the best of defense."
"I get the message doc!"

We both sat in silence for a while. I knew his mental gears and levers were clanking away in full fury. His eyes were frozen in thought momentarily. He looked up, smiled and then asked, “What’s my future?”

With the sails filling with the sudden breeze, the great ark of understanding rocks and is in motion.

The infant appearing doll revealed itself. ~ The Eight Undress

“Excellent! You have a 98-99% chance of living to a ripe old age.”
“Really!” Ever seen a 27 year-old transform into a 15 year-old? I did, with delight.
He got up and gave me a hug. A tear bubbled up in his right eye teetering on the edge of his youthful embarrassment but his inner discipline held firm.

He is, happily married with three of his own children, a philanthropist, by desire and wealthy by trade.

The life-journeys that we take or are forced to take build our innate character. They make us stronger. Give us discipline. Free us from smaller irritants in life and make for a joyous living.

Live long my dear young man and enjoy the fruits of your labor, your children and theirs.

But this is human life:  the war, the deeds,

The disappointment, the anxiety,

Imagination's struggles, far and nigh,

All human; bearing in themselves this good,

That they are still the air, the subtle food,

To make us feel existence, and to shew

How quiet death is.
John Keats, Endymion, Book II, l.153-159.

Sunday, January 8, 2012

Medicine is Killing Doctors

I looked around and didn’t see anyone, so I kept walking.
I stopped and turned around and there about ten car-lengths away from me was a figure dressed in a yellow sweater and blue faded jeans hailing me with his left arm. I looked behind me to make sure it wasn’t for someone else. There was no one behind me. I raised my hand half-heartedly, not knowing, who this person was.

Now before I go revealing his identity, let me take you back a few years. On a bleak winter’s night, I had just gotten into the hospital parking garage and was looking to where, I had parked my car, when I saw my friend, a surgeon lean against the support column. He appeared to be in some distress. I rushed over to him,
“Everything OK?”
“Yeah, I think so?” that did not sound reassuring. Needless to say, I walked him back into the hospital and settled him down in the ER. Called the ER doc and have her evaluate him. His blood pressure was 190/100mm Hg, pulse rate in the 100s and his EKG showed high voltage activity. He was exhibiting all the signs of stress; the reddened face, the slight tremor of his hands, dilated pupils, sweaty palms and all the rest that goes with fight, fright and flight. A little help from his friends and in less then an hour he was back to his normal self. Of course he 
would not stay in the hospital, “God forbid!” as he put it.

The next morning, I met him walking into the hospital deep in thought, for a surgical case. He was back to his calm self, we both mumbled a hello as our paths crossed and off we went onto our respective playing field. That very evening a similar episode happened with another physician friend of mine, only, I was not present but was alerted by the ER doctor.

And then, just like the day turns into night and leaves all its glory to fade through twilight, without any prompts or prior warning both of these friends retired immediately after those episodes. Neither declared the day of the retirement. They just upped and left the workplace. Gone! No farewell parties, no reminiscing, just, gone!

I remember the last time I had seen the surgeon, his face was a veritable topographical delight for furrows and frowns and crows feet. His shoulders were slightly hunched and the eyes sunk into deep orbital havens as if sheltering from the harsh light of reality. He was as I can remember then, around fifty-seven years old and one of the best surgeons in the entire county, if not the state. It was known through the hospital that his hands were “golden.” His success rate was in the stratosphere in surgical circles and his complication rate was non-existent. He was a surgeon’s surgeon. And yet with all that past success and promise of the future, he just left one day and I had not seen him since. I had missed him as a friend and for his expertise.

Now getting back to my story...

The image got larger and larger as the man hailing me came nearer.
“What, you don’t recognize old friends anymore?”
It was him! He looked like a man in his mid forties even though a decade and a half of time had passed by. The frown lines were gone. The eyes sparkled with a sense of self and purpose. The face was weathered, yet  bereft of the deep furrows of yesteryears, from the sun and his shoulders were broad and his spine erect.

“Wow, look at you,” I said, “which plastic surgeon are you hanging out with?” I hugged him and we sat down on the nearby bench. “Golf, a good life, family and grandchildren!” was his answer. We chatted awhile and he told me that he was working in another state, but not as a doctor. We both filled each other’s cup of life with the time spent away in each other’s absence and then he said to me the few words that have been tattooed in my mind. “Medicine was killing me!” I shared with him, the state of all the friends he knew and told him what had happened since he left; we had lost a brace of kinsman to heart attack. Some, I said, have been lucky undergoing coronary stenting of they’re 99% occluded left main descending artery (“The widow-maker”) while other’s less fortunate have died in restaurants or in transit. Majority of the coronary events seemed to have occurred on Monday mornings and most en-route to the hospital. His face seemed to weather the information with some difficulty as memories flooded. Yes, he was lucky. I saw the wisdom of his action settle its weight on him. “Auld Lang Syne” played silently somewhere and a friendship was rekindled.

As physicians we dwell in the world of people stricken with maladies that we try to fix. Much like the watchmaker with his tools fixing the intricate wheels and gears within, only we as physicians deal with animate objects, humans. The complexity of the situation and the constant alertness to detail causes a flow of blood humors that are evoked in a persistent state of agitation. The stress of it all is recorded on the cellular machinery, it gets imprinted into the DNA that fabricates cytokines, modulates immunity and forces all humanly self-protective measures to its knees. Each little bit of a runaway infection, a bleeding blood vessel, a malfunctioning kidney, a confused brain, an intemperate heart with its dissonant sounds and rhythm, the failing liver, the watershed moment of an electrical storm, the clouded vision, the obstructed respiratory passages, the uncontrolled sugars and the unregulated electrolytes, the vanishing blood cells or the Armageddon of the wayward leukemia and cancer cells, chip away at the physician’s inner reserves. And yet not only does he or she bear the brunt of this vocation, there are a multitudes of other externalities that constantly harass and harangue the beleaguered doctor. This then is the vice in the virtuous field of medicine.

Yes! Medicine is killing doctors.