Medical essays

Isocrates, Milton, Osler, and the Internet

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Democracy destroys itself because it abuses its right to freedom and equality. Because it teaches its citizens to consider audacity as a right, lawlessness as a freedom, abrasive speech as equality, and anarchy as progress. Isocrates, 436-338 BCE   

Some 2360 years ago, Chios, Cos, Rhodes, and Byzantium bolted from the Athenian Confederacy over abuses of central power by Athens. Isocrates wrote a long essay urging peaceful resolution of the conflict. It was surely not delivered orally for the reasons he mentions in the opening paragraphs:

“…you do not hear with equal favour the speakers who address you… while you give your attention to some, in the case of others you do not even suffer their voice to be heard. And it is not surprising that you do this ; for in the past you have formed the habit of driving all the orators from the platform except those who support your desire …you ( cause them to say) not what will be advantageous to the state, but what (pleases) you. …how can (we) wisely pass judgement on the past or take counsel for the future unless (we) examine and compare ( opposing ) arguments? …although this is a free government, there exists no ‘ freedom of speech ‘ except that which is enjoyed…by the most reckless… .

It sounds very 21st century USA, doesn’t it?

Fights broke out Saturday during pro- and anti-Trump protests in Berkeley, California.

February 1, 2017 - Berkeley, California, U.S - Anti-fascist protesters dressed in black arrive at a protest on the University of California-Berkeley campus against Milo Yiannopoulos, a Breitbart writer who has grown notorious for his comments targeting women and minorities. Yiannopoulos was scheduled to speak Feb. 1 at the invitation of College Republicans but he left the campus an hour-and-a-half before his scheduled talk as protesters grew unruly, throwing objects and setting off a bonfire

Anti-fascist protesters using “black bloc” tactics – covering faces, dressing in black – arrive at the protest last week.Jeremy Breningstall/ZUMA

 

In the mid 15th century, thanks to the printing press, common people began to acquire printed material containing ideas or knowledge formerly limited to wealth, state and church’  which were joined at the hip. Later, In 1522, Luther published the bible in vulgar German, instead of Latin, making it widely accessible for the first time. Over the next hundred years wildcat or unschooled publishing exploded, causing rulers to fear a access to information- arguably knowledge- putting power in the  hands of a gullible and ignorant public. In 1641 Britain–to protect the public (of course) !– made all printing illegal without prior official approval. Two years later a defiant John Milton published Aeropagitica, a title he adapted from Aeropagitcus, where Isocrates urged the revival of the Aereopagus, a court to control education of the young and public immorality.

Since the1990’s the internet has become exponentially available to an entire world. Authority is challenged or attacked by unschooled, unapproved wildcat non line e.publishing that is consumed by an awakened, restive national and transnational public. Free Speech is again so intolerable that Isocrates’ stale words echo down the hallways of time, and it seems clear that –again– civil dialogue and speech are true lies that recur throughout what we call history. While in the past, technology driven change required centuries to come to a boil, this pot took only a few decades to boil over.

I try to believe our little e.fire  will cool down, that we will control the pot of the e.verse. Yet it seems even more techno-crises are almost upon us: artificial intelligence; bioengineering; bioprinting; robotic automation and their spawn; Mars; and driverless cars (though two story high trucks of open pit copper mines in Chile have not had drivers for many years.) I was once an arrogant little pilot, like so many physicians who fly and sometimes die. But long ago on a several week trip to Punta Arenas, on the straits of Magellan,  I found that even a simple array of instruments was a better pilot than I. Therefore, thinking of the unknowable,  which is now seems almost everything ahead, I know that–looking back– my greatest good fortune was to become a physician, not so much through merit as luck, and the influence of a friend. To study my physician predecessors and colleagues is to move outside my own limits. It reminds me of this from Empedocles:

The nature of god is a circle of which the center is everywhete and the circumferance is nowhere—!

and this from Mathew Arnold’s Dover Beach:

I say: Fear not! Life still
Leaves human effort scope.
But, since life teems with ill,
Nurse no extravagant hope:
Because thou must not dream,  
thou need’st not then despair

So today, wanting a dose of something other than alcohol, I pulled down Osler, but quickly put him back, in favor of pulling him up : such is the joy of a browser! Aequinimitas was his valedictory address, University of Pennsylvania, May 1889. He spoke of the physician’s need for equanimity:

 “ clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm.”

Phlegm! How choice a word for equanimity that is! He continues in that grandiloquent elite euro-greco-roman slang :

“in the Egyptian story…Typhon with his conspirators dealt with good Osiris; …they took the virgin Truth, hewed her lovely form into a thousand pieces, and scattered them to the four winds; and, as Milton says, “from that time ever since, the sad friends of truth, such as durst appear, imitating the careful search that Isis made for the mangled body of Osiris, went up and down gathering up limb by limb still as they could find them; We have not yet found them all,”

And there it is again! The quote is from Milton’s ...Areopagitica! 

 

The Areopagus as viewed from the Acropolis.

From a Troubled Knee

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To a Surgicenter and KP:

          For listening

For hearing,

For lovingkindness

 And skillful doing:

         From the first step

off the gurney,

to the very last,

I’ll remember you,

        The skillful people,

whose kind attention

was gently lavished

on a troubled knee,

        Who slept on attic floors

of Alta Peruvian Lodge

doing light work,

to ski free that Spring of ’53;

         Was injured in a fall

leather strapped to 7 foot boards

with strips of metal

screwed to the edges;

         Who since those days

went many mountain miles,

but often effused complaints,

until it could do no more.

       How is it, Dr David,

that so many people become

a selfless, seamless whole

at a  Surgicenter,

       To give a stranger’s knee,

A second chance to ski,

lead pack llamas up trails,

bike, or walk the city,

         When the mother country

burns with uncivil warfare,

enraged by opinions

not our very own?

        This old knee

doesn’t give away

it’s private opinions,

except only to say:

       From the first step

off the gurney,

to the last off the earth,

… Thank You.

A Return to Panamà and Pànama after Fifty Two Years:

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Panamà…  as we pronounce it would be Pànama… is a metaphoric  inversion expressed by  the different accents.  I first went there as an  intern in 1954-55,  not yet age 22, interested- vaguely- in tropical medicine but more concretely in adventure. Among my 8  colleagues,  half  were preparing for missionary work,  one for public health, one for psychiatry.   Before 1903, Panama was an  isolated part of Colombia, an oligarchy run by four or five families.  It was inaccessible  by land across the Darien.  The  current sometimes road, actually highway 5,  or the Pan American Highway,  is still  often  impassable.

A canal had long been considered to facilitate travel between the Atlantic and Pacific, which required a long sea voyage around Cape Horn or difficult overland  Balboa took across the isthmus of Panama.  A French venture acquired permission to build the canal under the direction of  Ferdinand deLesseps  ( Suez Canal,  desert, flat,  no locks). He wanted to cut a similar sea level swatch across Panama. 40,000 French (and French colonials)  died there due to that  miscalculation,  graft, malaria, yellow fever, poor nutrition and dysentery; it was abandoned.  But in 1903  the US  felt it could big crazy things. Teddy Roosevelt tried to arrange a canal treaty with Colombia and failed. But because of the isolation of the isthmus from Colombia the locals felt like colonists, and resented their voiceless circumstances and  distant and neglectful rulers, like the rebellious British Colonies  in North America.  They  found common cause with Teddy Roosevelt who wanted a canal, and revolted, assisted by U S  gunboat diplomacy.

 

The US Canal Zone  was about 10 miles across and some 50 miles long. Panama is Water, and water is the Power that could  operate the locks of a  canal.  A dam was required to store that water, and also control the swampland created by the ever flooding Chagas River; and thereby  to control mosquito borne diseases.  Incredibly the huge project was completed by 1914!  The original locks still operate unaltered, today.

 Overall, The US Army Corps of Engineers and Black Caribbean laborers really did the heavy lifting: John F. Wallace conceived the engineering of the canal but became a victim of the terrain, disease, and the political bureaucracy; he survived there for less than one year. John Stevens, a famous civil engineer,  took seriously the yellow fever/malaria problem. The largest earthen dam ever built controlled the Chagas River, and drained the swamps; which controlled the mosquitoes, malaria and Yellow Fever, and provided the gravity flow water power to operate the canal locks. Col. George Washington Goethels was finally  given unrestrained authority, and was able to complete the job over the next 7 years. William C Gorgas, a U S Army physician who understood the relation of malaria to mosquitoes, convinced the Army to drain the swamps, making it possible from a medical standpoint to build the canal. A second canal was started  but abandoned because of WWII;  now it has been completed, arguably  by China, who also had studied the  sea level alternative as across Nicaragua but abandoned it.

In 1954 the canal was still operated by the US civil Service.   There was segregation of several  sorts.  First, upper level administrators and U S military had the option to  live on base, with typical military housing and   commissary privileges with access to US goods and food.  Most privileged long term US citizen employees of the Canal Company lived in bungalows.  Second,  short term US citizen employees like MD  interns, lived in curious multi family wooden apartment buildings, each apartment located upstairs from a parking area below.    The apartment buildings were oriented with long sides facing the sea breezes.  They were two story wooden structures with space for parking underneath, and 12 ft high ceilings. There were no internal doors;  the  kitchen, dining and bedroom were in one  line so that that the sea breeze, could flow through open screens placed above 8 ft.  Each apartment had a bathroom off center and a  heat closet to keep clothing dry.  Construction was so light that people learned to speak quietly, even quarrel in harsh whispers. Sexual revelry was often audible, though as invisible as  the morning alarm clock,  flushing of toilets. Notice the 6 ft eves,  a traditional style there. In the city they offer much needed shelter for passersby on sidewalks but shoot waterfalls out onto cars in heavy rain.

When I was there in 1975 the buildings were scheduled to be torn down. But the location was ideal, and all the infrastructure already in place. They were acquired somehow and have been gentrified, rebuilt so nicely that the  old structures can hardly be seen. In the photo above, some of the screened breezeways persist. The open lower floor also is still there, but made into a living area, like a covered outdoor garden or patio.

The third level of segregation was provided to ‘local raters’ whose situation devolved from the building of the canal.   The US Army had recruited English speaking workers among blacks of the Caribbean.   Communication was more practical in English, and the work performance was superior to indigenous workers. ( Only the Spanish had managed to induce los indios  to work through a brutal choice made clear in a statue at a Mission in Baja CA: a priest holds a bible in one hand and a skull in the other. Believe or die. Work now to live, and die for the glory of God and the Catholic Queen. But the Caribbean blacks were different, perhaps in part because, though paid less than US citizens, and they had significant inducements:  Local raters’ were provided decent livable wages,  living quarters, medical care, and allowed to buy US imported  goods at a reduced rate from a local rate commissary.  In the long run, however local raters felt abandoned after September 7, 1977, when  President Jimmy Carter gave the Canal to Panama; a long standing local resentment of blacks with special privilege boiled over. Soon many ex local raters had nether  job, nor any apparent citizenship.    Yet there was, and is, a  Black American Atlantic Coast and black Carribean island archipelago; it may be largely invisible to most of us in the USA, though it consists of many black communities which are the source for much unique American and Brazilian   music, art, dance, custom, and language.  Therefore, the abandoned  black local raters of Panama, did not live in limbo; they have adapted or relocated. It’s instructive to kindle and google the many American Black authors, and the Quaker beginnings of the emancipation movement. The very first American revolution was black: Haiti. * Like most US citizens I  often focus only on the Northern Hemisphere.  We tend to forget that we are  all Americans: one continent, one hemisphere,  with a shared history, indigenous, immigrant past, and present.

We visited Panama City in late 2016. Much has conspired to make it the commercial and banking center of South America, rivaling  Miami. The canal was gradually  and totally transferred to Panama  control by 2000.  Panama has  retained the $US as their currency, which stabilized the economy; despite many problems it became a place where people with means could find refuge from chaos at home, or for various thieves to hide money, including drug money.

The former head of the militarily, Manuel Noriega, a cooperator with the CIA, became de facto dictator and drug lord .The US invasion to depose him in 1989-90 was  complex, while brief was a real war that has left a shambles of Noriega’s base of operations still unpaired.  And the whole episode has became the source of many true lies:  afterward there was an election at the insistence of the US; but the winning candidate was assaulted and Noriega declared the election null and void.   While US invasion was widely supported by the populace, it was  real warfare against a well prepared military,  deadly and destructive. It was hugely condemned, as customary, in Europe and the UN;  The Panamanian military was dissolved.  However, the emergence  of Panama as a commercial and banking center, and a repository for suspect money, continued.


The second canal has been completed, financed largely by the Chinese. Transit fee $100,000,000. A Trump hotel, shaped  like a huge sail, looks like a twin to one in Dubai. A metro was completed last year.

.

 

Upscale barrios and yacht harbors, continued to appear.   Old is being gentrfied, the president lived there near a fast growing tourist area, and expensive restaurants  flourish. As to the currently  strong US dollar, Panama is something of an exception,  comparable to Chile.  Most other countries today are,  by comparison, a bargain. But it is a good place to visit, safe for the average sane foreigner, usually cool at night,  when the ocean breeze is up.   In the 50’s that meant street dancing to Lucho Ascarraga’s wild electric  organ: Cha Cha Chas, with  typical flat foot moves,   keeping the  whole foot including the heel on the floor and moving The Rest… none of that  heel-high stuff.  That, happily, is the same today.

Ancon Hill is the highest spot overlooking the Pacific entrance of the canal, with old gun embankments at the top,  set among tropical forest. Several hundred yards down hill is the site of  Gorgas Hospital where I interned in 1954. My oldest daughter was born there, delivered by a descendant of one of the founding families.

My Grandparents, Leon and Anna founded the Methodist church just at the edge of the Canal Zone. It was built and supported by the North American population of the Zone who operated the canal, and large number of military people who guarded it.  But when the canal was given to Panama that U S  population very quickly disappeared. The old church is imposing, but obviously neglected now. There was no pastor, but we spoke with a woman in the parish and she took us inside the elegant but sad  and  tired building.

 

 

We visited the site of the old Gorgas hospital, of French design. It had a stolid central administration building surrounded by a series of white one story buildings  in colonial French style… a series of medical units, white wooden buildings with 11 foot high ceilings where the top four feet were open screens. The units were interconnected by covered walkways among sculptured tropical gardens to allow for air circulation. How well I recall doing a femoral stick on babies or spinal taps, sweating in the humid night air. At least that is the way it all comes to my mind; it is all gone.  One wing of the admin  center where interns stayed and sometimes slept during 36  on and 12 off shifts looks down darkly past the  surrounding neglected  padlocked wire fence strangely dressed in banners left over from some event.  No one was around to ask if we might go in; and yet that seemed a small loss. I didn’t  much want to view the corpse from the inside.


Otherwise, Panama was no corpse, but alive and well.  

 

Even most of the relics of Old Town were full of color and life, on the way to being restored.  thier roof still extended out 4 feet over the sidewalks and balconies to shelter people from the rain.

 

And the restoration was everywhere evident as well, set among the colorful lives of a small rich country whose future seems bright.

 

 

And we pretended to be rich turistas nortamericanos:








 

 

 

*You may want to kindle and google the many black  authors of the Americas,  the John Woolworth and the Quaker beginnings of the emancipation movement, and the first American revolution, which was black: in Haiti. Like many US citizens I  often focus only on the Northern Hemisphere.  But we are Americans: one continent, one hemisphere,  with a shared history, indigenous, immigrant past, and present.

* * There is a  645 pp third edition of a book Americas by Peter Winn. But frankly, it seems to me  simply a compulsive compilation of the ‘news’ we read in the US. Whenever the author treats places and peoples I know very well, the omissions and commissions of errors really rankle me terribly. My bias is this: The record of a people and a time are found in between the lies, and lines; and in fiction, poetry;  in other words in Literature. Usually what we call News or  History is moribund  fiction without flesh or soul.

 

A Modest Proposal* on Diabetes Detection and Control

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Self Management of Early and Silent Diabetes or Pre-Diabetes

Colonet is an inland town of about 2500 in Baja California. I have gone there four times with my daughter Amy and the Los Gatos Methodist Church to build small houses. They have now built more than 40, generally during Easter vacations so school children can participate. There are two doctors offices and two pharmacies in the tiny  town but it serves a wide local area; ‘universal care’ is available at a government clinic staffed – in a common South American way –by a recent medical school graduate who must pay back year for year of medical school by staffing several remote rural clinics; he is there only a few hours each week, so people line up at 4 AM for one of the few openings. Otherwise they must see a private doctor at about US$35 a visit. For those who have a job, the average daily income is about US $10 per day, but work is not available year round. The nearest hospital is 60 Km distant.

It may seem surprising, but the area is highly agriculturally productive. The largest tomato grower in the world is nearby. The Driscol strawberries we buy here are grown in the region. Why? It sits between the ocean and the Sierra de San Pedro mountain range that reaches up 10000 feet to suck in winter  rain, allowing for irrigation like a tiny San Fernando Valley; water and sun and hard work make it productive. Migrant workers, often speaking no Spanish, invade for harvests. This year it rained a great deal and the area is lush with small blossoming plants and green with bushy growth.

The local Christian Church has been very helpful in building the small homes. They often help people to acquire a tiny  plot of land, which is a required, as well as someone in the family with a job. The pastor’s wife has diabetes as does her mother and their four year old  daughter;  they assisted in preparing for a series of evening diabetes screening clinics during my week there. The disease is so  common that among the first 20 people screened ( excluding the pastor’s family)  9 had diabetes or pre-diabetes.  Below is the translation from Spanish of the written introduction  and information that was given to people who attended the screenings. Of course, the problem is obvious: When you find a person with diabetes, under these circumstances what do you do? I believe self management is the only realistic, timely, and practical option. To make that sort of thing work, it is best for small groups of people with diabetes to work together over time to solve problems like Where to find medications and supplies most reasonably; How to measure and keep track of glucose levels; How to safely adjust medication in view of the results. The pastor  has an internet connection. It is a long and twisted road, but one that otherwise most Colonet people with diabetes travel alone. What follows below is information  provided at the screening clinics, addressing the screening process, the general nature of the disease, glucose self monitoring, and possibilities for  self treatment. It is translated and redacted  from a Spanish blog.

###################################################################################################

RAPID SCREENING FOR DIABETES AND PRE-DIABETES

Blood glucose is measured about two hours after a sugar or starch rich meal.

Diabetes Positive Screening test:

  1. Any blood glucose level above 200 mg/dL at any time, including the
  2. Challenge test: Blood glucose above 200 mg/dL 2 hours after a sweet or starchy meal
  3. After 10 hour fast: any blood sugar over 125 mg/dL

PreDiabetes Positive Screening test:

    1. after a  10 hour fast: blood sugar 100-125 mg/dL
    2. 2 hours after sweet or starchy meal blood sugar 140-199 mg/dL

 Conversions between mmol/dL  and mg/ dL  here

Screening tests are highly suggestive but not diagnostic. When positive, reconfirm whenever possible, with a qualified laboratory and physician.

 These screening tests are valid at all ages.

Diabetes has serious complications, all caused by elevated levels of blood Glucose (sugar). In early years the disease is silent. One feels fine while high glucose levels destroy the most delicate but critical circulation in the kidneys, retina of the eyes, feet, and elsewhere.Fortunately we live in a time when prevention of that damage can be  effective, and simple. But only those who have or who discover their  disease can successfully treat it; especially those with the most common kind:  silent diabetes. To do that the disease must be revealed… diabetes diagnosed if present,. , and then controlled by:

      1. Using a personal glucose monitor to keep track of blood glucose levels
      2. Measuring and recording glucose levels
      3. Learning to manage the illness… i contend that is best done as a member of a small group who regularly share their experiences and information.

Some may wonder why it is essential or practical to self control and self manage this particular illness. Although it can best be done with the help of a physician, only the person who has this disease can do so. Physicians cannot hang around 24/7. The time a physician can actually help most is after the disease had done so much damage that a foot has to be cut off, or a kidney replaced: too late for prevention. A competent physician welcomes self management of early or silent disease. All this may seem complicated, but it becomes quite natural quickly when the diabetic can:

  1. measure, blood glucose, record the result, and then
  2. use the results to manage and control the disease
  3. share results and experience with others who have diabetes for: a) interpretation of results; b) finding sources for test strips, medications or professional advice;c) understand medications and ways to manage it. For example, glucose monitoring is crucial, but very expensive. However, an hour drive away is a large international chain store where  costs for glucose monitoring supplies are: ( US$):  Monitor $  9.00; 100 test strips $17.88; one time cost of lancing device $5.84; 100 lancet needles, $1.84 Total $34.24 , adequate for about 6 months monitoring– $0.19/day! By comparison,  costs where test strips alone are $ .50-.75 each, are many times that depending on how many strips are required.

The personal glucometer (glucose measuring device or meter) is inexpensive, accurate and lasts for years. One must learn to use it, use it regularly and record results and circumstances affecting each  test. . At first it is advisable to measure glucose levels often in order to better understand the illness. Yet because test strip use can often gradually be reduced to as little as 5 or six times weekly, plus anytime a concern arises. For example, one might suspect, for whatever reason, a blood glucose is low, and eat “just in case.” That should not be done: measure, don’t guess!  

 

The blood glucose monitoring record: ( for one month…the first of 30 spaces appear) below)

Date mo/day Time 24 hr Level before meal 2 hours later Useful details like: what was eaten, an unusual event like illness, or any other comment

 

How food affects blood glucose:

Carbohydrates fats and proteins can all be converted to glucose…which  is vital to the human body even if too much is harmful. Some carbohydrates convert to glucose very quickly and therefore are a problem for people with diabetes:

Fast: processed or refined bleached grains like white wheat flour, and white rice; processed fruit sugars (fructose) like corn sugar and beet or cane sugar; starchy vegetables like potatoes and some sweet fruits like peaches, apples, bananas, oranges.

Slow: beans, seeds like most  nuts, peas, lentils, meat, fish, chicken, cream is less fast than milk because less lactose, milk sugar.

Take control of your diabetes when  it is silent and serious irreversible complications are most easily prevented.

You are the only person who can control your disease!

Note 1) Insufficient insulin was discovered to be present in diabetes nearly 100 years ago. Insulin is made in the pancreas; in the most common sort, Type 2 diabetes, the pancreas still can make some insulin, but not enough to meet the body needs; so glucose accumulates. The disease  usually gets worse with time– especially if not controlled well. In type 1 diabetes almost no insulin is produced, and that is a different but related illness.

Note 2) Fasting blood sugar— after not eating for about 10 hours– can be deceptive in Type 2 diabetes because the pancreas has been resting (usually overnight) making enough insulin to keep blood glucose levels normal or nearly so.

Note 3) Hemoglobin A1C test: Red blood cells are not alive. They were grown in the bone marrow, and when growth is complete, they are delivered to the blood where they act as tiny carriers of Oxygen. That Oxygen is delivered to the tissues, and the empty red blood cells are sent back for more. They live about 90 days and are then discarded. But when they were being formed they took in the amount of glucose that was in the blood at that time. Therefore, the average glucose level in those red blood cells is a measure of the average blood glucose during the previous 90 days. Problem: both high blood sugars and low blood sugars can be seen in early type 2 diabetes because the pancreas can over react to high blood sugars and therefore over-produce while trying to catch up at night. So an average of high and low glucose can be deceptively normal. Conclusion: a challenge test, similar to the old glucose tolerance test, is superior to looking at averages or fasting blood glucose level. This screening test is significant because it offers a fast, and economical screening that can be done by anyone with a glucose meter.

Note 4) The personal glucose meter was pioneered by Richard K Bernstein, an engineer with severe diabetes working on a glucose monitor for physician offices. His diabetes became so advanced he  began to control his own blood glucose very tightly and began to improve; then he did his own study among students, which suggested a personal glucose monitor was the key to diabetes control.   What happened is classic:The study results were rejected by the academic  medical profession. So he went to medical school and began to practice immediately as a diabetes specialist. His book –The Diabetes Solution- is largely viewable on line

Dr. Bernstein completely recovered on a very low carbohydrate high protein diet and tight glucose control; he suggests an average blood glucose of 81 mg/dL;  he is alive, and lively, over 80 years old. He participates regularly in Teleseminar Webcasts. The March 29 2017 event can be seen  here.

* A Modest Proposal is a 1729 satire by Jonathon Swift: For preventing the Children of Poor People From being a Burthen to Their Parents or Country, and For making them Beneficial to the Publick’. He outrageously suggests newborns be harvested for food to reduce the numbers of poor and also feed the rest. Perhaps the only bearing of Swift’s satire to this little essay is the focus on the millions of poor we seem willing to sacrifice to diabetes, even though it’s cruel, and irrational. and avoidable.

 By working together outside a system that tends to sacrifice the good to the perfect, and by self managing their own disease, people can at least greatly improve their lives and well being. Yet for our world’s millions of unsuspecting pre-diabetic and diabetic people, only those who discover their disease early and begin to self control it can easily limit its ravages. I believe that worldwide– and even in the USA– there are tens of  millions who could benefit from a similar process  until something more academically perfect comes along.

 Even privileged, idealistic and committed people can  become  insensitive, intolerant, and dismissive, based on disagreement about dogma, about the meaning of ideas and words. Words are, after all, only symbols; like metaphors they represent things or ideas usually unseen. When we hear or  read a word, we rewrite it in our own minds. We interpret and give it our own personal twist. When one half of our nation cannot stand to hear or see the other half, because of ideas or words, it would seem wise to ask ourselves Why do  Words Hurt? Why are we so willing to wound  one another? Or to  put another way, Why so terribly thin skinned? Who ever said ‘sticks and stones will break my bones but words will never hurt me’ was from another era; like Swift.

It seems to me more appropriate to think about deeds rather than only  words. So in Colonet this year, I wore a baseball cap with a silent modest proposal written on the face to imply  that :

We are in this together. In this place, this nation, this world. We should try to ‘read’, or value one another for what we DO, not what  we appear to BE: Not color of skin or political affiliation; or religion; or citizenship, or age, sexuality or gender— but rather, our behavior; our acts; and judge ourselves and others as reasonably as our acts allow.

“THNIK”

 

A Lament for P Dog

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Where oh where has my little dog gone; oh where oh where can he be?

With his ears cut short and his tail cut long

Oh where oh where can he be?

Children’s song by Septimus Winner (1827 – 1902)

 

Where O where has P Dog* gone,

Where, O where can it be,

With no ears turned on

My doc can’t talk with me.

 

With eyes on a laptop screen

And hands confined to its keys,

I’m cold, untouched and unseen

paper gown’d at 70 degrees.

 

My provider’s gloves are thick and blue,

We avoid each other’s infections

I find that considerate, don’t you?

Providers too need protctions.

 

But why, why not , touch me

or ask what’s on my mind?

Hear my lungs, tap my knees

To find what is there to find?

 

The EMR holds my future and past;

My imaging, scripts, and labs show

All that matters, first to last

All providers need to know,

 

To fill the blanks on screen,

Clicking each little square

So it can be clearly seen

every code is entered there.,

 

And kindly saying at the door

“See you next month; we’re done;

Your scripts are filled once more

For problems please call 911!

* Archaic: Physical Diagnosis by touching, feeling, listening, and speaking.

Pablo Pavo, Pisco, Guajolote

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What follows is Creative Non Fiction about a  hot air sauna burn in late November, 2016

 

I  am Pablo. I most enjoy those times when I alone am personally responsible for what I do, whether in on a mountain peak, or in an ultra-lite over the Sierras, or a Cessna flying from California to Punta Arenas, Chile. At times, of course, that sort of self indulgence, lust for adventure –  arrogance perhaps- has put me precariously clinging to a cliff face, or flying alone over SW Argentina when it was prohibited by the threat of war.  Similarly, I enjoy dry heat so much it recently put me alone in a sauna, on Thanksgiving day 2016, for between 20 and 40 minutes.  I cooked myself like a turkey. The recipe, or receta para asarse:

Lie down in a hot air  sauna at the highest, hottest level. If you are diabetic and use  repository insulin, which activates more quickly in heat, drink some water often, and eat an apple or an orange every 20 minutes.

I  followed the recipe, but remember nothing after lying down to begin my second 20 minute session in the sauna, until sitting in a wheelchair, confused,  frightened, and hyperventilating, amid  about ten strangely dressed strangers in a strange world who spoke in unintelligible tongues.  I had no recollection of being found unconscious in the sauna or being extracted. I could not formulate my own thoughts, or movement or speech. I began to shiver and have coarse  muscular spasms. There was no pain, but I was angry at having no control of what was happening; about missing the rest of my life; maybe that anger motivated me to mumble some jumbled thoughts that surfaced: though it took me several long minutes to get the words to form, i finally managed to say:

“Diabetes!”   a voice in English said,

“Your blood sugar is 87. You are going to be fine.” Happy to hear a familiar language, I said

“Adrenalin?” The voice said

“ No. ” and after  I insisted on some water with sugar. The voice said “ Your blood sugar is 87. ” I said

“Wet towels, Ice” …The voice responded

“Your temperature is normal now.”” But  then my wife and daughters appeared and got the towels, and gave me sugar water with a straw.  I suggested

“Ambulance.” The voice said

“ It is on the way” I still could not get up or control my movements, and felt hopeless, as if i were sliding into oblivion. But  gradually I was thinking more clearly assuming I was in Sacramento. I began to fear I would live, and be terribly embarrassed when my E R colleagues saw me and learned of my my stupid sauna behavior.

I was lifted on to a wheelchair and for what seemed a very long time was pushed down a long series of poorly lighted bare cement halls and walls, set among conduits, and dark recesses. Then out into the night to be lifted onto a sheet, and then to a cot and placed into primitive station wagon ambulance. I began to recall I was in some other country, but couldn’t recall which: In the ambulance I asked about a place I had been recently:

“ Brazil?” My wife,  Marili answered,

“ Panama!” It all came back to me. I had been  alone in the hot air  sauna of a hotel.   I felt that surely I would need to be hospitalized for some time and said,

“ You go home as planned. I’ll fly back later, or come by helicopter.”

“No, we will not and you will not!”

By the time we got to the hospital, I was fully alert, coherent, and coordinated. The nurse took vitals, did an EKG, asked my name and birth date, asked the litany of questions about illness, medicines, and allergies, and drew blood with some difficulty due to collapsed veins. The Dr. repeated the same questions, checked my coordination and strength. My Family Angels were allowed to be with one at a time. Lili asked about an MRI, because it might be possible I that I had a stroke or a fall with injury because  found unconscious  with strange lower extremity injuries. And though the Dr. said there was no need, and I agreed, the universal rule prevailed: when a test is possible and suggested it must be done. In short order the  normal labs and MRI results were back, and I was released. The Dr. explained that I had minor first degree burns. Obviously neither of us knew much about Hot Air Sauna Burns* at the time. We paid the $753 bill, of which more than $400 was for the MRI.

As I write it is six days since trying  to cook myself for Thanksgiving; I am now guardedly thankful to be alive, and in relatively human condition. It was at first curious that most of my  injures were below the knees; it became clear they were not abrasions, but: Bullae! Blisters. The skin is cooled by evaporation of sweat and by cooling from blood circulation; because circulation is less in the lower extremities by comparison to the rest of the body, both circulation and sweating are decreased there… more blistering or burning result. Deep partial thickness burns are  very tender to touch . They can look something like the skin of a turkey leg that begins to blister as it cooks. On standing up the pressure increases immediately and for about 10 min causing pain. very pa. Yet after lying down again they become more tolerable.  I lie about a lot. The deeper ones form an eschar… a leathery covering that must be scraped off to allow healing; that eschar removal process is almost beyond tolerable, but smaller wounds like mine are not worth the risk or trouble of anesthesia. When being cleaned up I despair about the purpose or significance of life.  On the other hand, yesterday I was able to do a half hour of upper body workout and a half hour of elliptical trainer. I should be healed within a few weeks, though full recovery will require several months, and resolve to avoid hot air saunas from now on.

Sinceramente,

Pablo

* two links on the subject:

file:///C:/Users/john/AppData/Local/Temp/Hot%20Air%20Sauna%20Burns-Review%20of%20Their%20Etiology%20and%20Treatment-3.pdf

  •  Virve Koljonen, MD, PhD Summary  from ResearchGate  \

Hot air sauna burns (HASBs) are rare but potentially fatal injuries with simultaneous rhabdomyolysis. The mechanism of HASBs involves prolonged exposure to hot air because of immobility. The burned areas are on the parts of the body that are directly exposed to hot air. This type of heat exposure results in a complex injury, in which full-thickness skin damage occurs concurrently with deeper tissue destruction. Sauna bathing is becoming more and more a popular recreational activity around the world. The objective of this review article is to familiarize burn care specialists on this unique and clinically challenging type of burn injury and to illustrate our department’s long experience in treating.

http://www.fox5atlanta.com/news/46530497-story

Book Review When Breath Becomes Air

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When Breath Becomes Air

by Paul Kalanithi

Forward by Abraham Verghese

ISBN 9780812988405 Random House, New York 228 pp

This author takes the reader with him through the terrible transition between his very ambitious and successful early life to his death as a 36 year old man– who gets lung cancer in the last years of his neurosurgery residency at Stanford. He had originally wanted to be a writer, but chose medicine instead. Yet he is still also a writer. As physician readers and reviewers, george meyer and I walked his walk not wanting to put the book down until the last word. Though Paul was unable to actually finish his book, he takes the reader to the point where he loses the ability to go on. His wife, Lucy, an internist whom he first met in medical school, provides closure in a touching epilogue.

The story begins at the ending…in the prologue. The author, previously treated for cancer, has recovered enough to nearly complete his 6th and last year of neurosurgery residency, when he develops extreme exhaustion and ominous symptoms. He pulls up and views his own CT scan with

‘lungs matted,… spine deformed, a lobe of the liver obliterated.’

Part I, 100 pages, could be of most interest to the non medically savvy reader. It tells of Paul’s life, from childhood through his years in medical school. Most interesting is that even while young he is concerned about life and death. That interest is sharpened later by patient care and by the death of his best friend. His writing is filled with pithy literary quotes, reflecting his extensive reading as a child and young man; and perhaps, great intimacy with his browser.

His portrayal of medical school and his experiences with patient care will be familiar territory to most physicians, and informative to others. He nicely portrays many of the challenges and contradictions medical students deal with as they progress through their training. Paul talks about the difficulty all of us (most of us) had with our cadavers and of the depersonalization we may develop so we are not too emotionally involved with the bodies we dissect. He describes the struggle of first-year residents who are fighting just to keep their heads above water. He worries that he was on “the way to becoming Tolstoy’s stereotype of a doctor”, dealing with the demands of residency, then practice, filled with the taste and smell of life and death while dealing with the ‘drama’ of the hospital, and administrators. It seems, though, that Paul develops a sense of who he is and what he stands for sooner than many of us do. He professes great sensitivity to patients and their families in the most trying of circumstances. He gets involved…intimately and actively, with patients, something often considered bad form or dangerous.

Part II, titled Cease Not Til Death, will likely be most meaningful to physicians, our friends, families, and other medical professionals. It is headed by this quote from Montaigne:

..to study philosophy is to Learn to Die”.

Paul, the physician, becomes the patient. He describes his years long struggle, both mentally and physically, fighting his malignancy. During a tenuous remission he is able to complete all the demanding requirements of his neurosurgery residency. He writes of the experience during diagnosis, chemo, recovery, mental rigors, and recurrence. Both he and his wife are high powered high pressure professionals, and the marriage is stressful and long distance; yet the cancer changes that, bringing them more together. Paul’s long drawn out dying also intimately involves his oncologist, who helps him consider and make crucial decisions. All their intertwined lives are changed.

This book– short by comparison with so many that are far less informative– is well worth reading both by medical professionals, and by the general public. The former often look into the eyes of death, and the latter will at some time… It seems likely neither will escape life without that encounter.