10 minutes

I got 10 minutes to write this post, so I'm going to ramble. Standard.

The holidays are here and its time to make wishes. Kids wish for toys. Adults wish for either more money or the complete opposite, completely immaterial things like happiness and families*. I want a toy. Enough about me. Lots of people are going to wish for peace on earth. Or for wars to end. Or for people to stop being killed. Etc.

I got a solution.

Shut the fuck up.


No, not you, well wishers. The world would be so much better if people learned that sometimes, you need to retreat to the shut-the-fuck-up box.

Med students know this all too well. If we don't have anything constructive to add to the discussion, most of us will remain in the shut-the-fuck-up box. If only more people understood this and used it. Not that we're an excellent example of remaining in it - most of us come out to say some stupid shit. However, the shut-the-fuck-up box is sacred. Let's look at a few examples.

• Don't know how global warming works and feel like you have to clamor against it? Shut the fuck up.
• Aren't gay and still want to get in the private lives of people who are? Shut the fuck up.
• Want to re-write textbooks to remove facts about evolution without basis? Shut the fuck up.
• Think you can comment on vaccines without a degree or data? Shut the fuck up.
• Think you can comment on anything without a degree or data? Shut. the. fuck. up.

Are you getting the gist of this? Of course there are exceptions. Of course the more people are listening, the more the box matters.


I'd expound more, but 10 minutes are up. I'm going back to my box.**

I spent 5 of those looking at pictures of cats on Reddit.

*: Not a terrible thing to wish for. [forever alone]
**: Actually, I'm finishing up an experiment.

M&M pancakes

At first it looks ok. Plenty of m&ms in the middle. 

Now to flip it..

Easy..

Easy..

Nailed it.

America?

America is a funny group of people. These last midterm elections were disappointing. Vote in the party that is probably not in your best interest! No tax hikes! (except it doesn't apply to 95% of people).

But the even weird part is, they know that. There's this fantasy that they'll eventually start making that much (250k+) and the big bad government is going to take away more than they would like.

And that's the funny part. From time to time, I have the opportunity to work with some amazing people. Leaders in their fields. Movers and shakers. So I ask - why aren't you a mover and a shaker? What happened to you that you couldn't get there? That you look at these leaders and admire them and do absolutely nothing about it? I'm looking at you, physician / businessman / politician admiring populace. What stopped you from becoming what you admire? What's stopping you now?

"I'm not that smart."

"I can't devote that much time to it."

"I can't go to school for that long."

 "I didn't get the opportunity."

"Look at their schedules, they have no off time."

and more.

And what makes you think the same reasons won't hold you back from getting into that highest tax bracket?

You chumps.

GOP tax policies aren't going to affect me. In fact, things will stay the same if they get their way. But if Obama-care is repealed and I lose my health insurance, then go fuck yourself, everyone who actively helped that happen.

BLS

I donated platelets about a week ago.

Blew a vein.

It has been an epic evening.

"Eye of Jupiter"

and

Chicken with peanut sauce

A few pictures from lab

Lady Research smiles again.

Now that she has lifted her 1 week long nazar off my work and I found my swim goggles again and I'm sitting in a Starbucks sipping a iced green tea while listening to Led Zeppelin, I feel like a million bucks. So I'll tell you a story.

Quite some time ago, I thought I'd compose a few bits about my family. Namely, extended family, because that's where all the crazy resides.

I have this uncle on my dad's side - dad's sister's husband. Let's call him the fat one.* This is really a story for another day, but on my dad's side, me being the only grandson (heir to coconut plantations?), I was the favorite. This was most evident through my grandmother, who kept a 8"x11" picture of me on her dresser (and, unabashedly, of no other grandchildren). So everyone who came to visit her instantly knew who she liked. And of course they had to like me in the process**. The fat uncle liked me, and wanted me to visit. I'm not saying he had to like me or anything, just that, if there was a grandchild to be liked, it was me.

So one day I visited. Plus, he had HBO and a nice theatre system so I was like, fuck this, I'm going over there to chill. The problem was, as I should have seen it coming, he loved food. Loved. I make fun of people constantly for liking food a lot but this guy LOVED FOOD. Every time he came back from work - pakoras (of different varieties). There was a pre-dinner dinner. A dinner dinner. A late dinner dinner while sitting around and talking. You'd wake up on Saturday and there'd be aromas in the house in the morning. From 7am! Multiple kinds of drinks/teas, pastries, veg/nonveg items - and that was just brunch.

Lunch was another spectacle all together. You wanted mushrooms? You got 2-3 mushroom dishes within 15 minutes. You wanted lamb? (I love lamb) You got lamb in 15 minutes. He had a nearby restaurant that he ordered so much from that they'd essentially be on standby and he'd fetch the servants to get the food. Now that, was part of the fucking problem. Not doing anything yourself.

Maybe some of you are salivating right now. I will tell you that after a day I was sickened. It was so hard to say no. The constant pestering of trying new things (it all tastes the same after a while). Every day. Even if you were full - you can take another bite, no? Just one more. Just finish this portion of this dish and right when you think your stomach is going to explode it filled up.

Part of it was my problem too - I try so so so hard never ever to waste food. The greatest luxury is not in vehicles or rapid transportation or concierge service, but never having to worry about food, having it always available, and having a selection to cater to your palate. I go to Costco and I see food piled from floor to ceiling and I think - I could have anything my heart desires in that warehouse.

I sometimes think that if you were to bring a caveman to modern times, and you were instructed not to teach him anything that would alter the course of history, but only to show him something amazing, I'd take him to Costco. Space shuttle launch? Eh, it's like magic to him. For all he knows, the thing is controlled by the gods. Medical miracles? Give me a break, he'd get bored in the OR. But to show him food stacked in an airconditioned warehouse 3 storeys tall? He'd understand how far man has come. Walk in, take what you want and swipe some shiny piece of plastic? Mind-fucking-blown.

It came to be psychological torture after a while. My mom called me (as she did almost every day, I mean, still does) and quickly picked up on my deteriorating mood. She visited later to dole out some truly Imperial-command level reprieve. I hid behind her, so to speak. She just said "no", and food, there was none. And she saw the tables cleared and the burden lifted, and it was good.

*: Undisputed.
**: Remind me to tell you the one story about how my grandmother once rained hell with regards to what happened to me.

Chimeric med students.

I was out partying this weekend, and people always want to hear patient stories. And I've got some good ones, as does almost everyone in my class. Even better - attending stories.

See, when you first start out, the simplest things seem fucking cool. When Bala first described a case where a woman started losing her peripheral vision before her central vision, leading Bala to instantly diagnose a pituitary tumor, we all felt like part of an episode of House. And that was fucking cool.

But now, decreased peripheral vision would easily elicit a differential of a pituitary adenoma or a craniopharyngioma. Instantly. Not only that, most of us could give a differential of what kind of a pituitary adenoma to look for, what symptoms to ask for, etc. etc. All this has become standard. But do any of actually believe we have achieved some miniscule level of Bala-greatness? Not in the slightest. Often, we'll ascribe that to someone else. That wasn't D, that was V.

A few weeks ago, when a elderly gentleman collapsed on my American Airlines flight, I had to assess his slight chest pain and syncope. If you asked me to describe that episode in excruciating detail, I'd probably stammer and 5 minutes later, come up with a half-hearted differential. But I knew then. I knew to look for the deadly chest pains and keeping in mind that common things are common, that he was probably dehydrated and fatigued. But that was someone else. All I do is mostly eat and sleep and occasionally crack open a book. Who was that delivering babies and performing CPR or explaining the side effects of FOLFOX to the patient constantly in denial? When the need arises, he better be back. The fear is, that he might not.

Not the Attendings. They don't have multiple personalities or the fear. They've got this. The white whales flee at sighting an attending.

Wikipedia says:

an attending physician (also known as an attending, or staff physician) is a physician who has completed residency and practices medicine in a clinic or hospital.

I guess? That definition is for the layman. 'Attending' means something else altogether.

And you always wonder if you'll actually ever get there. Even in middle age, you see yourself pilfering coffee and muffins and using silly mnemonics and stammering after every inquiry and running to UpToDate to look up everything.

But really, the point is, to never actually feel like you're there. One of Bala's favorite stories is the one about Type 1 diabetes, where upon administering exogenous insulin, a severely malnourished young boy regained his appetite and was back on the curve to good health. And you think, I could read, and listen to my patients, and not treat medicine like a game, I could be there.

Well, yes and no.

The uprising

It might be a good idea to include more of my thoughts, slowly delving deeper into the crazy. 


550AM.


So this morning - I'll talk about my morning. I awoke from a zombie dream - really common these days. Zombies are the one true evil I actually have a shot against.* 


So naturally, I woke up semidelirious in a hypnopompic state thinking there were zombies outside my apartment, but they had not realized my presence yet. Also, I didn't hear anything outside (no A/C machines, no pets, etc), so this only reinforced things. 


I slowly reached over to my phone, put it on silent, and checked its connectivity. Boom. 3G. 4 bars. Of course cell towers would still be operational; power plants were miles away. By this time, the music was already playing in my head. 


Hit play, and read the rest of the blog while it's playing.






So I'm slowly waking up out of this delirious state and I'm starting to realize that this is all probably false. So false in fact, that if there were zombies roaming outside my apartment (and in all of Houston), I might as well conjure up something else - an M92F on my desk with a few clips of ammo in the kitchen. You see, I was awake enough to logically conclude that as I was semi-dreaming, I might as well dream up a Beretta, but not awake enough to take me the entire way and snap me out of this delusion.

605AM.

I also conjured up some serious handgun and melee weapon** skills. I was ready to take on the zombies. Level 1 was supposed to be - wake up, arm yourself, survey your surroundings, realize everything had gone to hell, kick the door open and make my way to my vehicle and run over some zombies on my way to TMC.

Level 2 was to open with a cut scene of my disabled vehicle in the middle of TMC (in utter shambles), and the ground gives way to the anatomy lab underground (which is a formidable opener for a zombie level). Level 2 was to end with me escaping Houston in a MEDEVAC chopper.

610AM

Ok! Let's do this! checks Twitter feed for 77030*** - no reports of bitings or the dead coming back to life. Damn it. I must be fully awake.

I then woke up and made some veggie patties from the batter I had made last night. No M92Fs, epic melee battles or hospital levels to fight through on my way to the roof.

Sigh.


*: I think.
**: Working on this IRL.
***: I seriously did this.

Specifics

I've been searching for the right word for literally weeks now, and I haven't been able to find it, so we'll just have to roll with it. This about 'nice' and how I think almost everyone misuses it. Or at least, makes it so broad of a definition* that it becomes meaningless. So let me try to describe three categories of positive people:

Congenial - This is what most people think "nice" is. What do you think of that person? Oh, he's a nice guy. Well, what about the girl that brings cupcakes and brownies? Also nice? Fuck that. He is congenial, as in, won't pick fights, say mean things, is polite but generally remains within his comfort zone and would not dare to leave it / go out of his way for anything. Congenial. Most people are congenial or polite. They may not have your interests at heart, especially if it means deviating out of their comfort zone.**

Nice - This word, I think, has been ascribed such a large variety of meanings that I consider it to be grossly misused. A Nice person goes out of his/her way to do something. Often this has to do with food, but it can also mean foreseeing problems and correcting them from the beginning. Nice people also take risks with intervention, advancing their (non-selfish) opinion on how things should be for your own good. Sometimes they're wrong, but more often than not, right. But the risk is worth it.

Fiduciary - Now this is the word I have been looking for a replacement for, but haven't been able to find. Fiduciary is another level in itself. I thought about other words for a replacement - parental (already widely used and comes with a restricted connotation), watchful (too big brother-ish), patriarchial/matriarchial (also widely used and overbearing), so I've settled on fiduciary. It's a difficult word to describe. A few teachers would fall under this. The good primary care physician would fall under this. Fiduciary is going above and beyond the call of duty.

Wow, that explained nothing, huh.

Whatever, enjoy this fucking awesome song:



There really aren't that many words to this song, and Santana's solo very adequately complements them. Excellent.

*: We shall be talking about broad definitions soon, wrt Nobel prizes.
**: Not particularly a problem.

Birth of twins

I saw this the other day on the oatmeal blog - ‽ - an "interrobang" or a "quesclamation mark", which I think are both stupid names for a symbol of limited utility. Let me introduce two symbols that are much more useful - "!?" and "?!" 


The first symbol illustrates the true meaning of the preceeding sentence, and the second one spins the meaning These are best illustrated through example - "What the hell are you doing?"


"!?" - Let's say you see a friend beating up a seal, you would use What the hell are you doing!? Of course this is not a legitimate question, thus "!" is first. The "?" highlights the incredulosity*/stupidity of the activity. "!?" is much more limited in use than "?!" as you will see.

Some examples:

How can you eat so much!?

How can you sit at that computer so long!?

Why haven't I seen a post all month!? (could go either way)

"?!" - Let's say a friend has not picked up a phone call for a long time. What the hell (have you) been doing?! Legitimate question, "!" added for emphasis. In fact, you can add "!" to the end of any question for emphasis.

Some examples:

What should we do for lunch today?! (more excited)

How did you do that?! (more curious)

Who is following me?! (more worried)

The "quesclamation mark" bs is quaint and of limited utility. I like mine better.




*: Not a real word. 

Fk yea.

Discretionary.

I got another paycheck today, from my anatomy TAing work, and I thought I would write a bit on discretionary spending - how I calculate it, how I determine what discretionary means.

Right now, discretionary spending is set at 7.5% / 5% actual, meaning 7.5% of everything I get goes toward doing "whatever I want." You'll understand why I put that in quotes in a little bit.

Everything I get includes - occasional cheques from my parents for living expenditures, stipend money, random odd jobs I may do from time to time, etc.

So what happens to the rest? Well, most of it goes into rent, obviously. The remaining goes into groceries and utilities (my only 2 expenses besides rent). Simple enough, right? Wrong. Staying within these confines is exceedingly difficult, not because I tend to cross the 7.5/5 limit, but it's much more of a challenge to classify what's discretionary and what's not.

First, let's start off with this 7.5/5 business. What the hell? Ok. 5% actual means someone gives me $100, and I can use $5 on whatever I want, but that [whatever I want] my incur additional expenditures as well - best illustrated with an example.

Say I want to rent a movie (lol). I drive down to my nearest Redbox, pop in $1, come back and enjoy it. Well, what about the gas to go there? The electricity to run this endeavor? The food cravings I may have in the middle? All included in the 2.5% buffer. I realize 2.5% may be a little high, especially in the preceeding example. There is a minor problem with this - what about the time wasted and impact on career and life? Yeah, an extreme - but still a consideration (now that everything else is squared away, lol).

So out of $100, $5 to spend on anything I want (not $7.50) and a $2.50 buffer to allow for some flexibility - "it costs money to spend money" sort of deal.

Even more of a difficult question - What counts as discretionary spending? This actually has a lot of day to day variation to it, really, just depending on my mood. There are a few hard and fast rules, though:

Rent and utilities (except for the caveat above) obviously don't count.
Groceries - most don't count.
Bread / milk / eggs / cereal / rice / meat / pasta / fruit / other essentials don't count.
Gym membership doesn't count.

Ice cream does. Coolwhip does. Even juice does. Almost everything not in that list above does, actually. Clothes are iffy (usually not) but such a rare purchase that it's negligible.

Even still the 2.5% buffer is rather large, but it starts diminishing when you consider variations in expenditures above. The extra 50kWh of energy for gaming. The variations in price in groceries (when two different brands taste the same, one is more expensive and the difference counts as discretionary). So really, the 2.5% buffer is to keep me from going crazy. I think it's a good rate.

By now, a few of you might be thinking - D is a goddamn cheapass. I would argue for 'controlled'. There are some things I care about, and some things I don't. I have quite a bit of [actual] discretionary spending saved up - (some $400 ish), and I'm thinking about taking lessons in a few things. Maybe buy that expensive Sony blu-ray home theatre system I've been eyeing for weeks now.**

Finally, I don't really have the time and energy to impose this on anyone else, and I don't really care what anyone else does. Your limits are your own. Although, if you're doing crazy shit like eating out daily and spending a ton of money on ice cream, you've got issues and I just judged you.

*: Which, I would have done for free. Shhh.
**: To the point that TPTB are sitting on the buy button.

Fuck you, nature search.

Edit - should read #16 in the picture. Point still stands.

Tea

If there's one thing I can generalize about Indian people, it's tea. Well, that's all I have to say about that. Now for a personal anecdote.

Often when I go back home, I have to play chauffeur. Sounds boring, but it's actually a very interesting job. Mostly chauffering my mom around. Almost exclusively. So everyone piles in the tank, and off we go. And by everyone, it's mostly me and my mom and sometimes my sister. And more often than not, the destination is a mall.

"Great. Going to the mall." you say. Actually there's a lot of people watching to be done at the mall. And lots of interesting stores. Just lots of stuff to look at in general. Back to the point. Recently discovered by the D family is this place called Teavana. Basically, a lot of hippies work in the store, but upper class hippies* - the other, semi-homeless kind (having a thrown away couch and a mattress to sleep on does not count as a full home) can't afford the rent in Dallas.

Anyway, D family walks in there, actually just my mom and my sister, and start sampling all the teas. Then I start sampling, because - what the hell - I feel left out. Somewhere in the midst of asking me which one tastes good, as expressed on my face by an "eh" or a "it's ok" look, it was decided that I like the strawberry lemonade pomegranate tea blend.

Now, I'm not sure who decided this, or how someone misread the "it's ok" face, but there is now strawberry lemonade pomegranate in the pantry when I go home. And when I go home + 4 hours, there is fresh brew strawberry lemonade pomegranate in the fridge.

But really, I will say, my favorite part about Teavana is the sugar. (Of course.) Not just regular ass sugar, but this stuff :

Some seriously awesome sugar.

They have it in a jar inside the store with small 1/2" deep wide cups, and outside, there's this:

Look closely. SAMURAI CHAI MATE. 

The procedure:

1. Obtain about 15 rock pieces in the small 1/2" deep wide cup.
2. Pour in SAMURAI CHAI MATE.
3. Slowly swirl + sip SAMURAI CHAI MATE.
4. ???
5. PROFIT!!

No I'm kidding. The real way to do it is -

1. Obtain about 15 rock pieces in the small 1/2" deep wide cup.
2. Pour in SAMURAI CHAI MATE.
3. Slowly swirl + sip SAMURAI CHAI MATE.
4. Look around and notice everyone noticing you slurping your tea.
5. Ward them off with piercing eyes.
6. Feel like a fucking stegosaurus drinking from your stream while occasionally sticking out your tongue into the stream to taste/access the sweet rocks at the bottom.

Mock all you want, random Northpark mall by-passers.


*: Have a job, specialize in something - in this case, the marketing of tea.

Things I do

I occasionally go to this cafe on West Gray - aptly named WEST GRAY CAFE - mostly because there's no one there and since they know me I can get away with ordering a coffee and mooching internet / power for hours. It's not bad. Sometimes I'll get some fries / onion rings and I won't get judged for that either. 


Pretty boring so far, right? Well the real treat in a DITLO D is the journey there. If you could follow me around - pretty difficult since I'm both a defensive driver and somewhat maniacal* - would notice that I BUMP to music. And I only do this when I'm alone. Old school Eminem? D becomes the brown rapper on Montrose. Literally. Driving with my left hand, busting out beats with my right, windows down, sunroof open, volume pretty high and rapping out loud. Any song, you name it, after a few listens, I've got the lyrics down, and it's showtime. 


Most recently, I was bumping to Telephone by Lady Gaga. It's actually an insanely good song. It's not even some veiled reference about her rejecting some dude, which is what I thought initially. If you listen to the lyrics carefully, as I've had to do you'll hear - 

Not that I don't like you,

I'm just at a party.

And I am sick and tired

Of my phone r-ringing.

She's just at a party and is like - fuck this phone! I'm just going to dance and ignore it completely and possibly get drunk off bub. Also, not text anyone, either. That entire song is about JUST. THAT. 

Eh, eh, eh, eh, eh, eh, eh, eh, eh…

I sound like I have terrets**, weaving my little sports car in and out of lanes. People sometimes find me in the middle of my song and wonder if I need an MRI. Truth.


In any case, I can totally understand . Quick story, sometimes you'll have a chick over, watching a movie or something and things are about to get serious when you hear that familiar iphone mail notification sound. I can't onomatopoeia that sound very well. That sound often happens 5 times in a row in 10 seconds, which means the listserv administrator just approved 5 messages and they were all instantly pushed to my phone. And I, like a conditioned crackhead, put a pause on the serious moment and reach for my phone. This fucking junk mail (wilderness medicine / rotation swaps / SIMS / etc etc etc) is piling up and I gotta delete it. 


Fail.


Fuck this phone!


Other than that, a lot Lady Gaga's songs sound the same. I couldn't tell the difference between Lovegame and Just dance for the longest time. 


Lady Gaga is a pretty shitty artist. Yeah, I said it. 

*: Which is not dangerous. I'm predictably maniacal, which is safe. It's unpredictability that makes drivers dangerous. 
**: lol. 

Saturday morning

Saturday mornings have changed. I remember when I was 6, it was - get up as early as you can and switch on that tv with the volume as low as possible. I always had excellent hearing so I can pick up that high pitched whine the old CRTs used to produce if my sister woke up earlier than me. Why mute / low volume? My parents didn't like me watching too much tv anyway. Standard. Well, of course they knew I was up - I used to giggle like a jackass at every bit. Easily amused then, easily amused now. This would continue until 10-11am when the cartoons stopped. Of course that was a sad time. I knew it was coming from Friday evening. 'Just enjoy those few hours in the morning, D!'. Nah, I'm a realist. The end of the cartoons meant that teaching would start. Mostly math, but sometimes science. This meant I was always 2-3 years ahead in math and had a general idea of how things worked. Archimedes principle and TMNT go together in my head; they were imparted around the same time. By 6-7th grade most of the concepts being taught were so second nature to me I was surprised no one else knew. I was a goddamn genius back then. After teaching came market time and it's pretty evident I didn't learn anything there, lol.


Saturday mornings changed into version 2. All this time I realized my parents would sit in the living room talking about the rest our family, making calls to India, essentially, discussing policy. One of these days I realized that I could do both. I think it was when I was dragged there to say hi to relatives over the phone, mostly as a formality. And I hate formalities. In any case, I used to finish my cartoons and listen to the dysfunctional family. If there's one thing I learned, it's that you need both of these things to produce some massive family drama: 

1. An inability to shut the fuck up.

2. Stubborn people that hold grudges forever. 

If you even took one of these things out of the picture, 80% of the drama would cease. Mostly, it was a lot of me and my parents playing Steve Irwin watching the drama unfold. One of these days I'll comment about a typical Brahmin family hierarchy and how it functions. Anyway, the drama made things more interesting. Of course, within the drama were implicit lessons on behavior and social norms and responsibility (to both family and community) and loyalty. By this time, the math and science lessons had tapered. More.. social lessons. 


The hallmark of Saturday mornings version 3 were the lack of cartoons. It sounds sad saying that I don't watch cartoons anymore, but have you seen the latest ones? They're horrible. I used to think Looney Tunes and Tom & Jerry were made in my time, but I was surprised to find them to be pretty old. It's like America watched some pretty awesome cartoons for decades (which both adults and kids could enjoy - my dad used to watch loony tunes with us) and then realized she wanted stupid shit like "Ed, Edd and Eddy" and "Yu-Gi-Oh!". Pokemon was another one of those horribly mediocre cartoons. They were things that only kids with ADD would enjoy - formulaic, mind-numbing and just plain old fucking boring. So am I sad? Not in the least. I like not having a seizure every Saturday morning. Version 3 continues. More family drama. More stories. Sometimes I sleep in, wake up around 1030am and get the abridged version of all the stories. Maybe I'll ask for elaboration if one strikes me as particularly amusing. Maybe I'll offer my own solutions; they often include baseball bats and broken bones. 


I think I just described 1/14th of my life up until 18 years old, and pretty much every Saturday morning when I'm back in Plano. Speaking of which, I should go back sometime. 

The Skeptic

I usually get to lab around 7-something in the morning, which is earlier than almost everyone else. Truth be told, I've been trying to work in a 630am arrival schedule but my sleeping times have been much less resilient. In any case, I get some reading done in the morning - mostly stuff on my Google reader feeds.

This morning, I found this entry - Desiree Jennings on 20/20 - and had an epiphany:  (you can see a summary of my epiphany in a comment at the bottom). Most, if not almost all of the problems associated with the perception of science by the general public can be attributed to one word - proof.

With all the stories I'm hearing about people changing biology curriculuae, the anti-vaccination movement, I would be very happy if more people were scientifically literate, which is different from really knowing science in itself. I don't expect everyone to become a scientist, or major in a hard science; it's up to you how much you like flipping burgers, but I do expect people to be scientifically literate, or in the least, be amenable to be taught it.

I won't talk about scientific literacy now.  However, I can give my understand of proof from a medical perspective. That too, I'm going to talk about a very specific (but incredibly important) aspect of proof - causation.

MEDICAL CAUSATION, as I will call it. Actually, it's a summary of Hill's Criteria of Causation, a very eloquently put together set of tenets which I think are pretty easy to understand (for the non-scientific audience). It's important to note that there are rigorous numerical methods behind each one of these, except maybe #4. Let's begin.

Say you want to comment on ... vaccines (or the mercury they have). How would you know what effects they have? How would you prove that vaccines actually caused this effect? How would you prove that a vaccine causes autism? I'm not going to go further with this question; I don't have the data nor do I wish to really turn anyone away. Let's talk about apples, and how apples may keep the doctor away.

How to prove one thing causes another: 
The Tenets

With a short commentary on each.

1. Temporal relationship - The cause must come before the effect. You must eat the apples before your number of doctor visits start to decrease. Simple enough, right?


2. Dose-response gradient - The more of the 'cause' you have the more of the 'effect' you have. The more apples you eat, the more doctor visits are avoided. Still pretty simple, so far.

3. Consistent association across studies - In similar and/or different situations, the cause still produces the same effect. The more different situations you have, the stronger this tenet becomes. E.g. Your cousin finds that when he eats apples, he avoids doctor visits. Your aunt/uncle/neighbor/sister/brother/sick lady across the street/cancer patients/people in third world countries all find this same effect. Thus the association is consistent across studies (different population groups). 

4. Face validity - The association makes sense, applying common sense. E.g. Eating apples makes you healthier, so somehow you avoid doctor visits as you get sick less often? If this was something like, every morning you wake up and snap your fingers twice and that decreases your # of doctor visits, well, that doesn't make too much sense. It lacks face validity. Apples --> better health --> less doctor visits? Might make sense, thus, has face validity. 

5. Strength of association - This one is the hardest one to throw out there without statistics. Basically, how strong is it? Probably best to look at the example for this one. E.g. One apple avoids 20 doctor visits vs 100 apples avoid one doctor visit. The former is a much stronger association than the latter. Let me take a stab at explaining it. In the latter, the fact that you're eating more apples probably means you're eating healthier in general, which would certainly decrease the # of doctor visits. In the former, the implication is strong that there might be something in the apple itself that does the trick, not any personal habits you may have picked up.


There are more tenets to Hill's criteria, but I feel like if you understand these 5, you're well on your way to understanding medical causation. Particularly important are 2, 3, and 5. #1 is easy to understand and easy to refute if it doesn't exist, #4 is murky and dependent on how far research has advanced. 2, 3, and 5 however, will hold true regardless of how much research has advanced.

More on this, and proving things, and scientific literacy later.

Bias

I was reading a few things today, and that got me thinking.

I'll start with a disclaimer, which everyone in medicine can more/less ignore :

===MDs+associated staff ignore===

Patients often present to the ER or clinic with a host of problems, many of them chronic problems (e.g. hypertension, diabetes, high cholesterol) and one or two (hopefully not more than that) acute problems that brought them to the ER in the first place. General medicine teams admit the patient and (try to) manage all the problems, but if it's a more involved case, then consults are requested. Cancer and oncological emergencies almost always involve Heme/Onc consultations. Severe respiratory distress will command an ICU* consult, and they might decide to admit the patient to the ICU. Any sort of neurological problem might warrant a neurology consult.

Another reason to get a consult (in this case, a specific MD's consult) is if a patient is admitted into the hospital and his** particular MD staffs that hospital. He might want to come see that patient, and being familiar with the patient's history. Which, brings me to my next point.

The first thing you do is get a 'H&P' - history and physical. There are various handy templates to write all this stuff down on. You generally have a one-sentence about what's going on with the patient, whether they're stable and maybe a few vital signs but other than that, you're flying solo (comment on why I think this is a good idea below). The history consists of a fuckton of questions. An absolute fuckton. As an example you might ask the patient - "What brings you in today?", and they'll say one thing (again, hopefully just one) - "cough". Then you begin. When did it start? How many times do you cough? How painful is it? Do you cough anything out? Do you cough at night? Does it get worse at night? Better during the day? The opposite? Anyone else in the family sick? Do you have any other symptoms (might want to list a few) with your cough? There are a few mnemonics to help you formulate a list of questions, but it's good to get as many details as possible, as fast as possible. You then move on to other things like a medical history, a surgical history, a social history, a family history, medication history, etc. Each of which comes with it's barrage of inquiries.

You then do a physical exam, and if you're pressed for time, you will do a focused physical exam. Does that mean if a patient comes in with cough, you don't look at their legs? Yes and no. If he's young and has a clean medical history, there probably is no need to. If he's old and having a bit of difficulty breathing with exercise (you would find this in the history), then you might want to check for pedal edema (swelling around the ankles) - maybe his cough is from fluid spilling into his lungs (which would spill into his legs as well in a similar mechanism).

I'm not sure how much sense I'm making here, but I hope I got the point across that there are a ton of questions, and then, an exam. So you'll get your twenty thousand questions (+exam) from the general medicine team which is admitting you, and twenty thousand questions (+exam) from every consult service, as they have to do an 'H&P' when they consult as well.

tl;dr -  ಠ_ಠ All of it is important. Read it...

 ===MDs+associated staff ignore===

I remember when I was in my St. Luke's month of medicine on the Heme/Onc consult service, patients would (rightfully) complain and moan about the millions of questions that are being asked. And it's true, a lot of these questions sound very much the same.

But in reality (otherwise this post would be pretty short), the questions really aren't. Each consult service has this beautiful thing called BIAS. Now, bias usually comes with its own negative connotation, but it's immensely helpful in organizing patient care and teasing out details about this patient's history.

So I would ask my twenty thousand questions, and because I was on the Heme/Onc service, I would follow an oncology line of questioning. I would focus my history and physical on just that. The general medicine team might have details for me about the patient's cancer, but because I have instilled myself with a predilection for oncology, I would very likely find out more. Makes sense so far, right?

Well what if a patient comes in with a problem that isn't so clear? A good general medicine team (almost all are) will pull in all sorts of seemingly zebra but necessary consults. Who knows what underlying mechanism might be causing that cough - maybe it's a nephrology thing and he's spilling protein into his urine... maybe it's cancer and there's a small tumor causing an obstruction. You want your oncologist / nephrologist / pulmonologist / infectious disease consult to be fighting (reasonably) for their view of the etiology. You want to encourage them to ask as many questions as they want, almost arrogantly proving (or maybe, disproving) the need for their consult.

There is only one right answer, and if the general medicine team has done the right job in picking consults, you'll have your answer, very, very quickly. And an expedient answer is in the best interest of all of us.


So I'll be asking my twenty thousand slightly different questions concordant with the team I'm on, in the best interest of everyone around.

Also, +exam.

*: BTGH calls it MICU, which throws me off because I keep thinking mobile intensive care unit (ambulance) instead of medical.
**: I would have written his/her but I think current style is to say just "his" which encompasses both? Somebody correct me.

You can tell a lot from...

The inside of someone's fridge. I borrowed this idea from a friend who had a pretty atrocious [inside of a fridge] situation. Yes, Varun, I'm talking about you. I would post pictures from his atrocious fridge, but I don't have permission. Yet. Get some real food, dude. Let's take a look at mine!

Done guessing what they all are? Labels below. 

(click for a bigger picture)

I know what you're thinking. What the fuck is argula and why does this clown have it in his fridge?! Well let me tell ya:

Eruca sativa (syn. E. vesicaria subsp. sativa (Miller) Thell., Brassica eruca L.), also known as rocket or arugula, is an edible annual plant. It is a species of Eruca native to the Mediterranean region, from Morocco and Portugal east to Lebanon and Turkey. ... It is used as a leaf vegetable, which looks like a longer leaved and open lettuce. It is rich in vitamin C and potassium. It is frequently cultivated, although domestication cannot be considered complete. It has been grown in the Mediterranean area since Roman times, and is considered an aphrodisiac. ...It has a rich, peppery taste, and has an exceptionally strong flavour for a leafy green.

Now you're probably thinking - Damn, did I just get told?

Yes. By Chef D.

(Chef D likes to hide his face from the public.)

Actually, towards the end of medicine they had this vegetarian sandwich with cranberry sauce and spinach and it was hella awesome. So I decided I would make a sandwich with cranberry sauce (and argula) and it was epic:

Your final thought - Why does D have a glass of whiskey next to his sandwich? The sandwich is for me, the beer, not whiskey (Samuel Adams, because I cannot stand beer as it tastes like shit) is for the fruit flies. They love it. Ahh, sweet death. 

My final notes:

• I love marmalade. Is it obvious?
• I got that apron from Ikea. Manliest apron I could find. 
• Argula is fucking expensive.
• That white splotch on my plate is mayo.
• Mrs. Bairds Honey Oat bread is pretty damn good.
• I went to Kroger and saved $6.18 using my card. Total bill : $18.44. That's 25% off.
• There is another honey dew melon, some oranges, a few potatoes, and a few zucchinis in my vegetable drawer below.
• I'm a pretty bad cook.
• Tomorrow's lunch is going to be epic. 

Now if only I had better teeth. (To be fixed soon!)

武士道

The japanese have a saying in 武士道 something called "The Lesson of a Downpour." I remember reading/hearing about it a long time ago from when I took JPN at UT (greatly missed).

I'll paste an exerpt from a PBS documentary (I haven't seen it yet, so I can't recommend it) -

Fear not the Rain

One must know the so-called "lesson of a downpour." A man, caught in a sudden rain en route, dashes along the road not to get wet or drenched. Once one takes it for granted that in rain he naturally gets wet, he can be in a tranquil frame of mind even when soaked to the skin. This lesson applies to everything.

Calm and tranquility. Don't get the wrong message or anything. There aren't any downpours in my life (right now) but there is one going on right now outside.

Actually there are a lot of interesting aspects of samurai* society that could probably be applied to medicine. Take the 8 virtues which I've shamelessly lifted off this site:

•  A sense of Justice and Honesty.

•  Courage and Contempt For Death.

•  Self-Control.

•  Sympathy Towards All People.

•  Politeness and Respect For Etiquette.

•  Sincerity and Respect For One's Word of Honour.

•  Absolute Loyalty To One's Superior.

•  A Duty To Defend The Honour of One's Name and Guild.

They could all be applied pretty well to medicine in someway, although I'm not really sure we defend anything. But you know, the overall theme seems to be one of complete, benevolent control.

It's important to (and I will soon) make a short list about things that matter, and everything else be damned. List comes soon. For now, I'm going to get back to reading in one of my favorite Houston study spots which no one knows about. Because it's totally empty. Because it has been totally empty everytime I'm here. Because no post is really complete without a picture.

*: If you, for some reason, think this is rooted in anime, gfy.

Dessert

Few people are unaware of the multiple chaotic sectors in the world the British Empire left behind. Yet, in their conquest, the Brits may have a redeeming quality:

Good English custard, in the truest, most authentic sense, is a difficult dessert to make. Almost everyone screws it up somehow (and I'll try to point out common mistakes). Just remember kids, the point is, to not fuck up.

1. You need this. There's no need to order fancy custard powder online, although you might be surprised at how expensive this might be (I believe it's imported). Be sure to reseal. This powder is hygroscopic. Like... all powders.

2. You also need some sugar. "Did you really need to put in a picture of sugar?", you ask. Yes, because I like to show off my fancy container. Which I got from Ikea. Which was $2. Fancy.

3. So this is an important step. You must make a primer. Ever watch me get some coffee? I always make a primer. Let me comment on that. There are people that go apeshit over a lack of "stirrers" - those plastic things that solo makes billions of.* 

First of all, just take some cream and sugar and drop it in your cup first, then swirl it around for a few seconds. 

Second, add some coffee and swirl it around some more. 

Third, lift that coffee pot as high as you can (comfortably) and pour it into your cup. No stirring necessary. Now stop wasting plastic. 

Back to my procedure. You have to make a primer and you can't have any residual clumps of powder at base of your primer. But even if you do, when you're mixing in your primer into your milk, make sure you skim it off the top, not to get any clumps. Microwave for 30 seconds, skim off 2 spoons of primer and mix it in. Repeat. Also, you may want to microwave at 20-40% power.

FUCK UP MOMENT: DO NOT LET IT CLUMP AT THE BOTTOM

4. Watch this like a hawk. It's going to heave and lurch like a chronic alcoholic who's had his last drink, but you mustn't let it throw up and die!** This is where the microwave power limits come in. Don't nuke it. Negative style points.

FUCK UP MOMENT: DO NOT LET IT DIE.

5. Finally, after 6-7 minutes, it'll be done. Let it rest quietly. 

FUCK UP MOMENT: DO NOT SKIM THE TOP OFF REPEATEDLY. POINTLESS. 

6. Prepare your fruits. You can throw in anything in custard really, as long as it's soft (and not something weird like.. meat or pasta). Technically, it's now called fruit custard. Fresh fruits are better. Strawberries and mangoes are awesome. Blueberries and blackberries, fruits that generally tend to disintegrate with time are a bad idea. It's best to preserve the original custard color. But really, I only threw in this step for this:

FUCK UP MOMENT: DO NOT THROW IN ANYTHING HARD. LIKE APPLE PIECES. PEARS MIGHT BE OK DEPENDING ON HOW RIPE THEY ARE. 

This is the main fu moment. Also, make sure they're more/less the same size. And bite sized. Now cool everything down. 

And in the end, when you do finally get around to having some, I think you will concur - this is a mover and shaker. Like Physics and Medicine and Red Hot Chili Peppers, add English Custard to the list of things that can really bring peace. It's even halal. Now, come on Brits, spread the wealth!

*: Ending a sentence with a preposition. Bam!
**: Admit it, you did not get this reference when you read it. Some of you will never get it.

Abacus energy has a few dumbasses working for them.

I checked my mail today, and found this. I was irritated. Please GFY, abacus energy. I should get a discount for having to put up with this bs.

Of course, the date says 5/15, and nothing was disconnected. Still.

Poll: Should D throw a shitfit? And to what magnitude?

Fuck youtube.

I always get stuck on some series of videos.



Yep. Admit it. It was good. I also know how to say "Eddie marries bush bitch" in German.

MURPHY GIFTER SIG MED DJUNGELBRUD. I guess I learned something.

I went to a tattoo and body art exhibit this last weekend. It was pretty wild. I'd say more people were getting tattoos (or had gotten one there) than not. Also, they kept telling me to KEEP MY PHONE DOWN, so I wouldn't sneak any pictures. And I didn't really try since there were these huge biker gang people near the entrance waiting to pounce on the unsuspecting / running med student.

I was also horribly out of place. NASA cap, BCM "eat, sleep, medicine" tshirt, jeans, tennis shoes.

But you know, I think I'm eventually going to get a tattoo, I just haven't made up my mind yet. Someone once told me you need 3 good reasons? "Wanting one. Check." Now I need two more. I remember one guy at the VA had his last name tattooed across his lower abdomen. He was also encephalopathic and almost smacked me*, but that's another story. He was also going through 3-4 Type 6 stools** a day and the nurses would tell me, in broken english "HE SHIT THREE TIMES ALREADY", so I suppose they didn't like me either.

Fun times.

Back to the tattoo. It has to be something fucking cool like.. a science tattoo. I'm rather partial to the DNA helix wrapped around my upper arm. Or maybe something physics-y. Then people would say "wow, you must have gone through a lot of work/effort in physics to put that ink on you in the 'NEVER FORGET' kind of mentality huh?"

"Well, maybe, but I just got bored one day," I'd reply. Or maybe just stare off into space with a disaffected look, which I'm still trying to master, because there are a lot of boring people out there.

*: Don't worry. D > pt afflicted with hepatic encephalopathy.
**: I forgot the name of the scale, so I just googled "Bristol poo". Thx, google!

Day in the life of.

For most people that'll read this, this is going to be pretty routine. Everyone else, including [Future D], maybe not so. He will have forgotten what it was like.

That's YELLOW. 20th floor YELLOW is where I did most of my work. SLEH is a maze. I theorize it's because patient rooms need windows and hospitals love to expand. 

For most of my SLEH days, I get there at 630 or so. Not because it takes me a long time, but the walk can get hot and sweaty if I leave any later than 615.

1) Log onto a computer, review overnight and morning labs, see if you have any news for the patient, see if you have anything you need to focus on.

2) Wake up your patient. Some of them are up watching TV already. If they are, these people become my main source of news every morning. I learned of the NYC car bomb through one of my patients (and the next day he told me how utterly retarded the criminal was). I openly tell my patients that they're my main source of news. They feel useful, I get my dose of happenings outside the hospital.

3) Rounds usually start at 8AM. 8AM-9AM rounding. The attendings pretty much knew everything. There wasn't much pimping. But a fuck-ton of interesting facts. For example, 2 lectures on the history of chemotherapy. And did you know the nausea, vomiting, diarrhea can occur even before chemotherapy started? Maybe you did. But do you know which patient populations are most susceptible to it? I didn't.

4) Incredibly important is a cup of coffee. Here is my hand, holding a cup. I need a manicure. One of the many good things that came out of my SLEH experience was a GI tolerance to coffee. BRING IT. No more gastro-colic reflex. 

5) Sometime around 858, I start heading down to the basement to 9AM-10AM morning report*. Which consisted of a lot of napping with my eyes open, although retrospectively, I should have been paying more attention. Somewhere down this long ass hallway + a few turns = morning report room. That purple poster on the wall is about brain aneurysms and clipping/coiling techniques.

6) One of the most irritating things about the SLEH experience was the number of lectures. I usually had one hour after morning report to do whatever (usually finish up a note or finish reading an article). Then, on most days at 11AM, there was some sort of lecture. Sometimes ABG interpretation (done horribly), sometimes heart sounds (done well), sometimes an assortment of random lectures. Lunch is at 12PM. 

7) Another great thing about SLEH was the food. Sometimes we had a choice. I'm not a terribly big fan of choosing what I have to eat, since I'm ok with 99% of everything out there. Actually I'm going to end that discussion here and pick it up another day. It's a post in itself.  Here is some orange-ginger-chicken.

8) At around 1PM, I go back to YELLOW, 20TH floor. Maybe eyeball my patients once again for a second set of rounds with another attending at 2PM. Get another cup of coffee and wait in the meeting room, get some more reading done. Picture of me waiting minus me. 

Yes, I carry a travel sized bottle of Listerine in my white coat. God knows what you'll get for lunch. Also, I love onions. Listerine is a lot quicker at a temporary cleansing of teeth and breath. You'd have to chew gum for a good 5 minutes. Also, walking the hallways chewing gum makes you look like a fucking moron. 

9) Well, my day usually ends after 2-3PM rounds. Sometimes a bone marrow biopsy is required. Sometimes the intern likes to teach. Definitely by 4PM. 

10) On Thursdays we have grand rounds at Baylor at 1215PM. Here is a picture of a random naked man near Methodist. Zoom in by all means. The guy is completely naked. 

Did I miss anything?

*: Will talk semi-extensively about morning report another day.