Wednesday, January 8, 2014
Lou Reed
My sister called a few weeks ago to tell me Lou Reed's death had just hit the wire. She knew I was a long time big fan and guessed I would be upset. There are about six billion people on the planet and I wonder how many, besides me, were wearing a Lou Reed T-shirt the moment he died. That has to mean something and I have been pondering it since. Its raining today and Miles Davis' Kind of Blue is on the stereo. It's a good time to write it down.
I do not ever recall seeing a Lou Reed T-shirt for sale. More than 30 years ago I made one, probably with an iron on decal or silk screen, and I am now not certain how I did it. I do recall, however, why. Lou has spoken to me for many years and has come to my rescue on many of those occasions and for that, I will be most eternally grateful.
The shirt is predominantly black and a little hard to read from a distance. I keep it in my theme oriented "T-shirts-that-have-stuff-written-on-them" drawer, a category of wear that also includes T- shirts of places I have been, Centuries (one hundred mile bike rides) I have completed, restaurants, bars and classics like "Vote for Pedro" from Napoleon Dynamite. The contents in these drawers are always in flux with occasional additions and rejections. After a long hiatus, Lou will surface to the top. I will wear it a day or two, wash it, and not lay eyes on it for a long time. I doubt I had worn it in several years when I put it on the morning of his death. I had no idea he was sick. Hopefully, when he made it to the other side, he was able to see me and smile, like I do, when I see his T-shirt on the top of the drawer contents.
I need to elaborate on just how Lou has helped me. When he released his first album in the 1967 The Velvet Underground and Nico, I was not aware of it, or much of the New York music scene for that matter. Brian Eno the legendary musician and record producer once said:
"...the album only sold 30,000 copies, but everyone who bought it, formed their own rock band."
In the late sixties and early seventies Lou started the glitter rock movement with the more successful David Bowie. He was the voice of the Andy Warhol phenomenon. In the late seventies, he and Iggy Pop were the undisputed inspirations for the Punk Rock movement. A little over ten years later, still recording, he was a large influence on the Seattle "grunge rock" with Kurt Cobain, who Lou was, unfortunately, not able to rescue. Though quite compelling, none these achievements had anything to with me directly.
When I first reached some awareness of culture in my late teenage years, I concluded there had been few challenges and changes, from WW II to the early sixties. The mass culture was, well, comfortable, predictable, and numbingly boring. The music, movies and books, with few exceptions, pretty much sucked. Then, Society began to unravel. The United States went "eyeball to eyeball" with the Soviet Union over Cuba and people suddenly realized a nuclear war and a "Hard Rain" were barely avoided. Kennedy was assassinated, as was Martin Luther King a short time later. Dis-enchantment over Viet Nam filled the national media. The Civil Rights' movement gathered momentum. Riots broke out across the country as racial tensions tightened, and in New York, the NYPD raided 'Stonewall', broadening the Civil Rights struggles to include not only race and woman's rights, but those of the gay, and lesbian communities. A counterculture was inevitable and as the streets filled with chaos, I welcomed the "movement" with the enthusiasm as intense as the French cheering the liberators coming through the Arc de Triumph in 1945.
With the changes in the late 1960's and early 1970's we all had a good time for awhile. Being a baby boomer I was in school and had sufficient free time to listen to great records, to read good books, and my personal favorite-to see many independent and foreign movies. After college I signed up for a long medical training program at the University of Florida. Gainesville, along with Berkeley, California, Ann Arbor, Michigan, and Madison, Wisconsin, was allegedly one of the hippest places in the USA. I assumed everything from a culture standpoint would escalate in quality and intensity. Unfortunately for me, it soured.
Before the movement there were social rules and like cattle, most everyone followed them. Deviation was rare but reasonably tolerated. The Beatniks, Jack Kerouac et all, were perhaps ignored, but not persecuted. In Gainesville, and I suspect the other epicenters of liberalism, there was a fairly standard way of thinking and deviation was not well tolerated. You were considered a Philistine if you did not like this band or that book. I was annoyed by the moral certainty of those who proselytized the benefits of health food or megavitamins, while smoking cigarettes. The most important litmus test was the Viet Nam war. You had to be against it or you were 'an enemy of the people'. Don't get me wrong, I was not 'for' the war. To be honest, I did not fully comprehend the arguments at the time. I was only certain about 'me', not wanting to go over 'there' to get shot by 'Charlie' for unclear reasons. I never claimed my viewpoint was a noble position.
The whole scene put a very bad taste in my mouth. I liked it better when everyone was clueless. All of my recently acquired freedoms became like lengths of a python which were now strangling me. How did this happen? What to do? I couldn't move to another location. I needed an inspiration. One day on the radio I heard a very strange song by a guy who had a deep but sweet voice with an attractive balance between singing and talking:
"Holly came from Miami, F-L- A, hitch hiked across the USA, plucked her eyebrows along the way,... then he was a she....
Candy, from out on the Island ,... in the backroom she was everyone's darling.....
Little Joe, who never once gave it away...
Sugar Plum Fairy from out on the streets....went to the Apollo, you should have seen her go go go...
Jackie, just speeding away, thought she was James Dean for a day,......"
I loved those characters. I loved the music, the lyrics, the voice and mostly, the intensity. This was like no other act. Take a Walk on the Wild Side turned out to be just the tip of the iceberg. Lou consistently and cleverly juxtaposed pain and beauty, and helped me understand pain was not something to fear. Over the following years I needed a lot of help and Lou never failed me.
.
There was another complicated dynamic that surfaced: a personal sense of vicariousness. Though I felt quite content about everything I was doing in Medical School, there seemed to be some type of visceral, inner force creating in me a need to explore the wild side, though I was in no position to do so. As long as Lou and his friends were energetically involved and otherwise functioning, that demon was placated. He approached it with a passion that was palpable:
How do you think it feels?
And when do you think it stops?
"Embrace the pain, at least you know you are alive" is the message I received. I also felt he had a Coen Brothers dark sense of humor. Many of his songs, depressing to most people, made me laugh on the inside.
"It's such a perfect day.....
I thought I was someone else
Someone good"
The whole album Berlin took the dark side to the next level. Everyone in Gainesville hated him which, to me, was more amusing than the record. Lou Reed and the performers he inspired, kept me entertained and sane during my first major conflict and continued to do so in subsequent years when I was bombarded by the deeper wounds, the ones that emanated from my inability to handle real responsibility. He is still the "go to" guy when I am not doing well. Lou was the counter to the counterculture, just in the nick of time. Though his songs glamorized the seedier elements which were quite the contrast to my gig, he was in no way condescending to those who chose a different and more conventional lifestyle, like Jack the banker and Jane the clerk in his song Sweet Jane. They worked hard and saved their money. He contrasted the two with himself
" me babe, I'm in a rock and roll band "
There's no correct script, there are no limits of passion, and pain is an acceptable consequence of inevitable failures, but never the end of the effort.
"But anyone who had a heart
They wouldn't turn around and break it
And anyone who ever played a part
They wouldn't turn around and fake it"
Monday, September 9, 2013
Sunday Night at the ER
Saturday night is the traditional trauma night in all big city emergency rooms throughout the country. This particular evening generates high activity from your local gun and knife clubs, wreaking havoc on the public, and to a greater extent, each other. Add the alcohol-related driving victims, and the surgical teams are typically buzzing. The brain trauma is handled by the Neurosurgeons. In contrast, Neurology has no special day but lately a change in our local Medical Center policies has opened the gates for transfers to our hospital from all outlying facilities, which have no weekend Neurology coverage. The change: If our hospital is full, the patient will still be sent here and can park in our ER while being evaluated and treated. Just Say Yes would make a good policy title. This change has resulted in a dramatic increase in the number of calls from the ER, and has overwhelmed our Neurology group. It is now not unusual for us to be evaluating multiple very sick patients simultaneously. Last Sunday I had some difficult cases that turned out....well, you can be the judge.
The day started out quite well. At 6:45 AM, my friend Norman and I were able to start and eventually complete a 40 mile bike ride. We did 'loops', the 'on call' routine, which entails riding the same roads over and over again, never more than 10 to 15 minutes from home. This is the only way to ride while on call. I cannot overstate how important it is to do a ride, especially on the 'on call' days. A good ride will reliably jack up the endorphin blood level, an absolute necessity, before the inevitable poop hits the fan. It went well, though somewhat easier than usual, as I was still a little over trained from the Girona trip, and Norman was recovering from a recent injury. When the calls started coming from the Emergency Room, I took a quick shower and headed downtown.
I drove to the hospital listening to Radiohead's The Bends on my new and awesome sound system. The last song I heard was Sometimes You Sulk, Sometimes You Burn, which, in retrospect, portended future problems. I made my rounds at a comfortable pace, visiting patients seen by me or my partners during the previous week, with a small number of routine type new consults. Nothing at all stressful. At about 6:00 PM I was wrapping it up and thinking about the 7:30 PM French movie at the down town art house. Just as the endorphins were breaking down and leaving me a bit vulnerable, like Sampson without his hair, I picked up a tough case on the floor. As my input to this case was unfolding the ER started to call. Suddenly I had three patients with diverse and serious problems.
On the floor, the case was a 42 year old lady with a diagnosis of Multiple Sclerosis who, over the last week, had progressively declined from no problems walking to barely walking with the assistance of a large walker. She had a Neurologist in a neighboring town, but was not able to reach him, so she had gone to her local ER. Without a hitch, here she was, my problem. There are two ways to look at this. The first is to say "Wow, what a nice opportunity to help someone. I am so thankful she did not find her Doc." The other response, "Thanks a lot. I had enough to do already and now I am going to miss the movie." At first glance I assumed she was having an MS attack and the treatment is standard: continue the medicines that lessen the chance of an attack, and add large dose of steroids, which can be beneficial for an acute attack. I considered dismissing her, suggesting she see her hometown doc when available, who could continue this treatment plan.
However something about her problem did not make sense. The symptoms were typical of MS, in that the evolution of the problem was a matter of days and the location of the problem, per my examination, was the thoracic spinal cord, not at all unusual for an MS attack. A sudden onset would suggest a stroke and a more gradual onset would suggest a tumor. She was severely weak in both legs. The two, right and left, motor tracts in this part of the spinal cord are not contiguous. With this degree of weakness, an area of inflammation inside the spinal cord, which is the way a MS attack works, should have also caused some degree of sensory loss - numbness. On the other hand, some type of mass pushing on the spinal cord will frequently compromise the artery supplying blood to the cord. When this happens, the motor tracts are most vulnerable. In this latter setting, motor loss without sensation problems is common. I wanted to think about this some more, but then the ER called. After reflecting on this confusing array of symptoms, I fortunately decided not to send her home.
The first ER case was a very elderly lady who, while eating, suddenly dropped her fork from the right hand and was unable to speak. The ER doc felt it was a stroke on the left side of the brain. The patient made it to the hospital in time get the clot buster called TPA, but the doc was concerned about her age, and thought it might be too risky. In some patients, and the older the more likely, the TPA clot buster will cause a massive brain hemorrhage into the area of recent damage. His concern was appropriate, but there are no age limits for TPA. As long as the patient and/or family understood the risk, I was in favor of giving the clot buster. The patient had two very nice and intelligent daughters. I was able to go over all the pros and cons in record time. We called for the medicine from pharmacy and as a last precaution I went to the computer to view a CAT brain scan and lab work done on the patient. The scan looked OK, no bleeding into the brain and no hint of any other problem, such as a tumor.
However when reviewing her blood work, I discovered some of the lab results had not been completed. This never happens. The blood sent to the lab in this clinical situation of acute stroke, is labelled "STAT", and the results are always back in the chart by this time. For some reason this patient's blood work was mislabeled. When I called the lab to ask for the rest of the blood work, I was told it would take an additional 30 minutes to complete the coagulation profile and the chemistry profile which includes electrolytes (salt concentration primarily), kidney function analysis and blood sugar. Normally the coagulation studies are abnormal only if the patient is taking a prescribed blood thinner like coumadin, and the daughters were certain this was not the case. In the computer, I found a fairly recent normal blood chemistry analysis done on her. We did a quick finger stick for the blood sugar, which was OK. I then went over the conundrum with daughters. I told them the situation looked like a stroke which would likely improve with the clot buster if given immediately, and though we like to make sure all the labs are normal, there was no reason for these labs to be abnormal. Even if abnormal, it was unlikely a chemistry problem would mimic a stroke. I suggested not waiting and going ahead with the TPA. Were they OK with that? What could they say.
She received the usual 10% of the entire dose right away (bolus) and we were dripping in the remainder over an hour, which is all standard. I had asked the lab to call us when the labs were completed. In 5 minutes, (note: not 30 minutes), we learned the coags were OK. Ten minutes later we learned the sodium level was critically low. Low enough to cause neurological problems.Whoops. How this happened, I am still not sure. The question: did it drop because of the stroke? That is possible. Any brain injury can make your pituitary gland and neighboring hypothalamus area go on tilt, resulting in the "inappropriate" release of a hormone ADH (antidiuretic hormone). This hormone causes the kidneys to hold on to pure water to such an extent, the blood sodium level can be diluted to her critical level. This fast? Never.
Why does a low sodium cause neurological dysfunction? Most fluids, other than pure water, have a number of particles in solution. The number of particles determine the osmotic force. Small particles like sodium are in the bloodstream at a high number or concentration. There is a membrane between all tissues freely permeable to water but not to sodium or other particles. When the sodium concentration drops in the bloodstream, and the blood becomes contiguous with the brain cells, water is sucked out of the blood into the brain to maintain equal osmotic pressure on both side of this membrane. This is a well established simple rule of physics. The result is like a dry sponge absorbing water. Like the sponge, the brain cells swell and brain problems ensue. Usually the symptoms come on gradually. In this case the low sodium likely caused a small speech center seizure resulting in "speech arrest." This explains why her problem came on suddenly, mimicking a stroke. The brain in this area is then short-circuited by this seizure activity, and it takes a full day or so in some cases to reboot. This is the proverbial curve ball that always seems to come my way when least expected. She received a dangerous medicine, one that can cause a massive brain hemorrhage, for no reason.
So I had to drag my tail back into the room, announce the news to her daughters and turn off the TPA. They were not happy. The ironic part about this screw up was I could have easily remained silent about my blunder. It was likely she would fully regain her normal speech once her sodium was corrected. And in fact this did eventually occur. If she did not actually have a structurally damaged area, a stroke, the chance of hemorrhaging was minimal. Had we proceeded with the original plan to give a full dose of TPA, I would have likely been congratulated for such a good outcome.
My wife, the most enthusiastic of my many critics, would have chastised me for getting into this predicament.
" My husband," I have heard her tell her friends, "has a 'wait' disorder."
" He doesn't look too big or too thin," they might reply.
" I said 'wait,' not weight. "He can't."
Or, as she tells me, perhaps when going to the coast and I become very concerned we may have missed a turn,
" Why do you always drive me nuts by hitting the panic button?"
" I love that button," I reply.
Back to the MS patient. With some distance and time to think about it, I concluded she was not having an MS attack. Something else was going on. I cancelled my initial orders and set her up for an MRI the next morning through the appropriate area. It showed what appeared to be a metastasis of a malignant tumor, primary site unknown. Likely it was a lymphoma, because the scan also showed some tissue suggestive of this, outside of the neurological area. If dismissed, my initial plan, she would likely have been permanently paralyzed in a matter of a day or three. My friends, the Neurosurgeons, removed the tumor the following day and she greatly improved. We are awaiting reports to define the cancer from my other friends, the Pathologists.
The movie was over at this point which was irrelevant because it was back to the ER. This time it was a 50 year old guy of short stature, nicknamed ' Peewee," with "possible stroke." Less than an hour before arrival, he suddenly became wobbly and claimed he was seeing spots. His wife took his blood pressure, which was high, and called the 911 crew. He was quickly evaluated by the ER staff, this time with blood work, all in the chart, and nothing to prelude the TPA. His blood pressure was too high initially, but he was placed on intravenous meds bringing the BP to the 'safe' range for the TPA. He had a CAT brain scan showing no bleed but "early changes of CVA (stroke)," according to the radiology report.
When I arrived he was mildly confused, without visual complaint but wobbly when he sat up. During my examination, it was obvious his eyes were not focused on me when answering my questions.
"Peewee, can you see OK?" I asked.
"Yes," he quickly replied.
"How many fingers am I holding up?" (showing him my five fingers).
"One," he answered without hesitation.
"How many now?" (showing him two fingers).
"Five," he replied, again without hesitation.
His pupils were normal size and responded perfectly to a light by becoming smaller. This meant no major neurological problem with the eye nerves (optic nerves).
Peewee had "Anton's Syndrome," a rare problem occurring when someone has a sudden loss of function in the back part of the brain, the visual cortex, on both sides. Almost all cases are due to stroke. The victim will not realize the problem of ' cortical blindness,' as opposed to blindness from an eye disorder. With this syndrome, the patient is usually adamant he/she can see, and will confabulate when challenged.
So Peewee's condition looked like a stroke, and the CT was read as such. Not so fast on the TPA this time. Something about the stroke diagnosis was not right. Two blunders in one night are grounds for dismissal, or at least a beating with a cane. I suspected he had a condition with long name that occurs when someone's blood pressure goes up very high or not so high but very quickly changes. It's called "Posterior Reversible Encephalopathic Syndrome," aka PRES. The change on CT, read as stroke, was too early to likely be a stroke (changes on CAT don't occur until about 12 or more hours). Everything else was consistent with PRES. In this condition, fluid leaks out of the blood vessels in the back part of the brain, the visual cortex, but, mysteriously, no where else.
I decided not to order the TPA, but I needed some data to back this up. The first thing was to look in the back of his eye with my handy ophthalmoscope I always carry in my black bag. There are abnormalities specific for severe acute blood pressure problems one can usually see. This part of the examination is a somewhat difficult maneuver in an uncooperative patient. I always ask the cooperative patients in my office to fix their stare to something hanging on the wall opposite the exam table, (translate: write off all art work) which makes this much easier. Peewee, being blind and also confused, was going to be a problem.
So it was my face in his face for several minutes without success. Then I had to go to plan B. That is, make up plan B and go to it. I asked a medical student who was helping, to play a song on her cell phone and hold it in the exact location which would help me out, if Peewee looked at it. She played Sam Cooke's Cha Cha Cha. Again I tried to look in the back of his eye. Again Peewee proved uncooperative. Then I pulled out my phone, gave it to her to hold, and played Jay Z's Empire State of Mind. At first this did not work but when Alicia Keys came in with the chorus.
" New York. Concrete jungle where dreams are made of ...."
He went right to it. The woman's voice! I will remember that detail next time. I was able to see he did have most of the changes consistent with blood pressure problem. I don't think my butt was moving with the beat, though it was possible, since I was not paying any attention to that end of my body.
So he went to the ICU on appropriate IV meds for his blood pressure and no TPA. I was tired and hungry, so I headed home. The endorphins were a memory. I had ordered an MRI brain scan, confident it would show abnormalities confirming my opinion. The tech was still in the house and I calculated the scan would be ready for me to pull up on line to review, after the drive home and a snack. I called the nurse in the Neuro ICU from the car to make sure everything was in order. He told me that Peewee was now complaining of a headache and he had announced he was not having the MRI because he was claustrophobic. I made a U turn on the Interstate. I love that move. Back to the ICU, got to reason with Peewee.
"Peewee, I hate to kick you when you are down, but you are blind and you cannot be blind AND claustrophobic!"
" I'm not blind," he reminded me
"Ok, we will bring in a spare MRI machine that has a ten foot clearance in all directions."
"Maybe I can do that," he offered
Down to the scanner with Peewee, the nurse, a syringe of morphine and another with Versed (very short acting Valium like drug). In order to give these meds, hospital rules are: The doctor has to be in the MRI scan room. He did not bite on the big scanner story. An hour and a half later we had a snoring Peewee, two empty syringes, a hungrier doctor and a decent scan, confirming PRES.
With a balance of being settled and unsettled, I finally made it to the car for the drive back home. I removed Radiohead for fear of hearing the lyric "..sometimes you burn," which could've adversely tilted the delicate balance. I looked through my music selections hoping to find an old friend . Someone my age or older. Someone who had weathered worse storms than me, and had poetically recounted them. It was 1:30 AM and if I had any hope of sleeping, I had to calm down.
Easy, Leonard Cohen's The Partisan. Three and a half minutes. I played it four times:
There were three of us this morning
I'm the only one this evening
I must go on
The day started out quite well. At 6:45 AM, my friend Norman and I were able to start and eventually complete a 40 mile bike ride. We did 'loops', the 'on call' routine, which entails riding the same roads over and over again, never more than 10 to 15 minutes from home. This is the only way to ride while on call. I cannot overstate how important it is to do a ride, especially on the 'on call' days. A good ride will reliably jack up the endorphin blood level, an absolute necessity, before the inevitable poop hits the fan. It went well, though somewhat easier than usual, as I was still a little over trained from the Girona trip, and Norman was recovering from a recent injury. When the calls started coming from the Emergency Room, I took a quick shower and headed downtown.
I drove to the hospital listening to Radiohead's The Bends on my new and awesome sound system. The last song I heard was Sometimes You Sulk, Sometimes You Burn, which, in retrospect, portended future problems. I made my rounds at a comfortable pace, visiting patients seen by me or my partners during the previous week, with a small number of routine type new consults. Nothing at all stressful. At about 6:00 PM I was wrapping it up and thinking about the 7:30 PM French movie at the down town art house. Just as the endorphins were breaking down and leaving me a bit vulnerable, like Sampson without his hair, I picked up a tough case on the floor. As my input to this case was unfolding the ER started to call. Suddenly I had three patients with diverse and serious problems.
On the floor, the case was a 42 year old lady with a diagnosis of Multiple Sclerosis who, over the last week, had progressively declined from no problems walking to barely walking with the assistance of a large walker. She had a Neurologist in a neighboring town, but was not able to reach him, so she had gone to her local ER. Without a hitch, here she was, my problem. There are two ways to look at this. The first is to say "Wow, what a nice opportunity to help someone. I am so thankful she did not find her Doc." The other response, "Thanks a lot. I had enough to do already and now I am going to miss the movie." At first glance I assumed she was having an MS attack and the treatment is standard: continue the medicines that lessen the chance of an attack, and add large dose of steroids, which can be beneficial for an acute attack. I considered dismissing her, suggesting she see her hometown doc when available, who could continue this treatment plan.
However something about her problem did not make sense. The symptoms were typical of MS, in that the evolution of the problem was a matter of days and the location of the problem, per my examination, was the thoracic spinal cord, not at all unusual for an MS attack. A sudden onset would suggest a stroke and a more gradual onset would suggest a tumor. She was severely weak in both legs. The two, right and left, motor tracts in this part of the spinal cord are not contiguous. With this degree of weakness, an area of inflammation inside the spinal cord, which is the way a MS attack works, should have also caused some degree of sensory loss - numbness. On the other hand, some type of mass pushing on the spinal cord will frequently compromise the artery supplying blood to the cord. When this happens, the motor tracts are most vulnerable. In this latter setting, motor loss without sensation problems is common. I wanted to think about this some more, but then the ER called. After reflecting on this confusing array of symptoms, I fortunately decided not to send her home.
The first ER case was a very elderly lady who, while eating, suddenly dropped her fork from the right hand and was unable to speak. The ER doc felt it was a stroke on the left side of the brain. The patient made it to the hospital in time get the clot buster called TPA, but the doc was concerned about her age, and thought it might be too risky. In some patients, and the older the more likely, the TPA clot buster will cause a massive brain hemorrhage into the area of recent damage. His concern was appropriate, but there are no age limits for TPA. As long as the patient and/or family understood the risk, I was in favor of giving the clot buster. The patient had two very nice and intelligent daughters. I was able to go over all the pros and cons in record time. We called for the medicine from pharmacy and as a last precaution I went to the computer to view a CAT brain scan and lab work done on the patient. The scan looked OK, no bleeding into the brain and no hint of any other problem, such as a tumor.
However when reviewing her blood work, I discovered some of the lab results had not been completed. This never happens. The blood sent to the lab in this clinical situation of acute stroke, is labelled "STAT", and the results are always back in the chart by this time. For some reason this patient's blood work was mislabeled. When I called the lab to ask for the rest of the blood work, I was told it would take an additional 30 minutes to complete the coagulation profile and the chemistry profile which includes electrolytes (salt concentration primarily), kidney function analysis and blood sugar. Normally the coagulation studies are abnormal only if the patient is taking a prescribed blood thinner like coumadin, and the daughters were certain this was not the case. In the computer, I found a fairly recent normal blood chemistry analysis done on her. We did a quick finger stick for the blood sugar, which was OK. I then went over the conundrum with daughters. I told them the situation looked like a stroke which would likely improve with the clot buster if given immediately, and though we like to make sure all the labs are normal, there was no reason for these labs to be abnormal. Even if abnormal, it was unlikely a chemistry problem would mimic a stroke. I suggested not waiting and going ahead with the TPA. Were they OK with that? What could they say.
She received the usual 10% of the entire dose right away (bolus) and we were dripping in the remainder over an hour, which is all standard. I had asked the lab to call us when the labs were completed. In 5 minutes, (note: not 30 minutes), we learned the coags were OK. Ten minutes later we learned the sodium level was critically low. Low enough to cause neurological problems.Whoops. How this happened, I am still not sure. The question: did it drop because of the stroke? That is possible. Any brain injury can make your pituitary gland and neighboring hypothalamus area go on tilt, resulting in the "inappropriate" release of a hormone ADH (antidiuretic hormone). This hormone causes the kidneys to hold on to pure water to such an extent, the blood sodium level can be diluted to her critical level. This fast? Never.
Why does a low sodium cause neurological dysfunction? Most fluids, other than pure water, have a number of particles in solution. The number of particles determine the osmotic force. Small particles like sodium are in the bloodstream at a high number or concentration. There is a membrane between all tissues freely permeable to water but not to sodium or other particles. When the sodium concentration drops in the bloodstream, and the blood becomes contiguous with the brain cells, water is sucked out of the blood into the brain to maintain equal osmotic pressure on both side of this membrane. This is a well established simple rule of physics. The result is like a dry sponge absorbing water. Like the sponge, the brain cells swell and brain problems ensue. Usually the symptoms come on gradually. In this case the low sodium likely caused a small speech center seizure resulting in "speech arrest." This explains why her problem came on suddenly, mimicking a stroke. The brain in this area is then short-circuited by this seizure activity, and it takes a full day or so in some cases to reboot. This is the proverbial curve ball that always seems to come my way when least expected. She received a dangerous medicine, one that can cause a massive brain hemorrhage, for no reason.
So I had to drag my tail back into the room, announce the news to her daughters and turn off the TPA. They were not happy. The ironic part about this screw up was I could have easily remained silent about my blunder. It was likely she would fully regain her normal speech once her sodium was corrected. And in fact this did eventually occur. If she did not actually have a structurally damaged area, a stroke, the chance of hemorrhaging was minimal. Had we proceeded with the original plan to give a full dose of TPA, I would have likely been congratulated for such a good outcome.
My wife, the most enthusiastic of my many critics, would have chastised me for getting into this predicament.
" My husband," I have heard her tell her friends, "has a 'wait' disorder."
" He doesn't look too big or too thin," they might reply.
" I said 'wait,' not weight. "He can't."
Or, as she tells me, perhaps when going to the coast and I become very concerned we may have missed a turn,
" Why do you always drive me nuts by hitting the panic button?"
" I love that button," I reply.
Back to the MS patient. With some distance and time to think about it, I concluded she was not having an MS attack. Something else was going on. I cancelled my initial orders and set her up for an MRI the next morning through the appropriate area. It showed what appeared to be a metastasis of a malignant tumor, primary site unknown. Likely it was a lymphoma, because the scan also showed some tissue suggestive of this, outside of the neurological area. If dismissed, my initial plan, she would likely have been permanently paralyzed in a matter of a day or three. My friends, the Neurosurgeons, removed the tumor the following day and she greatly improved. We are awaiting reports to define the cancer from my other friends, the Pathologists.
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| This is a MRI side view of the patient's thoracic spine and spinal cord The spinal canal is behind (right) the vertebra.The parallel vertical white lines are normal spinal fluid on either side of the actual spinal cord. The arrow is pointing to the tumor, almost 2 vertebral body lengths, on the back side of the spinal cord, compressing the spinal cord to the extent the spinal fluid is obliterated |
The movie was over at this point which was irrelevant because it was back to the ER. This time it was a 50 year old guy of short stature, nicknamed ' Peewee," with "possible stroke." Less than an hour before arrival, he suddenly became wobbly and claimed he was seeing spots. His wife took his blood pressure, which was high, and called the 911 crew. He was quickly evaluated by the ER staff, this time with blood work, all in the chart, and nothing to prelude the TPA. His blood pressure was too high initially, but he was placed on intravenous meds bringing the BP to the 'safe' range for the TPA. He had a CAT brain scan showing no bleed but "early changes of CVA (stroke)," according to the radiology report.
When I arrived he was mildly confused, without visual complaint but wobbly when he sat up. During my examination, it was obvious his eyes were not focused on me when answering my questions.
"Peewee, can you see OK?" I asked.
"Yes," he quickly replied.
"How many fingers am I holding up?" (showing him my five fingers).
"One," he answered without hesitation.
"How many now?" (showing him two fingers).
"Five," he replied, again without hesitation.
His pupils were normal size and responded perfectly to a light by becoming smaller. This meant no major neurological problem with the eye nerves (optic nerves).
Peewee had "Anton's Syndrome," a rare problem occurring when someone has a sudden loss of function in the back part of the brain, the visual cortex, on both sides. Almost all cases are due to stroke. The victim will not realize the problem of ' cortical blindness,' as opposed to blindness from an eye disorder. With this syndrome, the patient is usually adamant he/she can see, and will confabulate when challenged.
So Peewee's condition looked like a stroke, and the CT was read as such. Not so fast on the TPA this time. Something about the stroke diagnosis was not right. Two blunders in one night are grounds for dismissal, or at least a beating with a cane. I suspected he had a condition with long name that occurs when someone's blood pressure goes up very high or not so high but very quickly changes. It's called "Posterior Reversible Encephalopathic Syndrome," aka PRES. The change on CT, read as stroke, was too early to likely be a stroke (changes on CAT don't occur until about 12 or more hours). Everything else was consistent with PRES. In this condition, fluid leaks out of the blood vessels in the back part of the brain, the visual cortex, but, mysteriously, no where else.
I decided not to order the TPA, but I needed some data to back this up. The first thing was to look in the back of his eye with my handy ophthalmoscope I always carry in my black bag. There are abnormalities specific for severe acute blood pressure problems one can usually see. This part of the examination is a somewhat difficult maneuver in an uncooperative patient. I always ask the cooperative patients in my office to fix their stare to something hanging on the wall opposite the exam table, (translate: write off all art work) which makes this much easier. Peewee, being blind and also confused, was going to be a problem.
So it was my face in his face for several minutes without success. Then I had to go to plan B. That is, make up plan B and go to it. I asked a medical student who was helping, to play a song on her cell phone and hold it in the exact location which would help me out, if Peewee looked at it. She played Sam Cooke's Cha Cha Cha. Again I tried to look in the back of his eye. Again Peewee proved uncooperative. Then I pulled out my phone, gave it to her to hold, and played Jay Z's Empire State of Mind. At first this did not work but when Alicia Keys came in with the chorus.
" New York. Concrete jungle where dreams are made of ...."
He went right to it. The woman's voice! I will remember that detail next time. I was able to see he did have most of the changes consistent with blood pressure problem. I don't think my butt was moving with the beat, though it was possible, since I was not paying any attention to that end of my body.
So he went to the ICU on appropriate IV meds for his blood pressure and no TPA. I was tired and hungry, so I headed home. The endorphins were a memory. I had ordered an MRI brain scan, confident it would show abnormalities confirming my opinion. The tech was still in the house and I calculated the scan would be ready for me to pull up on line to review, after the drive home and a snack. I called the nurse in the Neuro ICU from the car to make sure everything was in order. He told me that Peewee was now complaining of a headache and he had announced he was not having the MRI because he was claustrophobic. I made a U turn on the Interstate. I love that move. Back to the ICU, got to reason with Peewee.
"Peewee, I hate to kick you when you are down, but you are blind and you cannot be blind AND claustrophobic!"
" I'm not blind," he reminded me
"Ok, we will bring in a spare MRI machine that has a ten foot clearance in all directions."
"Maybe I can do that," he offered
Down to the scanner with Peewee, the nurse, a syringe of morphine and another with Versed (very short acting Valium like drug). In order to give these meds, hospital rules are: The doctor has to be in the MRI scan room. He did not bite on the big scanner story. An hour and a half later we had a snoring Peewee, two empty syringes, a hungrier doctor and a decent scan, confirming PRES.
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| This is an MRI brain slice though PeeWee's brain. The slice is parallel to the ground and you can see both eyeballs at the top (front of brain). The normal brain is grayish. The black is normal fluid inside the brain. Within the drawn rectangle, which encompasses most of the visual cortex, the bright white is the fluid which has leaked out of the blood vessels because of the very high blood pressure. This is not a stroke and in a day or two, with good control of his blood pressure, it was reabsorbed and he could see normally |
With a balance of being settled and unsettled, I finally made it to the car for the drive back home. I removed Radiohead for fear of hearing the lyric "..sometimes you burn," which could've adversely tilted the delicate balance. I looked through my music selections hoping to find an old friend . Someone my age or older. Someone who had weathered worse storms than me, and had poetically recounted them. It was 1:30 AM and if I had any hope of sleeping, I had to calm down.
Easy, Leonard Cohen's The Partisan. Three and a half minutes. I played it four times:
There were three of us this morning
I'm the only one this evening
I must go on
Tuesday, August 13, 2013
Deputy Dog
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| Deputy Dog in foreground with Katie in Profile |
In 2001 Charlotte and I went to Petsmart with the intention of adopting one dog. There were more than twenty on death row. After a family discussion we narrowed our choice to one of two dogs. Unable to decide which one to adopt, we took both for a long walk and quickly noticed they.played together like old friends. Predictably, we left with both as the gallows were being assembled. 'Katie' was two or three years older than the adolescent other puppy, who had a temporary name of ' Boris'. As a big fan of the cartoon Deputy Dog when growing up, I decided 'Boris' looked the part, so his name was changed. The lawyer/saint was able to legalize this name change for a minimal additional charge.
Kate (aka) " the Sheriff" and her "deputy", Deputy Dog seemed delighted with their new eleven acre home. They took their law enforcement duties quite seriously. Anyone driving up was immediately greeted, and we were duly notified by their distinctive barks. Both agreed that 5427 Rivolli Drive was not the place any rodent, or rodent like animal was welcome. Trespassing resulted in a team approach of search, seizure and execution. On most occasions the criminals were also eaten, but never in entirety. Charlotte and I debated whether this last action was meant to be a message for potential future trespassers, or some type of bragging ritual for our benefit. I recall a short period of time when a number of raccoons, attempting to relocate in our yard, were all killed, one at a time, over four or five successive nights. Every morning, just off the front porch, we were horrified to see the mangled top half of a grown coon. I recall telling Charlotte:
"Something about them raccoon's hineys seem to be aggravating to the dogs."
These two new family members were real dogs and not your typical modern day inside "yappers". For a decade they stayed outside the entire time. They reminded me of my younger years when I preferred to be outside 100% of the time. Even their attitudes toward the parental figures coincided with mine. In no way did they beg for our attention or seek constant approval. Most kids raised today are toted to their piano lessons, to karate, and then to soccer, where every practice and game is viewed by the adoring parents. This seems annoyingly similar to the indoor dogs, who race from room to room with the 'master', needing constant attention and praise. As a child I preferred our Sunday 28 inning baseball games with the neighborhood kids, in jeans, T shirts, and no parents, to the Saturday Little League games we played with standardized uniforms, umpires, chalk lines, and screaming parents. What a delight it was for Charlotte and I, as parents, to watch Deputy and Kate play together all day, always on a mission.
When we first brought Katie and Deputy Dog home we gathered everyone around and explained the lineup:
"Cats in, Dogs out".
Maybe the dogs should have contracted the 'Lawyer/ Saint' to negotiate on their behalf, but they didn't.
The cats looked rodent enough for us to be concerned.
Deputy was the friendlier of the two. He was more or less the Will Rodgers of the canine world, never meeting a dog he did not like. His good will extended to all human visitors as well. He was always so happy to greet everyone who came to see us, including strangers, running to them with his tail a waggin'. We assumed he had a sixth sense to discern the murderers, rapists and tax assessors. We had no problem with first two, but come to think of it, our taxes have been going up.
During the first winter, severe low temperatures were predicted one evening. The television/radio people repeatedly warned that all pets needed to be brought indoors. We had to do something. We did not want the Defax social workers in our home again. That was painful enough when those jerks showed up in earlier years, questioning our child rearing skills, something about:
"Why does your little girl not have a bow in her hair?".
We made nice beds for the dogs in Charlotte's studio located below the gardens East of the house and turned on the heat. When we woke up the next morning and looked outside we noted the dogs were comfortably sleeping on the porch, and it was 18 degrees. When we went to the studio we discovered they must have taken a running leap, and had gone right through a glass window. We never again tried to tell them where to sleep. This time, Defax saw it our way.
Katie died a couple of years ago of an apparent heart attack in her sleep. "The Dep" did not take this too well. He stayed on the front porch, hunted with little enthusiasm and less success. He was particular freaked out by the lightening and thunder. Apparently Katie made better sense of this threat and together, they weathered the storms. Missing his partner and finding himself alone, Deputy Dog seemed bewildered and frightened. As a team, the Dogs had been fearless. By himself, Deputy grew cautious. Fire crackers were the worst. Though otherwise a proud American and by no means a 'political animal', he grew to hate the 4th of July, then the flag and eventually the flag wavers.
"Assholes", he preached to the cats.
Soon thereafter, secure his years of good work assured him a comfortable lifestyle, he announced his retirement as a 24/7 watch dog, and asked to be an indoor dog. The vet by then had assured us the dogs knew the cats were family, and would inflict no harm upon them. So in he came. He never yapped, but he did follow us from room to room. We brought his bed from the porch into our bedroom every night and back outside in the morning to his favorite spot, depending on the season.
He remained skeptical of the arrangement to the end. Most nights the three of us would watch an entire movie together. I then asked if he needed to pee and I held the door open. Typically he would pause, refusing to exit, sensing the door would be shut behind him. Without fail I would then go out and pee in the yard. He followed and peed on my pee and the two of us would reenter the house to join Charlotte. Ditto the next night and ditto for 2 years.
Indoor dogs always develop a neurosis or two and Deputy was no exception. He refuse to bathe and amazingly, he did not smell bad. The only time he got into the car was to go to the vet. He was not good at the vet. Once, when he was sick, the vet took a rectal temp and Dep bit the guy. That didn't go over well with the staff, even after I explained to them Deputy's response was genetic:
" No one", I revealed, "in the entire family tolerates that procedure well. "
After this violation of his dignity, he refused to get into the car, no exceptions, even when we put bacon in the back seat. Luckily in Macon, we have a house call vet who looked after him, sans temps!
With declining skills he teamed up with the cats during the day to hunt. The cats advanced to indoor/ outdoor vocations after 'Jackson', the Maine Coon Cat, escaped and went on a 'walkabout' for 2 months and to our amazement was able to survive. That's another whole story. Jackson claimed he lived on coyote pups, going into the den at night when the parents were out hunting. Charlotte and I thought this was some sort of bullshit but Deputy bought it hook, line and sinker. Impressed, Deputy and the cats joined ranks though I felt it was a pitiful facsimile to the good old days with Katie. Typically Jackson captured the chipmunks and brought them to Dep, who would gobbled them down in a heartbeat. He loved those chipmunks and always referred to them as "potato chipmunks". He was predictably never satisfied with just one. Apparently there must have been some type of reciprocal protection arrangement. Since his Dep's death, the cats will not go outside.
He was such a handsome dog. Everyone knew he turned down multiple leading man offers from Hollywood, content to stay here hunting and watching out for the two of us. Even when he was older, with gray hair on his snout, he was offered spots in commercials. He turned them all down with the explanation he did not believe in the particular product. He had a few faults but he was definitely a dog with principles.
Dep was in serious decline the last few months even with the traveling vet doing all she could. He saw the end was coming and tended to reminisce. He told the same stories over and over but we loved hearing them. Mostly they were hunting adventures with Kate. Regrets? Well, he had a few.
" I should have come in earlier" he said.
" Air conditioning? Shit.Who knew?"
As you can see he did have a foul mouth and also dog breath, but we never mentioned our concern. I gave him grief about the theft of my precious all black El Camino, stolen one night right under his nose when we were both home. He claimed I deserved to have it stolen for being so insensitive to the plight of immigrants, evidenced by my custom made bumper sticker on the back fender which read: "I Swam the Rio Grande". Hell, I told him, I am practically an immigrant myself . Back and forth we would go. It's hard to argue with a dog.
The end was terrible. He went into kidney failure. We discussed options. Dep refused dialysis, I am proud to say, and on the last day he had problems breathing. We didn't bring up the ventilator. When he died we were devastated. I was surprised by the extent of my grief. More so, than when some people die; I mean the ones we knew. That's probably not right, terrible in fact. What a predictable and ridiculous Catholic thing to do: Feeling guilty about feeling bad. I am certain the nuns who mentored me in my early schooling would have been proud of my "bringing the abstract concept of misery to a new and much needed level."
But that is where it is. Bad feeling. Terrible loss. A great dog. A real dog. The dog's dog. Deputy Dog. We will never forget him
Wednesday, August 7, 2013
Girona
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| T and T enterprises reunited, in front of our hotel |
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| The Comeback Kid |
The original plan was to take on the high Pyrenees in the Southwest of France. But my aging weak legs and Ptosiphobia dampened my enthusiasm for the long 8 % to10 % climbs and descents. So we Google mapped several areas along the Spanish/French border where the Pyrenees begin it's slow decline into the Mediterranean Sea and settled on the city of Girona, a hour's train ride northeast of Barcelona. With an established cycling reputation and several shops renting high end bikes, this was an easy choice. As a bonus, it was not difficult to bring along a mini entourage of other friends and family.
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| We didn't go to France but Sarah did get a baguette bag |
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The routine was to ride very early every morning to avoid the midday heat, and to get back and spend time with family and friends. Our entourage included the wives, my daughter Sarah and 'other' daughter Jennifer. Our friends Doug and Susan eventually made it over from France and my sister and her daughter, Mary, each stayed with us part of the time. Todd and I averaged riding about 60 miles a day but were usually out for quite some time, having coffee and chocolate croissants, trying to talk to the locals, getting lost of course, and taking advantage of the numerous photo opps. The traffic was very light. The Spanish drivers were unbelievably courteous.
We never had an unpleasant experience while riding. It was as if the area's financial interests depended exclusively on the goodwill of the local and visiting cyclists. The drivers on the winding roads were content to stay behind any rider for a matter of minutes, rather than place either in peril. There was never an impatient car horn or an aggressive attempt to pass us. The contrast between our sometimes hostile locals in Georgia, the maniacal French or to a greater extent, lunatic Italian drivers, was shocking. No one was in a hurry. If someone from outer space dropped into Italy, after about 2 days, they would conclude, the entire purpose of life was to get from point A to point B faster than anyone else in the country. On one ride we stopped momentarily to look at our maps and several young boys approached to ask what I had on my helmet. When I showed them it was a mirror, they were able to surmise I perceived a need to see the cars behind. When I confirmed their theory, one immediately countered:
"But why do you need it? The cars will see you."
His innocence was moving. Culture there apparently matters. In Spain, bike riders are respected and admired. If he ever rides in the U.S. he will be shocked by the rudeness of American drivers.
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| The dwellings in Girona with Cathedral in back round |
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| From the Ride to the Sea |
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| Todd in front of apartment building that housed Lance and Tyler Hamilton |
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| The pool came in quite handy for recovery. Here we were telling Susan how many Spanish pro riders we passed up that day |
The entire experience was life sustaining. The riding, the small towns, the sea, the company, getting to know Mrs. Todd better (Susan, whom we love), breaking bread with family I don't see often enough, old and new friends, the pool side stories, the coffee, the wine, the food. It was a series of pleasures, each stacked on another, and another and another.How does one capture such an experience in words? The renewal of riding with a lifelong friend after a 40 year interval. The kindness of strangers. The pleasure of family and friends within the essence of a remarkable culture, brought together in this wonderful city. To borrow "a bit", as my my Australian friends say from Pat Conroy's Prince of Tides: Since I have been home, every day before work as I put on my gear to ride, ".......These words come to me in a whisper, as a prayer, as a regret, and as praise: Girona, Girona, Girona".
Friday, July 12, 2013
The Tuesday-Thursday Ride -Race
With few exceptions every town the size of Macon has some kind of Tuesday-Thursday Ride-Race. This has been going on since the mid 1980s when Greg Lemond broke out on the international bike racing scene, and won the World Championship one day race in 1983. He later went on to win the Tour de France 3 times. Inspired by Lemond's extraordinary achievement, all the serious US riders metamorphosed to 'racers' overnight, and we were desperate to mix it up with like minded types aficionados. In the early days, however, there were very few sanctioned races. I had to go on four to five hour drives to Ocala Florida, Asheville NC or Murfreesboro Tennesee to get the fifty five minute "rush" of guys, shoulder to shoulder battling it out in criteriums through the center of town, going full tilt, at thirty plus MPH, sprint premes, some breaking away, likely caught later in the race, occasionally crashing, and jumping back into the melee on the next lap.
Hometown amateur facsimiles broke out like a 1950's measles epidemic. Simultaneously in every podunk town the size of Macon between Miami and Seattle, a 'Tuesday and Thursday' ride race was born. Seasoned racers, triathletes, new racers, and dreamers showed up to duke it out on sparsely traveled roads or industrial parks cleared out by the afternoon time clock. Though not sanctioned by United States Cycling, with no motorcycles clearing the intersections, and no prize money, these were, and still are, races.
For me the only good things about aging are (1) functioning well on 6 hours or less sleep per night and (2) not needing to go far to find riders with superior skills. On Tuesday/Thursday, I rush home from work, leaving charts undone, blasting hard rock on the car stereo for transitional inspiration. After a quick change, I am on the bike. A perfect five minute warm up brings me to the start. I have been doing this for 25 years and loving it. Every year it is harder, and every year I plan to be better, and occasionally I am, but usually I am not. I don't care much when it doesn't go well. The point is, to go out and let the stress fly from inside to outside and off for good, if I do it right..
Being the second oldest of the 40 or so riders who show up, removes any self imposed pressure to win. If I hang in with the lead group of the ten or so "big boys" to the end, I am happy. The effort to do well draws so much adrenaline, it usually takes two beers, a tylanol PM and a Neurology Journal to calm me down enough to even think about sleeping. (No big deal, sleeping being a total waste of time, limited time, I am sorry to say).
Once a year while participating in this ride, I do something ridiculous. Last year I drove the truck a mile from the start, bike in the back. I hid in the bushes until the pack went by, jumped into the race from behind, and sailed through the whole pack in Superman Drag. I had a long sleeve classic Superman shirt, Superman underwear over my black bike shorts, and three foot bright red cap, flying off my shoulders when I was at full speed.
This year I decided to honor the greatest cycling movie ever made, Breaking Away. The movie came out in 1979, a few years before I bought my hot pink steel De Rosa bike. Several years ago I converted it to a fixed gear bike with one speed, no shifters, and no back brake The pedal stroke rpm (cadence) is directly proportional to bike speed. On the flats I spin this beauty at a normal 90 to 100 cadance. Down a steep hill I am committed to an rpm as high as 150 and it is difficult to stay upright. The locals in the movie were called "Cutters", (note my jersey) a word indicating they were locals, many of whom worked for a time harvesting stone in nearby quarries, which eventually made it to Indiana University, where much of the film's action occurred. Some of the sound track was from the Barber of Seville. This year my pro motorcycle racing young friends and filmmakers followed me out to a relatively flat part of the route where I again, jumped in from behind.
http://www.youtube.com/watch?
How did the rest of the ride go? Maybe the pack formed a few unsuccessful chases and I soloed home to win easily. Maybe that didn't happen. As Jake said to Brett on the last page of Hemingway's The Sun Also Rises " Isn't it pretty to think so"
Hometown amateur facsimiles broke out like a 1950's measles epidemic. Simultaneously in every podunk town the size of Macon between Miami and Seattle, a 'Tuesday and Thursday' ride race was born. Seasoned racers, triathletes, new racers, and dreamers showed up to duke it out on sparsely traveled roads or industrial parks cleared out by the afternoon time clock. Though not sanctioned by United States Cycling, with no motorcycles clearing the intersections, and no prize money, these were, and still are, races.
For me the only good things about aging are (1) functioning well on 6 hours or less sleep per night and (2) not needing to go far to find riders with superior skills. On Tuesday/Thursday, I rush home from work, leaving charts undone, blasting hard rock on the car stereo for transitional inspiration. After a quick change, I am on the bike. A perfect five minute warm up brings me to the start. I have been doing this for 25 years and loving it. Every year it is harder, and every year I plan to be better, and occasionally I am, but usually I am not. I don't care much when it doesn't go well. The point is, to go out and let the stress fly from inside to outside and off for good, if I do it right..
Being the second oldest of the 40 or so riders who show up, removes any self imposed pressure to win. If I hang in with the lead group of the ten or so "big boys" to the end, I am happy. The effort to do well draws so much adrenaline, it usually takes two beers, a tylanol PM and a Neurology Journal to calm me down enough to even think about sleeping. (No big deal, sleeping being a total waste of time, limited time, I am sorry to say).
Once a year while participating in this ride, I do something ridiculous. Last year I drove the truck a mile from the start, bike in the back. I hid in the bushes until the pack went by, jumped into the race from behind, and sailed through the whole pack in Superman Drag. I had a long sleeve classic Superman shirt, Superman underwear over my black bike shorts, and three foot bright red cap, flying off my shoulders when I was at full speed.
This year I decided to honor the greatest cycling movie ever made, Breaking Away. The movie came out in 1979, a few years before I bought my hot pink steel De Rosa bike. Several years ago I converted it to a fixed gear bike with one speed, no shifters, and no back brake The pedal stroke rpm (cadence) is directly proportional to bike speed. On the flats I spin this beauty at a normal 90 to 100 cadance. Down a steep hill I am committed to an rpm as high as 150 and it is difficult to stay upright. The locals in the movie were called "Cutters", (note my jersey) a word indicating they were locals, many of whom worked for a time harvesting stone in nearby quarries, which eventually made it to Indiana University, where much of the film's action occurred. Some of the sound track was from the Barber of Seville. This year my pro motorcycle racing young friends and filmmakers followed me out to a relatively flat part of the route where I again, jumped in from behind.
http://www.youtube.com/watch?
How did the rest of the ride go? Maybe the pack formed a few unsuccessful chases and I soloed home to win easily. Maybe that didn't happen. As Jake said to Brett on the last page of Hemingway's The Sun Also Rises " Isn't it pretty to think so"
Tuesday, June 25, 2013
Ptosiphobia
Recently, as if I don't have enough problems, I realized I had to make another psychiatric diagnosis on myself. Like several of my others, this newest one has not yet been described. You may remember that Freud, father of not so modern Psychiatry, was also a Neurologist. In the movie The Cameleon , a character played by Woody Allen, imitates a number of people. At one point, he was in Vienna, early 20th century, and was imitating Sigmund Freud. The character, in classic Woody Allen style states: "The major difference between Freud and myself, is that Freud felt that 'penis envy' was a condition affecting only women" The major difference between Freud and yours truly, who both enjoy inventing psychiatric disorders, is that he astutely noted these problems in other people, while I have consistently identified all of these previously unrecognized disorders in myself. Now, you may ask: how can someone with so many psychiatric conditions still function? The answer, I suspect, is some of these disorders may neutralize others, another novel psychiatric theory someone, with more time on their hands, should look into.
The Greeks and their phobias. I was always baffled by how such an advanced culture eventually collapsed. Given the number of phobias attributed to them, I think I figured it out. Googling 'phobias', one discovers there are almost 60 beginning with the letter (A). All are of Greek origin. If you multiply by 26 letters in the alphabet, and then by 50 or 100, likely the minimum number of people needed, to warrant naming the condition, you are approaching the order of magnitude of a Greek city. Eventually EVERYONE must have been afflicted with an incapacitating phobia- and this I think adequately explains the end of Greek civilization.
For 30 years plus I have regularly dealt with patients who have a problem known as "ptosis". This refers to having a droopy eyelid, partially, sometimes totally, covering the pupil. It can be on one eye or both. It is a problem because it impairs vision, but additionally it is very often is a sign of a more serious disorder, such as an impending cerebral artery aneurysm rupture, or myasthenia gravis, a muscle problem that can affect the breathing muscles in short order, or lung cancer, or dissection (torn) carotid artery, which can imminently occlude and cause a big stroke. There are subtle characteristic differences of the 'ptosis' in each of these conditions and it is my job to figure it out before the catastrophe occurs. For decades I assumed the Greek origin of the word translated to "droopy". Recently I learned the correct translation is "falling". I love this clarification, the eyelid is not "drooping", it is "falling".
Last weekend I made my first return to the mountains. It has been almost a year since 'The Fall' and I was curious to see if I was able to descend the mountains at the usual speeds. I knew I was in adequate condition to do the 6 or so climbs we typically make. In preparation, I have been riding up and down the few nearly one mile descents with greater than 5% grade, we are lucky enough to have in our area. It was during these practice runs I discovered I have 'ptosiphobia', fear of falling, a previously unrecognized condition I believe needs to be added to the Handbook of Psychiatric disorders.
In the last several weeks, whenever I have made these relatively short descents, I have had a massively intense internal butterfly feeling in my gut, the likes of which I have not experienced since I was a kid. The peculiar aspect of this feeling was that it was not altogether unpleasant. While descending on these preparatory rides, I was very concerned the bike, or the rider, would fail. This 'ptosiphobia', as it has now been labeled, is distinctly different than acrophobia, the mundane fear of heights any amateur might experience. But why was this butterfly feeling not unpleasant?
I had this feeling often as a very young person. It may have been on the playground slide or swing, climbing a tree, or jumping out of window in a partially constructed house my friends and I were trespassing upon, before landing on a pile of leaves. It was the same intense abdominal butterfly sensation. I kinda liked it when I was young because I was always sure everything would turn out OK. As previously discussed in an earlier entry to the blog (see Purgatory) I did not buy into many of the proclamations in the Baltimore Catechism, (manifesto of Catholic training we were forced to memorize in elementary school) but I did like the concept of Purgatory and also " the Guardian Angel". I was sure I had a guardian angel, given the number of tight spots I had survived in our totally unsupervised play. That butterfly feeling was never associated with a bad consequence, thanks to my angel. Over time these feelings became a pleasurable part of my adventures. Now having rekindled that exact sensation, ptosiphobia, I intermittently feel like a kid again
On the day of the ride, the weather prediction was 0% chance of rain. We lathered up with sunscreen at the base of Blood Mountain (bad name all factors considered) but before we were half way up the 7 1 /2 mile climb it began to rain. My two friends, Andy and Chuck (see future entry on the NYC Century involving these guys) and I, had planned to ride at a slow warm up speed on the first climb. Soon we were wet. Of course we brought NO foul weather gear. Just before the halfway mark, some guys passed us up. I was feeling great and felt I needed to pick.up the pace to keep warm as well as the other obvious shallow reason: Say you are 30 or so years old and riders pass you on a climb while you are warming up. If you then decide to catch and drop them, you are an asshole. But if you are over 60 and those same competitive juices still flow, with like reaction, it is my view, you're not! I know it seems like a double standard, but that's why we need and indeed have this good standard.
When we made it to the top,(after passing the other guys) we went into the small store for supplies Enough time elapsed to really cool off. When we started down the mountain I did not feel cold. As it turns out this was identical to the situation on the Grand Teton Pass 11 month ago, just prior to 'The Fall'. Major effort up, long wait, cool down, then descent. So what happened?
I sat up to wind brake as much as possible and reached very conservative descending speeds of less than 40 mph. It did not take long for the ptosiphobia to kick in and this time I did not care for it. At just over 3 miles down, the same distance as on the Teton Pass incident, the bike started to wobble. I had recently convinced myself the original high speed death wobble before the Fall was a technical problem, something to do with the new bike fork or the front wheel slightly out of true. Last weekend I was on different bike. Luckily I had started to slow for the hard left turn to Wolf Pen Gap and I was able to pull off the road. Only when I was off the bike did I realize there was nothing wrong with the machine. The bike was wobbling on the descent because I was shivering, with no other sensation of feeling cold.
The physiological explanation for this is complicated but the short version is, when one is working hard climbing a mountain for 45 minutes, there is a tremendous amount of heat production in the body, dealt with by dilating the skin blood vessels, which releases heat. You have likely heard of marathon runners experiencing hypothermia a short time after their race. During the race, their core body temperature is 105 degrees ( As a med student, I did an experiment with Dr Robert Cade, inventor of Gator Aid, on marathon runners and this was discovered). After the race, the hormones and neurotransmitters responsible for the vasodilation are still circulating and the runner continues to lose heat. Since he/she is no longer creating heat, hypothermia ensues. The runner never feels cold, because coldness is sensed by the skin, which remains warm. Similarly, when one has an adult beverage or 3, and sits on a bench in Central Park in the middle of winter, the alcohol dilates the skin vessels and there is a nice sensation of warmth, occasionally accompanied by hypothermia and death!
The rest of the day went well, though I was never able to shake my fear of falling. A bike rider who fears speed is like a gourmand who fears truffles. This a problem that needs to be solved. My instinct is to hit it hard pharmocolgically with extra espressos. Drugs are the modern day solution to all pysch problems and may only be a weak patch. This time I might stick with my buddy Freud and look into psychotherapy. In the meantime at least I learned a skinny guy needs to immediately descend, once the mountain has been conquered
The Greeks and their phobias. I was always baffled by how such an advanced culture eventually collapsed. Given the number of phobias attributed to them, I think I figured it out. Googling 'phobias', one discovers there are almost 60 beginning with the letter (A). All are of Greek origin. If you multiply by 26 letters in the alphabet, and then by 50 or 100, likely the minimum number of people needed, to warrant naming the condition, you are approaching the order of magnitude of a Greek city. Eventually EVERYONE must have been afflicted with an incapacitating phobia- and this I think adequately explains the end of Greek civilization.
For 30 years plus I have regularly dealt with patients who have a problem known as "ptosis". This refers to having a droopy eyelid, partially, sometimes totally, covering the pupil. It can be on one eye or both. It is a problem because it impairs vision, but additionally it is very often is a sign of a more serious disorder, such as an impending cerebral artery aneurysm rupture, or myasthenia gravis, a muscle problem that can affect the breathing muscles in short order, or lung cancer, or dissection (torn) carotid artery, which can imminently occlude and cause a big stroke. There are subtle characteristic differences of the 'ptosis' in each of these conditions and it is my job to figure it out before the catastrophe occurs. For decades I assumed the Greek origin of the word translated to "droopy". Recently I learned the correct translation is "falling". I love this clarification, the eyelid is not "drooping", it is "falling".
Last weekend I made my first return to the mountains. It has been almost a year since 'The Fall' and I was curious to see if I was able to descend the mountains at the usual speeds. I knew I was in adequate condition to do the 6 or so climbs we typically make. In preparation, I have been riding up and down the few nearly one mile descents with greater than 5% grade, we are lucky enough to have in our area. It was during these practice runs I discovered I have 'ptosiphobia', fear of falling, a previously unrecognized condition I believe needs to be added to the Handbook of Psychiatric disorders.
In the last several weeks, whenever I have made these relatively short descents, I have had a massively intense internal butterfly feeling in my gut, the likes of which I have not experienced since I was a kid. The peculiar aspect of this feeling was that it was not altogether unpleasant. While descending on these preparatory rides, I was very concerned the bike, or the rider, would fail. This 'ptosiphobia', as it has now been labeled, is distinctly different than acrophobia, the mundane fear of heights any amateur might experience. But why was this butterfly feeling not unpleasant?
I had this feeling often as a very young person. It may have been on the playground slide or swing, climbing a tree, or jumping out of window in a partially constructed house my friends and I were trespassing upon, before landing on a pile of leaves. It was the same intense abdominal butterfly sensation. I kinda liked it when I was young because I was always sure everything would turn out OK. As previously discussed in an earlier entry to the blog (see Purgatory) I did not buy into many of the proclamations in the Baltimore Catechism, (manifesto of Catholic training we were forced to memorize in elementary school) but I did like the concept of Purgatory and also " the Guardian Angel". I was sure I had a guardian angel, given the number of tight spots I had survived in our totally unsupervised play. That butterfly feeling was never associated with a bad consequence, thanks to my angel. Over time these feelings became a pleasurable part of my adventures. Now having rekindled that exact sensation, ptosiphobia, I intermittently feel like a kid again
On the day of the ride, the weather prediction was 0% chance of rain. We lathered up with sunscreen at the base of Blood Mountain (bad name all factors considered) but before we were half way up the 7 1 /2 mile climb it began to rain. My two friends, Andy and Chuck (see future entry on the NYC Century involving these guys) and I, had planned to ride at a slow warm up speed on the first climb. Soon we were wet. Of course we brought NO foul weather gear. Just before the halfway mark, some guys passed us up. I was feeling great and felt I needed to pick.up the pace to keep warm as well as the other obvious shallow reason: Say you are 30 or so years old and riders pass you on a climb while you are warming up. If you then decide to catch and drop them, you are an asshole. But if you are over 60 and those same competitive juices still flow, with like reaction, it is my view, you're not! I know it seems like a double standard, but that's why we need and indeed have this good standard.
When we made it to the top,(after passing the other guys) we went into the small store for supplies Enough time elapsed to really cool off. When we started down the mountain I did not feel cold. As it turns out this was identical to the situation on the Grand Teton Pass 11 month ago, just prior to 'The Fall'. Major effort up, long wait, cool down, then descent. So what happened?
I sat up to wind brake as much as possible and reached very conservative descending speeds of less than 40 mph. It did not take long for the ptosiphobia to kick in and this time I did not care for it. At just over 3 miles down, the same distance as on the Teton Pass incident, the bike started to wobble. I had recently convinced myself the original high speed death wobble before the Fall was a technical problem, something to do with the new bike fork or the front wheel slightly out of true. Last weekend I was on different bike. Luckily I had started to slow for the hard left turn to Wolf Pen Gap and I was able to pull off the road. Only when I was off the bike did I realize there was nothing wrong with the machine. The bike was wobbling on the descent because I was shivering, with no other sensation of feeling cold.
The physiological explanation for this is complicated but the short version is, when one is working hard climbing a mountain for 45 minutes, there is a tremendous amount of heat production in the body, dealt with by dilating the skin blood vessels, which releases heat. You have likely heard of marathon runners experiencing hypothermia a short time after their race. During the race, their core body temperature is 105 degrees ( As a med student, I did an experiment with Dr Robert Cade, inventor of Gator Aid, on marathon runners and this was discovered). After the race, the hormones and neurotransmitters responsible for the vasodilation are still circulating and the runner continues to lose heat. Since he/she is no longer creating heat, hypothermia ensues. The runner never feels cold, because coldness is sensed by the skin, which remains warm. Similarly, when one has an adult beverage or 3, and sits on a bench in Central Park in the middle of winter, the alcohol dilates the skin vessels and there is a nice sensation of warmth, occasionally accompanied by hypothermia and death!
The rest of the day went well, though I was never able to shake my fear of falling. A bike rider who fears speed is like a gourmand who fears truffles. This a problem that needs to be solved. My instinct is to hit it hard pharmocolgically with extra espressos. Drugs are the modern day solution to all pysch problems and may only be a weak patch. This time I might stick with my buddy Freud and look into psychotherapy. In the meantime at least I learned a skinny guy needs to immediately descend, once the mountain has been conquered
Friday, May 17, 2013
My First Time
It was warm December night, typical for Miami Florida, 1967. I had finished my first quarter at Georgia Tech and was home for a couple of weeks, just before starting on my not so illustrious career at Pan American World Airways. The quarter had been a success from an academic standpoint but a disaster socially and culturally. I had no car, little extra money and was at an all boys school. I had not thought out the social angle myself, and what were my parents thinking, sending me, in the prime of my hormone rage, into a situation with such little opportunity to meet any women?
I was a nerd to boot, which did not help. I studied all week and on the weekends as well. Many of my classmates were valedictorians of their respective high schools and I was insecure about my abilty to keep up. Later I learned many had attended very small schools with inadequate prep for a place like Ga Tech. Despite living in downtown Atlanta, I had limited assess to movies and other cultural venues
At home I had my parents car to use. Ecstatic as they were about my acceptable GPA, more than me as I recall, they threw a few dollars my way in an effort to ease my tenuous financial situation. Adding to this good fortune, I was able to reunite with my high school girlfriend, who was also home from college. Without cell phones or even a regular phone in the dorm room, and no car to travel on the weekends, long distance relationships were almost impossible, and rarely did anyone, especially a nerd, even attempt to continue one.
My girlfriend was good looking. She had beautiful very white skin that stunningly contrasted with her jet black hair, excellent facial features and hazel eyes. She was diminutive but curvaceous in all the appropriate places. Her name was Marilyn which greatly added to her mystique from my perspective, having never fully recovered from Marilyn Monroe's death 3 years earlier. When I picked her up early that evening in the 1964 Buick Wildcat, I had no idea the night would evolve into one I would never forget.
In addition to being a nerd, I was also a philistine. I labored through assigned literature readings with little joy and less wonderment. I had never been to art museum, and rarely to a concert. I did occasionally go to movies but never thought about them beyond the credits. That all changed in one night.
We decided to go see a new release at The Gables theater on Miracle Mile in affluent Coral Gables Florida, just a few miles from her house. The movie was called The Graduate, the lead played by Dustin Hoffman, someone we knew nothing about. We had not spoken to anyone who had seen it, and had zero expectations.
I remember watching the movie in a novel way, viewing it with an absorbing keen interest. I don't think I missed a single line but never had a clue what any character was going to say or what would next happen. I was first puzzled and eventually bewildered. I doubt I laughed at the funny parts, uncertain if the director meant it to be funny. When the credits ended, I was not able to get out of the seat. I was truly stunned.
We eventually made it to the traditional "parking" place behind some hospital and tried to figure out what it meant. We talked about it for quite some time, and BTW, nothing else "happened", sorry to disappoint those of you with prurient interests. My mind, For The First Time, was like a hornet's nest, disturbed, all parts buzzing with high energy. For more than a week I could not get the movie out of my head. I did not need to see it again. I was able to go over it scene by scene from memory, gradually coming to the realization I had witnessed an iconic piece of work.
From that point on, I felt every movie, play, novel, piece of music or even a painting or building was potentially mind altering. That someone in our time, not necessarily a Shakespeare or a Mozart, would be able to create a piece of work that could tickle my soul, gave me an overriding optimism and a power to endure anything. All was good. Movies became my passion and shortly thereafter, The Ainsley Park Theater opened in Atlanta, showing first run Indies and Foreign Films. I practically lived there my last 2 years of college
So what happened to Marilyn? I used to worry about that one. Besides being a nerd and a philistine, I was a pretty poor excuse for a boyfriend. Had I scarred her for life and put her in a convent? I did not go back to Miami much and lost track for a long while. Several years ago, her good friend Kathy had a birthday party in North Georgia on a weekend I was riding my bike in the mountains. I got wind of the gathering through Kathy, with whom I had been in touch, regarding a family member of hers with a neurological problem. I managed to more or less invite myself. Marilyn was there with her husband, whom she had married right after college. She was fine, great actually. Her husband and I had a few similarities. He was a doc and bike rider. He appeared to be a fine product of thoughtful WASP breeding, not like moi, the somewhat disturbed product of two conflicting neurotic immigrant cultures, Irish and Sicilian. I immediately liked him a lot. He was bright, easy going and very nice to her.
Perhaps it was hubris, but I somehow felt I had been a positive influence on her choice. The 3 hour drive back to Macon, ordinarily a penance, was a delight
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