Into the Burning Building

I am starting this piece 48 hours before beginning my new career as an inpatient Neuro Hospitalist at our 700 bed hospital. On one hand I am as excited as a kid heading to camp, on the other, as nervous as a fireman ordered into a burning building. Everything I have done professionally to this point has not only prepared me to possibly succeed. but in retrospect has been a clear pathway to what I assume will be my swan song. Several years ago I signed up to tutor a few courses for the preclinical medical students at the local med school . The decision to teach was supposed to be a logical segue into full retirement, but here I am, driving to work in combat boots (recently purchased for the event), ready for the front lines of battle in a level one trauma center.

A confluence of factors has brought me here. The first factor was 'need'. Currently there is only one neurologist at the hospital during the day, slugging it out, heroically doing all the work, seeing up to ten new sick patients a day and continuing to follow them through their stay. The Hospital has unsuccessfully spent a year trying to hire a second full time neurologist. Allocating 60 to 90 minutes to each new patient, this one neurologist has been understandably overwhelmed.

The second factor was my experience teaching at the local medical school. These young doctors-to-be simply do not know how to examine a patient in an acceptable manner, resulting in an inability on their part to determine if the patients are sick, 'why' they are sick and, most importantly, 'how' seriously sick. This disturbing fact is a national epidemic colorfully commented upon by the Stanford University Professor of Internal Medicine and writer (Cutting for Stone), Abraham Verghese, both in print and as a periodic contributor on public radio. Our local medical students are no exception. Ironically the primary reason for this lack of proper training is advancements in medical technology, most particularly diagnostic imaging, which has greatly improved our ability to evaluate patient problems since my days of training, and I am very happy it has. A physician can now frequently (not always) get away with assessing the medical problem merely by ordering an large number of imaging studies and later checking the results. But there are many instances where an intelligent and well trained hands-on  assessment will quickly lead to a more accurate assessment with no radiation exposure and with considerable less expense.

The third factor occurred when I applied for and was hired as the second inpatient Neuro Hospitalist allowing me  to see and follow a finite number of sick inpatients each day with two third year medical students. Now every single student will have the opportunity to see a dozen or so patients, complete a comprehensive physical and neuro exam under my direct supervision with no time constraints.

It is my view we are in the midst of a national cultural war on how to most accurately and cost effectively assess a patient. Though no one in an official capacity likely ever claims to forgo a detailed physical exam, somehow this time honored medical tradition has become a lost art. The echo cardiogram with  CAT and/or MRI scans of the entire body are too often these days accepted as the new standard of care. A while ago while on call, I was asked by a cardiologist to see a patient who was repeatedly fainting. The doctor had done a heart catherization and a long EKG reading both negative. He was concerned the patient might be having some type of seizure. After doing a complete exam, I told the cardiologist the patient did not have epilepsy, but merely a profound drop in blood pressure when she stood up, as a result of one of her medications. The cardiologist thanked me, adding:

               "It is easier for me to do a heart cath than to check the blood pressure".

This incident has become for me a perfect metaphor for what is missing in preparing future generations of young physicians. I have been teaching basic science courses over the last few years to first and second year med students. Teaching these four main disciplines heart, lung, kidney and brain has been one of the more rejuvenating experiences of my life. I have learned ten times what I felt possible for a number of reasons, mostly new developments in physiology since my time in medical school and residency. Besides being highly entertaining which is obnoxiously self indulgent, I have gotten to know almost everyone of the students. I am confident when we meet in their third year, they will accept my viewpoint about the other more traditional way to practice medicine: Doing an intensely detailed and informative physical examination is the hard way, but it is the right way, and the medical students as well as their patients will be the better for it.

I have fired a few volleys in the battle for awhile, running a third year ' selective' on the twelve week internal medicine mandatory rotation and a fourth year elective, both in my office. Like trench warfare in WWI, I have gained very little significant ground. In the office there are time constraints and the patients would be somewhat uncomfortable with even one, much less two, detailed multi-system physical examinations. Also, if they walk into the office, they are not likely too sick.

Is there a down side to what I have decided to do? Yes. My neurology group, myself included, spent more than five years weaseling out of inpatient duty, negotiating with the Medical Center, and encouraging management to hire three full time neurologists to handle the overwhelming number of sick patients being referred to this tertiary hospital. We felt the pay was lousy, the intensity of the problems were exhausting  and the patient/family disappointments, if things did not go well for the patient, were psychologically draining  and occasionally threatening. Our group's view was, ''the house is burning, run for your life''.To get back on the front lines will require a new level of energy and more importantly, a touch of invincibility, which may difficult for me to summon.

So how does an old guy prepare for this undertaking. Cycling, of course which has been my salvation for decades. This time however, it will require more than just being on the bike. I'll need to take my physical intensity to a philosophical level, to something more profound and relevant, namely The Rules, a popular unofficial manifesto of bicycle racing/training etiquette, well known by most cycling aficionados. There are 80 or so, covering all aspects of the sport, including grooming, attire, tucking on downhills, holding your line etc. But the most important and most relevant from my current position is, Rule 5:
                                   "Toughen the fuck up"

Pelvic Fractures Cheat Evolution

It is very important a rider has the best position possible on the bike. On flat ground with normal riding speeds, air resistance, the drag, accounts for 70 to 90 % of the force the rider has to overcome. This force increases with the square of the speed, so the faster you go, the more important it is to have efficient aerodynamics. The human body has it limitations. Years ago I capitalized on an unfortunate accident to improve my position, likely bypassing 100,000 years or so of evolutionary gains, assuming of course, fast bike riders are the major procreators, which seems reasonable, if not predictable. (Consider how universally attractive they are, the high energy level, unparallelled endurance and ability to suffer. And that's just the female racers)

Several days before a long vacation trip to the South of France I had packed my number one bike and rode my number two bike to the local Tuesday night race. This was almost 20 years ago, and in those days we carried a frame pump which worked very well but added a bit of weight. During the race I noticed it was a little loose so I snatched it off the mount, went to the back of a fast moving pack and tossed it to the side. When it hit the ground the pump took a wicked hop. Knowing I needed it for my trip, I had to look back a second to see where it eventually stopped. I bumped a wheel in front of me, and went down hard in a millisecond. I landed on my left hip and noted an immediate pain in my pubic bone.

The next stop was the ER where learned I had a pelvic fracture, requiring no special treatment. I was given a set of crutches and told to have my activity limited only by pain. The Orthopod  predicted I would not be able to ride for at least a month, but it was OK to try. The French trip was a done deal. We had paid for the plane tickets, the rental car and the house. We had invited a number of others who, like myself, had made all the 'not going to work' arrangements. So it was off to France two days later and yes I did take the packed bike.

This was my first broken bone and first set of crutches. I was given a prescription for narcotic pain pills which were stolen off my desk at work before I even tried one. No way I was calling the ER and asking for another prescription. They had heard the " pain meds were stolen or lost" story a million times and I would have been forever labeled a doper (pain med doper - the lowest). So I went with the ibuprofen whenever I had to do some moving around. There was usually no pain at rest. The problem with this anti inflammatory medication was it did something funky with my temperature regulation and frequently gave me hot flashes.

Dragging the luggage and getting on the plane caused a considerable amount of discomfort. After boarding I took a few pills and when all the lights were out, I felt I was comfortable enough to sleep. Mid flight I was awaken by the worst hot flash I had experienced. I made all the air control adjustments possible with no relief. I was burning up. Everyone on the plane appeared to be asleep including my wife Charlotte, who was right next to me. I had to take off some clothes. I assumed the maneuver would be frowned upon by any passenger taking notice but I concluded, besides family, I did not know a soul on the plane, would never see any one of them again, and could care less about their low opinion of me. I removed my polo shirt and carefully draped it over the back of the seat to avoid any skin contact with the upholstery. I had hoped to get several hours of sleep and get re-dressed before anyone could see me. I felt much better immediately and dosed off within minutes.

A short time later I was awaken by a belligerent passenger taking great offense with my attire. Fortunately it was my wife who already had a pretty low opinion of my antics. After a brief argument  it was back to sleep without the shirt. Luckily no one else was awakened, especially my 16 year old daughter, a typical American teenager, embarrassed to be seen with her parents. The sight of her dad without a shirt in a very public place would have put her on the Psychiatrist couch for a decade. When getting off the plane I wore my sunglasses with ball cap, looking down all the way to the baggage claim. I only saw a couple of people pointing.

We had rented an old farm house outside of a small village close to Moustiere  famous for painted china. The house was 20 paces from a thin country paved rode, half way up an 8 mile, 5 to 7 % climb, with a famous gorge at the bottom and the small village at the top. I was resigned to the likelihood  I would not be riding. It was very uncomfortable even to walk on the.ubiquitous uneven ground.

On the second day we went to the gorge and rented paddle boats to cruise the waters. To my amazement I discovered I could paddle (essentially same action as turning the crank on a bike) very hard with no pain whatsoever. Upon returning to the house, I unpacked, and with some help, assembled the bike. I put on my riding attire (kit), shoes, and helmet and went to the road prepared to ride. But reality set in when I found there was no way to lift either leg without feeling I was being pulled apart by some type a medieval rack. I could not get on the bike.

After standing next to the bike for a few minutes, pondering my options, I devised a plan. I walked the bike to a small tree in the front yard where there was a horizontal limb just over my head. I had Charlotte hold the bike and I pulled myself to a chin up type position. She then slid the bike underneath me as I lowered myself onto the seat. I was pointing downhill and toward the road. I could see there was no traffic. I clicked into the pedals, went through the yard and onto the road without a hitch. I was riding. Nothing beats the feeling of the first few minutes riding a bike in another country, especially with the scene so different from home. This was a mountain dotted with stone farm houses. Most of the farmers were growing fields of lavender, which we never see in the deep south USA. Their scent was glorious. Though July, it was cool and not at all humid. The road was winding and canopied with old oaks in single file, as is so common in Europe.

I started uphill knowing I could govern my speed so much more easily. It was four miles to the top and after a few switchbacks I was in a nice rhythm with no pain. No one was driving either direction. As I made my next turn, thirty yards ahead, stood a humongous wild boar in the middle of the road immediately displaying a hostile attitude toward my presence. I had never seen a wild boar and thought they only existed in story books. I would have been no less shocked to see a dinosaur. Going up hill, it is easy to do a near track stand i.e. moving way less than 1 mph. I crept along hoping he would move while slowly approaching his fixed position. The classic Mexican standoff.  I didn't think I could safely turn around on such a narrow road and I sensed my fleeing would provoke a chase I might not win. I prayed for a car either way which did not come of course. I knew I could not get off the bike. Five seconds seemed like an hour. Ten yards away I let out a blood curdling scream:

              " Get the fuck out of my way!".

Amazingly, despite the prehistoric look and the unlikeliness he had even attended preschool, the beast was able to understand enough English to get the point. He immediately turned and ran.

I made it to the top and back down without incident. I rode to the tree and grabbed the limb, clicked out of the pedals, pulled up and let the bike drop to the ground. This mount and dismount was repeated daily and I was able to ride for hours every day accompanied by my long time friend, Dick. The riding and the towns were fabulous. The bumps in the rode were killers, but other than these, which I learned to miss, there were no problems.

Given the new "flexibility" of the pelvis I decided to work on my position. Every day I moved my seat back a mm or so, stretching me out ever so slightly over the handle bars with my back more parallel to the ground. This did not generate any discomfort. I also was able to purchase a longer stem which is the piece connecting the handle bars to the bike frame, adding another cm or so of stretch. I then lowered the handle bars for the final adjustment.

I had successfully cheated biology and "evolved" into a really nice position which, despite my age, I have been able to maintain. When I bought my next bike and was fitted  at the shop in Atlanta sponsoring my team, the bike had to be specially constructed to add 2 full cm to the top tube, the part of the frame going from the seat (post) to the handle bars.

As you have likely heard "one good break deserves another". Two years ago another came my way. This one was at 54 mph coming down the Grand Teton Pass, resulting in another pelvic fracture, and as opposed to the first, "unstable". There was no riding for months and therefore no further work on the drag. I was happy enough with the position, so no issue there. This fracture necessitated a horizontal titanium bar about 12 inches long, running midway across the sacrum. It is very visible even with riding clothes. After the fracture healed I had to make the decision about it's removal. The new Orthopod went over the negatives: Infection, anesthesia, breaking off screws, chronic pelvic pain versus the benefit: It does looks a little weird and bothers me when doing sit ups.

To help with my decision I decided to review my old aerospace engineering books. My torso is a somewhat like a wing. The shoulders are the leading edge and with a small butt and some thickness though the chest I am convinced I have some "lift" at high speeds (Google- Bernoulli principle). Ever since my radical position improvement in France, I have been somewhat concerned about an unsteady back end and the implications it might have for further crashes. This is a problem for race cars and likely you have seen the solution. When I went back for the preop appointment he asked if I was ready to schedule the procedure. I replied.

             " I don't need an operation, I'd rather have the spoiler"
   
               

Graduation

Several weeks ago I received an invitation to attend a college graduation ceremony. Over the years there have been a number of these, and many more for high school graduations. I view them as announcements or more likely, solicitations for gifts, usually from children of friends or colleagues. Most often we send something but I cannot recall ever attending one. This invitation however was different, coming from a long standing patient who told me during her last clinic visit, she would be sending it. From her body language I sensed no intention to solicit a gift, but a genuine request that I actually attend. Considering our history and this perception, I assured her I would be there, barring a last minute emergency.

At the time of her visit, attending the event seemed like a nice gesture and unlikely to be much of an inconvenience. When the big day finally did arrive, and the reality of the commitment became clear, I developed a sudden case of the proverbial "cold feet". The ceremony was on Friday at 3:00 PM. With six weeks advance notice, it was easy to adjust the clinic schedule to get off early. This last minute shallow act of obnoxious self interest stemmed  from the fact it was a beautiful late Spring day, cool, and not too breezy. It was perfect afternoon with plenty of time to get on the bike. The ride was important, absolutely necessary to be honest, given that I was going on call for the whole weekend starting at 7:00 PM that very evening.

Our story began in 2002 . These were the days when we, Neurology Associates, alternated "call" on a daily basis. I was on the floor and in the Neuro ICU almost every day, rounding on patients I had initially seen on my day of call. I was generally aware of most of  the other serious cases, at least in the ICU. The graduate was admitted in June of 2002 at age 15 with a progressive paralysis of her arms and legs and a MRI scan showing what appeared to be a very bad spinal cord tumor. I was not her doctor at that point. She was being cared for by one of my partners in conjunction with the neurosurgeons.

I recall seeing the family outside the ICU. They were upset, confused and probably angry with the common "why us" and  "this is so unfair" concerns haunting them. She eventually had a biopsy which was inconclusive and she was subsequently sent to a tertiary care hospital for another opinion. A diagnosis of MS was made, which sounds better than spinal cord cancer, but likely more unsettling, given the severity of the attack and the uncertain future of all patients with MS. She improved somewhat but  remained quite impaired. She went back and forth between Macon and Atlanta. She was placed on immune modulating shots three time per week, standard treatment for the disease. For awhile I did not see her.

A year or so later, when I happened to be on call for emergencies, she developed severe visual problems in both eyes. The type of visual loss was typical of another entity, similar to MS but requiring an all together different treatment, steroids, in conjunction with a medication more commonly used for organ transplantation, and most recently a potent rheumatoid arthritis drug. She has been under my care since then, and has required very close monitoring. For many years, she had a number of set backs, making it more difficult to walk, compounded by the visual (optic nerve inflammation) problems. For the last several years she has done quite well with no setbacks and we have been able to cut back on some of the toxic medications as her mobility has improved.

Over this period she has been able to commute to college here in Macon, from her home town twenty miles away. She does not drive, so college has been a project shared by the entire family. She has a wheel chair but can walk short distances with a cane. She most often comes in with her mom or dad or sister. Over the last decade, I have gotten to know them all well. They couldn't be any nicer.

I made it to the auditorium in plenty of time to see the procession of the graduates into the auditorium and onto the large floor. I first covered the entire building on foot looking for the family, but did not see them. There were twenty rows of approximately thirty graduates per row, which multiplies out to a long time if they were all going to "walk". There were a couple of one minutes speeches and introductions for the two main speakers. One of the main speakers was the highest overall achieving student and the other was a highly recognized educator from out of state. Though I would not have likely driven or paid to hear either one, both were quite good.

After the speeches, the names of all the graduates were called and yes, they were all going to approach the stage, go up a flight of steps and walk thirty or so paces across the stage. Though the audience was instructed not to applaud the individual graduates, because the noise would drown out the subsequent name, almost every student announced, prompted a brief loud round of cheering from an anonymous small pocket, well hidden in the large crowd. I intended to pay very close attention to the noise when my graduate was called, so I could easily find the family after the ceremony and let them know I had come.

With not much to do as the first five hundred plus walked  across the stage, I became a little intrigued on how her situation was going to be handled. She entered the auditorium being pushed in the wheel chair and was planted next to the second to last row. She was forty yards from the stage. When her row came forward, she was pushed along aside the rest. When she made it to the stage I noted for the first time, there was a ramp next to the stairs. She was pushed up the ramp to the presenter on the edge of the stage. When her name was called, she stood up, received the diploma and began the thirty paces across the stage on her own. Immediately her classmates broke protocol and began to cheer. Three steps later the entire auditorium joined in and continued to do so, as she maintained her determined, though somewhat impaired, journey across the stage.

I was sitting alone in the top row where I felt I could more easily spot the family. Though curious I was not at all emotionally involved as the events unfolded. When the cheering started, to my astonishment and without  warning, tears ran down my face at record speed, enough of them for me to appreciate their warmth, a sensation I had never previously noted. While she slowly made her way, I did not move and may have not even taken in a breath, fearing, had I done so, she might fall. Frozen, I made no attempt to wipe the tears as they rolled off my face and onto my blue cotton shirt. When the ceremony concluded five minutes later, I looked down and it appeared I was suffering from a prolactin secreting pituitary tumor causing a bad case of galactorrhea (breast discharge), a not so rare condition I occasionally encounter.

Not being able to spot the family among the crowd  I bolted for the door I recalled seeing her enter prior to the ceremony, accurately assuming, as it turned out, she would leave the same way. No one else was there as she emerged through the doorway and we had a very nice greeting. I took her outside and after a short time we found the huge family gathering of aunts, uncles and cousins. There were many great smiles and hugs, and a number of photos taken of the two of us. The family was so happy, in contrast to a decade ago when I first saw many of them, outside of the ICU, worn down and devastated by the life threatening realities she was then facing. This contrast was profound and somewhat intoxicating in a very pleasant way. As I walked to the car, now only an hour or so before taking the weekend call, too late for a ride, I thought "What a wonderful world it is. "

It's The Haircut

When reaching the last quarter of life, one has to consider the depressingly short list of endeavors likely to be improved upon. I do not intend to surrender without some kind of fight, even if it is as hopeless as the the unarmed Russian soldiers defending Moscow in WW II, charging the well armed Germans, who mercilessly mowed them down. When it comes to sports, biology is the hard truth and to overcome the inevitable reality of progressive deterioration, creativity needs to rear its beautiful head.

I could be a better doctor for sure. Every new encounter has the potential of adding a unique insight which piles upon the previous ones. More is always better, when it comes to knowledge. I just have to avoid the "learn one, forget two" syndrome, known to plague the aged. As far as teaching, I am just getting started. I feel like I am cheating compared to my niece Mary, who works with elementary school kids in Harlem's ghetto.  She undoubtedly spends a tremendous amount of energy trying to motivate, which is the biggest hurdle. My medical students are all bright, all successful, all want to be there and all want to do better. I just need to be smart about selecting a way to dissect the material so they can truly understand it and hopefully remember it forever.

Rather than dwelling upon the more lofty concerns, I spend an embarrassing amount of time obsessing on how I can get faster on the bike. For the last few years I could feel it slipping away, just like it did with basketball decades ago. This year, however, the trend has turned, which has a few riders in the local peleton suspicious I am doping. How hard could it be for a Doc to get EPO?  Hard, as it turns out, having looked into it a bit. Then there's the trick of getting your blood testosterone level checked. The normal range is so wide, there's a good chance you can talk your own Doc into a prescription, if it's on the lowish side, which I have noted to be common when gathering lab values from referring docs on my clinic days. Mine turned out to be on the high side which precluded the script (and also explains the excessive and somewhat unattractive body hair).

So instead of turning to drugs in an effort to increase my bike speed, I wound up going 'biblical', a whole new area for me. First of all, I don't know a lot about the Bible. Having been raised 'by' devout Catholics (note, not "as"), the Bible did not come up much. The Old Testament was never mentioned during services. We learned those stories watching Hollywood movies. The New Testament was tapped during a short reading of the gospel, in the middle of the Mass. This was followed by a sermon, which was supposed to interpret the gospel or perhaps relate the story to something occurring in modern times. Though having no medical knowledge, I was puzzled by the frequency of the ailment "possessed" which was often successfully cured. I wondered why no one seemed to ever have a heart condition or infection other than leprosy. I also recall Jesus mentioning " it is as hard for a rich man to get into heaven as it is for a camel to go through the eye of a needle" and in regard to child rearing " even the pagans love their children". There were also constant reminders to help the poor. After Mass there was a brief pause for reflection, then everyone pretty much got back to main business of trying to get rich while obsessing about the children. We never spoke about the poor, likely because we were the working poor. We had no car, and rented a small house with all three of the older kids (before youngest was born) sharing the same room. Later in life, when I was more prosperous and  hanging out with similar types, I began to hear talk about the poor, mostly complaints about how lazy they all were.

My favorite Old Testament movie, made in 1949 but frequently shown, when I was a teenager, late at night, was Samson and Delilah. My devotion to this movie, which I watched at every opportunity, had nothing to do with Samson, played by Victor Mature, nor anything to do with the message of the 'power of the righteous' or 'the fall from grace through sin'. My interest was exclusively the very sexy Delilah played by the very hot Hedy Lamarr. I could not get enough of her and the movie/story has never totally left my psyche.

I can cover a lot of old material while riding alone and recently this movie popped into my consciousness. I began to ponder the whole deal with Sampson and the hair. Hair and strength, I decided to act on it. As everyone knows, his great strength was dependent on the length of his hair. My current interpretation is that hair and strength are related and it seems plausible the exact relationship between the two could evolve over thousands of years, just like the popular diseases have done. We all also know long hair is no good for strength and speed. Look at the hippies. What were their collective athletic achievements?

So I decided to go with very short hair on the sides and straight up on top, the 'hypo manic' look. Initially I had to do the sculpting  myself. The hairdresser was a bit incredulous, but she is now on board and I go in there often for a trim. After the first cut, it was if I had received a transfusion of multiple energy units. The need for sleep dropped, my concentration was better, the training sessions on the bike were longer and more intense. My position in the the peleton has move up several notches on the regular Tuesday night race/ride. I can now launch a few attacks, instead of just holding on for dear life at the back of the pack.

Cutting the hair two lengths was the easy part. Getting it to stand up straight on top has been the challenge. The hairdresser suggested  'product', which is standard and reasonable, but violates one of the unwritten rules for guys my age. We are the 'no accessories, no cologne, no jewelry, no hair product and no blow drying'  types.  Admittedly we all did use English Leather cologne for about five minutes during the late 1960's but now anything similar would be some type of foul. I never wore chains or bracelets and now I have no rings or even a watch. 'Product' seems unacceptable.

I desperately needed an alternative solution for getting my hair to stand straight up. In high school I drove my parents 1961 Plymouth Fury which had a great engine but many minor problems including the failure of the windshield wipers to work when you applied any pressure to the gas pedal. I developed a pretty skillful technique of driving with my head out of the window whenever it was raining. This was later popularized by Jim Carey in Ace Ventura Pet Detective when his windshield was bashed by some thugs. Not to brag, but it's a lot easier to do when it is not raining.

Every morning after my workout and shower, I leave my hair wet while quickly getting dressed. I hustle to the car and when going down my street, out the window goes the head, and up goes the hair for the rest of the day, This is very reliable and does not violate any generational grooming rules. There is only the minor issue of the cars passing in the opposite direction. They occasionally feel they need to give me an excessive amount of room and subsequently go perilously close the edge of the road, and on occasion, off the road completely.

It seems unfair such a simple manipulation would have such a profound effect but I have no other a plausible explanation for the shift in the winds of aging. I am currently just sitting back and enjoying the ride, trying not to think how short lived the hair trick might be, and still, occasionally dreaming about my Delilah.

The Coast

The 'Coast' for the last forty years has been my wife's family beach home on Alligator Point, an eight mile peninsula, fifty miles south of Tallahassee, Florida. Twenty years ago my father in law, Jack Yaeger, completed a unique and incredibly beautiful house hanging over the water, on Alligator Harbor, the richest bay for sea life in the entire state of Florida. Though smaller than many homes in the area, it is an eclectic monument to his design skills and building virtuosity. The house could be a Frank Lloyd Wright spin off, sitting on a hand made limestone foundation which he built, rock by rock, over nearly twenty years before construction of the actual house commenced. His architectural creativity encompassed the entire lot to include a Buddha rock garden, a collection of stone mosaics, cantilevered suspended steps, two outdoor showers and a number of limestone and granite walls designed to preclude structural damage to the house in the event of  hurricane flooding. The inside includes hand blown glass windows with sea life motifs and hand carved four inch doors between several of the rooms.

“Smilin Jack Yeager", was a larger than life character, near and dear to my heart, and merits special mention. He was the eldest child of a prominent Tallahassee family. His father was a crusty hunter type and his mother was a beautiful but bawdy lady, reminiscent of her contemporary May West. Jack was the most handsome young man in the area, an elite athlete and like his father, a passionate hunter/fisherman. While a still a teenager he was the stand-in for Johnny Weismueller in several Tarzan movies filmed in the area. He was paid $50 a dive and was able to share a drink or two with the hard drinking Tarzan as well as his costar, Cheetah, the side kick chimp .

In 1941 when the United States entered War War II, Jack enlisted, and was assigned to a squadron of thirty pilots flying missions in the Pacific theater on a daily basis. He primarily flew P 38 Lightnings and was a test pilot for the P 47. He was an 'Ace', with five confirmed 'kills' before he was 21 years old. He had eleven recorded 'kills' by the end of the War, and the number would have been higher, had the War Department continued to tally the Japanese student pilots he shot down just prior to the end of the conflict. Of the thirty original pilots in his squadron, my father in law was one of three to survive the war. It is an under statement to say he was monument to testosterone.

My relationship with Jack was a little 'stressed' at the onset. I first met him in Tallahassee when I was invited to 'meet the family' in 1970 just before graduating from Georgia Tech. I wore old bluejeans, high top black Converse sneakers, and a long sleeve Batman T-shirt which made me appear scrawnier than my actual 6 foot, 145 pound frame. With long black curly hair and a goatee, I was quite the contrast to my well groomed, brown haired, blue eyed, muscular framed future father in law. He referred to me as "Wild Bill Hickock", kept his distance, but was always polite. I gained some favor that weekend when I was able to dissect the heart of a deer he had shot, accurately identifying the chambers and the valves; and even more favor when I was amenable to eating half of the heart which he grilled in the backyard.

Though providing well for his family Jack was never an enthusiastic professional man. He completed law school but did not practice. He joined his father in a fire and causality insurance firm which did not suit him well. He redirected his passion to hunting on the Wascissa River and building his place on the coast. Every Wednesday and non hunting weekend, he would drag a small trailer of limestone rocks he collected throughout the week, down to "The Point". He initially built the only stone A-frame I have ever seen, which slept the family of four. Over the next twenty years he sculpted the Oriental rock garden, house foundation, utility building and retaining walls, primarily from the limestone rocks and boulders indigenous to the Florida panhandle.

Nothing is more ephemeral than plant life or human structures on the Gulf Coast of Florida, where the warm water for a thousand miles can deliver energy to the frequent hurricanes funnelled toward the inevitable landfall somewhere in the area. A house may wash away like an Andy Goldsworthy rock pile loosely stacked on an incoming tide. Mr Goldsworthy intends to see the end of his efforts as captured in his beautiful film Rivers and Tides depicting the construction and the destruction of a number of his works. In contrast, nothing is more permanent than one of Jack's rock walls. Was he reaching for immortality as any sculptor would claim, or goading the creator to revere his art and guide the storms elsewhere?

Having never resolved this ontology, I approach every opportunity to visit this home as possibly being my last. We have made far too few trips there as my working, bike riding and gardening duties generally present a direct conflict. We have lately learned it is as easy for my daughter to fly there, as it is for us to drive, which results in a nice family gathering, especially on holidays. Recently, she and a friend flew in from a Baltimore winter scene, and were picked up by Charlotte. I departed Macon the following day and headed South.

I crossed the Florida line near dusk, that magical moment of fading daylight when colors seen through dilated pupils are particularly stunning. I was pleasantly greeted, as always, by lines of Live Oaks, Georgia's state tree. On this long stretch of road the oaks appear most majestic, their broad horizontal limbs dripping with Spanish Moss. (Many years ago when I had the "what can go wrong" attitude of a typical young person, I would drive this part on moonlit nights with the car lights off. Moonlight on an abundant display of Spanish Moss was always such a treat.)  Entering Tallahassee, these biological wonders give way to a  mishmash of chain stores and restaurants displaying their plebeian signage. An encore of the Live Oaks provide the last aesthetic dimension before the lifeless government buildings, of Tallahassee's core. These buildings and the streets from which they emanate are at least well lit and able to guide the weary traveler through the half way point of the city.

Darkness and fatigue set in south of the city on the last fifty miles of my journey. Most of the locals heading to the coast had departed by this hour. When I finally exited the city, I seemed to be the lone remaining driver. In addition to my fatigue I knew I had to face the reality of abundant wildlife along this isolated stretch of rural road. On previous trips I had seen deer, fox, possums, dogs, wildcats, armadillos, raccoons, weasels and bears, a zoo like spectrum of uncaged animals. I resorted to my 'night time rural wildlife' defensive driving strategy I had seen perfected by my aforementioned colorful father in law, where I straddle the center line, as Jack would do, turn on the brights, and slowly weave to the right and to the left, scanning for approaching wildlife. I survived one near miss with a large raccoon, arriving at Jack's abode, just as the clan was sitting down for a late dinner

While I always enjoy these family gatherings at my father in law's home which I now own, I have never adapted to the basic coastal custom of boating. Most residents at Alligator Point and neighboring St Teresa have a life centered around boats, but we have never owned one. I hate the noise, the bumpy ride, and the smell of diesel. Sail boats are even less desirable, mostly because I hate the wind. All bike riders hate the wind. That reaction was formed and cemented early in my cycling career, with no exceptions.

On the other hand, walking the beach and shell collecting is our main activity. Going to the end of Alligator point, one passes a long line of homes on lots with minimal vegetation. Some of these dwellings are small and on the ground and others are massive, precariously perched on a comical array of stilt pilings. The last half of the beach journey is along a bird sanctuary in a pristine state. It is rare to see another human being on this end of the point. One does see flocks of birds, porpoises swimming along at walking speed, and soft waves quietly lapping in a comforting undulating drone.

My solo walk to the end of the point today was most spectacular. Officially a winter day, we were given a low 70’s spring-like temp with a slight sea breeze and a warming sun, shining through a mixed type cloud coverage, seemingly on command, not to block the sun directly. Early on the way back, the water beckoned me to enter. Sensing I was the only person on the beach, I removed all of my clothes and entered. The dip was thorough but brief. Once re clothed  I was pleasantly chilled on the outside and warmed on the inside. This elicited a most intense feeling of well being, a feeling, I realized, I had not felt for too long a time..

I made it home just before dusk. Like the day before, the light greatly amplified the visual treats. Sitting on the small deck Jack constructed on the west end of the lot, we viewed the three buildings, the walls and the gardens, with one panoramic view. Reflecting on the polarities of Jack Yeager's life, I acquired a heightened appreciation for what this tranquil piece of land must have meant to a man whose youthful years were spent fighting in daily death duels high above the Pacific Ocean.

"Smiling Jack Yeager" the man of restless, constant activity, never did settle for anything close to a sedentary life. He was the victim of a large heart attack early in his 70's which subsequently precluded many of the activities he so enjoyed. After frustrating months of treatment with drugs which lowered his blood pressure to dizzying levels, his doctors abandoned any chance of what would have been an acceptable recovery for him. He asked the doctors what would happen if he stopped taking the medications. They told him he would likely die within a week. Before leaving the office he quipped:

   " Well, I only hope I can do it well"

One week later he died at home.

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"

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.

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.

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