Right Between the Eyes

Day one, case one, a shot right between the eyes, and in more ways than one. It was several days before the official start of my new duties as a neuro-hospitalist, but I had the solo weekend call, all new consults, at the level one medical center from Friday at 7:00 PM to Monday at 8:00 AM. The third year students had just started their twelve week Internal Medicine rotation and two were available each day to work with me. My main goal, my raison d'tre actually, to convince these students how taking a thorough patient history and doing a complete physical examination will determine the problem, would likely be apparent by the end of the first day.

There always has been a potential problem on these full 'call' days of getting too many serious cases. For years there has been one neurologist assigned to take all new consults in the hospital, the ER and surrounding ERs that have no neurology coverage. Often the weekdays numbers are overwhelmingly  "difficult".  The case load on the weekend is generally lighter, the main problem being the sixty consecutive hours of availability.

The day started well because I had not received a single call from 8:00 PM Friday through the graveyard shift early Saturday, and therefore experienced no sleep interruption. I went on my traditional short "loops"" cycling ride, staying close to home in the event I was called. Before the house was out of sight, the cell phone rang and within fifteen minutes I was on the way in.

The patient was in his fourth day of recovery after an elective knee procedure. For three days he had been complaining of a headache, which is usually nothing, but that morning he was noted to be confused, which is always something. The combination is additionally alarming.

The patient's CT brain scan, ordered by the attending physician, showed a small benign pituitary tumor. This is not a rare occurrence and if small, very unlikely to cause any difficulty.  The Neurosurgery team, who deal with tumors, had been consulted and had reassured the attending physician the tumor was  too small to be of any concern. I had been able to glance at the scan on line while getting dressed and agreed with their opinion. An MRI had been attempted but was not completed  because of the patient's claustrophobia.

When I arrived with my student in tow, we did a detailed examination confirming a mild state of confusion, an elevated temperature and a stiff neck in the forward direction, all suggesting meningitis. (Stiffness in all directions indicates other disorders). The detailed neurological exam showed no asymmetrical strength, sensation, tone or reflexes to suggest a stroke, and no visual abnormalities to implicate the pituitary tumor. A normal pituitary gland sits below the crossing of both optic nerves at the bottom of the brain, just behind the eyes and above the nasal structures and sinuses. If significantly enlarged by a tumor it will press on the optic nerves resulting in loss of vision.

The chart indicated the patient had received a spinal anaesthetic at the time of his orthopedic procedure four days earlier, which means the numbing medication was injected directly into the spinal canal. There is always a rare chance of introducing bacteria which days later could turn into meningitis. The onset of his meningitis symptoms, the headache he complained about within 24 hours of the injection, seemed a bit early, so I assumed he had some type of sterile irritation from the injection, a self limiting chemical meningitis, which we occasionally see after someone has a myelogram (dye study into the spinal canal to image the spine in conjunction with a CT scan). He had already been started on the appropriate antibiotics to cover the usual bacteria, so there was no rush to prove it with a spinal tap.

I planned to research the time sequence for bacterial meningitis after a spinal injection when I had a break during the day. Unfortunately the new patient requests were coming in at an all time thirty year record high pace, and it was 2:30 AM the next morning before I could get to my computer search. This research was done in "my office" also known as "the bed", which includes the computer, a pile of books and journals scattered on the floor creating quite an unattractive mess and a major bone of contention with my wife.  I was surprised to learn it was possible to get meningitis within 24 hours of a spinal injection. My patient therefore needed a spinal tap to exclude unusual pathogens. I was too tired to hold the needle much less point it in the right direction, not to mention I was already horizontal and down for the count. I slept four hours and returned early to reassess.

The spinal  tap was easier than I anticipated confirming  meningitis with a profile of cells, protein and glucose indicative of a bacterial infection, rather than a viral, fungal or chemical meningitis. No bacterial organisms were seen on microscopic examination of the spinal fluid sediment suggesting successful eradication with the antibiotics he was receiving. By the end of the day he had no temperature elevation and he was clearing up mentally. By the following  morning he was back to baseline with no complaints, up walking with the physical therapist and back on course to do the rehabilitation from his knee operation. I apologized profusely for taking so long to identify the problem while keeping his very nice wife in an uncomfortable state of anxiety. We said goodbye and I was off to work on the other patients.

Having spent an inordinate amount of time on the case, I  was a bit behind in addressing the needs of my other patients. I also had to drive over to the medical school for a three hour teaching stint and then drive back to my office to clear up some issues there as well as see a few scheduled  'out' patients. When I finally returned to the hospital I had quite a large number of patients on my list. I assumed my "meningitis" patient would no problem whatsoever as he was obviously on the road to recovery when last seen. I had officially signed off the case with the intention of stopping by as he was finishing his ten days of antibiotics recommended by the infectious disease team. Once stable he was moved to a room next to another person I was seeing and just by chance I saw the two of them, patient and wife, comfortably chatting as I was walking past their room. I stuck my head through the door and asked if all was OK. His wife replied he was doing fine except he had earlier in the day noted a new problem of blurred vision. This couple was the type who would have never complained to the staff much less demanded I be called to reevaluate . I thanked my guardian angel for steering me their way.

I was stunned by this compliant and knew it meant a time consuming complete reassessment. Mentally he was fine. All eye, face, throat and limb movements were normal and he had no abnormal reflexes. When testing his vision, however, I noted a subtle problem with his ability to see laterally (away from the nose) in each eye. This means one thing only: pressure from pituitary mass on the optic nerves, which cross about one to two cm above the normal pituitary gland. This impingement seemed impossible given the small size of the tumor. An urgent MRI was ordered and performed, this time with a pep talk backed up with an intravenous sedative as he was going into the machine. Sedatives administered this way carry a small risk of breathing difficulty, and I was therefore required to accompany him to the scanner, which takes forever!

This turn of events was a two edge sword. First, given the unanticipated time it was taking to do an urgent evaluation, there was only a slim chance of finishing my appointed rounds for hours. Secondly, it appeared my initial assessment was probably incorrect, likely with serious consequence. As the latter realization bounced around my tired brain, I started to get that sick feeling I have unfortunately suffered in the past,  and more than a few times. It starts as a nauseating burn in the gut which migrates up and down. As it reaches my head the demons pour out, clearly reminding me this feeling is here to stay awhile and good luck sleeping.

I started to pray, well, more accurately, I brought up the lyrics of  The Killers song: All These Things I've  Done  
 
         "You know you got to help me out, yeah
         Oh don't you put me on the back burner
         You know you got to help me out, yeah
          Your going to bring yourself down, yeah."

This seemed to work, because I soon received a text from the night time ''on call'' medical student who had finished her regular duties. She asked to accompany me on my rounds. I had some research to do on this particular patient in order to possibly solve the dilemma of what at first appeared to be an unrelated spurious sequence of events.  I knew the student to be very quick on the small computer she carried with her and we could research the complicated array of issues as we were rounding on the other patients. The MRI demonstrated the pituitary tumor was more than twice as high as it was wide, which is very unusual, and, as I had only recently suspected, was putting a significant amount of pressure on the optic nerves.

It was impossible for me to combine all the findings and complaints under one entity, which is my usual modus operandi when analyzing difficult cases, a variant of Oscam's razor ( i.e. entities are not to be multiplied beyond necessity).  First I re-consulted neurosurgery who recommended medical treatment with steroids, Then we did the research, or I should say, the medical student did, as I was writing notes. Fortunately, there were no unexpected problems with the other patients to distract us, at least for the moment. Initial research data confirmed my belief that if a patient with a pituitary tumor suddenly develops visual and other symptoms, a scenario labeled ''pituitary apoplexy'', there is always a bleed into the tumor. Bleeding shows up nicely on CT and MRI scans and he clearly did not have a bleed.

But when we put in a search "pituitary apoplexy" and "meningitis" we found two cases identical to mine. Both cases had a pituitary tumor, a picture suggestive of bacterial meningitis, and eventually other neurological problem including visual impairment. The spinal fluid cells, protein and sugar readings were also typical for bacterial meningitis, and not the other infectious and chemical entities mentioned earlier. The hypothesis, suggested by one of the authors, is the tumor has some type of insult, leaks protein like material into the spinal fluid, causing a chemical meningitis which for unclear reasons, mimics bacteria.  The pituitary gland then swells up and pushes on the optic nerves, which are notorious for not being able to take much pressure without permanent damage.

The next day he was significantly worse. Yuk. Looks like an error on my part was going to result in an incapacitating visual loss, likely both eyes, and in a patient I was supposed to be helping. Worse, the disabling problem, the visual loss, occurred after I was on the case,  With no response to the steroid medication, he underwent an emergent neurosurgical procedure which involves going through the nose and sinuses, drilling a small hole through the bone just beneath the brain and then removal of the tumor, which relieves the pressure on the optic nerves. If the pressure on the nerves is quickly recognized and the surgery is done in a timely, skillful manner, there is usually little permanent damage to the vision.

After this surgery, however, the patient's vision deteriorated further. I guessed this had something to do with all the inflammation from the chemical meningitis.  I last saw him at a rehab hospital two weeks later on my way home from work, with severe visual impairment in all fields of gaze, and in my opinion, unlikely to change significantly. His job required he drive all over the state and clearly he could not. This was no different than a gunshot right between the eyes, and as alluded to initially, I felt we both had received.

I was able to do my work over the next few weeks but not a day passed when I didn't think about the pituitary disaster. I vacillated between a feeling of incompetence to one of frustration over the bad luck of having too many cases to properly handle the one that mattered most. This was hardly my first bad outcome and I wondered how many more bad outcomes I could  take. Maybe it is just time to quit.

Back to The Killers:

               "I got soul but I'm not a soldier
                 I got soul but I'm not a soldier"

I have come to know the medical student who helped me on this case quite well over the last two years. She has successfully endured a tragic set of events in her own life which makes my tribulations seem trivial. She has been a great inspiration to my whining side. One night, weeks later, I was coincidentally rounding with this same student. We were at the hospital, well into the evening, looking at MRI scans on the computer after seeing all of that day's patients. My phone pinged a text from a number I did not recognized. When the message started:

                " We saw the Neuro Ophthalmologist earlier today....",

I immediately knew it was from the wife of the patient I had failed. Wincing with a sudden jolt of intense anxiety and a rekindling of that sick feeling in the gut, I squinted and grimaced as I let my eyes role to the bottom of screen to see the rest of the message. The wife was writing to tell me her husband had somehow made a late, near miraculous improvement in his vision and had been cleared to drive and work. She wanted me to know. I blinked, took a deep breath, and passed the phone to the student. She read the message, looked at me, smiled, and handed back the phone. I sent the wife a short reply:

                               "Thanks for letting me know".

Soon I was driving home in a quiet car with no music which is unusual. Convinced everything has meaning beyond the superficial, I tried to make sense of this last lightning bolt. Initially I could not get anywhere. There are equal merits to the argument I should quit now, to the one I should never quit. Then I asked myself:  "What do I do when I go to a bike race and suck?"  I always come up with a elaborate plan to get better and sometimes it is actually effective. When I run out of ideas to get better as a Neurologist, I'll know it is time to quit.

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.
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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"