The Tongan Way

A lot of people visit our floor, but one patient in particular is quite popular. Around 8 0'clock when the announcement that the hospital's visiting hours are over, two dozen or so people come streaming out of the elevator bringing flowers, gifts and prayers. They talk with each other in the waiting room in Tongan while they wait their turn to visit room 31. I've heard soulful songs coming from his room, but he does not join in.

Mr. "Tonga" had been working out at the gym when he felt dizzy and collapsed. He was carried outside and he began to have ventricular defibrillation. With his heart malfunctioning, precious minutes were slipping away before his brain would start to die. CPR was administered and he was shocked three times before the paramedics arrived. He underwent emergency surgery by the request of his wife, but his condition did not improve. Oxygen deprivation had already robbed him of his higher brain functions. In just a few days, he went from pumping iron to getting pumped with IV fluids with a machine pumping his lungs.

His rapid deterioration must have been a shock to his family. I can understand their need to say their goodbyes, but as the weeks pass and he has shown no signs of recovery, long-term care is quickly becoming an issue. Hospitals have limited space and new people come in with problems everyday. Still, his wife still has hope for a miracle. His sister was flying across the Pacific ocean from Tonga to help in the final decision.

The decision of becoming a code III and be taken off of life support or going to a long-term care facility was not in his hands or those of his medical power of attorney (his wife.) The community helps him when he cannot help himself... that is the Tongan way.


This situation reminded me of another Tongan I met when I was shadowing an FP. Mrs. "Tonga" had a series of problems that she had been ignoring for too long. First, it was uncontrolled diabetes. She thought whatever happened was God's will... and medical intervention was not a part of the plan. Then a foot injury. Still, when things became unbearable, she found her way into the ER anyway. It was infected for two weeks before she finally came to the hospital. She refused to get amputated even though debridement had taken off the tissue on her foot all the way to the bone. Then she developed pancreatitis. She wasn't supposed to eat, but her family snuck food into the hospital for her anyway.

"Just let me go home..." she begged. "I'm going to die. I don't want to die here in the hospital."
She was fatalistic.

The FP was ready to let her go home, but she didn't want Mrs. Tonga to come back after her problems became even worse. The FP did not want Mrs. Tonga to think that she could make her own medical decisions and then change her mind and get "saved" by the hospital at a later time. She came back when repairing the damage and hoping things wouldn't get worse was all that a hospital could do.

The FP had legitimate concerns, but they turned out to be irrelevant in Mrs. Tonga's case. Before she left, she suffered from a heart attack. She was rescuscitated, but with similar results uncannily similar to Mr. Tonga's in my ward now.

Mrs. Tonga laid in the ICU for months, getting pumped with powerful antibiotics to combat the infection rooted in her foot, but growing through the rest of her body. She continued to get weekly dialysis, much to my growing puzzlement of the situation. Her care was transferred to a hospitalist and I lost track of her situation.


It is difficult to let go. Are those eyes tearing up because she hears my prayers? Or is it just because she cannot blink anymore and her eyes are dry? Is he clenching my hand because he is trying to tell me that he is still alive? Or is it a spontaneous clonic response?

It is hard to perceive how healthy someone is. Just because they can walk and talk without pain doesn't mean that underlying heart disease or diabetes will not emerge swiftly in unexpected ways.

It is hard not to judge people when they are put in difficult situations like this. Cardiac arrest used to be a fatal condition. Now that we can snatch people away from the brink of death, we are left with the uneasy consequences. Family members have to make choices that were once dictated by a tired body that just quit one day. Do you quit on someone that you love? How will that decision affect a community that is scrutinizing your every action?

Perhaps it is better that I do not know the ultimate fate of these Tongans. Their situations have touched me deeply and I do not think it would be right for me to pass judgment on their families for the personal choices they have made.

I do not know the Tongan way of doing things, but I'm trying hard to understand it.

Helpful Pre-Med links

As I went through my application process for med school, I found a number of online resources to be very helpful. In some cases, more helpful than the Career Services center at my University. I regretted the fact that I discovered some of these sources too late... they would have been useful in my first round of applications. Hopefully this compiled list will help out at least one aspiring applicant and make all the difference in their journey. :-)


The AMCAS and the AAMC website will be your starting points. They come with vital information like the college timeline you should expect to have, post-bacc programs you can take to explore your options, along with links to various applications you might have to fill out.

The Student Doctor Network is a great place to find a forum for students of all types -- dentistry, osteopathy, pre-meds, residents... they all have their own niche in the network. The essay section has a few sample personal statements that you can peruse for style and content tips. Interview Feedback has detailed info on what to expect from each school that you interview with.

Speaking of personal statements, here is a Xanga blog resource you can use to help you learn what to write! TheReporter was written (and possibly abandoned) by a medical school interviewer and adcom member. It includes tips on what to write for your personal statement, how to approach volunteer work and how to recover when you don't get that "absolutely essential A" for organic chemistry. ;-)

Accepted.com is a commercial website... there is some useful stuff here, but don't get sucked into spending more money than you really need to. There's tons of free stuff on the internet.

Kaplan and Princeton Review have a few MCAT thingamabobs. I didn't do too much internet scrounging for questions; I just took the Kaplan course to get a better grip on what to expect on the test.

MDapplicants.com is list of anonymous profiles of med school applicants. You can search by med school, MCAT scores and GPA to figure out whether or not your med school of choice is a safety school, a reach school or an "IN YOUR DREAMS" school. I'm listed here. In some effort to preserve my psuedonymity, while still getting to brag a bit... suffice it to say that I scored a 34 on my MCATs (somehow I got a 13 BS) and I had a 3.9 cum/science GPA.

Well, that's it for now.
Please comment and add your own links to this blog if you feel that there is something I have missed!

What Pre-Med Experiences Should Be. (Part II)

In a previous post, I talked about the first half of my improvised plan of "what do I do now?" when I didn't get into medical school. Shadowing doctors is easy to fit into a school schedule as a once a week sort of activity. People who have more time on their hands because they just graduated as an undergrad and didn't get into any grad programs face a new set of challenges.

The Real World. How do you apply your skills learned in a job? What job should you apply for? What are you really qualified to do after you've gone through a pre-med program?

These are great questions to be asking yourself. I certainly questioned myself as I pored through the requirements for various health-related professions. If you listen to your college counselor, they claim that "there are plenty of things you can do with a biology degree!" Of course, most of those things require more than a bachelors degree. I had no knowledge on how to draw blood, no clinical hours booked in any certification program, no experience in anything clinical, to be perfectly honest. I knew that I didn't want to take any extra classes to become a EKG tech, lab tech, nurse aide, physicians assistant, etc... I wanted to go to medical school! What would be the sense in spending money on a program for a job that I would expect to be short term?

All I had was my meager medical knowledge and my willingness to learn more if I was given the chance. Lucky for me, I found a job that had only these requirements.

Ward Clerk. Here's the requirements from my employer's website:

Minimum: Must be able to communicate with visitors, patients and staff, both orally and in writing. Previous experience dealing with the public.

Preferred: Knowledge of medical terminology. Prior Hospital experience.

Whoa. You don't even need to go to college to become a ward clerk! Then again, secretaries learn a lot of their skills on the job. Playing secretary to the nurses in a hospital ward is not as easy as you might think. It requires a significant amount of knowledge about the inner-workings of the hospital, because nurses, nurse aides, doctors, lab techs, patients and their families... pretty much everyone... expects you to have a handle on what is going on.

The job is very paradoxical. I was at the bottom of the experiential totem pole. Out of all the people working in the hospital (nurses, nurse aides, doctors, lab techs and so forth,) I probably hold the least qualifications. Yet I was in charge of the majority of what goes on in the ward. I made appointments for EKGs, X-rays, CT scans, MRI scans, nuclear medicine scans. I scheduled lab draws. I made sure that the nursing station is well-stocked. I transcribed (and often translated) doctor's orders. I relayed messages between pharmacy and the nurses, doctors and nurses, patients and family... it can all be very overwhelming and stressful, especially with angry doctors, whining patients and aggravated nurses breathing down my neck.

I've found myself in the situation where I don't know what the heck I'm supposed to do. I might not comprehend a doctor's order, so I have to ask a nurse. Then once I get that sorted through, I might not know what to do with this information. Does it need to be documented? Do I have to request something from another department? Do I have any forms that I need to fill out? So, I might have to call another ward clerk to get the answers I need (or make a quick consult in a manual of standard operations.) I've come to terms with my own incompetence and inadequacy... which is a good thing. You shouldn't fake like you know what to do.

Ward clerking has been an excellent learning experience for me. I've learned a lot about the different duties involved in the care of a patient and I got to see them day to day. I get to see what labs are drawn for patients, what meds are prescribed and how nurses work their butts off to follow doctor's orders. My only regret is that I am stuck with all the paperwork and I don't get to ever see patients.

Funny how doctors complain of the same thing... but I've gained a greater respect for the paperwork. Good documentation can make things run a lot smoother for everyone and this is a lesson I intend on remembering.

Aside from my growth of experience, my handwriting has improved tremendously. This stereotype is definitely true of doctors. After shadowing a doc through hospital rounds, I've seen how busy they are and how they need to rush through orders and progress notes to get things done. The handwriting that results is quite atrocious. I can recall one incident where I wrote an order for 500 mg of Warfarin (an anticoagulant drug) instead of 500 mg of Levaquin (an antibiotic.) The nurse kindly pointed the glaring error out to me and said "oh, I can see how you got this." The doctor's handwriting was so wiggly, that these two words would have looked identical. I thought it suspicious that the patient was already receiving 5 mg of Coumadin... but I just write 'em as I read 'em. I'm not supposed to correct doc spelling errors or write verbal orders from docs. I'm glad that the nurses double-check the ward clerk work.

Hopefully my penmanship will remain comprehensible in the years to come so future ward clerks won't face the same problems that I did!

Tips from Japan: Finger Band-Aid solutions

Do you ever have problems keeping a band-aid on your finger? Did you just run out of those fancy knuckle and fingertip band-aids that Johnson and Johnson charges extra bucks for (and you only use them for unique injuries!)

Over My Med Body! found a YouTube clip from the Japanese show Urawaza that you might find very interesting.



The solution is very elegant: take a regular band-aid and cut the adhesive strip in half (towards the gauze pad). Then you can fold the four strips in a way you desire that is more secure on a knuckle or fingertip!

Thanks for tuning in!

Saving a Life

Outside of the hospital, there are only a few things a trained health professional can do to save a life. For example, someone could develop complications on an airplane. Lacking access to meds, previous medical history, clinical consults, a sterile/private environment and personal protective equipment makes even an ER doc nervous... rounding at 37000 feet. The only thing that distinguishes him and any other passenger on the plane is his mind -- his training, his experience at dealing with crises, his cool confidence and quick wits.

Some of us might have taken First Aid in Boy Scouts or as a part of a volunteer training program. It does not take much to MacGyver up a splint or sling for a broken limb; nor does it require much experience to learn three ways to stem blood flow. Highlight for hints: direct pressure, pressure points and tourniquet (this last one is a last resort!)

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I took a Basic Life Support (BLS) class today. It covered two important skills for saving a life: dislodging a foreign object with the Heimlich maneuver and cardiopulmonary resucitation. The criteria for CPR have been changed and I think that it is simpler. This will make it easier to remember and administrate in a time of need. Hopefully, it will also encourage more people to take a class!

The Bee Gees song "Stayin' Alive" conveniently provides the rhythm of 100 compressions/minute. Knowing that cycles of 30 compressions to 2 rescue breaths are what you need for an adult, with the exception of a two-person rescue on a child (in which case you need 15:2) and you've got the majority of the 4-hour long BLS class down pat.

I had a sobering thought as I knelt in front of the dummy and provided mouth-to-mask breathing for the first time. This is my responsibility. I was training myself to become a lifesaver... and this technique would become more than "something to know just in case." I would be morally obligated to provide my services to someone in need! Some might even call me a hero for the stuff I'm learning right now! Whoa.

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The Mayo Clinic has a Guide to First Aid if you are interested in learning more about what YOU can do to save a life, if the situation ever arises.

Initiating Free Will

The Loom posted a very interesting article a few years back illustrating the one of the peculiarities of our brains. Yesterday I talked about the issue of free will on a quantum level... today I will talk about free will in less abstract terms.

In 1970s and 80s, a neuroscientist from UCSF conducted experiments to test the boundaries of consciousness. In 1983, Benjamin Libet published a paper entitled "Time of Conscious Intention to Act in Relation to Onset of Cerebral Activity (Readiness Potential)".

This experiment measured brain activity with an electroencephalogram (EEG) as the subjects pushed a button. The subjects noted each time they wanted to push the button based on the clock position of a dot on a modified oscilloscope. The average reaction time between the intention of pushing the button and actually pushing it was ~350 milliseconds with a minimum of ~150 ms. The EEG measured brain activity in the secondary motor cortex and noted that the subjects recorded brain activity ~500 ms before the button was pushed.

What does this mean? Libet's team suggested that the brain was preparing for action before the subjects even decided to push the button by as much as 350 ms. We are acting before we are even aware of our actions... the primary buildup in the motor cortex (readiness potential) was unconsciously driving the action. Libet felt that the role of the conscious brain is primarily inhibitive... we've all felt those moments when we had urges to do something that we strove to hold back. This inner control over our visceral impulses defines free will. After the brain ticks away and neurons are already firing to activate the muscles to push the button, the conscious brain decides to resist or comply.

The Loom talked about another followup experiment for the anniversary of Libet's experiment:

"... a team of European neuroscientists published a fitting tribute to Libet... They ran Libet's experiment again, but some of the people they chose as their subjects had damage to certain parts of the brain. As they report in Nature Neuroscience, some kinds of brain damage make no difference to people's performance. But something fascinating happened to people who suffered damage to the parietal cortex, located at the back of the head. Like the healthy controls, they could nail the moment they actually pressed the button, to within a few milliseconds. But they also noted that they intended to press the button just around the time they actually did press the button. In other words, they were completely unconscious of their action until the action was already taking place."

I found another example of how free will, awareness, and unconscious behavior play a role in our own actions:

Humans have the conscious experience of 'free will': we feel we can generate our actions, and thus affect our environment. Here we used the perceived time of intentional actions and of their sensory consequences as a means to study consciousness of action. These perceived times were attracted together in conscious awareness, so that subjects perceived voluntary movements as occurring later and their sensory consequences as occurring earlier than they actually did. Comparable involuntary movements caused by magnetic brain stimulation reversed this attraction effect. We conclude that the CNS applies a specific neural mechanism to produce intentional binding of actions and their effects in conscious awareness.

These experiments provide a great deal of insight into the pathology of brain damage and psychoses. Damage to certain parts of the brain can disrupt the cortico-cortical sensorimotor processing loop. Paranoid schizophrenia is a mental disorder in which the normal process of free will/awareness and unconscious behavior gets disrupted. The central nervous system has a way of fooling the conscious brain into thinking that it is directing movement when in fact, it is just predicting the responses of what other parts of the brain are already doing.

We are under the illusion that our bodies are governed by a singular consciousness. This is true for the most part... not very many people can concentrate on two tasks at once or have more than one inner dialogue at once! The people who can function like this are considered unusual at best, crazy at worst.

Our brains are hardwired to believe in this "Oneitude." However, the truth of the matter is that we run parallel processors (the left and right hemisphere) and they function both independently and interdependently.

Free Will and Quantum Mechanics

photo © Christof Wittwer for openphoto.net
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I have a question.

What is the difference between a random action that is uncaused and one that comes as a result of free will?

Science is a method, not a position speculates that they may be one and the same.

"They .... say that quantum indeterminacy is essentially random, not meaningful. But what if this is wrong? What if consciousness itself can influence the collapse of the quantum waveform, in a desired direction. This would provide the mechanism for consciousness to act within the world."

This is a weird concept for sure. I interpret it a little differently. If we are the product of quantum randomness, then we ARE quantum randomness. I don't know why we have to drag in the word consciousness to influence our decision-making on a pico (smaller than nano) scale. Consciousness, in my opinion, is an interpretation of a collection of interconnected events -- it does not describe the singular points that create the network. Still, calling us a bunch of collapsable quantum waveforms is a fun idea that preserves free will in a world of fixed causation. I'll bite the hook.

SiaMnaP also "cites" that neuron firing is indeterminate and probabilistic, meaning that the summation of the stimuli needed to trigger an action potential down the axon could vary. The process of stimulation and inhibition on the dendrites of the neuron could be the result of quantum tinkering by acting on ions and neurotransmitters!

Because the firing of a single neuron can be amplified through thousands or millions of other neurons throughout large areas of the the brain, and trigger motor neurons, this gives the possibility for individual quantum events to determine gross motor behaviors (shall I give the possible example of neurons controlling muscles in fingers typing a blog entry?). To a large degree, the brain can be seen as a device for magnifying the effects of quantum indeterminancy to the macro-scale, and if those quantum fluctuations are somehow influenced by consciousness, they can use them to drive behavior.

This is wacky stuff! I don't think that the butterfly effect applies in the case of "a single neuron fired can be amplify through thousands or millions of other neurons." I don't think that the butterfly effect applies much in the classical example either. Most of the time, these miniscule events are dampened by other forces. Tossing a pebble in a lake doesn't create a tsunami on the other side. Friction dampens the wave eventually. Neurons have more than one connection and it takes multiple, near-simultaneous firings to activate or inhibit the neuron they are linked to. Of course, some of the time, these tiny forces coagulate into something significant. Poised on the brink of a probabilistic hill, a ball has an equal chance of rolling in any direction. Any nudge will send it sailing on its way. If nothing nudges it, then it will remain static forever... but maybe, just maybe, quantum butterflies flutterby.

Saying that flutterbys happen on a constant basis, acting as the vehicle of free will is just wacky. It would help if SiaMnaP had a better citation for the indeterminacy of neuron firing. The link is questionable, dredged from the back alleys of some University of Edinburgh site. I would have liked a link to something with more substance (and further citations) that uses the search words quantum, probabilistic and neuron. Hey, Google Scholar's first link has something like that! It is from the Royal Society of London, 1986. Further delving reveals a more recent article by the National Academy of Sciences of the USA, 1992. Here's the abstract:

"The relationship of brain activity to conscious intentions is considered on the basis of the functional microstructure of the cerebral cortex. Each incoming nerve impulse causes the emission of transmitter molecules by the process of exocytosis. Since exocytosis is a quantal phenomenon of the presynaptic vesicular grid with a probability much less than 1, we present a quantum mechanical model for it based on a tunneling process of the trigger mechanism. Consciousness manifests itself in mental intentions. The consequent voluntary actions become effective by momentary increases of the probability of vesicular emission in the thousands of synapses on each pyramidal cell by quantal selection."

The outer layer of our brains, the 1 mm thick cerebral cortex, is responsible for perception, information integration, reasoning and directing voluntary behavior. I agree, these are the key aspects of free will. To say that fancy mathematics show that the likelihood of releasing synaptic vesicles increases by "quantal selection" sounds suspiciously like circuitous logic.

What is increasing the probability of neurotransmitter release? Massive (relatively) physiochemical reactions or teeny quantal selective events? In most cases, electrical impulses travelling down the axon tell the neuron to release its neurotransmitters as a result of simple cause-and-effect. When exocytosis is unlinked to this mechanism, we ask ourselves... what initiated this?

What is the initiating event for decision-making in our heads? It is cool to think that it is an aggregation of quantum activity that takes off as massive butterfly effects in our heads. I don't think that this necessarily implicates the additional driving meta-physical force of consciousness, nor does it happen continually. Every so often, metaphorical dominoes are dumped out onto a table and a few of them align, waiting for the quantum flutterby. This is the exception, not the rule.

I will tackle the subject of initiating free will tomorrow.

Am I a Scientismist?

One of my academic and religious friends sent me an article via IM a while back. It was entitled the Mantle of Science, by Murray Rothbard. Perhaps it was his dosed response to my criticisms of Catholicism, or maybe he just wanted to share something interesting with me in his random economic readings. I skimmed through the introduction and I realized that this phenomenon of Scientism certainly described me. Perhaps not quite in the terms used in the article which states:

Scientism is the profoundly unscientific attempt to transfer uncritically the methodology of the physical sciences to the study of human action... Only human beings possess free will and consciousness: for they are conscious, and they can, and indeed must, choose their course of action. To ignore this primordial fact about the nature of man—to ignore his volition, his free will—is to misconstrue the facts of reality and therefore to be profoundly and radically unscientific.

Scientismists, according to Rothbard, takes the claims of science to an exaggerated level and deemphasizes the uniqueness of humans. I didn't find very much of his paper to be compelling, probably because it kept talking about economics and society rather than the flaws of scientism. However, I did find myself exploring more on the topic of Scientism itself.

Wikipedia offers a few other definitions that raises science to the level of religion (including one from Isaac Asimov's science-fiction series.) My favorites are:

Scientism is the contention that the social sciences should be held to the somewhat stricter interpretation of scientific method used by the natural sciences.
Scientism sees science as the absolute and only justifiable access to the truth.

The first definition I like because I have criticized one of my friends majoring in a field called "political science" which in my opinion, lacks true science. The second tacks a name on my beliefs. Some people place their faith in God. I place my faith in rational people. Does this mean that I idolize scientists?

Yeah, I guess I do. Science leads to a greater understanding of our world and it challenges our assumptions. Buckminster Fuller, a Scientismist and an idol of mine, would harshly criticize concepts like sunrise/sunset, up/down, and wind blowing. We used to think that the Earth was the center of the universe. Now that we know different, we should start using the terms "sunsight" and "sunclipse." Up and down should be replaced with out and in, in relation to gravitational pull. Wind doesn't blow, it sucks... flowing towards areas of low pressure. Fuller ceased using the nonsensical words, prefering his more accurate descriptions of the phenomena involved.

Albert Einstein proved relativity which doesn't seem to mesh with our daily observation of the world. I mean, how mind-boggling is it, to realize that no two events can happen at the same time? They only seem to happen at the same time for one observer, but it is sequentially different for another. There is no objective, third point of view that decides which even happens first or which one happens second... it is merely relative. This seeming nonsense is TRUE.

Science has the power to confirm and deny truths in a way that nothing else can. Inner contemplation or discussion with intellectual peers can only take you so far in the journey to understanding. To progress further, you need to question, theorize, experiment and observe as a true scientist would. Yet scientists themselves often disagree on what findings are significant and what they really mean.

When we come to the study of human nature, a whole host of difficulties arise. Ethical issues in human experimentation, the fear of malevolent misuse of gained information, the biases of self-examination... the list goes on and on. Some people feel that the poetry is lost when we can be described in terms of neurochemical impulses, cellular mechanisms and physical action. For me, it just makes the world that much more amazing how we can sustain whatever it is we call a consciousness in the midst of all these self-described connections.

There are many personal and philosophical questions that science cannot answer. I feel that everyone has an inner-world we are reluctant to share and this hesitancy will forever propagate our own mysteries. This is not a bad thing... just an unknowable one.

Cancer Vaccine

On June 8th, a vaccine called "Gardasil" was approved by the FDA. It does not grant immunity to a disease like measles, mumps or rubella. Instead, it will give young women an excuse to avoid those painful and uncomfortable pap-smear moments with their doctors! This vaccine targets the human papilloma virus (HPV) responsible for most types of cervical cancer.

I noticed that the press release of this vaccine was preceded by drug commercials saying "I didn't know that cervical cancer could be caused by a virus. A simple, common virus!" The disbelief these women display is amusing, but sobering at the same time because many people remain ignorant of the facts. It is interesting to note that a decade ago, people thought that our next big invention would be a cure for cancer. Now, it turns out to be much more complicated than that, since there are so many ways regular cells can be subverted to become cancerous.


However, there is a downside to providing a sure-fire cancer-preventer -- many abstinence-promoting groups are afraid that it will spread the message to teens that it is okay to have sex (since women will be safe from cervical cancer.)

I find it puzzling how these coservative groups can jump to such broad conclusions. It is basically saying "we don't want this risky behavior, so we'll remove some safety precautions that will save lives."

1. We are afraid kids will get into risky vehicular accidents if we let them wear seatbelts!*
   
2. We don't want children to smoke cigarettes, so we'll remove the filters on cigarettes.
   
3. We don't want any kids to play with guns, so we'll permanently disable the safeties on them so they'll KNOW they are VERY DANGEROUS ITEMS!!!!
   

These situations just make the consequences that much more drastic. Their solutions do nothing to fix the problems and the end result is that it only aggravates them, instead of addressing root causes. THAT is the point. THAT is what they want. Abstinence does not become much of a virtue if using condoms and birth-control also lower the chances of getting STDs or getting pregnant. These groups want to punish people for behaviors that they see as evil (pre-marital sex) and this benefits the general public... how?

I don't understand how the riskiness of these actions acts as deterrents for kids. Ignorance and abstinence are not solutions that prevail over education and safety precautions (to be put in place in case the situation ever does come up)!

*An example provided by Alan M. Kaye, executive director of the National Cervical Cancer Coalition. "Just because you wear a seat belt doesn't mean you're seeking out an accident," Kaye said.

Poison Ivy = Allergy Ivy

My brother breaks out in hives after he touches mango sap. This used to be a problem because of the huge mango tree next door (or at least, it was an excuse for him to have me mow the lawn.) I was surprised to learn that the mango tree is a part of the Anacardiaceae family, which includes poison ivy, poison oak, poison sumac, cashews and a Japanese tree used to make lacquer. Whoa. Mango trees are poisonous like poison ivy?

Not quite. As it turns out, mango sap is allergy-inducing in the same way that poison ivy is.

Here's a picture of poison ivy from the Poison Ivy Tutorial. "Leaves of three, let it be" is the common mnemonic for hikers and campers, but the maker of the tutorial offers further information. Jewelweed is a plant that follows this rule, but it actually relieves the effects of poison ivy.

The allergenic resin to blame is called urushiol, so named after the Japanese tree -- ki-urushi. Urushiol is an oil that does not cause an allergic reaction the first time you come in contact with it. For people who become hypersensitive, contact dermatitis results upon subsequent exposure. A very itchy rash erupts on their skin and sometimes, it "weeps" with clear fluid.

Mango trees have allergens called mangols. A study done in Japan has shown that urushiol and mangol are cross-reactive.
This means that my brother would break out with a rash if he came in contact with poison ivy even though he might have never seen it before. He might even be allergic to uncooked cashew nut oil and gingko biloba (which is similarly allergenic.)

To add to my brother's worries, current trends in global warming might aggravate his problems. A few weeks ago, the St. Louis Dispatch had this to say:

Scientists have come up with something new to worry about if the level of carbon dioxide in the atmosphere continues to rise: It'll make you itch.

The noxious vine poison ivy not only grows much faster in a carbon dioxide-enriched atmosphere, but it also produces more urushiol - the substance that causes most people to break out in a rash, says Duke University botanist William Schlesinger.

Let's try to end on a happier note, shall we? Hm... Poison ivy berries are eaten by songbirds in the winter and they do not break out in hives. It is possible that the cashew-related plants evolved urushiol and mangol as deterrents against mammalian scavengers who might destroy the whole plant in search for tasty berries. The digestive system of mammals is quite strong compared to those of birds, so we might digest and destroy the poison ivy seeds that birds would otherwise carry and propagate.

So the discomfort my brother experiences might just be a product of millions of years of evolution trying to prevent him from enjoying mangos! It's really too bad that he likes them and I hate their slimy texture.

My first shameful memory as a pre-med

I've been cleaning up my room in preparation for the tons of books and supplies for medical school when I came across a packet that I had tucked in between my high school yearbooks of junior and senior year. What's this? I wondered to myself as I pulled the fresh binder from its dust-encrusted locale.

The title of the dark plastic folder read "National Youth Leadership Forum on Medicine" in gold-embossed letters. Ah yes... that time when I was especially clueless. This story is a difficult one for me to share, but I feel that it is important to do so.

Let's start with the beginning:
NYLF is an organization that takes young high schoolers and entering college freshman to a college campus where they learn more about a challenging profession like politics, engineering, law and medicine. Back in 2000, I went to UCLA for the summer to learn about medicine but what stuck with me was what I didn't learn. NYLF was crammed with a bunch of super-charged wannabes, self-absorbed know-it-alls, multi-talented maestros and curious impressionables. I was a mixture of the first and the last of these types -- the a dangerous mix of knowing nothing at all and talking a lot.

We were broken into groups of about a dozen students all teamed up with a med student mentor. My mentor was about the most laidback guy ever... which made our group very fun to hang out with, but also very unfocused in our work at the same time. We had talks with specialists and primary care physicians, AIDS patients and public health workers, we went to a hospital and a medical school, we got to see research and participate in a small group case study.

Our culminating project was an ethics presentation. We were in charge of organizing information on the topic of "fetal tissue research." It's hard to believe that a mere six years ago, the more encompassing term "stem cell" was not used in our packet, but thats what we had. Our mentor discussed a few of the issues at hand as mentioned on the one sheet blurb we were given on the topic.

Fetal tissue research has led to successful transplants and treatments for those suffering from Parkinson's disease. Fetal tissue transplantation research is still being performed for a number of other disorders including Alzheimer's disease, Huntington's chorea, acute myelogenous leukemia, diabetes mellitus and Hurler's syndrome.

Here's where I tossed in the red herring. "How did they perform these transplants? How did they know they were successful?"

"Well, they might have done a trial where they had one patient where they injected fetal tissue into their brain and compared it to the results of another patient there they didn't inject anything." Things went downhill from here. It all sounded very dangerous to me, not to mention that half of the patients were being lied to! How could these scientists operate under such callous measures and call it science?!?

Our issues to examine like "would it be ethical for a woman to get pregnant to supply fetal tissue to a relative?", "should a woman have to give consent to determine what happens to her fetus after an abortion is performed?" and "should women receive monetary compensation for their donation in fetal tissue research?" all went to the wayside. Obviously, there were better alternatives than deceiving half of the test subjects and injecting them with useless saline! My outrage spread through our throng of wannabes, know-it-alls, maestros and impressionables.

Our debaters did a great job of presenting their findings to the rest of the NYLFies. However, the moment they brought up our main discussion on the ethics of placebo effect, we were met with harsh resistance. Everyone voted on the measures they felt made the right decisions. Despite the fact that we had a great discussion and plenty of examples... we were shot down. It was quite shameful, really. While everyone else had ~70-80% approval, we had figures closer to Bush's current approval ratings. The contrast was a slap in the face and a wake-up call for our disappointed mentor.

Thankfully, no one in the group blamed me for this utterly embarrassing failure.

Now, as I close this beautiful binder and tuck it away back inbetween my yearbook collection, I notice how the pages of the book inside aren't ragged and dogeared like the other books on my shelf. Have I blocked this totally from my memory until now? Does any of it hold any credence whatsoever? How has my past ignorance impacted my present self? I began to search for answers.

I doubt our first-year medical student mentor knew anything about the actual research, but he knew just enough about clinical trials to deal the damage to our young debate team. Randomized controlled trials consist of mixing up a sample of patients and performing two types of procedures. In order to remove the psychological effect of feeling better after being treated aka the placebo effect, the patients do not know if they are receiving a legitimate treatment or the false treatment (ie the medicine and the sugar pill) or the classical treatment versus the new treatment. This is absolutely necessary for scientific research. Without a baseline to compare the results to, there is no way of telling what actually works and what is just spontaneous remission of disease.

Researchers often go a step further and they make sure that they don't even know who is receiving Treatment A and who is receiving Treatment B. This prevents them from preferentially giving the treatment they like to people they like or vice versa. Double-blind trials are very solid in removing bias. Statisticians might be blinded themselves in triple-blind studies, but then it seems like no one knows whats going on... until it gets magically published in some journal. ;-)

Anyway, the scenario that our mentor painted was likely the wrong one. Transplanting tissue is a very dangerous endeavor. Human trials of stem cell transplants into Parkinson's patients haven't been done yet (to my knowledge, please correct me if they have) because we have not yet perfected ways to limit their growth in mouse models. (Freed, 2002 PNAS) Due to the current controversy over current stem cell research (and the relative quality of the approved embryonic stem cells,) I doubt that we will see clinical trials reach Phase 1.

Looking back, my shameful moment really made me the person I am today. I learned how easy it is to let your emotions get in the way and distract you from the purpose of these types of experiments. Objectivity is not something that scientists are mystically born with; they have biases just like everyone else. This is why it is so important to perform double-blind protocols. This is what separates testable, provable medicine from snake-oil.

Robotic Worms

Geekologie presents its tongue-in-cheek take on the development of robotic worms for delving into your gut. A team of European scientists are taking the idea of a "camera pill" to a whole new level by mobilizing it in a freakishly eerie way.

The team has already created a few prototypes (see videos here and here), and they are currently working on a robot with a camera and a light to capture video as it travels. Unfortunately (fortunately?) the robot is going to need years of testing because, as one researcher put it, "if something this complicated goes wrong, it could be very hard to get out." I don't know why they don't just add a drilling device to the front of the robot. That way, if something goes wrong, the robot could just drill its way to freedom and safety.

I don't think that it would be that difficult "to get out." It would get packed into a bolus if subjected to regular peristalsis and come out buried in a turd. Intestinal worms have developed specialized mouths that latch onto specific parts of our guts and swim upstream constantly to avoid being pushed out before they are ready to go. Still, there are other problems that need to be overcome...

Like the "Ick!" factor. I would not want a little robotic worm squirming around in my intestines... I feel that regular parasites are enough cause for worry, thank you very much. Looking at their designs thus far, it doesn't look like it would be neatly packaged like the camera pill. Would you want to have the used version, knowing that it has gone through someone else's GI system from bowl to hole?

25 years of AIDS

Micheal Gottlieb, a doctor at UCLA's AIDS institute and a member of the Global AIDS Interfaith Alliance shares his story about discovering AIDS in today's LA Times. He published the first case of AIDS in the Morbidity and Mortality Weekly Report on June 5th, 1981.

Michael and my other early patients died within that first year. Within days of the June 5 report, doctors began telephoning from all over the nation to tell me about their own patients with pneumocystis. Over time, intensive care units at UCLA and across the country began to fill with young gay men requiring ventilators, their lungs choked with the same strange organism. The AIDS epidemic was underway.

It is still astonishing to me that a disease that spread from chimpanzees to humans in Central Africa probably as early as the 1930s was first detected in West Los Angeles in 1981. In retrospect, we know that HIV had traveled to U.S. shores as early as 1977. And the earliest known positive HIV blood sample is from 1959, obtained from an unknown man in Kinshasa, Congo, and frozen.

Twenty-five years later, a disease that used to be deadly and widely feared has been reined in by the development of drugs, a global effort to educate and a greater effort to use condoms for the prevention of STDs. Our progress is amazing and frustrating at the same time. It is easy to point fingers at many people who stymie the efforts of AIDS organizations... but it is amazing to see how far we've come in just 25 years.

Egg vs Chicken

A geneticist, a philosopher and a chicken farmer teamed up to answer the old riddle/koan (wiki def) of "Which came first - the chicken or the egg?"

The verdict via BBC and my retorts:

Charles Bournes, chairman of trade body Great British Chicken, said:

"Eggs were around long before the first chicken arrived. Of course they may not have been chicken eggs as we see them today but they were eggs."

• Bournes is a smartass. He doesn't answer the implicit question. Yeah, duh. Dinosaurs have eggs and dinos came before chickens. The question is more challenging when it is about chickens and chicken eggs.

Professor David Papineau, an expert in the philosophy of science at King's College said:

"I would argue it is a chicken egg if it has a chicken in it. If a kangaroo laid an egg from which an ostrich hatched, that would surely be an ostrich egg, not a kangaroo egg,"

• Papineau invokes a bizarre thought experiment to justify his claims. A crossbreed of two separate species of birds emerges from the first chicken egg as a chicken, unrelated to either parent because of magical X-Men styled mutations. He'll get credit for his "critical thinking" in eliminating the circuitous definition loop of "the first chicken must come from the first egg but ooh, that egg must have come from the first chicken so that was it, but the egg again..." but ostriches and kangaroos? What is this guy talking about?!? Papineau doesn't understand evolution at all. Lets see what the evolutionary biologist had to say.

Professor John Brooksfield of Nottingham University said:

"The first living thing which we could say unequivocally was a member of the species would be this first egg, so I would conclude that the egg came first."

• Bravo! That was concise. An egg has the same DNA as its resultant chick, so the egg is the first "instance" of chicken. Perhaps he could have defined the term "species" somewhere and he would have been on solid ground. I'll get to that in sec.

These arguments are disappointingly bland from this assembly of "eggsperts" (which incidentally, were assembled by Disney to promote the DVD of their movie Chicken Little.) Where are the deep philosophical ponderings of potentiality and realization? What about the speciated definitions artificially separating chicken (Gallus gallus domesticus) from its pheasant ancestor "Red Junglefowl" (Gallus gallus)?

What makes an egg? What makes a chicken?

Here's what I think.

An egg refers to the reproductive component of a mother (possessing half the genetic material needed to create a genetically unique individual.) The "egg" in question is different -- it is the external, calcified shell as well as the fertilized egg of a hen.

A chicken is an assembly of phenotypic characters (things that we can readily observe and quantify) of a particular animal. On a child's level -- does it crow and cluck? Is it short with a small beak and fluffy feathers? Does it think that the sky is falling? Zoologists go into great detail thinking up as many characters as they can, but even then "species" can be a hotly debated term. If they can crossbreed, they are generally considered to be the same species. Unless they are geographically isolated or they have different mating behaviors. But only with certain animals.

If we go this far, the answer is that the chicken came first and Prof Brooksfield gets the points for the most valid argument.

However, the question is flawed. The experts get a solid F for failing to recognize this. It is not an either/or question, it happens (relatively) simultaneously. You cannot define a species based on one individual. It might represent the earliest known example, but it is just that -- an example. Species are population-based. Meaning that in order for us to know what makes a chicken egg and a chicken, we need to see a family of them.

I don't know much about dogs. I might see one walking its owner down the street and think "oh look there's a dog." Someone else might say "ooo, what a cute doberman/chihuahua/poodle!!" A tall dog back in the day was mated with other tall dogs and eventually the great dane became a type of dog. That is what drives speciation -- random or sexual selection of characters. This takes a looong time. Our pet dogs haven't even speciated yet.

The idea of "First Chicken" is ridiculous. This in turn, makes the idea of "First Chicken Egg" equally silly. In order to recognize them as something special, they need to be a part of a group.

Animated Drug Mechanisms

Have you ever had a drink of alcohol and you wondered what exactly was going on in your brain to make you feel buzzed? Why would a "downer" make you more uninhibited and outgoing in a social setting? I've tried to figure this one out, but it isn't the easiest topic to think about while intoxicated.

If you ever wondered exactly how ecstasy, cannabis, speed, cocaine, heroine, alcohol or nicotine have their effect in the brain, now's your chance to find out.

Thanks to MindHacks (via Omni Brain), a short flash animation of various drugs is presented for your viewing pleasure! Keep in mind that the original site was written in Dutch, so the English isn't very good.

Refusing Medicine

Via uComics -- "Close to Home"

I love reading the funny pages. It is the first thing I flip to in the newspaper, but this strip from yesterday's paper made me pause. My ethical alarms went off, lights flashing and sirens blaring. Is this OK? Is it funny? I thought it was missing something. The artwork could be better, but the message behind the picture is unclear. Is this a joke, a bluff or a real thing done in the wacky cartoon hospital? Is this the general perception of patients in real life?

Here's a few stories from the Floor for discussion:

A nurse in Telemetry told me when he first started as a nurse. He used to strongly insist that his patients take their meds. With one who refused to take them because it tasted bad, he ate the patient's applesauce to show that it was OK. The thing is, he HATES applesauce and he tried to force himself to smile but ended up gagging instead. In the end, the patient still refused (amused at his nurse's antics, no doubt.) Now, he just confirms their decision and notes it "REFUSED" on the Med Admin Record.

Last night, a patient with bipolar disorder and respiratory distress started ripping out his IVs because he was upset. The IV was put back in by his nurse and he had a talk with his psychiatrist. After the doctor left, he ripped out the IV again and started walking off the floor.
"Why don't you just put me in handcuffs?" he asked the vexed nurse aides who convinced him to stay to fill out paperwork (disclaimers about Leaving Against Medical Advice and such) and wait for a few discharge meds.
"We don't need to do that," responded one aide (who clearly was considering restraints.)
"I don't like taking orders from ANYBODY..." growled the patient. "Why are you bossing me around?"
"Because you're under our care," replied the second aide. "It is our responsibility to--"
"You'll be under my care if you keep this up. All of you are under MY CARE" he said defiantly as he shuffled back to his room.
After another talk with his harried psychiatrist, the patient signed papers and left the hospital. The hospitalist's opinion? "If he's strong enough to rip out his IVs, he's OK to be off his antibiotics." My thoughts? Hopefully, after a good night's sleep he'll go to his followup appointment for more meds today.

Like the cartoon, I was under the impression that nurses actually had power over their patients for medication delivery. This notion is changing as I realize more and more how much power patients have over their own course of treatment. Obviously, patients have a right to decide what is best for themselves -- what is the "best"? Patient autonomy conflicts with medical authority in many situations. There are only a few cases where patients can be legally forced to consume medications. Noncompliant TB patients have actually been incarcerated for direct observed therapy, but even this is highly controversial (NewsRx, 1997, Souvannarath v Fresno, 1998.)

Belief plays a big role in noncompliance with conventional treatments. Over in Respectful Insolence, a discussion of two patients/"alties" refused life-saving treatment because of their faith in alternative medicine. A complicating issue that differentiates it from my two stories is that Orac's stories are about children. (Two young victims of alternative medicine, 6/1/06)

Ignorance can be countered with education. Confusion can be countered with communication. If knowledge is conveyed to the patient in a clear fashion, the patient is "Informed." This is all that the doctor can do... the decision is left to the patient offering "Consent" or not. The ethical reasoning behind Informed Consent itself is strong. The shaky areas of proxy consent (with minors, elderly and those who are incompetent) is not. I am certain that this will become a recurring theme here.