Como Agua Para Chocolate

Have become quite a fan of baking. Actually, a fan of baking things that I like to eat. Like brownies (yum...), chewy cookies (mmm...), cake, macaroons. Anything sweet and tasty. Since I'd never truly set foot in the kitchen until a few years ago, all my methods of cooking are somewhat unconventional. Perhaps, if yours truly had been at Grandma's side whilst still waist tall, she'd have learned how to do it the proper way. Or perhaps that would have been too cliche. Regardless, FoodNetwork has been a wonderful sources of recipes and a good teacher for the beginning baker. Except that this baker picks 'n' chooses what to learn, and refuses to use measuring instruments.

I bake without things most people would call essential. There are the trusty glass bowls, a couple of metal pans, glass tupperware from Costco (perfect for brownie and cake baking, by the way), and that's pretty much it. If the recipe calls for a cup of flour, out comes the little plastic cup (unclear where it initally came from). A tablespoon or teaspoon means bigger or smaller amounts on a regular metal spoon. After all, you can see how much Rachel Ray uses when she says "add a teaspoon of garlic," so just eyeball it. Am a big fan of guestimating the amount of materials needed to make something taste good. Why must the amount of water added be exactly 1.5cups? Why a third of a cup of oil? Just mix it, add enough to make the batter look right, and we're on our way. The bottom line is cooking is an art, and too much measuring takes all the fun away.

You might be afraid of how the desserts turn out. Never fear - although brownies from next week cannot be guaranteed to taste exactly like the brownies from last week, after all, the eyeballs are allowed a little artistic leeway, as long as the main ingredients are in a relatively good ratio, I've yet to have a disastrous result (knock on wood). True, sometimes the brownies come out more cake-like, and sometimes the chocolate cake comes out more brownie-like, but they still taste good, and then we've learned what too much or too little of one ingredient does.

Alas, the unconventional ways may be coming to an end. Watching food TV exposes one to all the superfluous (but so neat) baking accessories. It's an eye-opening process, and on some level, a perfect example of how advertising sucks you in. I mean, Emeril's $300 mixer may be an unnecessary instrument, but by golly, what a useful unnecessary item! It stirs all kinds of things at all kinds of speeds and can prevent tennis elbow and arm fatigue! Or that blender-thingy-ma-jig... Again, nonessential, but how nice would it be to just plop stuff in and have a machine chop it to just the right size or blend to the right consistency? Or fabulous ideas such as the silicone pad, or parchment paper. Just pick it up and shake the cookies right off. Brilliant! I'm afraid, though, that if I get started buying these wonderful things, I'll have a garage full of cooking instruments "meant to make cooking easier!" So I'm holding back. Although, I did break down and buy a hand held electric beater. It was getting tiring to incorporate wet and dry ingredients by hand...

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Chronic Pain - Your Baggage, My Baggage

Before we get started, just wanted to say that most people living in chronic pain are true survivors. I'm met people in chronic pain who are well-adjusted and really stellar examples of the adaptability of the human spirit. Many who have enviable personality traits that we should all work towards. This is NOT about them.
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Chronic pain. These are words that many physicians dread to see on a new patient's chart. It's not the pain that's hard to deal with. It's that pain often brings along a lot of unpleasant companions that can make it an emotionally draining encounter. It's hard to tease out all the different reasons, but here are some of them:

1) people in chronic pain have spent a lot of time trying to navigate the medical system, jumping through hoops, looking for answers, and so bring a lot of baggage with them. Some of them get stuck in a negative feedback cycle with the medical establishment and come to you with past experiences of resentment, anger, and misunderstandings that they bring to the table. It's not really their fault that they are they way they are, but it does make the interaction difficult. A good analogy would be a significant other with a lot of prior emotional baggage. You may want to work through issues, but every step you make has the potential to set off a long hidden landmine...

2) some people in chronic pain, just like some people without pain, have personality disorders that make them difficult to get along with. And others may have developed problems like depression and anxiety due to the chronic pain and its profound impact on daily life. Nothing against people with personality disorders, but for those of you who are on the more sensitive side, you've probably had the experience where, after talking to someone who is depressed, you leave the room or leave the interaction with your shoulders hunched and your head hung low. The sky no longer seems as blue, nor the grass as green. These personality disorders and resultant emotional issues need to be addressed, but unfortunately, it's not something that can be easily done by you (unless you're a shrink) or done in one visit.

3) A very small number of the patients are actual drug seekers, which means that we as physicians may fall into the trap and plop our own overweight baggage onto the table. Whether they are or are not should not be an issue when we're taking care of patients - ideally, we should be able to treat pain regardless of why they have pain, but it just takes one bad experience to really shake you up and make you think twice.

I still remember a young woman who came in with a large deep venous thrombosis (DVT), who gave a really good history as to how she got the DVT. She was admitted for pain control because of excruitiating pain in the affected leg. Although the pain seemed out of proportion to the problem, given that she did have a clot in her leg, we set out to treat the pain. Every time we walked in the room, she would be writhing on the bed in pain, complaining that we were completely ineffective at treated her, and yet, when we were nowhere to be seen, said patient would be strolling the hallways with her Dilaudid PCA pump, waving at the hospital staff. When we tried to switch her over to an oral pain regimen, she all of a sudden developed complaints suggestive of meningitis, accompanied with an excruitiating headache that required Dilaudid and only Dilaudid to treat. We were somewhat puzzled by how this would happen as she had no known risk factors, but again, she was very convincing and her symptoms were concerning. So to rule out meningitis, we discussed a lumbar puncture with the patient. She was extremely reluctant to get the LP, coming up with one reason or another why she shouldn't get it. Finally, the morning of the said procedure, her headache miraculously resolved.

This whole time, although we thought she was a tad melodramatic, and the whole clinical picture didn't quite make sense, no one suspected anything. The patient was extremely convincing, and even gave us a sob story of having two children at home that she had when she was very young, and told us that she was trying to get off pain medications because she wanted to be a good mother and role model for her children.

Meanwhile, the nursing staff stated that they believed the patient was "milking" the PCA pump. This was the first time I had ever heard of such a thing, but apparently, there's a way of milking the tubing attached to the PCA so that one can get more of a bolus than the machine delivers. The first time this happened, the nursing staff thought they had miscalculated the amount of opiate in the bottle. The second time, they got suspicious. The third time, they caught her doing it. We asked her about it, at which time she started crying and furiously accused us of not trusting her, stating that she didn't want to have the pump if we were going to accuse her of abusing the medication. By this time, this was three weeks into a hospitalization that should have taken a few days, and the attending physician decided to stop the pump and convert her to an equivalent amount of oral medication. Apparently you can't get as much of a high from the long-acting oral medication, because as soon as the pump was discontinued, she decided she was all better and was ready to go home.

Two weeks later, my co-worker, then on a rotation at a different hospital, admitted the same patient, who was now using A DIFFERENT NAME, from the emergency room with the same exact complaints. Because he recognized her from morning rounds at our hospital (but not the other way around), the medical team there did the necessary medical workup, but were aware of what she was trying to pull. She got oral medications but no PCA pump, so left the hospital very soon after admission. A week after that, I received a frantic email from yet another hospital emergency room, for the same patient, with yet another variation to her name. The patient had given a sob story and said that she had an extensive workup at our hospital, and we had given her this and that pain medication, and she was asking for the same from this third hospital.

On some level, we should feel sorry for someone who is so addicted that they need to do whatever they can to get the next dose of their drug. And in a way, it might be easier to just give the patient what they want. But that can't be the right thing to do by the patient - you just make it easier for them to abuse the system and abuse their bodies. And besides the ethics of the situation, when you're the one that was duped by that innocent face, that sob story, there is definitely frustration with the patient and anger at yourself that you were dumb enough to fall for it all. And the next time a similar patient comes along, the prior experience is there, reminding you to be on your guard. Our baggage, I guess, of sorts.

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Broken Health Care System

This is partly why the American health care system is broken:

Botox in several "cosmetic" units (i.e. all the needed areas of a face) takes minutes of time. Cost = ~$1000.
Insurance does not cover this, so patients pay with cash. Cash = immediate revenue = no need to pay someone to try to wrangle it out of insurance companies. $1000 buys a physician a lot more time with each patient. Time means the physician finds the interaction more rewarding. Time means the patient finds the interaction more rewarding.

Compare this to your average primary care provider:
Medicare pays very little for each primary care visit (usually much less than $100 depending on where you practice). If a patient needs a special test, you may never get paid for it if the insurance company does not agree. If you see a patient who needs a special medication, you may have to fill out form after form, and may still never get the needed approval. Frustating for the patient AND maddening for the physician. In an effort to cover operating expenses, to make the same $1000, you must see at least ten patients. Sheer volume of patients means less time with each patient yet more paperwork to be done. Less time with patient = unhappy patient = possibly worse patient care = increased risk of physician burnout.

How come people are willing to spend hundreds of dollars to look good, yet gripe about having to pay a $10 copay for a blood pressure visit? Just based on pure economics, is there any wonder that physicians in all fields - internal medicine, OB-GYN, surgery, Derm, Ophtho, etc. - are all trying to get a piece of the "cash only" pie? And while, at this point in my training, the thought of spending a lifetime performing relatively frivolous services like botox and lasers is distasteful, is this naive? How is a medical system to survive if physicians that are supposed to treat the medical problems of their specialty "sell out" to run a "medi"-spa or open weight loss centers, or run full-time cosmetic clinics? And yet, when one knows about how overworked and underpaid most primary care physicians are, can you blame them for looking for a way out?

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Consciousness - What Little We Know

Recent study in the journal Science:

Functional MRI imaging of a 23 year old vegetative woman shows that her brain still "lights" up in patterns that are similar to normal brains. The scientists tested whether her damaged brain could process speech, and the appropriate brain areas showed activity. She was asked to imagine playing tennis, and the motor areas of the brain showed activity.

What does this mean? That she could hear the physicians? That her brain was still processing commands? That although she was unconscious, her basic brain functions were still intact?

Medicine doesn't really know much about "consciousness." This brings up a memory from medical school. During the anesthesia rotation, one of the attendings was testing the Bispectral index (BIS), then a novel method of measuring the level of a patient's awareness under general anesthesia.

First, the background on BIS: This type of machine came about because of the rare but horrible stories of patients being under general anesthesia but feeling every bit of the procedure. General anesthesia has many purposes, including pain relief, which usually comes from being "unconscious," and sometimes paralysis of the entire body, for special surgical procedures. If someone is paralyzed with medications, but the pain relief is inadequate, there is the potential that they can feel the entire surgical procedure, but can't say a thing or even get out of the way of the scalpel. So basically they're operated on without any anesthesia, but the surgeon and anesthesiologists don't have a clue. Not a pleasant thought. So at the time, the BIS was this new device that was marketed as being able to measure the level of consciousness/awareness of a patient who was unable to communicate with the physician (eg while under general anesthesia). The machine worked by real-time and continuous electroencephalographic (EEG) analysis and generated a dynamic score ranging from 0 (deep anesthesia) to 100 (awake). Target goal for surgical anesthesia was around 40 to 60.

The anesthesia attendings were trying this non-invasive device on patients undergoing regular surgical procedures, and realized that it was pretty interesting and potentially very useful. Well, one of the attendings decided to try the device on a "brain dead" organ donor. (ie people who are in traumas who suffer irreversible brain damage, but wanted to donate their organs if the opportunity ever arose.) These organ donors have to "pass" a rigorous evaluation by two physicians to ensure that they are truly brain dead. This involves many tests of brain function, including shutting off the ventilator that they are on, and documenting that their brain stem no longer functions - which manifests in one way as a failure to breathe on their own. If they prove to be medically brain dead, the organ donation process may proceed. The process involves keeping the patient alive by the use of the ventilator and other machines, until the time of the organ harvest. When that time comes, the patient is taken to the OR and the organs of interest are "harvested" - taken out of the donor body and packed on ice for delivery to the recipient. The donor body is then closed and disconnected from the machines, and the donor formally passes away.

One would think that a brain dead person, one who cannot even breathe on their own, would not score very high on a BIS score. Unfortunately, they are also not at zero. The attending never told me what the score exactly was, but he did say that after using the machine on one organ donor, and seeing it rise with the scalpel incsions, he got the heebie-jeebies and had to disconnect the BIS. He never used it again in that scenario.

What does this mean? How can someone who is brain dead, who will die as soon as the ventilator is shut off, still have brain waves? Or still respond to external stimuli? What is the relationship of consciousness to the body, and how come there is so little understanding of this area?

* picture taken in lush Kaua'i

Ready To Eat? Maybe Not...

With ready-to-eat spinach/E. coli on our minds, I thought it perfect time to figure out just how these pre-washed vegetables maintained their freshness. We eat a lot of bagged, "pre-washed" baby carrots, and I've always wondered why they can sit around in a moist plastic bag and refrain from molding or other forms of rot.

You may (or may not) want to know how they do it... The following contains some data from USDA studies. The main methods of "preserving freshness" (quite an oxymoron) fall into two major categories:

1) Special packaging films with modified atmosphere packaging (MAP) method
2) Cleaning chemicals in the wash

Apparently, fruits and veggies are still "alive" and each item "breathes" at a unique rate. The plastic film's permeability to oxygen and the amount of oxygen/carbon dioxide initially injected into each bag differs depending on the bag's contents. Modified atmosphere packaging (MAP) is a method of "balancing oyxgen and carbon dioxide, which causes the produce to respire slowly." If there is too much oxygen, the product will brown. If it's too low, the product will "prematurely decay."

Here are some chemical agents used to wash cut fruits and veggies. They're mainly used to control microorganism growth - why mold and bacteria don't grow on these delectable looking products - and to preserve the visual appeal of the product ("antibrowning agents" and things that "slow decay").

Acidified sodium chlorite (ASC) - sanitizing agent on cut carrots
Chlorine rinses
PQSL 2.0 - "breakthrough for wash solutions because it not only maintains an apple slice's color, firmness, aroma and flavor, but also reduces levels of Listeria and Salmonella bacteria."
Calcium ascorbate dip – prevents browning on apple slices
1-Methylcyclopropene (1-MCP) - a gas treatment that slows decay, used on apples, tomatoes, avocadoes and more; has been shown to penetrate watermelon rind to prevent degredation, which "can buy extra time for shipping and prolong a product's selling season."

And apparently, manufacturers are warned that "wash solutions lost their antimicrobial activity over time, and should not be reused on multiple batches of produce.” But fear not, "research is underway to find a way to maintain the antimicrobial properties of wash treatments." Yum - A chemical wash that won't loose it's chemical-ness with time.

Let me just say that I have no problem with big business using and developing new methods that will help them stay competitive and earn a profit. Ready-to-eat things are all the rage as people have less time and less inclination to prepare their own foods, and businesses that make these need to be able to offer a product that will look good and sell well. And consumers are partly responsible - you can't have unadulterated fresh fruit that also sits on a shelf without rotting, and the fact that we demand this makes us partly responsible for the evolution (or mutation!) of food industry practices.

The only problem is that I doubt that Joe Schmoe really knows what manufacturers put into his ready-to-eat food, and I believe that he at least has the right to know. That juicy cantaloupe that Joe's about to bite into is deceptively like a fresh-cut cantaloupe, except that it's bewn processed and dipped in some pretty strange materials. And if Joe's OK with that, more power to him - that's Joe's choice. It's just that the Joes of the world should have the option of knowing what's been done with their food.

AM Drive By

Overheard in the routine AM elevator ride:

Tall skinny guy carrying a stack of books and a thin younger woman with glasses -

Boy: Yeah, so over the weekend I was trying to grow my cells, and I think I finally got it down.
Girl: Oh really? Are they finnicky?
Boy: They are. Too much blah de blah and they mold over, too little and they die out
Girl: (in awe) Wow...
Boy: Yeah. I've figured out that they really need more XXX medium, and less YYY solution
Girl: That's amazing. Maybe I could come over this weekend and learn more about that...

That, my friends, is the definition of nerdy flirting technique, coming right at you from Big City University Hospital. Never a dull day, I tell ya. Always learning... always learning...

Picture is of the gorgeous NaPali Coast of Kaua'i. Just a beautiful, majestic place.

These Are Your Leaders, People

Apparently, the Air Force Secretary Michael Wynne believes that our government should try out its "nonlethal weapons" on U.S. civilians (in "crowd-control settings") before using it on a battlefield. Here's a quote:

"The object is basically public relations. Domestic use would make it easier to avoid questions from others about possible safety considerations. If we're not willing to use it here against our fellow citizens, then we should not be willing to use it in a wartime situation," said Wynne. "(Because) if I hit somebody with a nonlethal weapon and they claim that it injured them in a way that was not intended, I think that I would be vilified in the world press."

Huh? Secretary Wynne, what are you smoking?! Are you really that out of touch with the common man? Would you "try things out" if your son, your wife, or your mother were in that crowd? You can't just experiment on humans. Even in warfare, you can't experiment on humans. Remember the Nuremburg trials? Do Nazi experiments and war crimes ring a bell?

I usually don't stoop to comment on politicians and their cronies, but this one was really out in left field. What are these people thinking???

TV, Tele, Televisor, Or Whatever You Wanna Call It

Ever turn on the TV after a long day's work to relax? Ever mean to just sit and watch one show, and end up dragging yourself off the couch after several hours? And although it seemed to relax you, ever feel more tired after turning off the TV?

After answering yes to the above, I set out to try to find why all this happens. Turns out, it's quite a common phenomenon with very interesting theories...

In February of 2002, an article published in Scientific American discussed just this topic. Back in the 80's, scientists realized that the orienting response was a key player in keeping us glued to the tube. The orienting response is defined as the instinctive visual or auditory reaction to a sudden or novel stimulus. Think of the kitten who's attention is raptly focused on the moving tail, or the dog that sees movement out of the corner of her eye - the rapid changes on a television screen are a non-stop stimulus for this orienting response. If you're curious, when someone else is watching TV, turn down the light, sit in that room, turn your back to the TV, plug your ears, and watch the dance of lights on the white wall as the TV images change ceaselessly. It's pretty interesting.

The article also discusses some studies that suggest that becoming accustomed to the rapid stimulation on a TV screen may decreased our attention span in real life and make us more easily bored. And that many parallels can be drawn between too much TV and any other addiction - especially the withdrawal part.

Also came across some articles discussing Mulholland's research on brain alpha waves (seen on EEG) induced by watching television. Couldn't actually find the quoted paper, but found several interpretations of the research, which was thought provoking. If you're interested, here are the Google results. What does all this mean? Probably that we should be more aware of getting sucked in by the tube. That anything done in excess is not a good thing. And perhaps that we should be thinking of what parallels are found between the TV tube, and the computer tube...

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Speaking of computers, how many of you have seen the pop-up window invitation or email invitation to participate in some eyeball-tracking program using infrared light? I don't know about you, but the last thing I want is some company in cyberspace tracking where my eyes focus on any given computer screen...

Picture taken of a nice rose on the way to work, and image toyed with in Photoshop. Oh, the wonders of digital technology!

Alopecia, And More

Hair and nails are considered "skin appendages," and so fall under the domain of dermatology. For those of you with a full head of hair - be grateful! After seeing people with alopecia (hair loss) of different kinds, what is striking is the immense psychological impact affecting people with hair problems. This is clinically more apparent in women, perhaps because men are more likely to expect (and are expected to) to lose their hair with age. And male hair loss, even if earlier in life, is less often regarded by others as "something wrong." Whereas women, even though they may suffer from the same type of hair loss - yes, if your father, maternal grandfather, or brother was/is bald, you are at risk - the loss is difficult to accept for both the woman and for the people who see that woman.

There are a surprisingly large number of different causes of alopecia, all of which may cause different patterns of hair loss. One would think that a patch of baldness (e.g. alopecia areata) might be more difficult to accept than diffuse hair loss (e.g. telogen effluvium), which gives a thinning of the hair with no discrete area of baldness, but that's often not the case. There are women who you might have passed by at Starbuck's, and you would never have guessed that they were going to see a dermatologist for hair loss. These ladies may have lost quite a bit of hair with their condition, but because they were blessed with a thick head of hair, it's difficult to see the effect of the hair loss. Yet these women are absolutely beside themselves with anxiety about the hair loss. It makes one think about how unaware we are of all the things that go smoothly in life, and how we rarely appreciate "normal" until things go wrong. It also highlights the sad fact that we are more attached to ourselves and social expectations than we know. After all, there is no functional purpose of the hair on our head. We do all sorts of things to it to make ourselves more attractive, or use it to make a statement (think mohawk), but truly, it is an unecessary thing. Yet, were your or I to lose all our hair tomorrow, it would be a considerable shock to our sense of self. And the loss of hair may draw unwanted attention and speculation from mere strangers that we are not "well."

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I've recently discovered local farmer's markets. Fresh fruit and veggies that were allowed to ripen before they were plucked. What took me so long?? Anyways, have found that I really like fresh tomatoes. Heirlooms, Early Girls, you name it - if it's fresh, chances are I'll love it. Peaches - HELLO! What have I been eating all my life? Certainly not this bite in and peach juice flowing out kind of fruit! Strawberries - could they be more fragrant? Beets - how are they so sweet? Could go on and on... if you can't get the "five servings" of fruits and vegetables a day, perhaps you too are suffering from chain supermarket's unripe, abnormally large but flavor-deprived produce syndrome. Get thee to a local farmer's market!

* picture of beautiful flower on the way back from the farmer's market... kind of looks like sea anemone :)

The Flavors of the VA

There are many types of VA patients, but they can roughly be broken down into two groups:

1) The nice, normal ones
2) Everyone not in #1.

Now, incidents with the #2's may get written about more, but fortunately, the number of people in #1 vastly outnumber the numbers in #2. Number ones are the ones that make your day, that make you love your job, that teach you about life and living, and inspire you to be a better physician and a better person. Usually there's not as many stories about them, but here are a recent few:

The patient who had a minor surgery procedure done and sent a long, handwritten thank you card. It was beautifully written, and is now attached to the "important stuff" board.

The patient who, after talking about a nonmedical topic the prior visit, brought a packet of printed material to the next visit so I could learn more about the topic.

The patient who is complicated and we have no idea what his diagnosis is, and he knows that we don't know and are trying to figure out, who, at a impromptu meeting down one of the hospital corridors, recognized me in "civilian" clothes and came over to give a hug.

And then there are the many that, after a visit or after a procedure, give a heartfelt thank you.

These are the people that make long days and tedious paperwork pass by. It makes a world of difference.

* Did you know that this is how pineapples grow? Picture taken in Hawai'i. If you're ever there, try the Dole plantation pineapple softserve. Touristy, I know, but SO delicious!

It's the Start of the Month Again...

It's amazing how much of a work day is devoted to mundane tasks that thankfully become second nature with time. Residents switch to a new rotation every 1st of the month, so that often involves learning a new hospital and a new system. Which mean the first few days of the month are difficult as you try to figure out tit from tat. As in, how to know where clinic is. Where you're supposed to be. Which clinic rooms are in use. What parts of the note to fill out. How to use the computer system. Where to find those pesky forms you need to fill out, after learning what forms you actually need. How to get a biopsy done. Who this Nancy person is whose supposed to be able to answer all these questions. Where to place charts that you're done with. How to work the dictation system. How to order labs. How to schedule follow-ups for patients. Sigh... I guess on the bright side, at least you don't need to figure out how to see patients...

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Did you see this? Some British guy, Rupert Sheldrake, claims that his research shows proof that "telephone telepathy" exists. He had 63 people for in a telephone experiment and 50 in an email experiment, where each trial participant gave four names and phone numbers of four contacts. These contacts were then asked to call the participant, who had to identify them before picking up the phone. Sheldrake presented this at the British Association for the Advancement of Science, stating that 45% of the time, participants were able to guess who it was, noting that this was higher than the expected 25%.

Hm. Sounds kind of fishy. I don't know why this Sheldrake is, or who the British Association for Advancement of Science is, and it'd probably be interesting to look it up. But it's been a long day, I'm tired, and there is still a pile of reading to be done. Why people are interested in telephone telepathy will have to wait for another day...

* Another beautiful rose on the way to work. Just the perfect thing to end a frustrating day...

Steve Irwin, R.I.P.

Steve Irwin, the Crocodile Hunter, has passed away. He was snorkeling in an area of Australia's Great Barrier Reef when he swam too close to a sting ray. The startled sting ray threw up it's tail spike and unfortunately caught Irwin in the chest. It's a horrible freak accident in many ways. While sting rays have a razor-sharp tail spine, they are not aggressive - given a choice, they would rather flee. Their tails are used reflexively when attacked or when stepped on. Unfortunately they tend to lie in shallow, sandy waters, and are often submerged with only eyes and/or tail visible. Given this scenario, usually humans are stung in the foot, after accidentally stepping on a ray, and stings cause pain and inflammation. Deaths are rare (17 deaths in the last 10 years) and occur because of severed arteries, or punctures of vital structures. The human chest, given the many ribs, is relatively well-designed to protect the heart and the lungs. However, the spike most likely entered from below the sternum up towards the heart to have caused death.

Irwin's death is a great loss to the world on many levels. He was a great TV personality, a champion for environmental/animal causes, and left behind a young family. His life and his death teach us to be careful, respect wildlife and nature, and live life to the fullest. Rest in peace.

The Circle of Life

I've been trying to wrap my head around the inevitable. One of my birds has a tumor.

In some ways, being in medicine makes you stronger - the first jaundiced, pancreatic cancer patient may take your breath away, and the first cachectic, dying patient may overwhelm with innumerable feelings, but eventually the feelings of ineptitude ebb to a level where one can function. After all, you learn what you can do for these patients and how you can make them comfortable. And most importantly, you can talk with them, and use the common language to help them through the difficult times. All things I cannot do with animals.

Finding the tumor on Ava's belly dredged up old feelings of inadequacy and helplessness. No matter how proficient at medicine I become, or how great my bedside manner, these are useless when I step outside the boundaries of the human race. In some ways, what is the use of more than 20 years of education and a lifetime in a healing profession if I don't have the slightest idea how to take care of my pets? And most heart-wrenching is to see suffering in a being smaller than the palm of a hand, knowing that they rely on you for nourishment and comfort, and knowing that you are not able to help.

I wonder at what goes through their minds as they experience discomfort and disease. I want to be able to tell her that things are as they should be, that disease and death are natural parts of the circle of life, and that they often bring us wisdom and acceptance. I want to be able to tell her that I love her very much, and that although I cannot change what may happen today, tomorrow, or in the future, I will always be here to take care of her basic needs. And I want to thank her, for shining light on the false sense of security that constantly creeps up and enshrouds our mortality, and for reminding us of the raw beauty and impermanence of this precious thing called life.

* Picture showing morning fog outside the log cabins in Yellowstone National Park. Reflects the current state of mind.

The War Against Fat

Here's another ding against trans fats:

A recent study published in the journal Archives of Neurology found that older adults with a diet high in saturated and trans fats and copper have a faster rate of cognitive decline.

Prior studies have shown increased risk for Alzheimer's and cognitive decline in individuals whose diets were high in saturated and trans fats. The idea for this current study came about from an accidental finding: rabbits on a high cholesterol diet who were fed water with trace amounts of copper had a faster decline in memory function than those drinking regular water. At autopsy, the rabbits on copper water had a substantial accumulation of amyloid beta plaques in their brains - plaques that are found in the brains of Alzheimer's patients.

This study look at this association in humans. More than 3000 people, 65 years and older, were included in the study. All study participants had cognitive testing and completed a food questionnaire that included questions about copper, zinc, and iron intake. Cognitive function was reassessed at three and six year follow-up interviews.

The results showed that in general, average cognitive abilities declined somewhat with age. However, within the "high bad fat" group, the 16% of people with the highest intake of saturated and trans fats, cognitive function declined faster in those with a higher copper intake - with up to a 143% increase in the rate of decline. But copper alone is not the problem - individuals with a high copper intake and a low consumption of saturated and trans fats did not show an increased rate of cognitive decline.

This type of study has inherent limitations due to the study type and design. Most importantly, it can only suggest an association between two things. But it does raise interesting hypotheses about possible environmental causes of Alzheimer's that may be further investigated with randomized, controlled trials.

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Update on "Don't Eat This Book" - Apparently during Super Size Me, Morgan Spurlock did an experiment to see how long McDonald's food would last before rotting. He took the Big Mac, Fillet O'Fish, a McD chicken burger, McD fries, regular burger and regular fries, placed each food item into a glass jar, and watched them decompose with time. The experiment was ended at 10 weeks because of the overwhelming stench of rotting burgers (and regular fries), but the McD french fries NEVER developed any mold or decomposed. They looked a little dehydrated, like cold leftover McD fries bought the day before. Disgusting!