OVERHEARD LINES; or, Attention: DCFS

3 year old: Grandma, can we play with matches again?

Grandma: Sure.

On Learning Another Lesson, or, To Every Thing There Is A Season

"I've got one for you."

The most ominous words that you hear as an intern are actually just that benign. Not because of the words themselves, but because of what comes next. And this time it came rapid fire.

"Mr. RM* is an 83 year old man who became unresponsive at home several hours prior to presentation, and he vomited three times. He's got a history of seizures, has a sodium of 128, a potassium of 5.7 but his troponins and CK and MB are negative. His chest film was pretty normal, and his brain scan was negative. We're checking his tegretol level, and admitting him for all of these problems, and also for the ones we haven't figured out yet. Don't really know why he isn't responsive." **

This all came out in one breath. Like an M-16 on full-automatic. I had stuck my head out of my foxhole by answering the phone with my usual, "Hello, this is Bryce." And I had been hit.

Needless to say, two weeks into my actual internship, I was feeling overwhelmed. As in, Polish-cavalry-facing-Nazi-Panzer-divisions overwhelmed.

Unfortunately, that was pretty much exactly what happened. But let's not get ahead of ourselves.

I went down to the Emergency Department, and turning to the electronic record, I did the “chart biopsy,” where I looked up what I could on this patient. He has a history of seizures, well controlled on tegretol. He was in the hospital most of last month after a stroke, and while there he also had ischemic colitis. Ischemic colitis means not enough blood flows to feed the intestines, so a portion of them die. He also had two pituitary surgeries in years past for a slowly growing benign growth. These surgeries can often affect the brain itself. He has high blood pressure, high cholesterol, low thyroid, and a funny heart rhythm. Walking into the little patient bay in the emergency department, I see he is also still not responsive.

His wife is sitting by the bedside. She confirms most of the history, adding a detail there, creating holes elsewhere, and usually not being able to confirm or deny my questions.

"Why is he on fludrocortisone? How long has he been taking that medication?"

"Has anyone ever told your husband to be careful about how much water he drinks?"

She has no idea about these, but she is able to tell me that she thinks her husband would want to be a “full code” where we try everything we can to save him in the event of his heart stopping. I dutifully note that down on his admission papers.

Continuing through my admission interview, I am nearing the end when the attending suddenly appears at my side, deus ex machina. I update him on what I had gleaned, he asks a couple questions, and then we excuse ourselves to talk about the plan. What did I think? Was this a seizure? Was it a new stroke that the CT did not pick up? Since we can't get an MRI because of his hip, what should be our next step?

"Well, it's straightforward, you see," said the young and smart and dashing young attending, quickly. "You need to figure out if this was a seizure or a stroke or his heart, or maybe it could be his lungs. So, here's what you do. Order an EEG tonight, get a neurology consult for the morning, and with no MRI available (because of his fake hip), recheck a CT of his brain in 24 hours. Keep checking his cardiac enzymes and EKG's for signs of myocardial infarction, and watch him overnight on the heart monitor. It very well may be his lungs, since he could have gotten some of that vomit down the wrong tube. So just check his chest film again in the morning. There is going to be a blossoming pneumonia there. Dollars to donuts, Bryce, there'll be a pneumonia. But he might have a big clot in his lungs, and since we can't get a CT scan for that because of his kidneys, we'll check his legs for clots, since that's where those would have come from, and then we can get a V/Q scan sometime tonight. OK? So I'm going to take off now, but why don't you go get him tucked in tonight and write these orders. I'll see you in the morning."

And just like that, my deus ex machina went right back to wherever it was he had come from. I do not know where backstage is at the hospital, but I am desperately trying to find it. I was left there, center stage, to walk this patient upstairs. Once we were on the medical floor I noticed that Mr. RM seemed to be breathing pretty heavily. Thinking on my own, I asked the respiratory therapist to come down and get a blood gas, and to get ready to start him on BiPAP while I kept working on his admission paperwork.

His new nurse, on the other hand, was more concerned. "He looks pretty sick,” she said. “Don't you think he needs to go to the ICU?"

“No. He was just seen by the attending a few minutes ago. He said the patient should come up here. Let’s get the gas and BiPap him.”

(I should interject here that my training situation is likely different than any you may have heard of elsewhere. It is nothing like TV, and it is almost certainly not like your hospital. At my residency, there is no team with intern, senior resident, and fellow in a hierarchy before reaching the attending. There is the intern. Then there is the attending. I do not have a senior resident that I report to before either of us discuss the case with the attending. Any patient you admit on call is yours and yours alone. You call whichever attending normally sees that patient as an outpatient (or the hospitalist on the case) to staff the patient each day. There are no table rounds. There are no herd rounds. Again, it is just you, sitting alone on your horse, holding your shiny-new-MD-diploma-of-a-sabre, staring across the battlefield as diseases launch their Blitzkrieg).

As I continued working on his orders, the respiratory therapist came and told me she could not get the blood gas. Poking my head in the room, I reassess the breathing. The patient now seems to be having Cheyne-Stokes respirations, where they breathe quickly for a period and then slow down, almost stopping, then start breathing quickly again. I tell her to go ahead and start the BiPAP now and then get the gas. I do not, however, return to my paperwork.

Watching the patient makes me more and more nervous. After waiting only two minutes for the respiratory therapist to grab the BiPAP machine, I begin thinking the nurse was right all along.

“How do I get a tube in a patient on the floor?” I ask.

“That has to be a doc-to-doc. Call one of the intensivists.”

“Well, why don’t we do that. Would you call one for me?”

A few minutes later I am on the phone with Dr. H, updating her on the situation with this patient. She would be happy to come down and help me out.

And that was when everything started to fall apart.

Since I am new to this process, I do not try and intubate myself. Shortly after Dr. H intubates, however, she asks me if we should call a code blue. Feeling for a pulse, we discover the patient had entered the realm of pulseless electrical activity, where the monitor looks fine but the heart is either not beating or only beating so poorly no blood is actually being pumped. We roll the patient up, put a backboard under him, and I start to give chest compressions.

It is difficult to describe, but when you feel an octagenarian’s ribcage crumple like a box of Kleenex under your hands as you start CPR, you can almost feel your own chest collapse. At least that is how you feel when you’re the admitting intern. As people continued to pile into the room, responding to the code, I feel myself stop thinking. Brain dazed, I keep thinking that the attending just saw him, not 30 minutes ago. What did I do? How did I let this patient get to this point?

I have been in codes before this. I have given CPR. I have seen patients die. I have been there after codes for those discussions with family afterwards. I have pronounced patients dead before who had died in front of families. This time, however, was different. Very different. This was my patient. I could not escape the feeling of horror as I watched, almost in third person, as we struggled to save his life.

After fifteen minutes, I walked down the hallway to talk with the wife, who was sitting with the social worker in a consultation room. Her face mirrored the emotions I felt surging within me: confusion, horror, and fear. I found myself having a discussion I barely understood.

“Mrs. RM, I’m sorry to have to come and discuss this with you. We are not sure why, but your husband’s heart is not beating effectively, and as you are aware, he was not breathing well by himself. Right now we are breathing for him and keeping him alive with chest compressions. We are still trying to figure out the different reasons why his heart is doing this. I know this is difficult, and we talked about this already downstairs, but should we keep doing this? Do you think your husband would want us to be giving him these chest compressions?”

As she said yes, I could see the fear and horror crowding her eyes. After walking down the hallway to his room, we kept going. Fifteen minutes later, I walked the reverse course, back to the consultation room.

“We are still looking for a reason, but the treatments we’ve tried have not been successful yet. We will keep trying.”

After another quarter of an hour, however, we had exhausted all of our ideas. We had checked the labs we could, given the drugs that might have helped. There was nothing left to do. Despite everything we had tried since he got to the hospital, some things had not changed. Mr. RM was still unresponsive. But now it was much worse. And much more permanent.

While the code team dispersed, a few people staying to help clean up the body, I slowly made the walk back towards the wife’s room. While I have had classes that covered how to deliver bad news, I have never felt as unprepared as I did at that moment.

“Mrs. RM, as we talked about, your husband’s condition was very serious. We have tried everything we could, but the other doctors and I agree, there was nothing more we could do. I’m very sorry to tell you that your husband has passed away.”

And just like that, I realized I was in way, way over my head.

*(actually not really his real initials, because even though I've worked with HIPAA rules my entire career, I have no idea what they really mean).

**I’ve taken the liberty of rearranging the order of this ED doc’s presentation, because he practically gives it backwards. Literally the last thing he told me was the patient’s age. I knew about his negative CT before I knew he was unresponsive.

Allow me to offer one additional thought, which I don’t mean to sound pretentious. I am not trying to pretend here that physician's have the hardest/best/most anything job on the planet, so please don't take that from this thought. Everyone I talk to about my training gasps about the hours. “You’re working 80-90 hours a week? That’s horrible.” Well, nearly everyone. The old-guard physicians think we're pansies for not spending 120 hours in the hospital a week like they did. Regardless, the hours can be tough, for sure. 30 hours straight of being awake is difficult. There is a very good reason no one stays awake all night after they graduate from high school – because it’s not actually any fun. But the hours are not what makes residency difficult. A 30 hour shift is actually pretty manageable. What makes residency hard, such a challenge, so draining, is the weight. The weight that comes with the decisions you make is what makes this different. It’s not about putting in hours. It’s not about “surviving” three to seven years of residency so that you can live the good-life of an attending, golfing to your heart's content. Residency is about a lot of things, sure. Learning how to remove an inflamed appendix or how to best manage diabetes are important, sure. But so far I think it is more about learning to deal with the weight. And I’m not sure that weight will ever go away. Because Mr. RM isn’t ever coming back. And that has some weight.

(As an aside to those of you close to me. I know this sounds depressing. It was. It happened in August. I’m doing alright.)

Quote of the time-period

Voltaire:

Le mieux est l'ennemi du bien,

or,

The perfect is the enemy of the good.

Evidently this is my 100th post. Woohoo me. Now, to pat myself on the back (since having a blog about myself isn't enough self-adulation), I'm just going to post something I wrote a year ago.

My brother-in-law is applying for residency, and I had the chance to help with his personal statement. This reminded me of the misery of applying and writing my own personal statement. Here it is. And half the reason I'm posting this is because I have the next chapter of the statement almost finished, the one where I learn the next lesson mentioned below. And that lesson was not fun or happy. Anyway, here is me in 569 words.

Toy Cars, Hospital Hallways, and Modern Medicine

BKP

Before entering my assigned ward on the first day of clerkships, I paused, intimidated. Thick fire doors guard each entrance to the hospital hallway. The walls are scuffed and marred, the tile on the floors dull, and the smell of disinfectant hangs pungent in the air. A cacophony of beeping alarms, loud pages, shouts and sobs crash through the silence. But despite the noise and the chemicals and the drabness of this hall, I have found warmth and caring and human commitment.

BM, a 3 year old boy, besides providing a chuckle over his unfortunate initials, formed a cornerstone that much of my pediatric education has been built upon. He initially presented with a history of decreased oral intake, decreased energy, and a unilateral swollen tonsil. The emergency department performed a CT of the neck which demonstrated a likely phlegmon developing. He, along with his twenty or so toy cars, came to our floor and received several days of antibiotics for the suspected retropharyngeal abscess. He taught me a lot about that disease while in that hospital hallway. Except he never did have the typical fever. After failing to improve to the antibiotics, he was taken to the OR. While under the knife the infection suddenly morphed into something worse; something far more sinister. That was when BM stopped being the kid with the infected throat and became BM the kid with Burkitt's lymphoma. He left our service, and all of his cars went with him.

A week later I left the Infectious Disease floor to go to the Hematology/Oncology wing. Who else was there but Mr. Toy Cars himself? I quickly snatched him up as my patient. Even though he was now a cancer patient, we still played with the same cars while he received his chemo, and he taught me about induction therapy. He left, only to return to our hallway a week later having developed a fever. Since his immune system was so weakened due to the poison that had been pouring in through his central line, this "simple cold" was now a medical emergency. BM was providing me another lesson, this time while deathly ill. Thankfully, he improved to be able to play cars again, and avoided teaching me a final lesson, one that I hope to delay learning as long as possible. And until I learn that last lesson, and hopefully afterwards, too, there will be plenty of cars to play with.

Because of these (and other) experiences, hospital hallways no longer remind me of a noisy warehouse. I walk these corridors with a new perspective, and I now know that more than just my passion for medical science drives me to be a part of this bustle. Real people, with genuine, human needs are found here - people who touch me at least as much as I touch them. They walk through different hallways at times, requiring different levels of medical care, but they carry the same toys, the same human needs whatever the hallway they are currently in. Presently, I walk these halls as a medical student, providing the care I am currently able. Someday soon I will walk the hallway as a physician. And I look forward to providing the same care and compassion that I have seen provided so far, with the special opportunity as a family physician to help guide my patients through the different hallways they will need during their medical care.

The Guiness Book of World Records, or, Welcome to Utah

Two words. Actually only one, if you consider this particular phrase as a single compound word. Two words is all it took for a certain Labor & Deliver nurse to decide I needed to go on a date with someone she knew. Two words. Those two words acted as introduction, point, counter-point, and conclusion to her. I, on the other hand, still do not know this particular nurse's name; come to think of it, I am not sure she knows mine. Those details were not part of the conversation. A conversation went like this:

Bryce, walking down the hallway, discussing with fellow intern the intricacies of the housing market: I know, unbelievable, right?

Fellow Intern: Ridiculous. I can't belie-

L&D nurse, to other nurses in hallway: I can find out.
L&D nurse, interrupting Fellow Intern: How old are you?

Bryce, uncertainly: Twenty-nine.

L&D nurse: I have someone I want to set you up with.

And, scene.

I'm still a little confused myself.

On Shaving Legs

I would like to take this opportunity to discuss some issues about cyclists. First, they are extremely sensitive about their name – cyclist – as opposed to biker. This likely stems from the latter’s preference for leather instead of lycra. Which brings up another issue: spandex. Cyclists wear this for several reasons, such as aerodynamics, reduction of that annoying flapping while doing some awesome descent, and also the opportunity to show off the physique attained while doing some hideous climbing. Which brings up another, larger point. One that almost everyone asks a male setting out on a cycling trip. The shaven leg. Below is a brief discussion of the pros and cons of shaving the lower extremity, which we discussed on our short trip from Buckeye to Phoenix, before our presentation to the University of Arizona Medical School about global health. Fourth year medical education at its finest, right here. But enough about medicine; back to the legs.


Reasons Cyclists Shave Their Legs

1. Road rash – this is allegedly the real reason people shave their legs when cycling. The shaven leg is much easier to debride, or scrub gravel out of forcefully with a stiff plastic brush, than the hairy leg. Thankfully we have not had a crash resulting in road rash yet, but Katie Kidwell did have an excellent dismount from her bike at a stop light that day in Phoenix. She didn't even remove her feet from her bike as she lighted on the ground - all those years of gymnastics paid off!

2. Improved aerodynamics – lets be honest, this is pure B.S. The cyclist may feel they are faster without leg hair, but there is no way that cyclists, especially at our level, will have a gain in performance due to a lack of hair; if anything, you may miss the feel of wind in the leg hair making you aware of your pace, and paradoxically feel slower due to the newly naked skin.

3. Solidarity – this is a very important reason. Several of the male riders had already shaved their legs for aesthetic or other reasons, and the shaven ranks swelled by a few in the first few days, as Tim Mitchell joined in with his razor. The sense of brotherhood and team is an important part of why people shave their legs for cycling.

4. All the girls were doing it – past tense. The less said about this the better.

5. Sunblock – since we are riding for several hours each day, sunblock is an important part of your morning ritual, unless your name is Maggie Rosen. Leg hair, especially thick leg hair, can greatly complicate and lengthen this maneuver. A shaven leg is much easier to apply sunblock to than a hairy one.

6. Insect Rights – believe it or not, every day after a ride I have to dig at least three bugs out of my leg hair. This is somehow more disgusting to me than the bugs swallowed while riding or the bugs that you wipe off your face. Without leg hair, the bug would slide right over the leg, continuing to live. At least until it met an unshaven leg. Or a windshield.

7. The calves – you know you want to see them. A shaven leg just puts them on display that much better.


Reasons Cyclists Should Not Shave Legs

1. Time – from a base state of hairiness, it takes about 45 minutes to shave a leg. One. Singular. This is a serious time commitment.

2. Razorburn. Ouch.

3. Folliculitis/ingrown hairs -> necrotizing fasciitis -> sepsis/amputations -> death. No one wants to be a case report.

4. Razorburn. Hurts even worse the second day.

5. Sunburn - according to Travis Grace, M.D* hair acts as a natural sunblock: “I mean, your scalp doesn’t burn unless you shave your head.” Sounds scientific to me.

6. Awkwardness – the positioning required to shave, say, the popliteal space behind your knee or the back of the thigh properly requires a PhD in yoga. And may make you feel like you need to have a confession.

7. The itching – it does not stop.




What, then, is the reasonable cyclist to do, given these facts? The answer seems clear enough to me. Shave one leg, and let the other go.





*pending satisfactory completion of the Ride For World Health

My Life Recently, or, The Ride For World Health

As some of you may already know, I am currently riding my bicycle across the country with a group called Ride For World Health. We are a group of mostly medical students who are riding our bicycles across the country to try and raise money and awareness for some global health issues. And I have been lax in my reporting thus far; we have completed about 55% of our ride now. I’ll try to briefly catch you all up to date on our adventures. Imagine some Doogie Howser, M.D.ish music playing as I’ll try to sum up the one or two items I learned that day of the ride.

3/27 - Do you know how long it takes to drive from Columbus to San Diego? I do. And it might be reducible to 36 hours, but it is a very, very, very long time. (Columbus, OH to San Diego, CA)

4/1 - 56 miles the first day, with 6600 feet of climbing thrown in for fun. Not my idea of fun, and I don’t think most peoples, either, but allegedly a person exists somewhere who finds that fun. (San Diego to Lake Morena, CA)

4/2 - Riding down a 6% grade could be fun – heck, it should be fun. But it is not when on I-8. (Lake Morena to El Centro, CA).

4/3 - Even if you fastidiously apply sunscreen twice a day over all of your skin, your lips will still sunburn. And blister. Also, flocks of red-winged blackbirds outside dairy farms create memories that last lifetimes. (El Centro, CA to Yuma, AZ). Oh, and those neat stateline “Welcome to Our State” are actually really difficult to find.

4/4 – Riding in groups is fun. (Yuma to Dateland AZ).

our pace line in the AZ desert

4/5 – The Ohio State University is going to take over the world. The town was named by proud alums back in the day – true story! (Dateland to Buckeye, AZ)

4/6 – Short, fun ride that led into our first Global Health Day. (Buckeye to Phoenix)

4/7- And if you ride to DQ after a long ride, you will hit your first “century” ride, where you cover more than 100 miles on your bike in one day. (Phoenix to Picacho Peak State Park, AZ).

Me after my first century ride.

Picacho Peak is pretty awesome

4/8 - Waking up early to hike a peak makes even a short 43 mile ride pretty long. Especially when there is a stiff headwind. Still worth it, though. (Picacho Peak to Tucson, AZ)

4/9 – Having a day off, even if it starts out with ornery custodians, is glorious. (Tucson AZ)

4/10 – New rootbeers in the middle of the day make any day better! (Tucson to Wilcox AZ)

Captain Eli's Rootbeer - really good, fully flavored and fairly sweet - 8/10

4/11 – Lordsburg is a horrible, horrible place. Also, I have a very different scale as to what is spicy, according to one Katie Kidwell. (Tucson to Lordsburg, NM)

4/12 – It’s a good thing there are signs to mark where the continental divide lies out in the desert. (Lordsburg to Deming, NM)

The continental divide

4/13 – I really love small-town America. (Deming to Las Cruces, NM)

4/14 - The whole group rode together for much of the day. And I finally found a state border sign! (Las Cruces, NM to El Paso,TX)

4/15 –White Sands National Monument is the prettiest bombing range I have ever seen in my life. (El Paso, TX)

4/16 – 4/21 – If you wake up 15 minutes before your flight leaves to Cancun, you can get there earlier than scheduled. I'll have a different post about this some other time. Maybe. (Cancun, Mexico for AMSSM conference

4/22 – Did you know Methodist churches have roller skating rinks in them? And bowling alleys?(Abilene, TX to Ranger, TX)

4/23 –The first 50 miles of this 107 mile day were some of the most beautiful I’ve ever seen. We had a nice wind, and the Texas wildflower bloom is really something everyone should see sometime in their life. (Ranger to Ft Worth TX)

4/24 – Ft Worth is a really fun town when spent with 20 of your friends.

4/25 – Horrible headwinds for the first thirty miles are totally redeemed by tailwinds for the next fifty, when you can average 30mph and end it with a dip in a private lake. (Ft Worth to Greenville, TX)

4/26 – The church ladies in Greenville and Paris are amazing. Really amazing. (Greenville to Paris, TX)

Some people struggle with directions

That's it for now. I'll try to be better in the future with reporting on the ride. It has been a really, really ridiculous amount of fun. I doubt I will ever have a better trip in my life, honestly, but it has also been a ton of work.

Also, if you want to follow some more faithful chroniclers of the ride, here are some of my friends' blogs:

The official blog is written by a different rider each day: http://www.rideforworldhealth.org/blog/

Tim Mitchell - tmr4wh.blogspot.com

Maggie Rosen - Maggier4wh.blogspot.com

Libby Huffman - http://libbyr4wh.blogspot.com/

Justin Harper - http://www.justinsride.blogspot.com/

Chris D'Ardenne - http://buttbutter.wordpress.com/

Adam Koon - http://adamshead.tumblr.com/

Andy Nyberg - Cdrifter.wordpress.com

Soo Last Week, or, I Matched!

I was on the news. Or my class was on the news. You might not know, but we're kind of a big deal.

http://www.abc6onyourside.com/shared/newsroom/top_stories/videos/wsyx_vid_3171.shtml

I wish I could embed the video on that page, but I'm not that savvy. The main reason is that I would like to ask one question: who in the world writes for these TV newscasters? They should all be fired. I mean, take the opening line of that story: "It's called medicine's own March Madness." Really? Who calls it that? Not only is that not factual, it's not even catchy.

In other news, I'm headed *gasp* back to Utah. I will spend the next three years as a Family Medicine resident at McKay-Dee hospital in Ogden, though I do plan to live in the SLC.

In other, other news, I leave to start my bike ride in less than 36 hours. Not that I'm stressed. Wish me luck.

My Boring Life, or, For Google's Eyes Only

I recently presented this paper at a History of Medicine conference in KY. I enjoyed writing the paper. Sort of. I enjoyed the conference. Sort of. It made me very glad I am not a Ph.D historian, because, while I enjoyed talking with them, I asked one what his emphasis was on. "Empathy," was his reply. Anything related to that word, which was only first introduced in the 20th century, believe it or not.

That is my way of saying that you, my average reader, will probably not enjoy this post whatsoever. I'd be delighted if you prove me wrong, but this is something of an esoteric, dry paper on medical philosophy.

So, only because Google is good about indexing everything, and this doesn't stand a chance of being published elsewhere, I thought I would post this article so someone, somewhere, sometime, might read this and get a little help on his or her research paper. Just remember that I didn't talk about Ibn al-Nafis in my introduction of Harvey. If you are doing a more exhaustive work on Harvey himself, you should read about him as he did present a logical discussion of the heart and continuous circulation in the 13th C and Harvey may or may not have read al-Nafis's writings. But the history of Harvey wasn't really the point of my paper.

The <> markings are where the slide was advanced.

William Harvey, “The Book of Nature,” and Modern Medical Thought

Bryce K. Peterson

Wm Harvey, Baldness & Ulcers

<>

Briefly, my talk will have an introduction, then we’ll talk about the history preceding Harvey, then Harvey himself, then we will talk about two other medical discoveries.

Introduction

<> This is a picture of Frog Basin in Northern Idaho, one of the more beautiful places on Earth. If you were to hike over this ridge, you would be met, not by a view of the ocean, the city, or any other prize signifying the end of the journey. Instead, you would be met, <> with a new view of more beauty, but one that differs in the details. New vistas can emerge as we are raised by the vision of those who have gone before. Giant’s shoulders are required to stand upon to climb to new heights. <>Einstein required Newton; Martin Luther King, Jr. needed Gandhi. As thorough readings of history reveal, few ideas are completely original, or outstandingly revolutionary. So it was with the introduction by William Harvey in the 17th century of the circulation of the blood. Built upon a long, solid history of medicine, and on the backs of others mining for new knowledge <>, Harvey was then able to unearth the stone, which, according to the Kenneth Franklin edition of De motu cordis, is “the most important work in the history of medicine” (Franklin, flap).

<> Occasionally, however, these new discoveries lead to conclusions that are not correct, such as with the 17th C advent of telescopes leading to the 19th C (erroneous) discovery of canals on Mars, quite the engineering feat of the intelligent Martians; similar such blunders have occurred in medicine, whether in topics as superficial as baldness or as serious as peptic ulcer disease. While the work of men and women in times past is essential for forward progress, healthy skepticism must remain for new discoveries.

While striking the balance between acceptance and skepticism when approaching new scientific findings can clearly be difficult, it is of vital importance in our approach to not only the patient, but the world. Although this is a topic being approached from a historical perspective, this talk is not intended to be a rigorous historical treatment; it is, rather, meant to be a thought piece that provokes conversation about the consideration a clinician must use when examining new information from any source, as well as remembering the human filter through which that information flows, affecting our own view of ideas, both old and new.

Ancient Medicine

<> To better understand the view that William Harvey had of medicine and the world, it is important to first briefly recall the historical context in which Harvey lived. <> As an obvious medical phenomenon the blood itself was given attention by the earliest ancestors of medical scientists. Many theories were given, but predominant in the Middle Ages was the view of Galen from the 2nd century A.D. I might recall to you that these theories relied on the Platonic ideas of physiology, where pneuma (air) was modified by different organs for the various requirements within the body. <> The liver combined air with digested food and produced the ingredients for growth and nutrition to be distributed by the venous system, while the heart utilized the arterial system to distribute heat as along with pneuma to envivify the body. The brain produced the necessities required for sensation and movement, distributed throughout the body by the nerves. <> Relying upon ingenious experimentation, Galen rejected the ancient idea that arteries contained only gaseous material. Instead, Galen held that upon diastole the arteries drew air in through pores on the skin, mixing it with blood drawn in from the veins. After being used in the body, the spent air or “sooty vapor” was then passed through the septum of the heart into the left ventricle, carried to the lungs, to be there expunged. (Magner, 90-93). Galen’s remained the principal theories for the next 13 centuries, and gained such respect that they were revered as nearly Holy Writ.

Harvey’s Predecessors

<>The Medical Renaissance of the 15th Century brought “admiration for all things Greek” (Porter,Greatest, 169). The original Greek texts were sought, clean of Arabic or Latin interpretation. 1525 brought a Galenic codex published in Greek, paving the way, along with other Greek works, for physicians and researchers of the modern natural philosophy to question the conflicts between these two.

One such critic came in the mid 16th Century; Vesalius, trained by a conservative Galenic advocate, studied anatomy and dissection. “Vesalius grew . . . critical. {His} Familiarity with human anatomy drove him to the unsettling conclusion that Galen had dissected only animals . . . no substitute for human [cadavers]. He now began to challenge the master [Galen] on points of detail” (Porter, Greatest, 179). Vesalius, in Book VI of Fabrica, explicitly denies the permeability of the heart’s septum to allow for the transfer of the sooty vapors as described in the Galenic model, thus clearly weakening the Galenic model of physiology. This work was continued by Vesalius’s successor, Realdo Colombo, in a similar fashion.

<> Colombo, a respected surgeon, took Vesalius’ post as Professor of Anatomy and Surgery at the University of Padua. He continued in the work of Vesalius in presenting questions regarding the Galenic models, but he made a very large, and very public, break with Vesalius, until their relationship became quite tainted. By pointing out Vesalius’ shortcomings, Colombo sought to bolster his own reputation. Colombo’s major work, published in 1559 was an anatomical text wherein he argued against the Galenic idea of blood and pneuma mixing in the right ventricle, his reasoning based on a logical analysis of the size of the components, namely the lungs, right ventricle, and the pulmonary artery. Instead, he presented what we now recognize as the pulmonary circulation, where the blood flows from the right side of the heart, through the pulmonary artery into the lungs and through the pulmonary vein into the left side of the heart (Magner, 190; Porter, Illustrated, 158).

<>Hieronymus Fabricius, Harvey’s mentor at the University of Padua, also made notable progress in anatomy, notably in embryology and the discovery of venous valves, which he published in 1603. He assumed that the valves’ physiological function was to retard the flow of blood so that distribution would be symmetric throughout the body, thus regulating volume instead of direction. (Porter, Greatest, 192-193).

Wm. Harvey

<> This milieu of ideas was present as William Harvey was receiving his education and training. Starting his training in medicine at Gonville & Caius College, Cambridge, Harvey received an Aristotelian education, considered quite archaic and outdated by the rest of the contemporary medical community (French, 51). He then left Cambridge for Padua, “the natural choice for an able and ambitious medical student. A Paduan degree was recognised . . .[as] it was the most famous medical school in Europe” (French, 59-60). Thus, from his Cambridge education steeped in natural philosophy and his cutting-edge medical training in Padua, Harvey was a hybrid from two different worlds. Whitteridge quotes Ent’s early translation of Harvey, where Harvey notes that his world view was clearly framed by the work of those giant’s whose shoulders he was climbing onto:

“. . . know I tread but the steps of other men who have lighted me the way, and (so farre as is fit) I make use of their notions. But in chief, of all the Ancients, I follow Aristotle; and of the later Writers, Hieronymus Fabricius ab Aquapendente, Him as my General, and this as my Guide.”

<> One of the steps that “lighted the way” for Harvey, according to Robert Boyle, was the discovery of the venous valves by his predecessor. This acted as a spark that turned him towards the search for an acceptable physiological answer to a picture murky with ancient ideas (Whitteridge,Movement, 27). He wrote:

“I do not profess either to learn or to teach anatomy from books or from the maxims of philosophers but from dissections and from the fabric of nature” (38).

As the above mentioned discoveries were presented in the medical world, Harvey, true to this statement, evidently repeated the experiments himself, using the “body” as his educator and authority, rather than relying on books written elsewhere. Though Harvey found the same experimental results with the venous valves, he came to very different conclusions. Harvey argued against the explanation of venous valves acting to prevent pooling of blood in the legs and feet, pointing out that the jugular veins’ valves are oriented in the opposite way. Harvey began to reason that the purpose might not be to “retard flow” but to create a unidirectional flow. Later experimentation was to prove his ideas correct (30).

I might recall to you that Harvey’s experimental research that led to the introduction of his theory of general circulation in 1618 was extensive and spanned nearly twenty years. <> He realized, by a logical argument he presents in chapter 9 of De motu cordis, that the heart pumps, by his conservative calculations, three and a half pounds of blood in one half of an hour, while the whole body only contains, upon inspection, four pounds (Franklin, 62). Many other experiments were conducted. <> Harvey proved the unidirectional nature of the venous valves with his famous ligature experiments by manually pushing the blood out of the vein and demonstrating that it could not be forced past a venous valve in a direction distal to the heart. <> He beautifully detailed these findings. <> He surmised a connection between the arterial and venous systems by noting a pulse remained and the veins grew when a tourniquet was placed upon an arm. By turning to “the Book of Nature” and performing his many vivisections and dissections, inspecting anatomy and noting the movement of the heart and blood vessels, Harvey came to conclusions which contradicted the Galenic model. Harvey was then able to utilize the rich array of ideas and observations that had been provided, <> offering up his own theory of general circulation which he published as De Motu Cordis, the writing served the “same purpose as modern scientific article[s]” where the world is informed of new findings and invited to test the theory (Movement, 13). His formal treatise arranges the argument into an exhaustive description of his observed data, presentation of the hypothesis in chapter eight, followed by proof by demonstration, logical arguments, and arguments e consequentia (predictions) and a posteriori (explanations of previous findings) (39).

<> However, though Harvey did present the idea of the general circulation of the blood, it is important to note that the current modern model differs in many key points from that put forward by Harvey in the 17th Century. The physiology behind Harvey’s model is quite similar to that of Aristotle: the distribution of heat throughout the body. The purpose of the heart, while including that of the actual movement of the blood throughout the body, was principally to envivify the blood, bestowing it with some essential quality which it would distribute to the tissues. In the extremities the blood would “coagulate,” and cool, requiring a return to the heart to repeat the cycle. The cause of the heart’s beat was mystical, as well, ultimately springing from the soul. (The modern model, of course, is one of distributing nutrients and other essentials to the tissues of the body and removing the wastes of the processes of life, with a chemo-electric cycle causing the beating of the heart). Harvey’s early education at Caius College is important to remember; Aristotle’s ideas were embedded deep within Harvey, and he held with the idea of the spiritual driving force within the heart and blood being the essential component of the blood and the point for its circulation, with the idea of the blood moving, “as it were, in a circle” featuring prominently as well. Hence, although Harvey put forward the modern idea of continuous circulation, it is also important to note the mystical, Aristotelian physiology he associated with it.

<> What effects did Harvey’s research have upon the world of medicine? His own practice was to suffer, as patients were frightened of new ideas then as well; but of the bigger picture the view becomes murky. Harvey’s scientific approach smacks of the new scientific method that was soon to become a driving force, but in Harvey’s case the roots are more ancient Aristotlean and Galenic in origin than a foreshadowing of “new science.” There were plenty of reactionary writings, both opponents and proponents, so we can certainly say Harvey’s work stirred scientific discussion. <> Ultimately, however, the influence of Harvey was in the attack upon Galenic physiology, not in his contribution to medical knowledge of cardiology (Conrad et. al, 338-9).

Modern Medicine’s Myopia

<> Harvey’s proposal of continuous circulation of the blood forms a fine example of scientific progress; he used the findings of those before him, examined them and, discarding those he found unworthy, kept only those he found accurate. Occasionally, the opposite can happen, and an article from the Journal of the American Medical Association in 1903 is illustrative of this point. <> Allow me to briefly digress in my introduction of this topic to discuss two interesting words. First, phalacrophiba – somewhat irrational as it is, <> the word describes the fear (known primarily by men in their twenties) of becoming bald. The second word, peladophobia, seems to describe a more logical fear,<> as it describes the fear of bald people themselves. Returning to the 1903 JAMA article entitled “Prophylaxis of baldness,” the introduction follows: <>

“If anyone had insisted 25 years ago that tuberculosis was only slightly hereditary, but distinctly communicable, they would have been laughed at. The germ theory has now become a doctrine of ever-widening scope, and we realize that many affections are directly communicable and only a few hereditary. At the present moment it seems that even for so old-fashioned an affection as baldness a complete change of opinion as regards etiology is taking place. As with tuberculosis, so it has long been noted that baldness is likely to run in families.”

<> The author goes on to cite findings that premature baldness is “practically always associated with the presence of certain bacteria” and then suggests a causative relationship, further hypothesizing that “undoubtedly the ordinary conditions of scalp hygiene among men are favorable to the development of these germs” and that the relative ischemia caused by hatbands may play a role as well, possibly by decreasing the ability to combat the microbes mentioned above.

<> As an exemplary clinician, the author’s principal concern appears to be for his patients. He counsels:

“Greater care should be taken with regard to brushes and combs, especially in families in which early baldness is the rule. The hair brush should be dipped in an antiseptic solution several times a week. Combs should be boiled regularly and frequently, and under no circumstances should members of precociously bald families use other combs or brushes than their own, or allow them to be used on them, in barber shops, unless they are assured of their sterilization beforehand. These precautions may seem a high price to pay for the prophylaxis of premature baldness, and many will prefer to take the chance of becoming bald, but some have such a horror of the affliction that they will willingly put themselves to much trouble to prevent it.”

While we are able to now, with the support of more than 100 years of scientific progress, find this line of reasoning and counsel humorous, it does offer an important point. New findings are being interpreted by people living in a world steeped with ideas, opinions, and “facts.” This is why progress must be met with skepticism. Not all of the “facts” are actually factual; certainly not all that is written is true. Personal observation of, as Harvey put it, “The Book of Nature,” should not so easily be replaced by new discoveries.

To turn to a more modern (and more medical) example, the history behind the approach to peptic ulcers is illuminating. <> First described by William Brinton in 1857, the lesion was accurately detailed along with its accompanying symptoms of pain, vomiting, and occasionally hemorrhage. Brinton’s conjectures as to etiology were quite varied and had an impressive scope, including “old age, privation fatigue mental anxiety, and intemperance” (Grob, 551). <> As time passed the consensus became an excess of acid as the primary factor, but this merely displaced the search for a cause to what was causing the acidification. Grob notes that “the absence of evidence that could relate causes to disease processes did not prove a deterrent. Physicians instead drew upon prevailing medical paradigms and external social and ideological belief systems to develop what appeared to be defensible etiological explanations” (Grob, 557). Such explanations included focal infection, leading to many extractions, appendectomies, colectomies and colostomies, although this explanation fell out of favor in the 1930s as no causative organism could be isolated; <> stress and psychic factors also featured prominently, with “shell shock” and the increasing demands of the industrialized world pointed to as evidence; racial factors were also considered, as one physician noted a relative dearth of ulcer disease in the African-American population, writing that it was due to the “slow-moving” and “easy-going [nature] . . . untouched by aspiration for culture.” (560)

Of course, our current understanding of peptic ulcer disease is not perfect; while the etiology is now attributed to infection with H. pylori or NSAID use, only a fraction of patients with these risk factors develop symptoms. <> Grob, however, points out that “medical explanations and therapies . . . do not always follow from rational scientific discovery, and conflicts between medical specialties, prevailing medical and scientific paradigms, ideological beliefs, and personal allegiances affect the manner in which diseases are interpreted and treated. . . To point this out is not in any way to denigrate biomedical science . . . it is merely to remind practitioners that it would be wise to recognize the contingent nature of etiological explanations and therapies.” (564). Although we strive to live a higher law, we must remember that physicians and scientists are, after all, human as well and subject to all of the interpretation flaws that history has shown us. By recognizing these flaws, we can be watchful for them and thus be able to provide better care for our patients.

Conclusion

<> With the benefit of three hundred years of scientific progress, the significance of Harvey’s discovery could be either exaggerated or minimized. His courage in tackling the Galenic fortress, though it had been softened by those before him, was immense; critics, on the other hand, could cite his inability to dispense with the mystical ideas of Aristotle as his downfall. Regardless, Harvey has influenced medicine by breaking the foundation of Galenic physiology as noted in his writing, “I do not profess to learn or to teach anatomy from books or from the maxims of philosophers butfrom dissections and from the fabric of nature.” As long as we, as clinicians, can also remember to interpret new ideas with a sense of transference and counter-transference towards the new research, we can look at Harvey’s great contribution as providing yet another, greater height whose new vista will beckon to the generations to come as they go forth on their own quests for truth.

Bibliography

Conrad, Lawrence, Michael Neve, Vivian Nutton, et. al. The Western Medical Tradition. Cambridge, England, Cambridge University Press, 1995.

French, Roger. William Harvey's Natural Philosophy. Cambridge, England, Cambridge University Press, 1994.

Grob, Gerald. The Rise of peptic ulcer, 1900-1950. Perspectives in Biology And Medicine2003;46(4):550-66.

Harvey, William, Gweneth Whitteridge, ed., De Motv Locali Animalivm. Cambridge, England, Cambridge University Press, 1959.

Harvey, William, Gweneth Whitteridge, ed., The Movement of the Heart & Blood. Blackwell Scientific Publications, Oxford, England, 1976.

Harvey, William, Kenneth Franklin, ed. The Circulation of the Blood and Other Writings. J.M. Dent & Sons, Ltd., London, England, 1979.

JAMA 1903;40:249 as quoted in JAMA 2003;289(4):494

Magner, Lois. A History of Medicine. New York City, New York, Marcel Dekker, Inc., 1992.

Porter, Roy. Cambridge Illustrated History of Medicine. Cambridge University Press, Cambridge, England, 2001.

Porter, Roy. The Greatest Benefit of Mankind. Harper Collins Publishers, Ltd., NYC, USA, 1997.

Whitteridge, Gweneth. William Harvey and the Circulation of the Blood. MacDonald, London, England, 1971.

On Honesty and Dating, or, This Mormon Life

My friend Chris had the idea to try and create a Mormon analogue for the amazing radioshow, This American Life. To that end, he created a group blog that explores a single topic each week. The topic is dealt with by a variety of individuals, all of whom hopefully approach it in a different and creative way. Last month was a discussion of honesty and dating, particularly in the Mormon sphere. While the discussion takes place with that narrow scope, I think most of the principles are applicable whatever your personal creed. Anyway, since I haven't posted anything substantial for some time, here is my bit from last month. If you do have comments, which I would love to hear, I would ask that you please post them over at the website where the original article was posted. I think you might enjoy the blog.

On Honesty & Love in Dating

David Sedaris has a lot of stories about hitch-hiking. He said it started out as an easy way to get to the other side of town, then became a cheap way to get to the next city, and then became a way to enjoy the thrill of being able to recreate himself. With every new driver he got the chance to fashion a new identity, an opportunity to become someone more interesting; someone more exciting; someone more, well, new.

One of the places that it is easiest to become someone new is, of course, the internet. Take, for example, the first girl I ever chatted with over a modem. Back in the days of BBS’s and direct computer-to-computer connections, we met and chatted about various things. Eventually she sent me a picture of herself, really without prompting.

While everyone on the internet is obviously not a liar or sexual predator, it does become very easy to misrepresent yourself and be dishonest. I was recently at a coffee shop with my friend Linezolid.¹ She, along with about fifteen other friends, has been telling me I should look into the world of online dating. The implications of this on my personal life are best saved for another day. This did, however, lead to a very interesting conversation about dating. She told me of an older man she came across on one of these sites. His profile was different because, well, it candidly disclosed the fact that he had a sexually transmitted infection. One of the permanent kinds. I did not ask if it was as serious as HIV or as (relatively) benign as genital warts, but that is really beside the point. What was interesting was that he was so candid, so up-front and open about it. Almost in-your-face about it. While his staunch rejection of the easy opportunity to be dishonest is laudable, was this stark honesty the right approach? Sooner or later, the woman he ends up in a relationship with will find out, anyway. Hopefully from him, and not from her physician. If the disease was going to be a deal-breaker in itself, we figured he was probably just trying to weed those people out early. Really early. Before even meeting.

But what if it was not going to be a deal breaker? How many people would this early disclosure, this preemptive strike, drive away too early? How many that, after knowing him better (or at all) would have otherwise still accepted him, warts and all?² After all, none of us are perfect. Such blunt honesty is not only awkward, it is almost dishonest in itself. Are there others on this online dating site whose profiles include “anger issues” or “horrible with directions?” “Compulsively late” or “commitment issues?” Before knowing someones shining points, how can you really judge their weakest ones? If there is such a thing as too much honesty, I think this is it.

But isn’t that basically the point of dating? I mean, dating seems like some sort of complicated dance where we slowly reveal portions of ourselves to each other as we become more and more intimate. And I do not mean intimate in a necessarily sexual way, but rather the real intimacy. The intimacy only reached by sharing time together, talking, learning each others’ secrets, and holding those secrets close. Becoming aware of how the other person thinks, feels, and lives – that is intimacy. In that way, I believe that Internet-Guy-With-An-STD was on the right track, but jumped the gun. He was trying to be completely honest, but a bit too soon. At least of this sort. While he has probably had good reason to do so, likely by being hurt in the past because of late disclosure, he is skipping steps in the dating process, revealing too much, too quickly. And those steps are there for a reason. Maybe presenting your best face, which some may call lying, is not only appropriate but often necessary in dating. Dating etiquette requires phased honesty.

In unrelated conversations with a few other friends, the issue of honesty and dating was repeatedly brought up with specific regards to faithfulness within Mormonism. As many of you know, there are, in fact, varying degrees of Mormons within our community. There are Iron-Rods and Liahonas, there are the EQPs and FEQPs.³ There are Peter Priesthoods, Molly Mormons, and Jack Mormons. There are True Blue Mormons and Cafeteria Mormons.⁴ It is with some of these last type, friends who are quiet (and active) cafeteria Mormons, that this idea of honesty and dating has come up frequently. And the conversation usually gets pretty heavy, pretty quickly. I mean, what would you say if someone asked you, “Do I need to tell her that I don’t believe in revelation?” or, “How early should I tell my boyfriend/girlfriend that I can’t support the Church’s policy on Proposition 8 [or the stance on the role of women, or whatever]?” or “I may go to church every Sunday, but I don’t believe in God the same way everyone there does. When should I tell him that?” Is there a right answer to those types of questions? I didn’t think so either.

Another friend, Ember¹ thought these dilemmas of faith (or lack of faith) an absolutely essential subject for discussion, at least as relating to relationships and Mormonism. Bishops, home teachers, or anyone else besides a boyfriend/girlfriend, are another matter. To her it was simply a matter of timing, not an option of whether or not to have the discussion at all. How early, though,one should “drop the bomb” was a little less clear. Should this timing relate to kissing? To dating exclusively? To discussion of marriage? The conclusion was that you should tell them as soon as you (or the significant other) starts to think seriously about the relationship.⁵

It seems, to me at least, that uber-bluntness is not quite the right approach. But neither is persistent deceit, whether by creating a new persona or hiding your true one. I think they both fail in relationships because they prevent that intimacy, that closeness, from forming. David Sedaris has a lot of stories about hitch-hiking. He said many of the stories involve lying through his teeth. He said that the feel of the cold gunmetal against his head felt exactly like he thought it would. He said that after the second time he had a gun pulled on him, he gave up hitch-hiking all together. Maybe he should have just tried being more honest while hitching. Then maybe he wouldn’t have had people lying to him, too. He might have even found someone who would drive him around for eternity.

1. Name changed to protect identity or somesuch.
2. Sorry. Horrible, I know. I couldn’t resist.
3. Elders’ Quorum Presidents and Future EQPs.
4. A cafeteria Mormon is one who chooses which teachings to believe, a la carte style. Not my term.
5. In Ohio terms, I believe this is also known as “the first date.”

Way cooler than the Fonz

Seriously, is there a band cooler than OK Go!? I'm not necessarily talking about their music. I'm willing to bet everyone has seen some of their music videos (which they direct, by the way), and many have read the NYTimes OpEd piece by them about the music industry, but their latest video is really amazing. I was laughing and smiling through almost the whole thing - I felt like Charley getting his first glimpse of the Chocolate Factory.

For those of you who have missed their older ones, here are a couple. I haven't really watched the remixes of the WTF video - anyone have favorites?

OK Go - This Too Shall Pass from OK Go on Vimeo.

Becoming Part of History, or, Pastings from my Journal

2/3/2010 – Wednesday

Yesterday was a very packed day. We glanced through the local brochures – there was lots that looked fun around Plettenburg Bay, South Africa. Ziplines around a river with a bunch of waterfalls; a bungee jump from a bridge over 200m high (world's highest bungee base); a private game reserve just outside of town; ocean kayaking near dolphins; a large nature and marine reserve on a peninsula just down the beach. So much to do, so little time!

We planned out the day to do the furthest activity first, then work our way back towards Plettenberg. So we drove out first to the Tsitsikamma Adventure Tours, which is in Tsitsikamma National Park and we did the zip-lines around this river, near some waterfalls. It was pretty fun – especially since our two tour guides – Heinrich and Henry – were pretty funny. Henry had all of the English phrases down, and kept repeating things like “brother from another mother” during our tour. The river we kept crossing was a dark, cola-brown color. Evidently this is from the tanins seeping out of the trees into the water. Safe to drink, according to our guides. Just unsettling to look at, and will give you stomach cancer and tan leather, I suppose, at least that is what LGRichards told me. Then we saw a two-tailed lizard Just your average day, so far.

Our next stop was the Bloukrans River Bridge, where this bungee jump is located. Guiness Book of World Records Certified. Maybe not as memorable from 5th grade as those fat twin brothers on their motorcycles, but still in the book. We spent a little while looking at the bridge and watching some of the jumpers. I knew I wanted to do it, as I knew I'd never have this chance again and have never been bungee jumping. Chris wanted no part of it whatsoever, but was content to watch and take pictures. Although it was about $90, I thought it worth it. So they got me in a harness and then walked out to the bridge. I started getting more and more nervous as I saw how high the bridge actually is, likely accentuated by the fact that the walkway we used to get out to the middle of the bridge was bolted to the side of the roadbridge. It had a metal-mesh flooring that not only allowed one to see the horrible height that was growing under us, but was also only spot-welded to the metal frame, and had an uncomfortable give to each step. I was quickly becoming more and more nervous.

Arriving at the middle of the bridge, they had house-music blaring, and several other jumpers were having their harnesses removed and gave me some of the strangest looks – pity mingled with awe and fear in equal parts. The crew started wrapping my legs up, and claimed to attach a bungee rope in two ways to my feet, but both caribeaners attached to the same spot, and I could not see the connection between the stuff wrapped around my feet and the harness. My anxiety continued to grow as they stood me up.

Hopping with the aid of the staff to the edge, they kept hold of me until my toes were just over the edge. Looking down was a mistake, but a mistake that I had just paid $90 to make. Counting down from five, the crew did not give me a chance to back out. So I bent my legs and jumped out, away from the bridge and towards - nothing. For the next ten seconds, the only thought in my mind was, “This was the worst decision I've ever made in my life.” It was a very long ten seconds.

Then came the rush of blood to the head. It wasn't anywhere close to a neat experience, like Coldplay may have led you to believe. As I felt my head nearly explode from either the worst valsalva maneuver I've ever performed while upside-down or the change in inertia at the bottom of the rope, I had another clear thought that reconfirmed what a geek I am. I didn't think, “Whoa, what a rush,” or, “Awesome!” No, I thought, “Well, I guess I don't have a berry aneurysm because I'm sure this would've popped that sucker.”

I continued to bounce up and down 4 or 5 more times. Those ones were just fun. No lame thoughts or fear at that point. Just the fun experience and an incredible rush of adrenaline. Once I got back up to the bridge I remember feeling a little really jittery from the adrenaline. I also had a clear thought at this point. “I'm going to enjoy having done this a lot more in the future.”

It's the future, now. I'm not sure if I was right or not yet.

Chris is a Flight Genius, or, On Saving 69 cents.

For those of you who didn't know, I'm in Africa. And I'm pissed, because Toto has had me so excited for years about the Africa. There haven't been any rains here. What a waste of a trip. Anyway, I'll try to post some updates of what we've actually done while here, but the only time I've had to actually write was while on the plane over here a week ago. And without further ado:

Far and away this has been the most difficult trip I've ever been on. It started out with my roommate not having a single item in his suitcase 15 minutes before we had planned to leave for the airport. Well, I suppose it really started for him when it took me 10 minutes to buy my plane ticket, and since I'd just bought a ticket it increased the price for his flight – which he was not able to change after more than an hour on the phone. (The fare came back down later that day). At the airport, it continued with the plane taking us to DC having a mechanical failure. After waiting in the long line, we spoke with the gate agent who rebooked us. Now we were to be routed through London and would not arrive until more than 12 hours after planned in Cape Town. At this point I was fairly content to sit and read my novel, but Chris whipped out his trusty iTouch and, exploring options on Travelocity.com, found what he thought to be a superior option. The gate agent told him that particular flight was not available. Chris, however, was not to be so easily deterred. After finding another flight, through Chicago and Amsterdam, he thought it worth another shot – but I had to go bug the agent this time. Knowing I had to spend the next 6 weeks in pretty close quarters with Chris, I thought it best to humor him, though I had little hope.

To my chagrin, it worked. Chris approached the counter, looked at me and said, “I am a flight genius.” I was forced to agree. If the whole psychiatry gig doesn't work out, he should totally just work expedia.com for people. The connections worked, and we were booked for Amsterdam to get to Capetown at about our original destination. This was great, because the hostel we'd arranged for that night (from the airport – late, admittedly, but still) had required a 10% deposit. It came to USD 1.38. Split between us, that is 69 cents each.

While we did have to see the gate agent in Chicago because Chris didn't get all the right papers from the Columbus agent, we had a nice little flight to Amsterdam. Our connection time was short, and so we quickly printed out our boarding passes for the Cape Town flight from a self-serve kiosk. Since I'm a good person, and karma is real, mine printed without a hitch. Chris's, on the other hand, said that he had to see a gate agent. You can draw your own karmic conclusions. Now we had a new problem, though. Finding an agent. It took us at least 10 minutes to find where the gate agents were. Probably because they were not at the gate, like you might expect. There wasn't even an agent in the same terminal. Turns out that since they wear such nice periwinkle uniforms, they like to cluster the gate agents together. Gives them more of an effect, I suppose.

After watching the agent work on a computer with two different phones glued to her ears for at least 15 minutes, it became clear we were not going to make our flight. Since we don't have phones or any real plans in S. Africa yet, we elected to stay together and started discussing what two things we could do in our 24 hour layover in Amsterdam. (Incidentally, do vacation rules apply in Amsterdam? Or do their lack of rules negate the traveling rule of acceptable rule-breaking?) After our original boarding time had passed, the agent suddenly printed out two boarding passes and said, “Run to your gate.” Obedient young men that we are, we double-timed it across two terminals only to be asked by the security guard, “Why are you so late? Everyone is waiting for you two!”

Not everyone appreciates what a flight genius Chris is, evidently.

Folgers and the Sacrament Cup Redux, or, What I Did Last Saturday, or, Omphaloskepsis

Last Saturday was our ward talent show. This is what I did. You may remember it from here.

Depressing Realization of the Time Period, or, Why I Hate William Harvey

Some people dream of awesome things, like flying or interacting with beautiful people. Some dream about crazy things, like teeth falling out. Some dream about high-school puppy love but wake-up screaming curses (my sister is awesome).

Not me. I'm old and boring.

I dreamed last night about preparing my presentation and powerpoint slides for a conference six weeks away. The dream was detailed - I remember typing out the bullets. In an outline format. I even remember what those bullet points were.

My life is average.

Best TV Intros of the Time Period, or, I Have Too Much Time On My Hands

First impressions and introductions are funny things. We judge people by them, and ignore later contrary evidence. Of course, this isn't just with people. We judge albums by their cover-art. I remember not buying the first book in a series for several years because the cover was too dorky looking. It later turned out to be my favorite book saga to date.

TV is no different really. Some shows have awesome intros, some have crappy ones. Think of that happy, care-free tune during the intro to The Office. You can hear it now, and if you’re like me, you are starting to laugh a little. I think I have been classically conditioned to expect funniness is coming when I hear that ditty. (We won’t speak of the past season or two).

Other intros channel awe, or wonder. Think of the LOST intro. That ethereal sound as the word spins across the screen combined with the narrow depth of field giving a blurry focus to it and the lack of anything else just seems to add to the questions surrounding the show.

Or there’s this intro, for Dexter, a show about your everyday-average-likeable-serial-killer-next-door. Somehow this just hits the spot between creepy and relatable.

My personal favorite introduction comes from a show that I actually do not enjoy all that much anymore, Rescue Me. But the music, the lighting, and the speed just work so well that it becomes, well, incredible.

However, the award for Best TV Show Intro has got to go to David Lynch’s Twin Peaks. The beautiful pastoral scene with its accompanying relaxing and melodious music makes one think of a hypnotist at work, and forms a stark contrast to the insanity of the show’s characters.

Of course, I have neglected many other great TV intros. What are some of your favorites?