Pebbles and evil

Disclaimer: This post is some kind of failed allegory for something but I’m not sure what.

Little does the little pebble have going for it. It is, by definition, an unsubstantial fragment of something that was once substantial but that is now just pebbles. Pebbles—if I may be so coarse as to discuss for a moment all pebbles at once as though the whole lot shared a lineage or an ancestor—are a geological diaspora with no hope of the nostos that drives diasporas. There will be no reunion with volcanic relatives in the mantle or whatever crusty oven whence they were baked.

A pebble is certainly no boulder, rock, or stone. It is not even a shard or nugget. It ought not deserve a place in the lithic family.

Now, the stupid pebble’s raison d’etre is to give the surf an audience and the stone skimmer a hobby as it makes little prayers for surface tension. I don’t know what it prays for. An abrasive life on the beach destined for even smaller pebblehood or a very similar life amid currents and crustaceans where pebblehood is rock bottom. Either way, pebblehood ends with sandhood after much wailing and gnashing of pebbles.

I don’t know if the pebble is endowed with a soul. Maybe some are. The good ones. Or, more likely, the bad ones. Because why would a good pebble have a soul? An evil pebble needs a soul because a soul can be punished. And pebblehood is, if you accept the forecoming conclusions, certainly enough punishment for any soul. Thus all pebbles are, quite likely, evil by nature. Well that’s surprising.

All is right and just in a world where evil meets with its punishment at no cost to the taxpayer.

42

There's often something else in the background. A weird platelet count, a low sodium level, a little anion gap--something that might be easier to ignore than to try to figure out how it fits into the clinical picture. I'm assuming that I'm going to at least notice these annoying details. That is, I'm already assuming that I'm vigilant.

Vigilance makes a doctor good. A good doctor will diagnose the pneumonia and treat it. Curiosity makes a good doctor better. A curious doctor will be driven to figure out why these other lab values are a little off because, it’s true that there could be all sorts of silly explanations for an out-of-range test result, yet the doctor's job is not only to figure out what's not wrong, but also--when the dust settles--what is.

Like any other job, medicine can become routine. The evidence that we have been accumulating on medical and surgical interventions has to some extent standardized our practice. Data have helped to define the 'standards of care' for investigation and management of many diseases. Some of these well-studied diseases for which there is more or less widespread agreement on management include heart attack, heart failure, diabetes, many infections, and certain kinds of trauma, to name a few. The purpose of evidence-based medicine however is not to make the job of the doctor easier nor is it to make sure everyone gets the same treatment just for equality's sake, but rather to apply particular medical decisions that have been shown, hopefully in high-quality experiments, to be effective. The medical community decides that interventions that improve outcomes should become standard because they're better.

The word that doctors use is not 'standard,' though. It's 'guideline.' This is not because doctors think that they're better than everyone else and that rules shouldn't apply to them. Rather it's to make room for judgment because it is impossible to study every intervention in every population of potential patients, and because even effective interventions are rarely effective for every eligible patient. We have therapies that may approach 100% efficacy (eg, penicillin for syphilis), but they are few and even they're not perfect. We think that preventing death in only 1 out of 42 people treated with a beta-blocker for two years after having a heart attack is pretty good. In addition, accepted algorithms for investigating disease will not include every possibility, so the doctor needs to have an index of suspicion for diagnoses that may not be on any algorithm.

So, is this science or art?

Everyone knows that doctors like to say that medicine is as much art as science. My own quibble with this has nothing to do with medicine (nor with art or science for that matter) but rather with the public's perception of these things. The word 'science' evokes--in most people I think--accurate, precise, and reproducible results. But science is nothing more than approximations and arbitrary constants, especially in the practical application of physics, chemistry, and biology. Engineers have to compromise and allow for some inaccuracy and imprecision in their end design ('tolerances') because they have to live in the real world where mathematics has to be a little looser than it is in the classroom.

At its heart, science is built on hypothesis-testing. Who comes up with hypotheses? People. Observant, curious, creative, artistic people. If hypotheses could be generated based on precise formulae then we could just build a science machine and let it figure out the secret to life, the universe, and everything for us. We know how that would turn out.

Science, like art, requires creativity (neither science nor art are sui generis things). I'm not going to pretend that I can define art, but maybe besides creativity it might include some element of perception by an observant person. At its simplest, then, art is a creative person's response to an observation synthesized into some form (canvas, performance, sculpture, music, prose, poetry, speech, hypothesis--whatever). Science is the same thing I think. Isaac Newton observes that an apple falls from a tree. It's fair to say that millions of people have seen this happen before him but he is curious--inspired--enough to design unique and creative experiments to calculate the rate at which it falls. He is finally able to synthesize his data and determine the gravitational constant (which is an estimate). Newton's laws are works of art. Da Vinci's sketches are science.

The doctor is a scientist, but the scientist is an artist and the artist is a curious human. The uncurious doctor is a mediocre one because he is just a human who is happy with what he knows and doesn’t care about what he doesn’t.

Screenplay: Providence's Wildebeest

This is an excerpt from a screenplay by the legendary Ingvar Stig Ogvsbrotkulniiskaa. This was his last work before his death in 1994 of lutefisk poisoning and also exposure. Notably, it is the first screenplay ever to require audience participation in the form of sound effects during the diabetic baby fight scene, which was nominated for a Golden Ice Pick at the Kirovsk Novelty Film Party in 1993. His works focused largely on the unknown and some of the known, though in some cases he also included the marginally familiar as well as some of the fairly obvious (though this was rare and indeed included merely as satire). In retrospect, there is a clear progression of political views in his works from pure ignorance to ignorant indifference to confused apathy that has made his film adaptations of newspaper articles compelling for so many disaffected youth as well as the illiterate.

Mr Ogvsbrotkulniiskaa was known for translating his works into many different languages himself, a remarkable talent in its own right especially since it is almost a certainty that he only spoke Finnish and a few words of Russian (enough, it has been rumored, to get him arrested by the MVD once in 1958 for public lakeside pessimism in Novgorod; he was later released following revocation of his ice fishing license and a promise never to return).

Now, I include the author's own English translation of the first scene of Providence's Wildebeest, a powerful condemnation of cowardice and theft and a loving collage of stunningly poignant dialogue. In this, the opening scene, we learn that knowledge is ignorance and age is meaningless in a world where years are frozen to the ceiling like icicles that may fall at any moment and hurt someone--or worse, cause an insurance flap.

INT. ROOM -- NIGHT

The room is dark. There is 1 window through which light from a street lamp comes. But even the light is dark. A man sits at a table. We see him from behind. The door opens behind us and a yellow rectangle briefly dances on the man's back around the silhouette of another man. The DOOR CLOSES.

MAN #1

(Staring out the window, motionless.)

I knew you'd come.

MAN #2

(Still out of view. He has a deep, aged voice.)

Quiet. You know nothing.

We see MAN #1 jump out of his chair and face MAN #2, and now we see that MAN #2 is dressed in a black three-piece suit and thin black tie set against an agonizingly starched white shirt. He is smoking an ivory pipe filled beyond the bowl-brim with rarefied yak hair.

MAN #1

(Wide-eyed, panting, savoring the smoke.)

Your yak hair is magnificent.

MAN #2

Indeed. Your sense of smell is profoundly uncanny. My yak hair is cut fresh morningly with a pair of cheap aluminium scissors. It was the way of the ancients.

MAN #1

(Starting to pace.)

You abuse your position sir. You know it and I know it.

MAN #2

(Slaps MAN #1 with a velvet undergarment from Belgrade.)

Silence. I've brought you here for more than your sassy insolence.

MAN #1

(Weeping.)

You promised me that which was undeliverable. I should have known!

MAN #2

You had the longing of a broken heart. Fool! Yes, you should've known that the banana-Nutella-banana crepe you desired was not attainable.

(He removes his spectacles and peers into MAN #1's nostrils.)

No man has the acumen to place Nutella between two layers of banana. No man would dare to even try. Cardinal Greigel von Nusselkopf-Schokolade himself was excommunicated for merely slicing a plantain near some cocoa not a half-century ago. That for which your loins pine is implausible.

MAN #1

(Removes an unconscious wildebeest from his pocket and now wears a look of horrified indifference on his gaunt face.)

You leave me no choice, old man.

MAN #2

Come to your senses child!

The streetlight flickers and the sun rises immediately. A glass of orange juice from the countryside appears on the table, which we now see is made of wax. We can also now see that MAN #1 is MAN #4, to whom we have not yet been introduced. We gasp.

MAN #1/MAN #4

You bastard!

MAN #2

(His handkerchief is ablaze and he savors the acrid smoke like a connoisseur.)

You have brandished your last wildebeest, ignorant roach!

MAN #2 waters his suit with the orange juice. A beautiful plant sprouts from his lapel and flowers before our eyes. It bears an ugly poisonous fruit which kills MAN #1 with a blow to the spine. The sun sets and the streetlight flickers on and we fade to black. MAN #2's VOICE can now be heard, menacing, old, and decrepit.

MAN #2

It was not hate that was this man's undoing, nor was it love. It was apathy. And a vicious genetically-modified apple with an unlicensed firearm.

END SCENE

When Yignaz Boroslovosibirskov directed this masterpiece in his film of the same title in 1993, it is said that he exhausted his body's supply of tears and resorted to a lacrimal gland transplant to regain his ability to weep (he has since died of complications of immunosuppressive therapy for graft rejection). The entire film was shot on location on the smooth side of an ancient mud-brick wall in Kamchatka in glorious black and grey for a grainy look that pummels the heart with relevance and gravitas. The writer of this note himself has only just recovered--after 15 years and 3 colonoscopies.

HMR, December 27, 2008

Helsinki

Quiet hour

Mr. Peterson has a pulmonary embolism--a clot in one of the blood vessels going from his heart to his lungs that threatens to keep his blood from picking up oxygen. It most likely came from somewhere lower down in his body, sliding up his vena cava and into the right side of his heart. While there isn't much that we can do about it now, we need to prevent the clot from getting bigger and new clots from getting started in the first place--he needs heparin. Because everyone responds a little differently to heparin, we have to make sure that his blood gets tested every few hours (around the clock) and adjust his dose until he is in the therapeutic range.

I am the 'night float' intern; I take care of patients like Mr. Peterson (which is, of course, not his real name) overnight while the three day teams get whatever sleep they can. It's quieter at night, and with only the occasional beeping of infusion pumps, telemetry monitors, and pulse oximeters all just out-of-sync, I'd even say it's soothing. So far I've been too terrified of something going wrong in the hospital to go to sleep, but I've become used to sleeping during the day. Not so for my patients.

I should say that I've never spent a solid amount of time in the hospital at night before this, my first month of internship. As such, I'd never really thought about how care continues through the night. I never considered that, when I ordered a test or a medication to be performed or administered 'q6h'--every six hours--patients would at some point have to be awakened from sleep during at least one of those instances. And, of course, worse for q4h orders, and so on. I just never thought about it.

Now, I am sitting in a call room and waiting for 4 am when I am to draw another tube of blood from Mr. Peterson. Just a few hours earlier overnight, I had woken him for the first tube and the result showed that I needed to increase his heparin infusion rate because his blood was still clotting too quickly, which I did. Now, I need to wake him for more blood and I know that if I don't, and his response to the increased heparin dose was not adequate, the complications could be disastrous. His clot could get bigger, or a new one could materialize and shoot up his veins through his heart and into another pulmonary artery. Pulmonary emboli can be fatal.

Often, with busy day teams trying to get through their mounds of work, little thought goes into how much sleep patients might need. I mentioned this in an off-hand comment to a colleague and he said, "Patients are always in bed and have nothing better to do than sleep!" But what about the quality of that sleep, interrupted as it is without fail for this blood pressure or that blood draw, sometimes barely an hour apart and not usually more than four or five? It's not surprising that patients--even the most positive and pleasant ones--quickly tire of being in the hospital. Insomnia and irritability go hand in hand.

Although many researchers have discussed the importance of sleep, including in critically ill patients, none have actually studied the effect of its deprivation on hospitalized patients and hospitals do a poor job of promoting good sleep hygiene. In the hospital where I work, a large academic medical center, there are signs posted at the nurses' stations telling staff and visitors that between 2 am and 3 am our patients are asleep and would appreciate quiet. Nurses, doctors, and phlebotomists walk into patients' rooms at all hours of the night for any number of reasons--urgernt or not--turn on the light, poke around, and sometimes forget to turn the light off or close the door when we leave. Alarms, chatter, and beeps puntuate the dark hum of the hospital at night, and they would certainly keep me awake. Sleep is clearly not a priority here, nor is it at any hospital where I've trained so far. How could it be? This is not a hotel; these people are sick and we are working tirelessly and at the expense of our own sleep hygiene to get them well again.

But sleep does matter. Several pre-clinical and clinical studies have shown us that deprivation of sleep, and particularly REM sleep (thought to be the most 'restful' phase of sleep, and the most fragile), affects all sorts of brain and body systems from memory and mood to the heart and general health. In one study, rats were shown to be more sensitive to pain the less REM sleep they got. In many other studies, shortened sleep cycles have been associated with obesity and diabetes--in humans. In a very recent Chinese study, also in humans, sleep deprivation increased inflammation and blood clotting--both involved in stroke and heart disease. And pulmonary embolism.

So what is the right thing to do? In Mr. Peterson's case the decision is simple: I'm going to wake him up. His life is on the line. But what about Ms. Simmons in room 436 who's getting routine (that is, not urgent) lab tests at 5 am--the time designated for AM blood draws throughout the hospital--despite having been kept awake until after midnight in our busy ER awaiting admission to the ward? No one really stops to think about how little sleep this poor sick woman has had last night and how important it might be to her recovery here. We have far too much else on our minds.

Anyway, it's time to go wake someone up. This time I have the luxury of not agonizing over the decision. It's not always this easy.

Favorite words

#3. Diphthong. Diphthong. Diphthong.

A word so ballsy it doesn't even come close to demonstrating its own meaning despite a surplus of idle letters.

I make a point of creating social situations in which 'diphthong' is not only a propos, but rather expected. Yes, I'm very talented.

Come on. You see it and you just want to say it aloud. It makes you want to twist your mouth into trying new maneuvers. Do you pronounce the 'ph' or just the 'p'? Say it both ways. Say it ten different ways. If you're using this word, I'm sure you have the time.

L'homme de 70 kg est mort !

I am the exemplar. I am the specimen in your anatomy atlas, the most deeply understood datum in your pathology textbook, the model to whom the parameters of pharmacology apply the most accurately. I am the standard-issue chassis: medically, humanly--decidedly--average. I am the 70-kg male.

Yet an exhausting week weaving up and down midtown Manhattan clearly leaves me thinking that the 70-kg male is dead--at least economically--in the estimation of clothiers and cobblers. Especially this 70-kg male, searching for a simple white shirt with a french cuff that does not make me look like I'm wearing my daddy's nightshirt for walkies. Or for a light jacket, or a pair of trousers, or even a pair of shoes that actually measure what they portend to measure.

As usual, several things are bothering me at the moment and if you know me, then you know that I wouldn't have it any other way.

The fattest common denominator.

It seems that clothing manufacturers and their retail henchmen are complicit in this plot to systematically disrobe those no longer falling within the nation's ballooning average. Put another way, they are seeking to surreptitiously recreate 'average' in their own bloated overgrown image.

This runs deep. Oh I'll feed you, children. Gargle this mindful of truth-flavored listerine:

The people eat. The people get fat. The people try to buy clothes but oh! now they've moved up a couple of sizes and they feel bad, guilt-stricken by their doctors and ridiculed by bufoons in fat suits. Meanwhile, they are herded into Big & Tall and have to start dressing like Cedric the Entertainer. No, you're not going to like the way you look, I guarantee it.

Oh but here's the hat-trick.

The clothing giants, hand-in-dirty-hand with the food conglomerates, agree to slowly increase the real sizes of their clothes while maintaining their labeled sizes. In essence a medium is now the size of what was previously large and a small is now what used to be medium. And the little guy gets shut out. We, the old mediums, are now sifting through piles of small and extra-small and shopping at Petite Sophisticate which is very gay because the stretch-pants-and-skirt look is not unisex.

Système International d'Unités? Bah and harumph.

It doesn't stop there. Not content with the outerwear and the casual vestments of the commonfolk (sized as they are in an appropriately common and course scale: s, m, l, xl, xxl, xxxl, 4xl, 5xl, and two-seat-minimum), the sartorial serpents are infusing their venom into our all-important standard units.

How else could it be that, despite being a very clear 9.5 on the Brannock device (pictured here), I must purchase Johnston and Murphy's in a size 8.5? Or Kenneth Cole's and Aston Grey's in a size 8? So what if I wasn't going to buy them anyway? I should be able to try on a pair of $350 shoes at the store with confidence as I gather the necessary capital over the next few years.

Why is there so much variability in 30x30 trousers? Some fit perfectly, yet many hang from my frame like wet underpants.

Why is it that the neck of this 70-kg male--an exquisitely empiric 14.5 inches--happens to be the smallest size in production anywhere? Still, there is not a 14.5 shirt that will fit me adequately enough to look presentable. When I am told by the helpful salesman at Thomas Pink that I'd be hard pressed to find 'a man's shirt' in my size without having it tailored, and that--if pressed for time--I should shop in the boys' department, I feel so very small. And little boys don't wear shirts with French cuffs, sir. Cufflinks are a choking hazard.

From the ashes, a gaunt phoenix arises!

I know that I am not the smallest man on Fifth Avenue. I know there are people in the Village who share my travails, who've felt the diminution of standing next to the mother of a prepubescent scamp trying not to cringe at the horrible things t-shirts have stamped on them these days. I've seen these men: skinny, lanky men, wispy even. It is as though our money is stained yet we have no voice.

Brothers!

We must speak as one. Join me now to fight the tyrany of these coddlers of the corpulent, these pamperers of the portly, these indulgers of the inhumanly big! They subserviently change their tallies for the tall and the tubby, and yet they spurn the business of the slim and the slight! We say they can't have it both ways! We say we can no longer be the average when it suits science, while being the extra-small when it suits suits. We can no longer abide the slights of this...this obesity-industrial complex! React! Rebel! Revolt!

Or we could just go for coffee. Either way we can meet for sandwiches at Ben's Deli on 38th and 7th but I can't be out too late (my wife, she worries). Or bring a sack lunch why don't you, we might eat outside if it's nice. And a beverage maybe? Whatever.

The dojo of the master putter of the foot in the mouth

There is an art to making an arse of oneself. I have practiced the ephemeral wushu of the social nitwit, studied the polished crudeness of the transcendent imbecile, and perfected a flawless mimicry of the natural idiot. I constantly challenge myself by dusting the most tranquil social landscapes with my lovingly crafted organic awkwardness. Just a spoonful of sugar may help the medicine go down, but it totally ruins caviar.

I paint my world with an angel's lock brush dipped in smooth golden weirdness.

I make my awkwardness myself in my distillery from the rarest, purest, and sweetest of character flaws. The craft is delicate and arduous, requiring patience and an apetite for one's own foot.

First, I gently warm twenty gallons of misunderstanding in a cherrywood cask. I then crush four pounds of self-esteem and drop that into the cask and stir gently and regularly over a fortnight with a four-hundred year old oak ladle inscribed with the words 'Cave quid dicis, quando, et cui. Quod non cotidie.'

Then, delicately, I add juice of stutter root, a fine distilled licqeur of ignoring better judgement, and granulated introversion.

By this time, the preparation has become thick but clumpy. I scoop out any precipitating self-awareness and inhibition with a gold sieve and feed it to my cat, Minerva.

Then, I bottle the sweet nectar and sprinkle liberally in the center of groups of three to four people seconds before redirecting my foot's Qi through my mouth with the grace and purpose of a master capoeirista. O berimbau na roda de Capoeira!

'What's that you say? Really? You know who else I heard is going? Elizabeth!'

'But I'm Elizabeth.'

'Oh. Then I don't believe we've met. I'm an arse.'

And you may address me as maestro chef sensei Haatem-san.