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

Zen diagnosis

So I've been watching episodes of Namaste Yoga on FitTV and trying to play along when my body will allow me to place parts of it where they don't really need to be. It's true, though, that you can only achieve a deep union of spirits when you can surrender your mind and scratch your left ear with your right big toe from behind. It's fun too. Once you loosen up the joints with some strategic dislocations, the ligaments can start to work with you, not against you. That is zen.

As I was reflecting, and because I'm a dork, names of diseases started to force their way into my meditative center to ripple my heart chakra. It was annoying but kind of funny (if you're also a dork). Here's an even nine of them.

• Metaphysical acidosis
• Transcendental thrombocytopenic purposefulness
• Adult Inspirational Distress Syndrome
• Nirvana gonorrhea
• Reflectory anemia
• Spiritual Liberation monocytogenes
• Osteomyelenlightenment
• Haikuphilus influenzen
• Lymphadenopath-to-wisdom

Sorry. That was stupid. Anyway, namaste.

Goethe and the proverbial substance

In its finality, the cul-de-sac of knowledge impresses those who've been disappointed by education as the mode and mark of social evolution. It is where, in order to learn more (that is, to drive through the proverbial living room of the proverbial house at the end of the cul-de-sac and out into the backyard and through the proverbial fence and into the darkness beyond, perhaps into a ditch or ravine of some sort where we might meet an early but satisfying proverbial death), we must peer over our shoulders at what we learned before we turned into the cul-de-sac o'proverbs after we bought 'cigarettes' at the proverbial corner store when the (proverbial) man said something kind of profound but not so much really because he was selling cigarettes at a corner store and of course every once in a while he'll say something that's not completely bereft of substance as he exhales. That sort of thing makes me feel warm inside.

That reminds me of the time when Goethe and I were camping in a totally appropriate male-bonding sort of way, making 'smores and conversation and dispensing wisdom and recyclables (and recyclable wisdom) across arcades of sparks and embers. He was sugar-high and said something like--and I am translating his medieval German--'Yo Cauliflower, monkey library Simon as scallops handbanana cheek absolute yellowcake* sportyshine leaf-faucet National Public Radio fork.' I'm paraphrasing; my medieval German isn't as superbly excellent as my English.

My memory does fail me at times, but this time I am fairly certain that what G-Tonez was trying to tell me was that we must reflect upon our past if we are to avoid living hand to mouth. To me this just sounds like an elitist assault on the decent hard-working hunter-gatherers in society, especially the ones who have amnesia. But even though he probably meant collective and mostly scientific memory--the (proverbial) shoulders upon which we stand before we can advance as a species--social memory is no exception, I think.

The problem is that memory does fail, and social memory is no exception. One might say that, because of the sheer noise involved in the laying down of memories on a social scale, it is impossible to nuance them with those subtle (and essential) features that temper the imagination and tame the reflexes. Indeed some social memories occupy such an inflamed corner in our collective mind that even accessing those memories tends to lead to wildly impulsive, base, even animal responses. Case in point: September 11, 2001. Despite it not being the first nor the worst event of its kind, our self-proclaimed keepers of the social memory (journalists, politicians) have wrapped us so tightly and rigidly in the inflamed axons of its memory that to move one way or another, to reach into our pockets for nuance, becomes impossible at least as part of the mainstream discourse.

Whenever I use words such as 'mainstream' and 'discourse' I know that I've gone too far and need to shut up.

* I would like to stay off the no-fly list, please, because I have places to go from time to time.

Sometimes a phallus is just a phallus

Psychiatry is a field that makes sense in the sense that if you have any sense (in the sense that you are sensible) you will find it difficult to make any sense of it. My feeling is that there is a nearly invisible boundary between effectively mapping out the currents deep in the id and prancing about at the shallow end of the ego, unless you can't swim.

Where do you look for meaning in relationships with people? Can a label that one uses to define a relationship be simply a preemptive defense of that relationship? I mean, saying 'we're married' is clear and in any case more an apology to one's tamed and beaten demons than anything else. But what about relationships that can be approached in an accusatory way? So-called platonic relationships, for example. If you have to specifically preface a friendship with 'platonic,' then is it really platonic? Psychoanalysts make phallic balloon animals out of unsuspecting platonists. True, sometimes an apple is just an apple, but that's so uninteresting. (Even a granny smith is mildly tantalizing at best, compared to a shiny green boob with a stem that grows on trees and tastes so sourly delicious.)

Enough psychobabble. I like the stuff and appreciate it, but I'm not creative enough to whip up a la carte syllogisms around a patient and still be composed enough to fill out the invoice with a straight face. Another feature of the inpatient psychiatric experience that has struck me is the staggering degree of impairment with which some psychotic patients have to live. I don't know what I would do without reality. Well, reality is reality, and what we experience is what we experience, and it is nothing if it does not depend on the sartrean cogito's automatic comprehension of existence--the human-reality at once creating and created by the juxtaposition of l'etre and le neant.

Saying that kind of crap without smoking a cigarette just looks and sounds stupid and I have the most delicate pink little lungs. Whether or not experience and reality are the same shouldn't make any difference to us, social interactions notwithstanding. If this is a blue ball, but I see a pair of orange galloshes, it's still my experience and its accuracy is irrelevant even though I am laughed at by my peers for stumbling around in the rain trying to balance myself on a blue ball like a clowning sad kierkegaardian lunatic full of anguish and pneumonia. So I suppose reality is not as important to me as I thought. Who's to say that I experience reality anyway except me? You can say I'm crazy but then I can say I know you are but what am I times infinity times infinity plus one squared to the power of you're stupid! In fact, I renounce reality. A bas la realite!

Alright enough of that nonsense.

Paranoia, on the other hand, is truly debilitating. Voices, hallucinations, the government melting your ice cream on purpose via satellite. So maybe reality is a good thing after all. But if my brain were forced to choose between a reality that really bites on the one hand and a Statler and Waldorf commentary trained with deadly aim on my inadequacies on the other, maybe I'd take the two grumpy old beans rather than the haldol. Of course, if I'm up in the balcony with them and they're telling me to jump off in that endearingly funny gruff heckling tone of theirs, I hope I'd reconsider or call for Dr. Bunsen's help. Yes I know he's a PhD, but who else am I going to call, the green frog? That's crazy.

Speaking of haldol, my tic has been out of control over the past few days and my neck, shoulder, and wrist are quite sore. Antipsychotics are good for mental psychosis as well as somatic psychosis but oh so bad for your liver.

Paradoxically, however, this is a sentence for which the word 'paradoxically' was completely unnecessary. But what discussion of psychiatry--no matter how half-baked--is complete without 'paradoxically'? In my next post, my judgement may improve but I will always lack insight.