Love is a many-splendid thing

"I never realised that the best things in life are hidden in the most mundane things."

"Love is a feeling you can’t hide. You don’t plan it out at all. It makes your head spin. It paralyses any sense of logic with an incredible destructiveness. The ecstasy caused by love can numb your senses to an extent where you don’t even feel the pain of death. It’s incredibly dangerous."

- Eve, Ep 6 (K-drama)

It surprises me how a script that is translated from Korean to English can be so powerfully eloquent. Truth is universal.

It's funny how life works. How the things you fight so hard for can suddenly be rendered meaningless by a change of heart.

I'd always felt convinced that whatever my path, that my life's work was to do something good for the world. To make a difference. Or something cheesy like that.

A point of honesty is reached when you realise that maybe the world doesn't actually need that. It doesn't actually need me. That maybe altruism is only a form of disguised egotism (I do think egotism gets a bad rap, and that it's an essential part of the human condition, the human will to survive and thrive, but that's another blog post perhaps). 

That perhaps my life's work is simply to let the world be (good, or not), and appreciate what, or rather who, comes to me.

the art of letting go

being a grown up
the super ego prevails
heartbreak of the id

Movement is life

What it is about art, that the impetus for production is repression and deprivation? War, sickness, separation. Death. Unresolved love. Crises of the spirit catalyse art. The more we repress the subconscious it seems, the more active it becomes, the more its activity seems to bleed into consciousness and find an eventual manifestation.

The other day I was having a conversation with an Israeli about how much I loved the Israeli approach to movement, and how much respect I had for their movement techniques such as gaga and Feldenkrais. I reflected on how dancers here possess a totality of movement that seems to come from a much deeper attunement to the mind-body connection. She said with a sense of humour that it was because in Israel, where we are surrounded on all sides by the intensity of conflict, war, and crisis, we search for something else to focus on with greater intensity. We search within ourselves.

Perhaps it was environmental pressures that selected Israel to become the mecca of contemporary dance it is today. Richard Wolpert hypothesises that the mind was made to move; that the nervous system was evolved to allow complex movement, citing the example of the sea squirt, which digests its own nervous system for food once it has settled on the rock it will call home. It no longer needs to move, so it no longer needs its brain.

The humble sea squirt, incidentally,
may also present a potential treatment for mesothelioma.

There is something deep within us that needs to move. Whilst it stretches the metaphor to say the sedentary lifestyle is eating our brains and causing strokes, even in the language of evidence based medicine, we know this to be true.

We are in a generation which venerates the mind and dismisses the body. Yet the language of movement is impossible to quantify and analyse through the language of cerebral science alone. It needs to be embodied to be fully understood. That is what dancers do. Research movement. The connection of movement to the body, the connection of moving bodies to each other, the connection of movement to rhythms.

As the world turns to the advancements of medicine and technology for the elixir of health and youth, there is a need to return to the arts. To come back to what is within us, the fundamentals of who we are, and embrace and enjoy what it is to be humans - minds made to do, and to move.

Whatever will be will be

Do you want to be a dancer
It means travel
It means loneliness
It means poverty
It means toil
It means sweet passion for perfection
for expression
for a voice that can be felt more powerfully than words
It means doubt
It means conviction
It means love
You should only be a dancer
if you cannot be anything but.

Do you want to be a doctor
It means hard work
It means fighting
against systems that don't really work
for people who don't always help themselves
losing battles
but giving hope
It means stability
It means reliability
It means respect
It means empathy
It means sorrow
It means love
You should only be a doctor
if you cannot be anything but.

I can say now that I've travelled the world
I've lived a double life
I cannot be anything but.

I will be what I will be
but only as much as it matters
for what matters most.

You can only love

for you cannot do anything but

to find what matters most

is not what you love

but whom.

Always look on the bright side of life

Like many of my friends, I've been struggling during the final years of med school with stress. I've been constantly run down and tired. I've fallen ill so many times, for so long this year, I've lost count. I've been angry, snapped at people more. Instead of being genuine, I've maintained a pleasant demeanour motivated sheerly by the need to remain professional.

And I've been questioning why. Something definitely isn't right. Something more than just being sleep deprived. Cynicism and pessimism has crept in. I've been getting stuck in the negatives.



So this talk is a good reminder. In it, Alice Ledgerwood discusses our human tendency to remember the negatives over the positives. We find it easier to change from a positive mindset to a negative one. By contrast, it is much harder to change from a negative mindset to a positive one.

She suggests two ways to combat this; ways which closely parallel Christianity. Ledgerwood firstly describes how important taking time to be thankful is, how it makes a difference in terms of health, happiness and wellbeing. As Christians, saying grace, and thanking God, is an integral part of the relationship that we have with Him, and the practice of our faith.

The second point is addresses the way we tend to fixate on negative perspectives. We remember the insult far longer than we remember the compliment, and we pass on that negativism. Someone shouts at you, and you shout back, and you snap at another person, who snaps at another person, who snaps at another person... Ledgerwood suggests that returning good for bad is a way to break the chain. She suggests we return negative interactions with positive ones. For instance, giving the waitress with a bad attitude the extra large tip. This bears a striking resemblance to Jesus' preaching to love our enemies:

27 “But to you who are listening I say: Love your enemies, do good to those who hate you, 28 bless those who curse you, pray for those who mistreat you. 29 If someone slaps you on one cheek, turn to them the other also. If someone takes your coat, do not withhold your shirt from them. 30 Give to everyone who asks you, and if anyone takes what belongs to you, do not demand it back. 31 Do to others as you would have them do to you. 

32 “If you love those who love you, what credit is that to you? Even sinners love those who love them.33 And if you do good to those who are good to you, what credit is that to you? Even sinners do that.34 And if you lend to those from whom you expect repayment, what credit is that to you? Even sinners lend to sinners, expecting to be repaid in full. 35 But love your enemies, do good to them, and lend to them without expecting to get anything back. Then your reward will be great, and you will be childrenof the Most High, because he is kind to the ungrateful and wicked. 36 Be merciful, just as your Father is merciful. 

- Luke 6, NIV

Positivism doesn't just affect you, one person, but it affects others around you - your network. About a year ago, I read a thought-provoking book written by Daniel Goleman called Social Intelligence. Contrary to what the title might suggest, this wasn't a self-help book on improving your social skills and emotional intelligence. Rather, it explored the implications of the neuroscience of our social brain, and how it affects our lives. Goleman names the phenomenon put forward by Ledgerwood emotional contagion and discusses its effect in relationships. Research has shown that stressful relationships and conflict drives up stress hormones and blood pressure, and lowers immune function. By contrast,  positive relationships providing a major source of satisfaction and well-being, as well as general good health. This opinion piece describes a similar phenomenon with regards to marriage. Goleman goes on to cite numerous scientists and physicians who provide both anecdotal experience as well as supporting data to show how important emotional support, or simply put, the Christian tenet to love thy neighbour, can make all the difference in preserving quality of life and coping with disease. Reflecting on my course of my study, I have found that this echoes resonates with a significant base of evidence to show that in numerous conditions, from suicide risk to heart attacks, from stroke to dementia, the presence of emotional support, such as a spouse, can make a critical difference.

So how do we skirt illness and death? How do we find happiness? How do we find meaning in life? Peace? It would seem Jesus is right. Ledgerwood is right. That the answer is simple, simply love others, and be thankful. Jesus terms this loving God and loving others. There are many ways to love God, but a major way we do this is by giving thanks to Him. And perhaps, in some very indirect way, all these things - happiness, good health, and everything we think we want - will fall into its place.

27 “Consider how the wild flowers grow. They do not labor or spin. Yet I tell you, not even Solomon in all his splendor was dressed like one of these. 28 If that is how God clothes the grass of the field, which is here today, and tomorrow is thrown into the fire, how much more will he clothe you—you of little faith! 29 And do not set your heart on what you will eat or drink; do not worry about it. 30 For the pagan world runs after all such things, and your Father knows that you need them. 31 But seek his kingdom, and these things will be given to you as well.

- Luke 12, NIV

---

On another vein, these thoughts have interesting implications on the practise of health. To my knowledge, public health has generally revolved around epidemiology and prevention, but the importance of "soft" factors like staying postive, like being loved, are still under-recognised.

Letter to a lost love

Dear lungs,

Long have I laboured in ignorance of the music that you make. 

Yesterday night I sat down and thought about you, attempting to ponder over your intricacies as a lover would their love. Then I suddenly realised that you are just as simple as my love, the heart, to understand. Like the vascular system, you too have tubes, and fluid dynamics that obey laws of relationships between pressure, volume, velocity, wavelength, and frequency. Just like the heart, you are a musical instrument which obeys the same laws that govern a Classical orchestra.

Bronchial breath sounds

You can simply be thought of in terms of a series of pipes (trachea, bronchi), branching like a tree into smaller and smaller (mini bronchi known as bronchioles) in cross sectional area / radius. When air enters this instrument by breathing in, it reverberates through the bronchi, creating the bronchial component of the breath sound. This would theoretically result in a long inspiratory sound as one breathes in, a pause of variable length, and long expiratory sound as one breathes out, with no gap in between them as the air reverberates (bronchial breathing). 

The air that enters the larger airways are at a high pressure, low velocity, but as they progress to smaller airways, they are at low pressure, high velocity. Low velocity sounds are low frequency. High velocity sounds are high frequency. Thus the air travelling through the bronchi sounds deeper than the air travelling through the bronchioles. This accounts for the rise in pitch that is heard when you take a breath. Correspondingly, the sigh (lowering of pitch through the sound) of expiration is the product of the air being expelled from the most distant, narrowest passageways (bronchioles) through the larger passageways to the nose and mouth. 

Vesicular breath sounds

Thinking about the breath sounds as a continuous rising pitch, then fall in pitch, does not account for the final component of your musical abilities - your alveoli, or tiny sacs at the end of those pipes. At the end of these pipes, there are small bags (alveoli, sing.=alveolus), which may collapse and expand depending on the air that enters them. As one breathes in, creating the inspiratory component, the air travels to the end of the air passageways, and the bags get inflated. When one breathes out, air leaves the lungs, starting with the alveoli. Imagine how suddenly, the pipes become encased with multiple deflated little sacs - almost like a porous sponge. This sponge acts to dampen the end part of the expiratory phase when you listen over the area with a stethoscope (vesicular breathing). Therefore, normal vesicular breathing through the pipes and bags has a long inspiratory phase, and shorter expiratory phase due to the muffling of the soft expiratory sounds at the end of expiration.

Crackles

Now, these bags may be surrounded by fluid (infection, oedema), or surrounded by a connective tissue wrapping (fibrosis), like little sweets in plastic wrappers. This makes for some interesting acoustics. When the bags are lined with fluid or surrounded by connective tissue wrappings, they tend to collapse. When air enters into the collapsed bags, they pop open. With infection, the fluid that lines the bags comes from the bags and the pipes themselves. In chronic bronchitis / COPD, the passageways that are closed off by obstructing fluid are the distal bronchi. As air passes into the ends of smaller bronchi, and terminal bronchioles, which are filled with fluid, the passageways snap open with a pop (early inspiratory crackles of COPD). Although this has not been suggested in the books that I've read, the way I see it, it is the sound of the pipes opening up that is heard, rather than the sound of the alveoli. This would account for the fact that the early inspiratory crackles of COPD are often less than 4 pops (fewer bronchi:alveoli) and occur early on in inspiration (air passes through the bronchial passageways first to get to the alveoli). Although I can't logically explain the reason why, the fewer 'pop' sounds correspond to their lower frequency (coarse quality). In contrast, when the fluid fills the alveoli/bags, rather than the bronchioles/pipes, as with pulmonary oedema, what one hears is the sound of the alveoli snapping open against the surface tension of the fluid filled bags, creating a higher pitched sound like bubbles popping (medium quality). This occurs later than the opening pop sounds of COPD crackles (late inspiratory). The more alveoli: bronchioles accounts for the fact that the medium late inspiratory crackles of pulmonary oedema are more pops  compared with bronchioles (4-9). With bags popping open against fibrosis, imagine the rustle of sweet wrappers as they are opened. The crackles produced are >10 pops (estimates are from Talley's) and also occur in late inspiratory crackles. Once again, increased number of pop sounds corresponds with the higher frequency, i.e. fine quality of their sound (and are therefore described as fine late inspiratory crackles of interstitial fibrosis). As you know, the human ear hears higher frequency better, so although they are described as fine, high pitched sounds sound louder (and harsher) compared the lower-pitched coarse crackles.

Variables	Pneumonia(n = 37)	CHF(n = 5)	IPF(n = 13)
Inspiratory crackles
Crackles per breath	9 ± 5	13 ± 06	24 ± 17
Crackle frequency or pitch, Hz	316 ± 71	326 ± 43	441 ± 80
Expiratory crackles
Crackles per breath	6 ± 4	6 ± 2	8 ± 5
Crackle frequency or pitch, Hz	289 ± 79	303 ± 55	421 ± 78

Taken from Chest. 2009;135(1):156-164. doi:10.1378/chest.07-1562 

Wheezes

The lumen of these pipes can become clogged with mucus (as with asthma or chronic bronchitis), thus becoming smaller in cross sectional area, or may obstruct complete such that no air can pass through (in which case no sounds would be transmitted). When one breathes in, the pipes expand slightly due to their compliance. When one breathes out, they reduce in diameter slightly as well. According to Poiseuille's law, when the diameter of the lumen is smaller, the air will travel at a faster velocity (and correspondingly, produce a higher frequency, or pitch, of sound which is be more likely to be heard than lower frequency sounds which may be inaudible to the human ear). Additionally, when the fluid-lined lumen is dilated during inspiration, the surface tension of the fluid is higher than when the lumen is constricted, as it would be with expiration. When the fluid is at high tension, it is less likely to generate as much vibration. When the fluid is at a lower tension in expiration, as is the case in smaller diameter airways during expiration, an audible sound is more likely to be produced. The air rushing along the surface of the fluid creates a wave, generating a musical note, similar to the way a violin string would if it were plucked (wheeze). If that process were more severe, i.e. more fluid in the airways, the smaller the diameter of the airways, and the greater the potential of the fluid to vibrate at an audible level. That would result in the transmitted wheeze being heard earlier and earlier. Wheezes can even be heard during inspiration in severe blockage. 

So how would I manage the stuff that plagues you? Get rid of the fluid, make the airways bigger, and address the thing that causes the fluid to appear in the first place. As for fibrosis, well, there's not much I can do but appreciate your contribution to the music. 

Oh lungs, if only I had known sooner how sweetly simple, and how simply sweet your melodies are. 

Your dedicated servant,

Xin

References

1. Chest. 2009;135(1):156-164. doi:10.1378/chest.07-1562 
2. Talley's Clinical examination

Medical authorship, Part II

To continue my exploration of medical authors' personalities:

For the many men suffering from prostate cancer throughout the world, we must continue our efforts to improve diagnosis, treatment, and basic understanding of this fatal disease. —Walsh and Brooks

The author of this chapter most senior in age (JES, 67 at that time) had a complete physical examination by Dr. William M. McClatchey in March, 1987, which was reported as negative. Because of pain in his left knee, he had another partial examination in October, 1987.
WMcC:     I want to do a rectal.
JES:     But I had a rectal by you 6 months ago.
WMcC:     My professor told me that not one patient will leave my office without a recent rectal examination.
JES:     (Unwillingly) O.K.

Rectal exam revealed a prostatic nodule. Prostate specific antigen (PSA) from the earlier exam had been 0.3 ng/ml; the current report was 0.4 ng/ml. Both were within normal limits. But biopsy revealed adenocarcinoma. Radical prostatectomy by Dr. Sam Ambrose 2 weeks later revealed that the prostate (including its capsule) was full of cancer. Five years later an LHRH (luteinizing hormone-releasing hormone) agonist (Lupron) was started because the PSA had risen to 5.3 ng/ml. At present, Dr. Skandalakis is asymptomatic and the PSA is under 0.

PSA is a marker of prostate disease. In the clinical context, it is probably most useful for monitoring cancer recurrence.

Dialectical: Hide/Seek

Is face value too skin deep?

Or do I need to psychoanalyse?

Should I trust my instincts?

Just dive in?

Drowning babies won't survive

while doubting Thomas dithers five.

Doctors hide behind diagnostic labels

and paternalistic care disguise.
Patients hide behind false confidence:
Doctor, doctor, yes, I'm fine -
but when the truth gets out,
instead of empathy,
the doctors try to hide

And there's 

nothing I can do
but learn from other doctors,
learn how to hide

behind paperwork,
and behind-the-scenes condescension,

We avoid lawsuits,

and avert blame.

When all I want to do 

is hold you,

tell you I'm sorry,

you're wanted,

please don't hurt yourself,

please don't try to die.

How to hold a steth

Hold the pipe between the thumb, and the chest piece between the forefinger and ring finger.

According to Stanford's PA training website, the stethoscope makes a nice hearing aid with hearing impaired patients. Put the eartips in the patient’s ears, and talk into the chestpiece.

Medical authors

It's most endearing that many of the authors of medical textbooks have a personal voice that reflects their particular eccentricities.

The nose is sited conveniently in the centre of the face. In this position it may readily be inspected inside and out.

Or

Even the experienced gastroenterologist must restrain his or her excitement and begin the examination of the gastrointestinal tract with the hands. ...Self-restraint is no longer required and it is now time to examine the abdomen itself.

On coping with sa-stammering

The other day a proz- s- saic^
friend mused:
I wish I could write music or poetry.
I didn't know what to say because
I'm always lost for words -
groping for them
in the greyish p- m- m-uddle
from which the right word can never be extricated
by my clumsy tongue

(instead some subpar subs-
titute stutters its way through my pharynx
unsuccessfully conveying
the glistening clarity I see/think/feel
in my head

mixing orders of
words up by the time they translate to

spoke- o- on tongue)

How do you convey the simultaneity of graphic thought
ad verbatim?
The words that delineate in a mental landscape
transmute not to linear argument.

Which is why I so admire Rhet-t-
-oric which seems to work
with the smooth efficacy of a Butler
redeeming you to his point of view.

While my words are some kind of Scarlett
lett-er -lett-ing on my stupidity instead.

Oh my silly friend
the silence of my prosaic grin
is saying only this:

If I could say in it prose,
I would not need prosody.

^Prozac is an antidepressant drug that was once widely prescribed for depression, particularly in the USA. It can also be used for the treatment of OCD, panic disorder, bulimia and PMS. In certain rare cases, it is also used for ADHD, and Asperger's.

Pet peeve

I'm often stuck for an answer when asked about my pet peeves, but I think I've recently got one: I hate reading medical journals that are filled with platitudes, non-specific guidelines and cliches. Things like ''everything is poison, there is poison in everything. Only the dose makes a thing not a poison. (Paracelsus)", or "the only certainty is that there is uncertainty", should be reserved for public addresses, philosophical musings or random bloggings where the only responsibility to the audience is to guarantee a wasted time.

If you have to use one, please use sparingly. Just as too much salt causes high blood pressure, too many platitudes aren't doing any wonders for my amygdala.

As a scientist, researcher or medical practitioner, we read journal articles to glean specific information that is applicable to our research or case study. We don't need to know your personal beliefs when we are reviewing pages and pages of literature. Generalisations and conceptual abstracts can be thought-provoking and paradigm-shifting and what-have-you, but in the right context, please.

Don't even get me started on disease aetiology. If I have to reading something along the lines of 'complex interaction of multiple factors', or 'genetic and environmental interplay' one more time...It's either that or it's idiopathic. Yes, we are a load of idiots who don't know what's really going on.

The worst part of it is, as much as we students (or at least, I) complain, I realise that us students do it too. Because we see teachers doing it, we assume it is what they are looking out for (an assumption which is not totally erroneous), and model after it.

It's the heart that matters most

[Warning: as you may have discerned from the title, this will be a cliched and gushy, probably preachy post.]

Looking around at the doctors and doctors-to-be around me, I see people of all walks of life. There are the foul-mouthed swearing types, there are the jokers, there are the cold and distant types, there are the overtly caring ones, there are the ones who claim they don't give a damn.

But they do. We all do. The thing that binds us isn't that we're high academic achievers, or that we're competent, or that we've an all-consuming interest in what we do.

It's that we've got heart. Underneath our exteriors, whether hard and clam-like, or soft and welcoming, we feel for others. When we see another human being suffering, some part of us is fundamentally driven to do something, unselfish enough to care about it, and to want to make a difference.

If you're in the profession for anything else - whether it's the so-called glory or prestige, or the financial stability, or even for the intellectual gratification, you're bound to be disappointed. There's little real glory to be had - every other course from Politics to Culinary Skills, has its fair share of high-fliers. As for financial stability, there are easier ways to get that. You will spend a long time awaiting intellectual gratification, if that's what you're hoping for. Frustration is more likely, with all the loose ends and incomplete science.

The only thing that I can think of that makes us want to go on in this race is that we care. We care about our patients. We care about being good doctors. We care about each other.

Chicken soup

I've been moving my old blog entries to this blog over the past few months, and I came across an entry that's very relevant, what with H1N1; sometimes the best medicine is a good ole' dose of mum's wisdom.

Although colds and flus are not the same, they share inflammatory effects (your body's response to most invading pathogens), so if you happen to be down with either, according to RealAge (which is apparently six years out of date),

"Chicken soup really can help you get over a cold. Ingredients in chicken soup have anti-inflammatory properties that inhibit the movement of neutrophils into airways. Neutrophils are white blood cells that contribute to the inflammation that causes cold symptoms. Combat your next cold with plenty of rest, lots of fluids, and a bowl of homemade chicken soup...chicken soup contains compounds that help inhibit mucus production. In addition to chicken soup's anti-inflammatory effects, the heat and steam may help open up nasal passages...Sipping hot chicken soup may help, as well -- a steamy bowl of chicken soup with plenty of garlic and a sprinkle of cayenne pepper will boost the nasal-clearing effects of the soup. And be sure to finish the broth; researchers determined most of the anti-inflammatory effects of chicken soup come from the liquid."

(first published 7/3/06 9:11 PM)

My timetable for thursday:

9-12noon - sex

1-4pm - emo

4.15 pm- run

Seriously.

I think studying for Medicine can sometimes be really strange.  What we have learnt, in summary, for this course is: 1) how to take care of kids (parenting), 2) how to stay happy (depression), 3) sex ed.

Of couse, there are other incidentals like, how we hear, the fact that you are going to fall sick from invading pathogens, and an introduction to neurology and endocrinology (which are both very interesting, much more interesting than they sound).

But I think studying Medicine is like the University Course to Living Well.  Though studying for it is living hell (sorry, I know that was lame, just couldn't resist it).

Medicine course takeaways

Over the last two days of my course, the things I have learnt from my lectures and tutorials include:

1. guys who clean get women hot
2. I should probably have gone into arts, based on my personality - we did a Big 5 (extraversion, openness, neuroticism, agreeableness, conscientiousness) personality test tutorial, and I scored low on conscientiousness, and almost off the charts on openness.

Kenny's amazing expert tute on embryo