The Doc

     As difficult as it was to leave the almost-comical but deadly serious world of politics, it was time for a pause.  And why not since the time had come for my annual physical, a time when you're checked (or should be checked) for the health of your colon, nerve reflexes, cognitive function, internal organs, skin, and more.  And no matter how many pundits (and your mind) tell you that 60 is the new 40, or that 70 is the new 50, such a check of your body quickly snaps you back to reality.  70 years of wear is 70 years of wear, much like when someone tells you about their old car saying, "this baby runs like new."  Uh, no.  And it's the same when you look up something on Dr. Google, or make a doctor's appointment...when the result turns out to be "no big deal," you tend to leave thinking, "well I could have figured that out."  But again, no.  Here's just one example...

     There was a nursing prep book (the NCLEX-RN) at the library sale, one of those SAT or ACT books that provide sample questions to help better your score or pass your exam (such books cover law, medicine, aviation and many other fields; I did once peek at the air-traffic controller book, and failed miserably).  So at random, I stopped at a page on the nursing exam book and read its multiple-choice question: The nurse reviews the medical record of a client after surgery for removal of the parathyroid glands.  The client reports difficulty swallowing and a feeling of "pins and needles."  Which of these laboratory values is consistence with this finding?  1) Decreased calcium; 2) Increased lipase; 3) Decreased potassium; 4) Increased sodium. (the answer was decreased calcium): Hypocalcemia is an indication of hypoparathyroidism; symptoms include dysphagia and paresthesia.  What??  So it appeared that nursing was also out for my future years (but it gave me a broader respect for those pre-doc visits when you thought all nurses did was take your blood pressure).  Time to try out that law book...

     Surgeon Gabriel Weston, wrote in her book Alive: It's tempting to think the Emergency Room is all drama.  The truth is that doctors in this setting need to function simultaneously in two gears, alive to the fast-changing adventure of a patient's state, but with the solid knowledge base that must guide all decision-making.  So she provides an example, that of a patient walking in with severe abdominal pain: As on-call surgeon, you arrive to find your patient clutching their middle or too sick to move, belly rigid as a board.  First, assess for signs of a life threat.  Shock?  You're looking at a pale, sweaty person, with low blood pressure and a racing heartbeat.  Peritonitis?  You'll know it straightaway because they can't move for the pain.  Gangrenous bowel?  The agony doesn't fit the soft clinical signs.  Ruptured ectopic?  The only way to exclude it is by pregnancy- testing every single woman of reproductive age.  Patients like this don't have time to lose.  Hook up fluids and oxygen, but don't waste another minute before calling theater.  Whatever lies inside --gunshot or stab wound, ruptured abdominal aortic aneurysm, perforated viscus, gangrenous bowel, ectopic pregnancy-- only a surgeon can fix.  For everyone else, take a breath but don't stop moving.  Give pain relief while asking questions.  Slide in a nasogastric tube to decompress the stomach if they're vomiting, but also inspect.  Send off blood, to look for obvious things like diabetes and pancreatitis, but know that the results won't do the work for you.  Then, settle the key conundrum: where is the abdominal pain coming from?  The nature of the symptoms gives clues.  Colicky pain comes and goes, implying a blockage trying to free itself, like obstructed bowel or a gallstone stuck in the tight neck of the gallbladder.  Dull aching discomfort with nausea is usually an inflamed viscus.  Lower abdominal pain, sudden like a a light switch being flicked on, could be a twisted testis or ovary.  A writhing young man has kidney stones until proven otherwise. 

      Wait!  You're not done.  She goes on (same patient):  Embryology says the primitive foregut travels from esophagus to the first part of the duodenum; pathology anywhere in this stretch will produce discomfort in the epigastrium, at the top of the abdomen.  The midgut runs from the duodenum to the final third of the transverse colon and gives up near the belly button.  The hindgut goes from the transverse colon to the upper anal canal and generates pain above the pubic bone.  It's also worth visualizing the abdomen in quadrants as this calls to mind cardinal problems that arise in each: gallbladder and pancreas pain to the right upper quadrant and appendicitis in the right lower quadrant, for example.  Keep your eye on the prize but don't let it blind you.  Sometimes, problems in the abdomen refer pain to other places: pancreas and spleen pathology to the left shoulder, gallbladder inflammation to the right scapula, for instance.  By the same token, emergencies elsewhere --heart attack, diabetic or sickle crisis, blood clots or infections to the lungs-- may declare themselves with pain in the abdomen.  Still baffled?  It's time to bite the bullet with a size 10 blade, slicing the patient open from xiphisternum to pubis to unveil the disaster.  

     I went on a bit in quoting her book because it helped to show what medical people have to go through, and often in a hurry (imagine medics in battlefield situations).  And yes, some people thrive in these situations, their knowledge on rapid-fire to stop the bleeding or to even find the bleeding.  But diagnose or guess incorrectly and you may be threatening (or ending) a life...the wrong med or the wrong dosage (mg. vs. mcg.) can be fatal.  So yes, be thankful when you find a good doc, whether at the ER or at your physical.  And oh yes, my physical.  It took over an hour, his exam detailing and explaining every chart and nerve function along the way, most of it in language I could sort of understand (those hematocrit/creatinine blood results always jumble past me like falling snowflakes, disappearing almost as quickly as they land).  He had me feel the pulsing of nearly every one of my arteries (I didn't know that I had so many, or that the femoral artery was so powerful in its feel).  Cut a main artery and you can bleed out in 7-8 seconds, I had read.  True, he answered, with barely a wince.  Then he moved on to the 10 nerves of the head, and what each did (I had to perform each of them, from moving my tongue inside my mouth to my eyes watching his fingers move just to each side of me while I stared straight ahead).  He pressed hard on each organ in my stomach, describing what each was and what its function was (didn't feel your pancreas, he told me, which is good because if I did it would be too late...as in, I would likely have a month or so to live).  Then came the horror stories, well, to me at least.  He's a four-generation doctor, treating grandfathers, fathers, children and grandchildren of the same family, and as such, has had both good and bad news to tell.  Patients beating the odds, only to discover ssomething else and be dead within weeks.  Flip these numbers, he told me, partly to snap me back to reality.  24 became 42, then 583 became 385, then 8947 became uh --a pause-- 7498.  Don't need the clock drawing, he said (the typical but last-resort test for dementia when you find yourself on Medicare).  So were numbers the first thing to go with dementia, I asked him?  It's the spatial reasoning, he said, and moved to the wall.  What am I writing, he asked as he pantomimed drawing letters and numbers as if on a chalkboard (luckily I could answer each correctly; he didn't allow any dawdling when answering).  With the start of dementia, you lose that ability to visualize, to flip numbers or to picture imaginary letters.  And the drawing of a clock, I asked.  They usually can draw it (a clock face with hands pointing at 11:35, say) but the entire drawing will be bunched into a small quardrant of the clock.  He moved on.  Your heart scan showed a small bit of calcium but I didn't hear any blockages or reduced blood flow which could indicate a possible aneurysm (phew); but remember that what percentage calcium is in your heart is also in your brain; heart = brain.  Now, let's move onto balance...

      To be honest, I had never had such a thorough physical and it was both educational and somewhat scary.  There went all my "70 is the new 50" thinking.  Calcium in the heart and brain meant that I was now a candidate for both a heart attack and stroke (albeit a slim one, he said, then added: ...at this point).  Dang.  What else?  Maybe it didn't help that I had just been reading What Does It Feel Like to Die? by hospice author Jennie Dear (perhaps this wasn't the best book to peek at before one goes in for a physical, but then we older folks seem to do that after a certain age, or when we feel an unexpected twinge somewhere in our head or chest).  Wrote author Dear: Many of us have little touch with what dying is actually like.  "Think about how people die on television or in the movies," says Marian Grant, a hospice and palliative car nurse practitioner and senior advisor to the Coalition to Transform Advanced Care.  "They are awake to the end.  They have meaningful conversations, and then their heads just turn to the side and... then they're dead.  But that image doesn't mirror reality.  That is not what any of this looks like," Grant says.  "A hundred years ago, people died at home.  People died in childbirth, children died.  You should never have made it into adult life without having seen someone you know, a neighbor or someone in your community, actually die.  Now, you could make it into your sixties or seventies and never have seen that.  And what you see on television is this lovely romantic notion.  But real life is not like that."  More than 90 percent of all Americans will almost certainly die as my mother did, living for weeks, months, or even years with the knowledge that they have a fatal disease.  But most of us know little about what to expect during that time -- despite the research from scholars on the experiences, symptoms, and emotional status of dying people, ranging from the "existential slap," the shattering realization after a fatal diagnosis that we really are mortal; to the amount of pain dying people endure; to the most successful methods in helping dying people cope.  That knowledge still isn't widely available, despite growing appetite for information about dying. 

     Once long ago, I asked my uncle, then a respected thoracic surgeon with his own practice, how it felt to lose a patient on the operating table; he replied that --at least for him-- after a dozen of so deaths, you buffered yourself with the knowledge that you did everything you could, as in everything.  But still, with the pressure to keep up with procedures, and medicines, and reactions, and related causes and diagnoses, it would haunt me for far longer than that, I thought.  Or would it?  I had no surgical or medical training.  And faced everyday with the reality of dealing with people's lives,  how long would it take to harden up to that feeling that you knew the procedures and had kept up with the studies, and that there really was little else you could have done.  And yet, would that one inkling of doubt creep in at an odd hour, a speck of a recalled textbook or a part of a colleague's conversation that would make you wonder...did you miss something, were you too tired that day, was your mind on something else, should you have prepped more?  Did police feel that when firing their first shot?  Their fifth?  Did soldiers?  Did criminals?  

      But the more I read about the body, the more amazed I became.  Our bones replace 10% of themselves each year; the genital structure of the male and female bodies are virtually identical until near the 13th week of growth internally (wrote Weston: In both sexes, this structure contains the exact same three columns of erectile tissue -- two corpora cavernosa and a corpus spongiosus); the kidney filters an amazing 200 liters of blood each day (and dialysis effectively can only do 10% of that); the magnet in a MRI machine is strong enough to lift a car; and heart disease is the leading cause of death for women worldwide (childbirth is the second leading cause of death worldwide...for girls under 15).  Wait, what was that last part?  So how many women overall still die either in pregnancy or during giving birth?...nearly 300,000.  But here was yet another stat from Weston and one which I've touched on briefly in the past, the microbiome, the gut being: ...the largest sensory organ we have...With more immune cells than across the rest of the body put together, and an internal surface area a hundred times bigger than the skin, the gut is held with an elaborate harness we now call the gut-brain, which contains up to 600 million neurons.   And speaking of the brain, she added a quote from neurobiologist Steve Rose: ...cut out 50mm of brain [less than 2 inches] and you have, in this one sample, 5 million neurons, 50 billion synapses, 22 kilometers of dendritic, and 220 kilometers of axons.  

     But wait, if I recall, my doc mentioned my possible risk of heart attack or stroke.  And then I read this in Barron's: Forty years after the first statin drug started lowering levels of artery-choking cholesterol, heart attacks and strokes remain the world's biggest killers...Besides LDL cholesterol, other fatty risk factors for heart attack and stroke are triglycerides and lipo(a)...There is no approved drug treatment for the roughly 65 million Americans whose genes leave them with high blood levels of lipoprotein(a) and an estimated two-to-three times higher risk of cardiovascular disease.  On the plus side, I have been able to (so far) fight my family's history of high cholesterol with diet and exercise.  That said, genetics is tough to keep battling and I realize that there may come a point where I grudgingly have to admit that maybe I can't continue winning.  But in the end, who knows?  Again from surgeon Weston: Early civilizations made no distinction between the mechanical and emotional aspects of the heart.  Chinese parchment from 3,000 years ago described it as xin zhu, ruler of blood and spirit, while Hindu scripture from the eighth century BC presented the heart as both the physical hub and a person's emotional compass.  The Egyptians' belief in the heart's symbolic value even extended to their death rites.  When all other organs were removed from a corpse before mummification, this one was left in place to allow a special test.  The dead body was believed to pass to the jackal-headed god Anubis, who placed the heart on scales, weighing it against the feather of truth.  The heart represented the conscience and could speak against a person, while the rest of the body was there to appeal for mercy.  Purity of heart granted passage to the afterlife while failure resulted in the heart being gobbled up by the monster Ammit, Eater of the Dead. 

Self-portraits: William Utermohlen

     Perhaps we all carry a tell-tale heart.  "Will you say that I am mad?," wrote Edgar Allen Poe in his story: The disease had sharpened my senses --not destroyed-- not dulled them.  Above all was the sense of hearing acute.  I heard all things in the heaven and in the earth.  I heard many things in hell.  How, then, am I mad?  For me, if not a stroke or heart attack, there was that upper half, that calcium on the brain.  Would I be sinking into those stages of dementia?  And as a piece in Scientific American asked (it was on the new biomarkers that apparently are able to show if you're likely to have Alzheimer's), would you want to know?  "Is it burdensome to live with the knowledge that you are at risk for dementia?," asked the piece (it also noted that those new early-Alzheimer drugs to slow the progression run $26,000 to $32,000 annually).  At a recent dinner this topic came up because several friends of ours now reside in assisted living and yet when we occasionally get together with them, they seem as lucid as ever, except for those occasions when they obviously are not (denying they ordered a dish when it appears, or repeating a topic 4 or 5 times).  So what was that percentage, I wondered, those times when you become "aware" of where you are and why you're no longer living in your home?  10%?  20%?  And during those times, do you briefly sink into knowing that where you are is where you'll die: the same meals, the same routines, the same small room, the same "activities."  But you will never "go home."  How horribly depressing that must be if and when such thoughts arrived.  Would I then be the one asking, "am I mad?"  Or would I be truly mad, as in angry mad, that I was now confined, locked in to a convenient, some would say comfortable, prison?  That thought alone is depressing, even while looking from the outside.  But here's something even more depressing...privatization.  Wait, what?

    Said another piece in the same magazine: Of the roughly three million Americans who die every year, around half now do so in hospice care...Today nearly three quarters of hospice agencies operate on a for-profit basis.  The sector has become so lucrative that in recent years private equity firms and publicly traded corporations have been snapping up previously nonprofit hospices at record rates.  But it also noted: In an analysis of how well countries around the world deliver end-of-life care, the U.S. was ranked 43rd out of the 81 countries assessed, despite being one of the wealthiest nations (somewhat ironically, the U.K .ranked at the top).  Bloomberg wrote that private investment in healthcare has amounted to nearly $1 trillion over the past decade, but also accounted for 17 of the 80 hospitals that declared bankruptcy (80 hospitals went bankrupt?).  One of the largest to do so was $1.4 billion in debt, and yet paid investors "a $484 million dividend" and the CEO bought himself "a $40 million mega-yacht."  With such track records (the piece noted that private equity funds keep such investments --hospitals, anesthesiology clinics, nursing homes-- an average of just three to eight years), why wouldn't firms cash out and head over to more lucrative waters?  Take the new at-home saliva tests for prostate cancer (preliminary results show them to be far more accurate than the current PSA urine tests), or the new blood tests for cancer (biomarkers are showing the probability of cancers up 3 years in advance, wrote Discover), or the upcoming cardiovascular drugs to be taken as pills, biweekly or semiannual shots, and even as a once-for-a-lifetime infusions, wrote Barron's, and more.  Except that most of these "advances" are coming from China.  Wrote another piece in the same magazine: All but the largest US biotechs generally develop just one or two experimental medicines at a time, while Chinese biotics of a similar size "could have a dozen" different drugs in trials, according to Cantor Fitzgerald analyst Li Watsek.  This caused US pharmaceutical firms such as Pfizer and Bristol Meyers Squibb to give pharmaceutical firms in China an unprecedented upfront sum of $25 billion for partial access to their research (giving such money up front is quite rare among pharmaceutical firms): Until recently, the US drug industry has largely seen Chinese biotechs as a source for cheaper "me too"  assets, which echo but don't duplicate existing medicines.  Now, with the latest cancer drug deals, Chinese companies are innovating a new class of drugs that every Big Pharma firm seems to think it needs to get in on.  The recent Chinese immunotherapy drug outperformed Merck's version, Keytruda (each 6-week dose of Keytruda runs about $26,000).  With funding cut for many research projects (Trump canceled funding for the final stage testing of Moderna's new Covid vaccine, even though the new Covid strain has been affecting the UK for several months), and bankruptcies in US healthcare continuing as a poor investment, is it any surprise that investment would move in another direction?  We may have moved out of the 4-generation doctors and into the world of profit and politicians, wrote The Conversation.

      And maybe my wife and I were jaded because of watching the Danish series, Borgen (first 2 seasons excellent), but there is yet another set of doctors making the rounds, the spin doctors.  Here's my take on Vance (no relation to J.D.) Boelter who allegedly shot and killed a Minnesota state Representative and her husband, and had 65 other names on his list: Upon questioning, Boelter tells the police that he is part of a larger web of MAGA-X followers, a far-right group tired of a TACO president who says "some" illegals are okay, and who bows down to Jews and Putin, and says he supports the poor but only if it helps him get richer.  We've got a manifesto, he tells the detectives.  I'm not the only one.  You're going to start seeing us popping up around the country because we're taking back liberty and patriotism and doing what those MAGA people once said they'd do, but haven't.  Just wait.  And the police detectives listen as he goes on and on, which is when the high-up administration spin doctor walks in and says that the story the press will hear won't be that one, but will be this: he acted alone and was a religious zealot, very anti-abortion, targeting anyone who didn't share his views, including Planned Parenthood.  The detectives look puzzled but the spin doctor tells them not to worry, that all the rest will be taken care of and to just go with that story.  He was a lone wolf and had a history.  End of story.  Except, as Professor Alex Hinton, who specializes in the study of genocide and human rights, told The Conversation: After decades of research on numerous attacks that have left scores dead, we have learned that extremists are almost always part of a pack, not lone wolves...Far-right extremists may physically carry out an attack alone or as part of a small group of people, but they are almost always networked and identify with larger groups and causes...The vast majority of far-right extremists are, in fact, otherwise ordinary men and women.  They live in rural areas, suburbs and cities.  They are students and working professionals.  And they believe their extremist cause is justified.  This point was illustrated by the spectrum of participants in the Jan. 6, 2021, Capitol insurrection.  Boelter is a father of five who has worked various jobs in the food industry and with funeral service companies and a security service.  If my Borgen-like spin sounds as if I may be "mad," it seemed little different than that of my far-right friends who sent me TikTox/X/meta/NewsMax threads of "dems" sending pallets of bricks to demonstrators and handing out $200 checks to protesters (which would be quite a sum considering how an estimated 5 million protesters showed up across the country for No Kings day).  Who's spinning who? 

     But enough of that (I raised the white flag to my far-right friends and said "truce" -- the clips and such they used to send have ground to a halt).  The reality of the mind and how it can give us a different view may be shown by the above sketches of the famous illustrator, William Utermohlen (his early 1967 self-portrait is on the left).  When he was diagnosed with Alzheimer's, he decided to document his diminishing mental and visual view of the world, which was stark.  For in the end, his view of himself was little more than someone trapped in a shell, as seen in his last self-portrait before he passed away.  For me, having such a complete mental and physical "physical" was both reassuring (basically healthy) and mortally scary (calcium in my heart/brain).  You go into such exams wanting to know, and yet not wanting to know.  You're healthy until...you're not.  Cancer, tumor, dementia, each life-slaps that you didn't see coming.   Author and surgeon Weston wrote in an earlier book To be a good doctor, you have to master a paradoxical art.  You need to get close to patients so that they will tell you things and you will understand what they mean  But you also have to keep distant enough not to get too affected,  This distance keeps both parties safe....But sometimes you feel the likeness between you and your patient more than you feel the difference.  Sometimes your own body declares its fallibility as if in sympathy for the person you are consulting, or your heart defies you by responding just when you least want it to.  I felt fortunate, not only in being examined by the doc I now had, but also that I had been given a pass for another year.  And as I read Weston's words, I thought that she could also be describing life and relationships, your heart catching you off-guard and overriding your brain as if saying those same words: listen, feel, experience.  Life, loves, friends are all precious...and fleeting.  Discover what matters because it could and will disappear one day.  So I end with those pictures taken in a dry field, weeds to most and yet a field where resilience is on display everywhere.  Amidst the relentless heat and the lack of water, beauty and life still emerged.  And when I saw that perfect flower below, I saw not only myself, but our people, our country, and our democracy.  What seemed a light and brittle framework, a shell of its earlier self, was instead a display of grit and determination, a showing that despite harsh conditions, despite being ignored, despite being thought of as something ready to fail or be cut down, that in truth it was not close to giving up.  Instead it showed that it could and would resist, and resist peacefully and with grace and beauty.  That flower was displaying how I felt, continuing the best it could, taking its place in the world and not paying attention to all the noise, or to the feet not wanting to visit or see the life that others were missing, as if unimportant.  Now that I am older I may seem a thin skeleton of myself, but I am still here, still content to have be granted more time, and still ready to show that life, in all its forms, is everywhere.  So let's call a truce, for the sake of ourselves...for the sake of our planet.  Let us do what our hearts tell us.  Listen.  Feel.  Experience...