I’m not sure I can live up to the promise of this post, but as I crouched naked on my hand and knees this weekend, crippled in the 6th hour of profuse diarrhea and vomiting, a few thoughts came to me.

First, how woefully miserable it is to feel sick. Not just sniffly-nose-nasal-congestion-sick, but rather the kind of sick that if it went much longer you might question your will to keep suffering.

I felt a tight, painful clench in my trunk that would not ease; a foul urgency to sit on the toilet as liquid poured out; that familiar burst of saliva and welling nausea as I scrambled to clean one end before the guttural retching ensued on the other; the hot splashing of acid on the palate, and the awkward stare of the spinach from the toilet bowl that just moments ago was floating in my intestines; the exhaustion; the light-headed flop back into the stale bed; the pounding of my heart, craving more fluids with which to pump, but my stomach blockaded by a pervasive and perverse sense of nausea and pain.

God bless the sick.

As I slowly recovered, there were many thoughts. First, there is no greater pleasure than not being aware of your own bodily existence. Tragically we are unaware of these moments, since they are imperceptible by nature. But to lie still in a bed, or to read a book in a hammock, not beset by the gurgling and bloating of bowel, the burning of stomach acid, the congestion and difficulty of breathing through mucous, the constant nudging pain of a bad back, the pulsing of a migraine… to be free of the alarms of internal machinery is heaven. Perhaps there is a fasting monk on a mountaintop who knows what I mean.

And for as much grandiosity as I’ve already written, I know that my brief “suffering” was small, as is my very existence. Have you seen the photo that the Cassini spacecraft snapped last week of the pale, blue dot that is our Earth? Isn’t it absolutely magnificent? How have the people of the world not stopped everything, laying down their baskets and bayonets and briefcases, to begin the Age of Aquarius?

Because unfortunately, when we are in our life, we are in it. We are billions, programmed to compete, stuck on this little blue dot, howling at each other. Because the struggle is actually much easier than the big picture. How luxurious it is to be grounded in misery, our bowels and bile and wars and petty atrocities tethering us to the moment. Having seen ourselves on this pale blue dot, should we choose to keep being boorishly human, or to seek an enlightened state of relative harmony, peace, and understanding among our similarly diarrhea-plagued brothers and sisters?

As a kid I imagined that once aliens reached our planet, all the different tribes of mankind would unite at last, albeit in self-defense, but finally aware of our common bonds. Yet looking back from Saturn should really be that kind of spark, too. But it fails to trigger our survival instincts, appealing instead to lofty notions of beauty, imagination, and awe. And then we go right back to diarrhea and taxes. Is there comfort in blood, muck, and cruelty? Are we shackled by double helices to be forever self-absorbed and self-serving? And when I wish to see beauty and transcendence in the Cassini spacecraft photo, am I instead glimpsing Life’s unmoored scream into the bitter cold vacuum of radiation and godstuff?

It’s hard to bring this post to any kind of sensible conclusion, but If I were to narrow it down to just two sentences it would be these. If you are currently feeling well, be aware of it, and be humbled by the Universe. And learn more about oral rehydration therapy.

The origin of a word is fascinating, and the etymology of a word’s evolution tells a story.  You can almost picture syllables and letters marching like armies through distant lands – Old England, Low Germany, Ancient Greece… or rising up from a dark, primordial world of shapeless magic to take form and structure.

I’ve changed the anatomic names of the human body on this diagram to tell the story of each organ’s epithet. As a primary source I used Online Etymology Dictionary, which is a labor of love created by Douglas Harper using the best classic sources. The fantastic 3D anatomy rendering is from Zygote Media Group. I found some of the derivations and etymologies quite thought-provoking, while others such as “knee” are simply stated. I had to do a lot of work with my “something broken” to compose this diagram, so please enjoy!

Brain – from the Celtic bhrag-no, or bran, “something broken”
Skull – Dutch schol “turf, piece of ice”
Hair – from PIE ghers– “to stand out, to bristle, rise to a point”
Eye – from Proto-Indo-European (from here on abbreviated as PIE) “to see”
Ear (Pinna) – from the Proto-Indo-European “backbone, dorsal fin”
Cheek – Old English ceowan “chew”
Nose – PIE nas, “nose”
Mouth – Old English muþ “mouth, opening, door, gate,”
Throat – Old Norse þrutna “to swell”
Neck – PIE knok– “high point, ridge”
Chest – from PIE kista “woven container”
Breast – PIE root bhreus– “to swell, sprout”
Heart – Old English heorte “heart; breast, soul, spirit, will, desire; courage; mind, intellect”
Aorta – Greek aorte, term applied by Aristotle, literally “what is hung up,”
Lungs – Proto-Germanic lungw, “the light organ.” It is speculated that this derives from the fact that lungs of a slaughtered animal float in water, while the heart, liver, etc., do not.
Esophagus – from Greek oisophagos “gullet,” literally “what carries and eats”
Stomach – Latin stomachus “stomach, throat,” also “pride, inclination, indignation”
Liver – PIE leip– “to stick adhere; fat”
Gallbladder – from PIE root ghel– “gold, yellow, yellowish-green” and PIE bhle– “to blow”, “to blow yellow, green”
Pancreas – Latinized form of Greek pankreas, from pan– “all” (see pan-) + kreas “flesh”
Kidney – perhaps a compound of Old English cwið “womb” + ey “egg”
Intestines – Old English hropp, literally “rope”
Spleen – from Greek splen, associated with “violent, ill-temper”
Ovary – classical Latin, ovarius, “egg-keeper”
Uterus – PIE root udero, “sticking out”
Vagina – PIE wag-ina – from root *wag- “to break, split, bite”
Penis – from Latin penis, “tail”
Thigh – PIE teuk– from root teu – “to swell”
Quadriceps – Latin quadriceps, “having four parts”
Leg – PIE root meaning “to bend”
Knee – well, basically Latin genu “knee”
Calf – Old English cealf – “young cow”
Ankle – PIE root ang-/ank– “to bend”
Foot – Proto-Germanic fot, “foot”
Toes – from Proto-Germanic taikhwo, “fingers”
Shin – Proto-Germanic skino, “thin piece”
Arm – PIE root ar – “fit, join”
Shoulder – West Germanic skuldro, shield
Biceps – Latin biceps “having two parts”
Elbow – Old English elnboga, from ell “length of the forearm” + boga “bow, arch”
Hand – Old English hond, hand “hand; side; power, control, possession”
Finger – PIE penkwe, the root meaning “five”

Do you want to know if your doctor has been eating pizza for lunch that was purchased by Pfizer as she listened to a drug rep describe a new medication? Do you want to know if your endocrinologist has been paid $1,500 to give a brief talk about a new injectable diabetes medication to his colleagues as they gobble down filet mignon? If the answer is “yes,” then you are in luck.

As the August 1st, 2013 deadline to start reporting information about these sorts of transactions approaches, doctors and hospitals are reevaluating whether a free tray of chicken salad wraps is worth the scrutiny.

The Sunshine Act, a provision of the Affordable Care Act (aka Obamacare), requires companies that make drugs, medical devices, and biological medicines to report payments and items of value given to physicians and teaching hospitals. (specifics outlined by NEJM and AMA)

Additionally manufacturers and group purchasing organizations must report certain ownership interests held by physicians and their immediate family members. It seems like physicians who own stock in a publicly traded pharmaceutical company do not have to report these shares, as they are generally available to everyone and are considered an “exempt” interest. But other terms of ownership and investment interest must be disclosed, including the dollar amount.

A transfer of anything between a company and a physician that has a value above $10 must be reported. Cumulative gifts totaling $100 or more over a year must be reported.

One way a sneaky physician might find a loophole in this regard would be to ask the drug rep who comes to the office for a lunch time meeting to bring just one hot dog, valued at $9.99. This would fly under the radar… at least 10 times per year – but if the total cost of the hot dogs brought into the doctor’s office exceeds $100 for the year, said hot dogs must be reported. One could then log on to the Medicare website and see how the 11 hot dogs your doctor ate over the year totaled $109.89, which carries multiple degrees of shame.

The Sunshine Act will expose or stop many physicians from making additional money through relationships with manufacturers that represent a conflict of interest.

It will also represent another dreadful use of the word “sunshine,” and makes for great irony as our government increasingly operates in darkness.

The threat of public shame and public misunderstanding will also create fear among physicians, and new treatments and medications will go unnoticed without the occasional lunch used by drug reps and physicians to communicate.

I’m looking forward to less patients assuming I go golfing for free, or thinking I get taken to Las Vegas for a free convention every year.  This has been outlawed for some time.

Office morale will plummet in many locations that used to host drug reps for lunches, occasionally or daily. The medical assistant who used to look forward to getting a free eggplant parm with arugula salad once a week (as her doctor learned about a new blood pressure medication) may now be upset. A lot of mom and pop restaurants will see fewer business lunches purchased by drug reps, and more fancy dinner venues will see a decline as well.

In any other facet of the American economy, the “business lunch” is revered as an opportunity for communication, networking, and an exchange of new ideas. In medicine it has been cast as a seedy chance for manipulation, kickbacks, and brainwashing, and is now subject to the sanitizing UV radiation of “sunshine.”

If we as physicians are to be held to such monastic, ascetic terms of engagement with the business community, then fine. I’m all for keeping drug reps carrying trays of chicken nuggets away from the office.  I’m all for those few specialists and physicians who are much too cozy with pharmaceutical companies getting the public scrutiny of their speaking fees and other arrangements. BUT THEN EVERYONE ELSE BUTT OUT, TOO.

Insurance companies paying CEO’s hundreds of millions, malpractice clients and their lawyers getting paid millions, overpaid health care administrators emulating corporations, and third party profiteers of all stripes… EVERYONE OUT.

The examining room should be about a doctor and a patient, with the unfortunate reality of the economic exchange feeling no more corrupt than payment for a bag full of groceries.

The pupils of the eye become smaller as we age,
shrinking to a mere third of their robust, youthful size.
You knew this, even if you were not aware
of the vanishing look in your grandmother’s window,
the reptilian ooze of warm blood over the cliff.

Open wide. Please. Open wider,
so that we might forget the collapsing,
the narrowing portals of grace,
the cold neutron stars,
in to which we are crushed.

In this gaping sun filled array
of gently swaying green,
wide opening pink petals,
and blue azulejo sky,
I lament the constriction of your pupils
more fervently than you can imagine.
For all things that shrink from the sun
might never have been here at all.

As anyone with seasonal allergies to tree pollen knows, allergy season has begun. Aside from the sneezing, itchy eyes, nasal congestion, and general sense of being ill, is there anything good about this springtime immune system dysfunction? I came across some evidence that might slightly relieve that annual sense of “suffering” – having allergies of any kind seems to reduce the risk of glioma, including malignant brain tumors, by up to 40%.

Asthma, eczema, and hay fever seem to all have this “protective” effect. Multiple observational, case-control studies have shown that allergic conditions are associated with a lower risk of glioma, and this has been confirmed by a larger, systematic meta-analysis. One prospective study found a 25% lower risk of gliomas in subjects with high IgE levels. When women alone were analyzed, those with the highest IgE levels had up to a 50% reduced risk of gliomas. IgE is the type of antibody most often found abnormally high in those with allergic/atopic conditions.  It is not known why women seems to have greater protection than men.

It is postulated that a general immune system activation with heightened immune surveillance explains this cancer reduction phenomenon among those with allergies.  An activated, vigilant immune system may destroy central nervous system cancer cells.

Ironically, the most common treatments for allergies, antihistamines, contain precursors of n-nitroso compounds which have been found to be potent neurocarcinogens. Some think these chemicals, which are also found in cured meats and bacon, may increase the risk of brain cancer by 2-3 fold. More recent studies, however, have been done prospectively and show no clear association between n-nitroso compounds and glioma.

And so while the nuisance of allergies as a medical problem cannot be compared with the profound suffering of those with malignant brain tumors, it seems as though all the sniffles, wheezes, and congestion may have at least one potential benefit.

 

References:
1, 2, 3, 4

There was an article in the New York Times recently about the importance of cultivating a family narrative to instill a sense of identity, control, and resilience in children. The more children know about their family story, the better equipped they are to handle stresses that would shake their foundation. Is it possible that, in the realm of personal health and well being, the cultivation of an affirmative family medical narrative might bolster one’s constitution?

Family narratives tend to follow one of three arcs. First there is the ascending motif: your grandfather came to this country as a peasant, his son became a teacher, and now you are in medical school. The second theme is the descending one: we used to have it all but now everything is falling apart. And the third narrative, which seems to be the most edifying, is the nuanced one: your father was a great business man, but he sometimes drank too much. Your grandmother was an excellent piano player, but her brother was in trouble with the law. No matter what, they stuck together as a family.

Children with the most confidence seem to possess an inter-generational self, a sense of identity that is part of something bigger. They can recall past chapters of hardships overcome by other family members, and get to work writing such stories of resilience when life presents new setbacks and sorrows.

Is it possible that in order to create a healthier, adaptive sense of well being we should set out to tell stories of good health and sanguine habits, and at the same time revere the tales of medical adversities overcome? Often we cannot control what medical ailments come our way, and many are utterly devastating. But as a family doctor I have seen family ailments that are less a genetic predisposition than an inherited legacy of symptom comprehension and behavior.

I hope to incorporate the strength of my great grandfather, who built his own house in the forest and chopped wood well into his eighties. I recall and regret that my grandmother smoked for fifty years, addicted as most of her generation was to nicotine. Yet I honor and hope to emulate her courage in the face of chemotherapy when it is my turn – may I have the strength of character to still make it to church and the farmer’s market on Sundays, holding my bald head high and keeping my exhausted eyes open to fight another day.

We should tell our medical histories, both good ones and bad ones, to our children – with hopeful, brave, and steadfast themes of endurance and vigor. It might just save or comfort a life.

You’ve probably watched the Super Bowl as I have many times, faithfully, elevating the occasion to some kind of macabre family tradition. It is a spectacle of athletic agility, drama, and struggle; the pinnacle of American sporting contests.

Despite the heavy onslaught of commercialism, faux halftime culture, and evident violence on the field, we suspend our awareness that this event may not be a magical moment worth our time and validation, even as its winners call out to some magical disney kingdom. Here are 7 points to consider:

7.) Obesity and cardiovascular disease

Up to 45% of youth participating in football are overweight or obese. The nature of the sport favors, and increasingly demands, a large body size. The physique acquired in adolescence often persists into adulthood.

According to a 2007 study of 653 boys ages 8-14 playing football in Michigan, 20% were overweight and another 25% were obese, as defined by body mass index. Studies have shown that linemen have high early mortality rates, and for all professional players who have played 5 years or more, life expectancy is less than 60.

6.) MRSA infections and abscesses

• Quarterbacks Tom Brady and Peyton Manning have suffered from it.
• In 2003, five members of the St. Louis Rams developed large abscesses due to methicillin-resistant Staphylococcus aureus.
• In 2002, two members of the USC football team were hospitalized, with one requiring multiple surgeries and skin grafts. The following year USC football reported 17 players contracting MRSA infections requiring incision and drainage.
• A 2007 survey of collegiate football players found an infection rate of 6.7%.
• Three studies completed by the Texas Department of State Health Services found that at least 276 high school football players in Texas were infected with MRSA between 2003-2005, at a rate that was 16 times higher than the national average.

MRSA infections can be fatal. Football is a particularly risky sport for contracting MRSA due to skin abrasions, potentially contaminated turf, sharing of towels, poor hygiene, and high antibiotic use (in the case of the St. Louis Rams study, players were given antibiotics at 10x the rate of the general community).

5.) Heat illnesses

CDC researchers analyzed cases of dehydration, heat exhaustion, and heat stroke among players of 9 types of sports at 100 high schools. 70% of illnesses occurred among football players, many of whom were overweight or obese. This translates into roughly 6,400 annual heat-related illnesses resulting in at least one day of athletic participation lost.

4.) Spectator heart attacks

The most vivid anecdote of this phenomenon may be the story of a Pitttsburgh Steelers fan who went into ventricular fibrillation, a lethal heart rhythm, as he watched Jerome Bettis fumble while crossing the goal line.

A German study found that cardiac emergencies were over 3 times as likely in men, and almost 2 times as likely for women, during days the German national football (soccer) team played in the 2006 World Cup.

3.) Concussions

The violent shaking of the brain against the skull causes a flood of neurotransmitters and discharged neural circuits in the brain, leading to varying degrees of confusion, blurry vision, nausea, dizziness, headache, memory loss, imbalance, and sometimes unconsciousness. Repeated concussions lead to permanent brain injury and long term degenerative brain disease as listed below.

2.) Musculoskeletal gore

Athletes become paralyzed from vicious collisions, accidental and malicious. During some games it seems there are more pauses for injuries than forward passes. Microphones capture the crunching sounds, cracking joints, and juice-filled meat poundings of each hyperintense collision.

How often can the mob watch breathlessly as another football player lies motionless on the ground, hoping for a twitch to assuage the collective guilt of a blood thirsty audience?

If the sum total of all the torn cartilage, tendons, muscle, skin, and fat were placed in an abattoir-worthy heap it would tower into the sky like an oozing, fetid, bacchanalian monument to human misery. Need references for that claim?

1.) Chronic Traumatic Encephalopathy

CTE is thought to be caused by repeated blows to the head. It has been implicated as a cause of depression, completed suicide (football players such as Ray Easterling, Junior Seau, and Dave Duerson), and dementia in untold others.

Even mild but repetitive impacts have been associated with long term brain damage, and increasingly attention is being focused towards the negative consequences of the sum total of head trauma.

Perhaps George Will said it best in an editorial in the Washington Post last summer:

In the NFL, especially, football is increasingly a spectacle, a game surrounded by manufactured frenzy, on the grass and in the increasingly unpleasant ambiance of the fans in the stands. Football on the field is a three-hour adrenaline-and-testosterone bath. For all its occasional elegance and beauty, it is basically violence for, among other purposes, inflicting intimidating pain.

So join me in boycotting the Super Bowl and its grandiose commercialism, entertaining violence, and sad risks for the health of its gladiators. Create art, have a conversation with your kid, get a colonoscopy… there are much more edifying pursuits than tolerating, nay worshipping, the violent tendencies within.