Mental Lint

This latest chapter in the nationally televised serial The Cluckshow is surprising even the gaggle of old hands who gather ’round the woodstove of a chilly morning. Yesterday the group, which hardly ever agrees on anything, unanimously came to the conclusion that there are a significant number of Americans who are perfectly daft.

No matter how many sober people come up to the mike and say that the election process wasn’t corrupted these misguided ones continue to believe the opposite and that somehow their champion will pull off a miracle.

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It doesn’t help that they are supported in their delusions by some very corrupt people indeed, people like Senator Turtle, who stand to gain by keeping governmental matters in a continual state of chaos. So much of the public chatter is how Cluck disrespects our traditions and the nation’s best interests (and he does) but Cluck suffers from serious mental disturbances. This gets him exactly one smidgeon of sympathy. Sen. Turtle does the same thing but is completely venal, which qualifies him for no smidgeon at all.

So the members of the hot stove club went home yesterday wondering how things ever got so bad that we all agreed on something. It was unsettling, to say the least.

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A gallery of images of Senator Turtle

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Yesterday as I was listening to NPR I found that I had moved even further down the list of People Who Will Get The COVID Vaccine First. When this all started I felt confident that my age and many infirmities would put me right up there after emergency room physicians. But as each new draft proposal comes out my number gets further from being called.

So after spending some idle moments reflecting, I have voluntarily assigned myself to a new place in that therapeutic line. I plan on waiting until I see that all serial killers in solitary confinement in maximum security institutions have been protected, and then I will step forward. I believe that in this way I can avoid most disappointments.

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No Love, No Tacos

Here’s a simple little story that was a total day-brightener for yours truly. It’s about La Carreta Mexican Grill, a small restaurant in Iowa that mixed politics with business and some of the blowback that resulted. My hat’s off to Alfonso Medina for his clear thinking in these murky days. This guy is the sort of citizen that will help bring us out of the mess we’re in. Someone who believes in the promises of America and acts upon those beliefs.

A man who is closing his place of business on Election Day so that his employees can vote, while he himself volunteers as an election worker. (BTW, he is also paying those employees their salary on that day.)

I wish we lived closer to Marshalltown IA … how could their tacos not be excellent?

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BTW, about Mexican restaurants. My first visit to a new one is always the same. I order their beef tacos.

I think of my “system” as a sort of biopsy of the kitchen output, if you will pardon the clinical comparison. It tells me what I need to know about the place. If that simple, uncomplicated item is not savory, if the sauces are lacking in interest and authority, if the shells are stale … why bother with the Camarones a la Diabla? They are very likely to be an expensive disappointment.

Oddly, one of my favorite tacos was served up not in a Mexican establishment but at the salad bar in the Bonanza restaurant in Yankton SD. I say “was” because try to find a Bonanza steakhouse anywhere today. There are only a handful left in the U.S., victims not of Covid-19, but of rising beef prices and changing dietary tastes.

We have a number of Mexican-themed dining places here in Paradise, most of which are interchangeable and unremarkable. Close your eyes and you wouldn’t know which one you were in. They have the same offerings, the same plastic menus, the same unadventurous menu items. No one with chiliphobia would be threatened by what what comes out of their kitchens.

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I have lived in Montrose for nearly seven years, and before that in Yankton SD for several decades. In all that time, I have not had what I would consider a thorough physical examination. The kind that I was taught to do in medical school. The kind that picks up problems when they are smaller and potentially more treatable.

Now, for me personally it has not been a disaster. I can fill in a lot of the gaps with my own self-exams, at least of the places I can reach. I can stand in front of a mirror and check probably 90% of my skin surface. In this way I try to avoid nasty surprises. Otherwise the physicians that I have encountered have basically looked at only what I was complaining about, and usually in a more superficial way than I was taught to do.

My present doctor, who seems a capable person, has never asked me to undress, but listens through my clothing to my heart and lungs, a poor second to placing the stethoscope directly on the skin. I could have a skin lesion the size of New Jersey and she wouldn’t know it unless I brought it up. During my very recent brush with a serious problem (and although I am soooo grateful for the excellent care that saved my personal bacon), no one ever did a complete neurologic exam, or looked at the rest of my body for indications of possible reasons I might have had a stroke at the tender age of only 80 years. This in spite of the fact that my disease was of the central nervous system.

On the other hand, I had two CT scans, an MRI, an echocardiogram, and beaucoup lab tests. It would have been hard for any occult disease process to make it past those inquisitors, so I am not too worried.

My own training was at a very different time, I admit. A time when we were much more dependent on the physical exam to help us come to a diagnosis. The CT scan, the MRI, and the echocardiogram were yet to be discovered. So it would seem that extensive and time-consuming physical examinations are not prized the way they once were, and maybe that’s not a bad thing. Maybe they are only artifacts of a dinosaur age of medicine.

But god forbid that these physicians ever have to go to work on a day when the electricity is off.

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In the Humor section of the New Yorker this week was a series of caricatures of “other otuses.” This was one of the most tasteful of the lot.

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Today I will haul myself to Grand Junction for a visit to the Stroke Clinic. I have a few questions for the neurologist, and also wanted to give him the chance to see me with pants on. I am a much more impressive person when fully clothed, and in the name of full disclosure, I think he deserves to know that.

Otherwise I am doing well and the only change in my life is a single new medication. I have no problems that I didn’t have before my adventure of two weeks ago, and those basically come down to remembering where I put my car keys and to zip up before I go out in public.

Yesterday I was on the phone with friend Bill H. and he asked if Robin and I planned to cut back on our explorations and hikes because of this hour-long brush with an alternative reality. The idea being that we might be sometimes hours away from the terrific care that I received this time. And in the case of a stroke, everyone knows that hours is too long.

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I have given that a lot of thought, and decided against making big changes. If I were to push this line of thinking all the way I’d have to rent an apartment across the street from the hospital and have my groceries delivered, just in case … . So we plan to live our lives as before, not out of some false sense of bravado, but because making sure that we’re never more than an hour from a stroke unit doesn’t work out well in real life. We will minimize the risks where we can, but there is really no risk-free existence, is there?

The number of ways that life could catch any of us unawares is infinite. So we all cover the bases we can, and then we lock the door behind us and go out into the that uncertain world, anyway.

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I Now Pronounce You …

Although the wind blew and the smoke hid the sun, Amanda and Lee were married on the grounds of a South Dakota hunting outfitter in a very well planned ceremony. Bride and groom were cool as the proverbial cucumbers, while the bride’s parents were somewhere on the other side of the vegetable spectrum. Being a parent can occasionally be tough, and a wedding is one of those instances where you are called upon to exercise skills you were not given at birth, learned in school, or picked up at the coffee shop. In short, you are flying somewhere near blind.

Unless you can afford to hire a wedding planner, and even then there are hundreds of questions to answer and so very many checks to write

But it all went down so well. It was a lovely time, and Robin and I are very happy for the couple and wish them long and happy years together. They have already been through more trials than most newly marrieds and deserve a break. A good, long one.

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To bring things back to the ground a bit. We left the grounds shortly after the ceremony, skipping the reception and wedding dinner, which were to be held indoors. This had been our plan from the beginning and we stuck to it. There were only three attendees who were masked, and we were two of them. Our plan also includes self-quarantine when we get back to Paradise.

I don’t know about you, but we really don’t love this era of the coronavirus. It’s like a big paintball battle, but one where the opponents are invisible and the paint is poisonous. Sheeesh.

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… Nothing To Fear …

I find that in some ways I’m not a good person to discuss Covid-19 with. My internal sensors regarding exposure and risk are set differently from that of many other people that I know. I am missing some of the fear that they describe. Not all of it, but some. This is not due to courage, since I have no more of that quality than anyone else, but it comes from repeated experiences over a medical lifetime.

On Christmas Eve of 1966 I was a pediatric intern on call. A critically-ill infant had been admitted that day with meningitis, and I was covering for the physician responsible for her care. At around 10:00 P.M. she suffered her first arrest, and I began CPR immediately using an infant-sized bag and mask and chest compressions. At her second arrest an hour later, the bag malfunctioned and became unusable, and someone had to be dispatched to another area of the hospital to retrieve another. In the meantime, I used mouth-to-mouth respiration. We were once again successful in bringing the child around, but by midnight she had died in spite of our efforts.

The next morning the lab reported out the causative infectious agent as meningococcus. The members of the team that had worked with her were prescribed sulfonamide tablets as prophylaxis, and I dutifully took mine for the designated number of days and that was that.

There was no pause when the mask failed, I believed that this is what doctors did, this was part of the “contract” I signed when I decided to become a physician, even if I hadn’t thought it through as fully as I might have.

Over the years there were less dramatic episodes, but the theme was always the same. We (members of the medical team) would protect ourselves as much as was possible, but we entered those sickrooms, gave those treatments, did what was necessary to do. It was our job and we adapted to that reality in our minds.

So I completely understand the concerns and actions of workers in hospitals today who have to work with scanty protective equipment. You don’t prize your own life any less, but you took on the job on a sunnier day and now you are working in a hailstorm.

BTW, not every health care worker I have met feels this way. Some of them begin looking for the exit at the first sign of danger. I recall when Yankton SD’s first AIDS patient showed up at the hospital with appendicitis. It was early in the course of the AIDS epidemic, when information about transmission was still pretty sketchy.

It took a while to round up an OR crew to do the surgery necessary on that Sunday afternoon. Some personnel refused to answer the call. But others did, the operation went well, the young man went on his way, and his caregivers suffered no adverse effects.

So I protect myself, those around me wherever I can, and I limit my exposures. But I am intimately acquainted with the knowledge that there are perils in the world. A viral particle, a frayed bit of electrical wiring, a car being piloted by an intoxicated person. If you think too much about all the hazards that life provides, it could be almost paralyzing, couldn’t it? But we all open those doors and leave those safe spaces when the need arises. We suit up and show up. You and I.

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While I’m talking doctor stuff, I have a true short story for you. On a summer Sunday afternoon in 1967, a very ill six year-old boy was admitted to University of Minnesota Hospitals with fever, lethargy, and a dramatic rash. None of us assigned to this patient recognized the rash, so we stat-paged the chief resident on dermatology to come to the admitting examination room.

Now, for the most part, stat pages are extreme rarities in dermatologists’ lives. It is one of the attractions of the specialty, along with regular hours, weekends off, and freedom to vigorously nag anyone with a suntan. So when the derm chief resident heard the page, he grabbed a piece of equipment to bring with him to what would possibly be the only emergency call he would ever receive.

My question to you is: what did he bring with him? (Answer is below)

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From The New Yorker

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He brought a camera.

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We watched the Democratic convention again on Tuesday and Wednesday night, on ABC live. It’s interesting how the “meeting” is being presented, and of course it is basically all scripted and managed. But still some of the speakers come through those LEDs and LCDs pretty well. So far my favorites have been Michelle Obama, Barack Obama, Kamala Harris, and Jill Biden.

ABC has George Stephanopoulos managing a shifting group of commentators sitting at a long and socially-distanced desk. So long that not all of them are in the camera’s view unless one pulls it back a good distance. They jumped into the discussions whenever there were pauses in the “convention” schedule. I found them largely annoying.

For instance, at this point in the history of the republic, I don’t really care what Chris Christie thinks – about anything at all.

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Smoke is in the air this morning, so heavy that we can barely see the silhouettes of the San Juan Mountains to the south and the Uncompahgre Plateau to the west. And the closest fire (below) is a hundred miles away from us, north of Grand Junction.

Another large fire near Glenwood Springs has closed Interstate 70 for about a week now, with no predictions as to when that vital highway will be open again. East-west traffic is being rerouted in several directions, one of them being through Montrose along Highway 50. When we returned from Leadville a couple of days ago, there was heavy traffic both ways on a road that is usually lonesome traveling.

It is truly crispy here in Paradise. The amount of rain we’ve received at mi casa this year wouldn’t make two pots of good coffee.

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Made up a quart of ghee yesterday. Got into it while learning something about Indian cuisine a while back. It’s a simple chore that produces something which is priced akin to liquid gold in grocery stores. All you need is some unsalted butter, a saucepan, and about twenty minutes of your time. Ghee is great for cooking, since it provides buttery flavor but does not brown or smoke at ordinary cooking temps. And it keeps for months at room temperatures.

There’s a decent tutorial at this website if you’re interested.

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Burning Perfectly Good Food

We’re having the Manns over for dinner tonight (Wednesday). Grilling outdoors and serving on the deck, where any stray coronavirus particles can be puffed away by the evening breezes before they have a chance to land. All of the distancing stuff will be observed, food preparation is being carefully done, and we earnestly hope not to share anything with our guests but clean vittles and our lovely selves.

It’s our first such social foray since the outbreak began. The Manns live just up the street, and are people who frequently pop into our minds as “We should have those folks over sometime and get to know them better.”

The evening forecast promises that it will be rainless, warm, and almost windless. There will be tunes, of course. What summer night would be complete without them? It’s a touch of the homely at an extraordinary moment in time.

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There is a form of cancer called a pheochromocytoma. It originates in the adrenal gland, which normally produces several hormones, including adrenaline (epinephrine), which is a fight or flight hormone. A “pheo” can over-produce these hormones, and occasionally if one unwisely presses too hard on the tumor during a physical exam there can be a dangerous flood of these substances into the patient’s bloodstream.

So where am I going with this? The P. Cluck gang seems to me to be the political equivalent of a pheochromocytoma. They are a cancer on our body politic for certain, but not just any old tumor. If it is squeezed or threatened in any way out comes all manner of violent and unhealthy behaviors and pronouncements which do further harm to our citizenry and our country. When the moment comes in November this neoplasm needs to be cut away ruthlessly from the corridors of power.

Too overblown a comparison? Perhaps. I do tend to overblow. It’s one of the things I like most about myself.

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The cookout went very well. First of all, the gods of weather cooperated by providing one of those soft summer evenings you dream of in February. And the company was excellent. Zoom has been a boon and we are grateful for it, but there is nothing like face to face conversation. For me, all substitutes pale before it.

Unfortunately and eventually twilight turned to dusk turned to darkness and our guests had to go home, where they feared to find that their new puppy had probably reduced some rugs to shreds. It’s the difference between puppies and kittens. (Although a kitten can take a nice couch and turn it into a ratty-looking mess pretty quickly.)

I had a friend while in the Air Force who told stories about raising a St. Bernard from puppy-hood. One day he and his wife returned home to find that their new charge had chewed the entire arm from their couch. And when describing paper training, he grimly volunteered that when your puppy weighs fifty pounds, its toilet habits present an emergency.

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Heroism comes in all flavors and sizes. My own experiences have taught me that over and over. I will explain.

When I was working in Buffalo NY in the late 70s, it was at a hospital that was transitioning from an old-line private institution to a county hospital. Which led to a disconnect. The buildings themselves were located in an older and genteel part of town, while the populations that it served were elsewhere. At the pediatric clinic, I worked every day with a succession of grandmothers who were bringing in their children’s children for well-child care.

These women saw to it that those babies received their immunizations and examinations even when it required taking city buses and transferring two and sometimes three times, through the toughest part of town, to get there. Summer and winter. Rain or shine, they suited up and showed up. My own children were still small back then, and whenever it was my turn to bring them to their pediatrician for the same care, I generally regarded it as a chore eating into my precious day and would whine about the time spent.

But not these women. They saw the same visits as important enough to the lives of their charges to spend most of a day in transit just to get them done. To me their actions were heroism, of a very quiet and uncomplaining sort.

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Miss It?

Even though I’ve been retired quite a while now, there are still times when meeting new people that I am asked what I used to do when I was a productive member of society. I tell them I was a children’s doctor. Their followup question is frequently “Do you miss it?”

I usually give the short answer “Parts of it.” And that seems to satisfy the stranger.

The long answer is that there are parts that I miss terribly, and some that I wouldn’t revisit for anything you could offer me. There are also parts, quite a lot of them, actually, that bored me to death.

I do not miss being the bearer of bad tidings to parents. Not in the slightest.

I do not miss the routines, where a well-tuned android could do the same thing that I did, perhaps better because they are sooo reliable and never forget.

I do miss the thrill of waiting in an emergency room for the ambulance to arrive, with a team beside me. Not knowing exactly what was coming, and worried/scared each time that I would not be up to the challenge. Then to be completely lost for a time in the struggle to sometimes reclaim a life and hand it back to the person. That, I miss. (Adrenaline junkie variant?)

For similar reasons, I miss the excruciating nervousness during a high-risk delivery, when the baby-yet-to-be-born’s vital signs had turned to merde. Waiting with the knowledge that there was no one else in the room with the skillset that I had, and wanting so achingly for the obstetrician to please get that baby out and give it to me so I could do what I knew to do.

That, I miss.

I miss the puzzles posed in differential diagnosis, where a patient or parent tells you a few things, an examination tells you a few things more, and perhaps the lab or x-ray departments make a contribution as well. And then it is you, using that mainframe in your head going over and over the data, back and forth, testing and rejecting hypotheses before you finally come up with an answer. Sometimes you have weeks to make up your mind, sometimes a tiny fraction of that time.

That’s a longer answer to the question.

The one that if I tried to give it each time I was asked, I would probably end up talking to the back of the stranger’s head as they walked away. We don’t always really want the answers to the polite questions we ask.

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I, Too

by Langston Hughes

I, too, sing America.

I am the darker brother.
They send me to eat in the kitchen
When company comes,
But I laugh,
And eat well,
And grow strong.

Tomorrow,
I’ll be at the table
When company comes.
Nobody’ll dare
Say to me,
“Eat in the kitchen,”
Then.

Besides, 
They’ll see how beautiful I am
And be ashamed—

I, too, am America.

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