Bread Between The Legs

English: Candida albicans
We call these ‘branching hyphae’

Yeast infection: Yuck-central to the average vagina owner. Discharge like milk curds, funky smell something akin to old toes floating in rotten vinegar, and an intense itch that you can’t actually itch because if you try, it hurts. Cool, huh?

When you’re talking about this fun experience, what you’re largely talking about is overgrowth of a specific type of yeast called Candida albicans, which is actually a fungus. Pretty gross.

Truth is, there’s probably a few of these little guys hanging around the average human vagina all the time and it’s no big deal, but too many of ’em and you’ve got a problem.

Candida albicans
Same as the above pic, just the DANCE version.

Of interest, Candida is kept at bay by another creature that you want hanging around in your vagina called, as a group, the lactobacilli. These guys don’t fight candida, they’re much more suave. They simply produce an acid (“lactic” acid…get it?) as part of their normal life cycle that subsequently keeps the vagina acidic. This makes things real tough for most other creatures, except for the odd Bear Grylls of the Candida world who eat acid for breakfast.

Yeast infections result when the acidity levels in the vagina drop. It’s hard to predict when and how the pH will change in that region of the world, but often it does.

Historically, yeast infections were easily treated with anti-fungal creams or a single pill of the drug fluconazole. But the “easy” part is going away. Increasingly, I’m seeing patients who have recurrent yeast infections despite the usual treatment.

Often, these patients have a history of heading to the doc for “that pill.” And often, docs (or the “provider”) just fire the pill at them and everyone calls it a visit. It’s quick for the patient, saves the doc time, everyone’s happy. Unfortunately, the happiest of all in this equation is the yeast.

Fluconazole
Fluconazole

Fluconazole works by blocking an enzyme. That enzyme facilitates reactions that create the yeast’s cell wall. With the drug around, their cell walls get floppy(er) and don’t hold together as well.

But that doesn’t mean the bug is dead. Fluconazole isn’t some flaming thunderbolt from Mt. Olympus that blasts yeasts back to the Elysian (bread) Fields. The drug is fungastatic, not fungicidal. The weakened yeast is then susceptible to other bugs our our immune systems. Like a mob boss of the pharmaceutical world. It doesn’t do the killing, it just arranges, eehh, ‘tings.

These days, fluconazole isn’t as tough as it used to be. It doesn’t work like it did, often not with the strength it had. So tossing this pill at a yeast infection is a bad idea. Real bad.

Certain types of yeasts make poofy bread and good beer and they keep Jewish people busy (some would say crazy) during Passover. So they’re not all bad. But it’s an organism that we could do without. Fungal infections, when they become systemic, have always been tough to treat; more so than bacterial. And systemic anti-fungals have always been tougher on the body than antibiotics.

Under these circumstances, the best approach to recurrent yeast infection is NEVER to just go get another pill. You should firmly request that your doctor not only get a wet prep (which is merely looking for the presence of yeasts on microscope slide), but also order a culture of the yeast should any grow on the prep. From that culture, not only can the species of yeast be determined, but it can also be tested for sensitivity to fluconazole and other anti-fungals to see if the right drug has been chosen.

Recurrent yeast infections are beatable, but not if you’re lazy about it. For reasons that most men can understand, yeasts really, really like the vagina. If you don’t like ’em there, you’ve got to put more than just a little effort into getting ’em out.

Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...
Father Ventura, surely a surfer
Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.

Officer Basic Training – Day 1 (or, The Subjugation of Befuddlement)

I have left my family in Germany and successfully arrived in tepid San Antonio, TX for 28 days of training to become an officer in the U.S. Army Medical Corps (pronounced ‘core’ not ‘corpse,’ though both work pretty well).

On my flight over here, I called some in-charge guy from Oh-Hare airport in Chicago to ask him where to go when I arrived last night because I was a day early.
 
***note to friends and family who know anything about me…I showed up EARLY for something I regard as totally stupid.  Note that. Somewhere.  Just get it down for posterity somehwere.  Not just on-time.  Early.  Me.***
 
A guy actually picked up his phone when I called and told me to go to building #596, which is an Army hotel on Ft. Sam Houston. 
 
“Nice,”  I think.  “I’ll be staying there for a month.”  I take a cab from the airport to the hotel.  The cab driver drives away.  I walk up to the counter, am asked for a copy of my orders, then am told that my room is at the Holiday Inn next to the airport.
 
“I was just at the airport.”
 
“Yep.”
 
“I just paid a cab guy to get me out here.”
 
“Yep.”
 
“Thank you, so much, ma’am, for your help.  Can I have my orders back?  And, could you call me a cab…maybe even THAT GUY driving away over there who just dropped me off?”
 
She calls a cab, but not that guy.  It will be a half-hour, she says, until a cab can get here. 
 
Hmmm.  K.
 
Then, feeling Army-saavy, I ask her to COPY the copy of my orders she asked me for, and make me a few extra, AND SHE DOES!  
 
We’ve been told to come here, inexplicably, with 10 copies of the orders telling us to come here.  The need for a billion copies of paper orders is one of the many stipulations that totally befuddles me.  I am actively in the process of subjugating all sense of confusion, befuddlement, and mystification, with mixed results. 
 
But with respect to my orders, I’m making it my personal goal to leave this course with MORE copies of my orders than I arrived with.  If I get back home with more than 10 copies of my orders…I’m taking my wife to dinner or something.
 
Anyway, it’s a nice hotel, and I have to keep reminding myself that I am NOT here for the usual blah-blah conference.  For example, our day starts tomorrow at oh-430…well before the “free” breakfast I’m entitled to.  And some of the classes we’re supposed to take start at 6pm or later.  So, it ain’t a cardiology meeting in Oahu.
 
I’m in SanAntonio, in August, in a heat-wave that is about to break historic records.  So yes, it is butt-hot outside.  And I’m the kind of person who thinks PERFECT weather is overcast, rainy and 65 degrees F.  Seriously.
 
But it turns out that the heat actually doesn’t bother me, so far.  Mostly just feel like I’m back in Beer Sheva, Israel where I went to medical school.  I haven’t been running around in it yet, but so far it hasn’t really phased me.  It’s hot.  Like med school.  Who cares.
 
I met a guy at breakfast this morning who is also in the class.  Cool.  Older.  Knows stuff, like what he “makes” per day and that it’s good to bring a roll of toilet paper when we go “to the field.” 
 
As he sits there describing Army stuff, I wonder what my problem is with details and why I’m so averse to them.  He’s talking about tax-deductions for military pay or something and I’m thinking…”Kyle Orton, he’s really the guy who needs to play for Denver this year”…and…”At some point, this guy is gonna tell me how to get out of deployment AND monthly drilling and when he does, boy, I’ll be RIGHT HERE ready to pay attention…but he just said ‘requisition’ so no need to tune in yet.”
 
His name’s “Ray” and I’m extremely proud of myself that I remembered it.  I came up with “First-day Ray” and now it’s in my head forever. 
 
Ray assures me that since we’re off-post, I won’t be given a roommate.  That was an “on-post” stipulation because it was a barracks environment.  The hotel lady yesterday told me otherwise, saying that I would be getting a roommate and I had not choice in the matter and would not be allowed to pay extra for my own room. 
 
So, the jury’s out on “Ray.”  If my single room survives today…he wins.  Stud.  Fount of knowledge.  I’ll actually like him at that point.  And he won’t be placed in my category of people who talk like they know stuff but who I ignore for your own safety.
 
Having my own room is pretty cool.  I can sit here, for example, completely naked and type my little blog.  I’m NOT, actually.  It’s just that I COULD if I wanted to…which is the whole point. 
 
It’s the Manhattan Effect…the desire of millions of people to live in Manhattan so they can be near museums, shows, galleries and restaruants and theaters even though they won’t patronize even 5% of what’s available to them for the entirety of time they actually there.  It’s just that the CAN go if they want to.
 
‘s called freedom, and I’m rather partial to it. 
 
So, my own room is nice in that way.  Doesn’t sound like I’ll be in it much, though.  Class starts at 430 in the morning, and the last class starts at 7pm.  So it doesn’t really matter who’s in here.
 
And I suppose I won’t type naked anyway. I’m afraid that as the hard drive warms up, a film of sweat will form between the laptop and the actual “lap”, as it were, and the machine will short itself out in an explosion of wicked-blue electricity bolts right into an area that really should have been covered out of respect for my readers, for God’s sake, if not for my own sense of Fallen-Man shame.
 
I do have a sense of pleasant anticipation as the day gets started.  I’m like any average boy who grew up crawling around fields and forests “fighting” Nazi’s and aliens and dragons.  Already I was “ordered” to buy a pocket knife, which definitively makes this better than your average medical seminar. 
 
So as I enter day 1, I can say that if over the next 28 days there’s firing of weapons – of any kind – any choppers, night-vision goggles, topo maps, compasses, smoke, explosions, crawling on elbows and knees, face paint, knives, matches, tents, or at least 11 copies of my orders…this little month away from my family might just be worth it. 

‘Concierge’ Medicine – A De Facto Manifesto

My blogging output has been at an all-time low since moving to Europe.  Who knows why…this place is such a bore.  I continue to hack away at my book, which never seems to get close to done – the literary equivalent of Sisyphus’ ever-rolling stone.

The other day a reporter contacted me to hear my thoughts on so-called “concierge” medicine.  It was a timely query, since I’m considering a loose offer to join a concierge practice back in the States.  In my email reply to him, I found myself writing my own little manifesto on the subject.  A treatise, if you will.  A declaration.  A primer? A resolution, a promulgation…

William Osler (1849 - 1919), Professor of Clin...
I have a idea...how 'bout I actually know who you are, AND care about your medical issues?

 

I’m a big believer in concierge medical practice, although I use the term “concierge” only as a nod to already-established norms.  Really ‘concierge’ medicine is a throw-back to true primary care medicine before it was ruled by other industries.  So the idea isn’t new.  It’s old – old as William Osler and Johns Hopkins and William Carlos Williams.
This industrial “take-over” I mention isn’t entirely due to craven insurance businessmen.  It’s also due to the allure of “Wal-Mart” pricing that so captivates Americans.  I suppose you’ve heard the adage that as a consumer, you can only have 2 out of 3 options in the market: Fast, Good and Cheap.  If you want something fast (hamburger), you can get it cheap (McDonald’s) but it won’t be good.  Or, you can have it fast and “good” (quality, taste, etc), but it won’t be cheap (maybe, Red Robin?).
This principle is true in medicine too.  Americans, over the past 20 years, have been trending toward Fast and Cheap medicine, just like they want clothes, household goods, food, etc. quickly and cheaply.  Hence, the rise of WalMart, which provides easily acquired things of questionable quality.
Concierge medicine isn’t “cheap,” by WalMart standards.  It requires real cash investment.  But it IS better.  And, while there is little problem with wearing nondescript, zero-style golf shirts to work every day, primary care is different.  We’re talking about your life, here.  Not only are you likely to live longer and healthier with good primary care, but it really is cheaper over time because it is so effective in offsetting gigantic medical calamities later.
I dispute the notion that no one can afford concierge medicine, by the way.  Most people in the richest nation on earth perceive they can’t afford it, but really can.  I blame this perception on the invention of the 10-dollar co-pay.  This idea was such poison in American medicine.  It made medical care seem like the equivalent of a few iTunes, or sunglasses from a roadside gas station – just another in the ocean of cheap, disposable and generally worthless products. Yet so many Americans shell out enormous amounts of money on alcohol, cigarettes and fast food.  They don’t think twice about coming up with over a thousand dollars to fix the clutch on their car, or to trick it out with lights and racing wheels.  But when it comes to good, relationship-based primary care, they resent anything more than “10 bucks.”
I’m currently in a line of work that provides “free” care to everyone (the military), so at the moment I have no vested interest in the above comments.  But I continue to feel strongly that it is not immoral to require a reasonable, even significant, amount of money for true primary care, especially when obtaining that care may require cutting out things that are terrible for your health.  I see major problems with a medical system that tries to provide unlimited access, especially when coupled with zero perceived cost for that access and care.
More health care is not better health care; worse, it can be dangerous.  On a daily basis, people needlessly lose breasts, prostates (read: sex life), resistance to microbes, and countless other quality of life measures in the process of hunting down phantom maladies or responding to false-positive tests.  High-quality primary care offers good, analytically based work ups of genuine symptoms that justify that work up.  NOT investigating something further can often be the best medical care available.
I mention ‘analytically based’ decisions because most mid-levels (a cost-cutting invention in American medicine) are trained to provide algorithmic decision-making:  that is, if X symptom, then Y action with little analysis involved.  recipe medicine.
Often algorithmic medical decision-making is just fine, but it easily leads to over-testing and over-treatment.  When it comes to possibly dying from cancer, for example, most of us want someone who knows us, knows how we communicate, and what is important to us (e.g. dignity vs. “full court press”). Further, we want that same person to be well-trained in weighing the risks vs. the benefits of treatment vs. non-treatment, based on the latest available medical knowledge.
Doctors seeing 20 patients a day can’t provide this adequately.  Mid-levels are not trained to provide this type of risk-benefit analysis, and don’t have the hours of training experience even if they wanted to.
Disclaimer:  I’m speaking in generalities here; there are fantastic PA’s and NP’s out there, many of whom are compassionate and professional; better than many physicians.  Most I’ve met are smarter than me.  But in general, the care from a mid-level is fundamentally of less quality because the training of a doctor is an average of 3 times more than any mid-level (roughly 3,000 hrs vs. 12,000).  This differential limits mid-levels to algorithmic, rather than analytical, decision-making.  When it comes to your health care, the mantra should be “reason, not recipes.”
These days, you can’t get this care from HMO’s (Group Health in Seattle is getting very close), you can’t get it from mid-levels.  The only place I know where you can get this level of care, is in a ‘concierge’ practice, where the benefits of the increased cost are immeasurable.

Health Report – Mickey Mouse

Our family just returned from Disneyland Paris.  We had a great time.  As a doctor, however, I just couldn’t ignore the many health problems clearly evident in the thousands of images I saw of the world’s most famous mouse.

Fictional characters on the Hollywood Walk of Fame

I can say with confidence that this will be the first and only time that I publish the health record of a patient without his/her consent.  But then again, I’m not even sure this little rodent was my patient at all.  Furthermore, I can’t vouch for my physical exam of our storied mouse – given his rather cavalier take on the idea of ‘physical’ – but I do believe we should all be alarmed at the probable health status of our big-eared friend.

Of greatest concern is what can only be described as HUGE feet.  Unfortunately, this does not suggest enviable male endowment, as it is sometimes rumored in those with enormous paws.  Rather, these feet are swollen.  A close look at most pictures of this patient suggest that he in fact can’t wear shoes at all, but instead some sort of stretchy slipper.

The illustration shows the major signs and sym...
I Kept Seeing This Instead Of Enjoying Space Mountain

The best explanation for feet this swollen is congestive heart failure.  This is a situation where the heart has pumped against a dysfunctional circulatory vessel pressure for so long that the muscle fibers have becomes stretched out and weak.  Eventually, the heart becomes incapable of pushing blood around the body effectively, causing pooling of fluids in the extremities, especially the feet.  Judging by the thousands of pictures of him, most drawings were likely done after this patient had been on his feet all day.  Let’s face it, an 80 year old mouse can only walk around smiling waving at kids for so long before problems arise.

CHF is progressive (meaning it just gets worse over time).  Elizabeth Taylor just died from this, for example.  Mick could use any of a number of meds to lower his blood pressure, and (arguable, these days) something to strengthen the contractions of whatever functioning heart muscle fibers he still has.  He should also go with low-salt cheese, lean scraps and whatever else a billionaire mouse might eat.

The little guy also has disturbingly white hands.  Leaving aside the perplexing question of how a rodent has human hands (and feet), what we’re probably seeing here is Reynaud’s phenomenon.

In itself, this is a circulatory system peculiarity that is not medically-concerning.  However, it can be very painful.  Mickey appears to be in the early stages of the process.  Likely shortly after his portrait sittings, his hands turned bright blue, then eventually into a deep red.  Throughout the process, he would be in quite a bit of pain.

Of course, I can’t be sure if he isn’t wearing gloves (assuming that garish white color IS his skin, frequent glove use makes sense).  Gloved or not, we still have the problem of clearly HUGE hands, suggesting edema like that described above in his feet.  Assuming, however, that we do in fact have Reynaud’s here, the concern is of an autoimmune disease in the category of lupus.  “Lupus” is a reference to the facial rash often seen in the disease and how it mimics the fur-pattern of the red wolf.  Given that wolves engorge themselves on mice whenever possible, this diagnosis is insult to injury for our poor little entertainer.

Furthermore, lupus typically causes joint and connective tissue pain.  It can lead to heart problems, anemia, serious lung problems including emboli and hemorrhages, kidney damage and neurological problems.  There is no known cure, although the disease can be managed usually to good effect with oral steroids (not of the Lance Armstrong type…we’ll get to that), but the Mickster here clearly needs to get them started.

Mickey Mouse Bus
On The Way to Rehab?

Next, the rotund belly.  This is the physical sign most associated with diabetes and other metabolic diseases (or could be another sign of his CHF).  Termed by doctors as “central obesity,” this malady affects a HUGE proportion of American men, especially.  To our knowledge, little else puts a person more at risk for big metabolic problems.  Mickey lives at Disneyland, where he can expect to eat things like spun sugar, rock candy-encased apples (I presume of the sort that felled Ms. S. White) and shovel-fulls of sweetened popcorn.  So, as a nearly 90 year-old mouse, he can be forgiven the “Gaston Gut,” as it were.  Still, a strict diet is highly recommended.

Another thing:  look carefully, and you’ll realize that Mickey’s head is larger than his entire thorax (body sans legs).  Babies exhibit this phenomenon – watch a toddler reach overhead…only the hands extend beyond the giant head itself – but adults don’t.  Mickey may have been born with something called hydrocephaly that was inexplicably untreated for 80 years.  Maybe he was too busy as a child prodigy mouse, or maybe everyone thought it was “cute.”  He may also be suffering from Cushings, an overabundance of the steroid cortisol.  He has some other physical signs to support that diagnosis too.

Lance Armstrong and John Korioth in the team t...
THESE Guns Don't Come With Serial Numbers

But he also could be doping.  By doping, I specifically mean HGH, or human growth hormone.  Lots of athletes do (or did) it, like Barry Bonds (yep, I passed judgement…don’t care about some goofy trial) and probably Lance Armstrong.  Here a note to Armstrong supporters:  almost EVERY top-5 pro cyclist, and every one of Lance’s main competitors over his winning years, has been busted for doping of some sort.  Except him.  Savvy, not legitimacy, I say.

Anyway, HGH makes you huge, but it can disporportionately affect the bones, especially in the head.  Of note, HGH isn’t bad in itself, per se.  It stimulates muscle growth in a way that can be very helpful to geriatric patients, for example.  And, as with many Hollywood elites, The Mickster shows his age about as much as Dick Clark who looks 40 but was actually personal friends with Moses.  So, I think Mickey can be forgiven for taking a shot or two from the possible fountain of youth.  But, unfortunately, that HUGE noggin gives it away…to me at least.

So, let me say that DisneyLand was a great adventure for our 4 kids.  I, however, kept getting dragged into unnecessary endeavors like rides or shows even as I frantically searched high and low my latest, and sickest, patient.  Sadly, I never had a chance to warn him of his predicament.  So, the onus is now on you, dear SW101 nation.  Find him.  Tell him.  He’s sick.  He needs help.

Next Week: Goofy comes out of the closet and reveals that he has Marfan’s Disease…and everyone pretends to be surprised.

Interview with A Virus

SW101: I’m sitting here today with Herpes Simplex Virus, type 2.  It has agreed to answer a few questions for SW101 Nation.  Thanks for joining us today, um, is it…Mr. Simplex?

HSV: “Mr.” Simplex.  Sure.  I’ll go with that.  (rolls eyes, muttering “humans”).

SW101:  Tell me, what do you regard as some of your greatest accomplishments, to date?

Mr. Simplex: We’re awesome, basically.  We like to consider ourselves ubiquitous, yet cosmopolitan.  We are particularly fond of the human idea of “make love, not war.”  mmMM.  Huge for us, that one.

SW101:  Ubiquitous?

Transmission electron micrograph of herpes sim...
Self-Portrait: Mr. Herpes

 

Mr. Simplex:  You got an ulcer on your nether-parts after a groovy night wearing nothing but beer goggles?  Probably us.  Any version of sexually active with any version of human being (we don’t like animals)?  Excellantae!  30% chance we’ll be right there with you.  Me and my posse are hanging out with 30-45 MILLION Americans.  And that just in the, ah, “middle” parts of the human landscape.  We got some cousins who live in the windy North quite happily.  We cross paths from time to time.

SW101:  Wow.  Qute a party.

Simplex: Yep.  And we’re inviting picking up around 300,000 new groupies every year.

SW101:  How’s that?

Simp:  We’re launching out all over the atmosphere much more often than people realize.  Those blistery sores we cause?  Well call ’em “pleasure domes,” referring to what they do for us as well as how our gracious hosts acquired them in the first place.  Anyway, we don’t just blast out from the popping penile blisters.  Usually, we send out early drones before the sore even forms.  We’re terribly proud of this tactic.

SW101:  Soo, when does the ‘party’ end?

Simplex:  That’s the best part.  Pretty much never.

SW101:  Like, never?

Simplex:  Oh sure, we take a break sometimes.  Lots of times, actually.  We hide most of the time.  But once we’re in a body, we don’t really ever leave.

SW101:  What do you hide from?

Simp:  There’s two things we don’t like in this world, and the Great White Army is the main one.

SW101:  Um, you refer to Tsar Ivan III‘s anti-Bolshevik Imperial Russian Army in the 1920’s?

Electron microscopic image of a single human l...
Human Lymphocyte. Non-friend to HSV's everywhere (everywhere it thinks to look, that is)

 

Simp:  What?!  What kind of freak-show wonk are you?  No!  The human immune system.  All the cells in that army are white.  Or clear.  Or something.  Scary, those guys.  They can blow us up, eat us, chew us up, spit out pieces of us so their comrades can eat the rest of us…it’s disgusting, really.  It’s like a bad horror movie.  Ugh!  Look at that picture of the immune cell!  Don’t you have any shame?  I didn’t walk in here holding up pictures of car accidents, or guys who accidentally fell into meat grinders, did I?  Why don’t we just sit around and ponder Charles Manson, and all his fabulous exploits?  Oh, actually, that guy was pretty good for us, as I recall.

Anyway, where was I?  (fans self, leans back weakly).  Oh yes, when it’s up and running full-bore, the human immune system it a giant headache for us.  We try to lay low.  No sense in getting our heads knocked off.  The good news is that it gets stretched pretty thin trying to cover all the problems that come up in those unnecessarily complex organisms of yours.  It’s pretty easy to come out and play once the person is stressed, sick, too hot or cold or with some disease that naturally keeps the White Army back in the barracks, so to speak.

SW101:  So, you hide in the nerves, right?

Mr. Simplex:  (looks left and right conspiratorially) Yep.  Broadly speaking.  This is the secret to our survival, by the way.  Our lair.  Your nerves.

SW101:  And, specifically?

Simplex:  Well, you guys have no hope of actually finding us, so I’ll just go ahead and tell you.  My guys hang out in the roots of the nerves that extend from the sacrum.  S2-5, usually.  In the ganglion.  It’s nice there.  Our version of what you’d call waterfront property, I’d imagine.  Our cousins hang out in similar nerves in the face.

SW101:  You mentioned two things you don’t like, what’s the other?

Simplex:  Condoms.  We hate ’em.

SW101:  That bad, huh?  Your great nemesis?

Simplex:  Well, actually, our relationship to them is a bit complicated.  Maybe like Ariel Sharon vs. Yassir Arafat.

SW101:  Surely you’re referring to the Israeli-Palestinian former leaders…both dead now?

Yasser Arafat at 'From Peacemaking to Peacebui...
Ariel Sharon thinks I'm a punk. I told him the feeling was mutual over tea this afternoon.

 

Simplex:  Dead?  Really?  I don’t think we had anything to do with that.  We try not to kill our hosts…bad for real estate, as you can imagine.  But yeah, them.  They hated each other, but at the same time, they created lots of business for each other too.  Get it?  People don’t like using condoms, for some reason.  But those that do are WAY lax about concerning themselves with us.  Since we don’t just hang out in areas covered by those suffocating, smothering latex udders, we get around pretty well when condoms are in the mix.  People jump into their illicit affairs, thinking they’re safe…and forget to ask anything about us.

So, it’s a love-hate thing.  Overall, condoms are probably pretty good for business.

SW101: So, you hate condoms.  What do you love?

Simples:  Promiscuity.  We’re BFF’s.  Make love, not war, dude.  Preferably, don’t even look down at what you’re doing.

It’s not personal, by the way.  We’re just doing what we are meant to do…which is reproduce.  Everyone who is living with us now should understand that.  It’s one big happy family of organisms doing what they were meant to do…mate, and reproduce.  It’s natural.  When you’re mating…so are we.  All I can say is, sorry for the inconvenience.

Reader Q, Probable Farewell

Q – I just discovered your blog and have had fun reading it, however, it seems that you have stopped blogging?

A – It’s true. I burned out a little. Well, that’s a simplification. Moving here (to Germany), emerging from survival mode from medical training and settling into a normal life opened up all kinds of new emotions in me that I didn’t anticipate. The most important of these was a distinct realization that I wanted to deepen and widen my relationship with my wife.

So instead of pounding out these blog posts, I’ve been cooking dinner once a week (“Daddy Dinners”) and spending the majority of my nights watching some show or other with my wife by my side as I run my fingers slowly through her hair.

I’m gradually putting together a new blog – “Lover, Daddy, Doctor” – that picks up where SW101 leaves off. But it reflects my new focus in life.  I’d anticipate some humor, occasionally more intensity, less medicine.  I’d even expect the occasional Bible verse to accompany an irrepressible proclivity to pepper my writing with a well-placed swear word (Hey, I’ve come a long way…plus I’ve long bet that God nods to honesty before Christian decorum).

To survive in medical training, you HAVE to make survival and success your number one priority. I would have sworn this wasn’t true for me, but it was. Failure anywhere along the training path is a conscription to a lifetime of insurmountable debt, even poverty. Now that I’ve survived, my genuine priorities have emerged. I love to write, so it’s natural that I would blog about this new direction in my life. But I’m not sure. This is personal. More personal than just the experiences of being a doctor trainee. Maybe the story of one guy’s quest to be a better man is better left to be pondered quietly in the heart.

So, I’m mulling my next “move”. Maybe I’ll just pick up where I left off and start up SW101 again (thanks, everyone of you who wrote in to ask where all the good times went). Maybe I’ll finally finish my book.

Ultimately, I just can’t tell you where I’m going because I myself don’t know.  I DO know that I’ve successfully grilled tuna fillets, invented a mango/pear/mint salad that everyone loved, and I can broil Portabello mushrooms all by myself.  I learned the difference between Goat Cheese and Feta Cheese.  I know where the measuring cups are in the kitchen.  I can tell you every character in Lost (and the top 4 theories about what the freaking show even means).

But what I REALLY know is that my wife looks at me with eyes I haven’t seen for 13 years.  And this stirs my soul in ways that make most of the rest of my life comfortably superfluous.  This blog got caught up in that eternal vortex…

When I know anything more than this, you will too.

SW101

“All that I am, all that I ever was, is there in your perfect eyes…they’re all I can see.”  -Chasing Cars, by Snow Patrol

Movie Review – Avatar

I enjoyed myself fully last night as I entered the world of ‘Avatar’, James Cameron’s new sci-fi epic that already handily broke a 1 billion-dollar landmark record of some kind.  I’d watch the show again tonight if I could.  I’d probably watch it every night for a week like my high school buddies did for “Bill and Ted’s Excellent Adventure” once upon a time.

You don’t have to care – or understand – the point of the movie to completely enjoy the stunning visual spectacle presented in wide-screen, 3D wonder.  In fact, I’d advise constraining yourself specifically to the visual effects and skip putting any real thought to the message of the movie.  In essence, just sing along with the song, but don’t think about what the words actually mean.

The story follows an ex-Marine named Jake as he becomes part of a mission to subjugate – or at least translocate – the natives on a strange new planet (a moon actually, but does it matter?).  On the n0t-so-subtly-named Pandora, the “aliens” congregate around an enormous tree set in the middle of a seemingly endless forest.  They stand about 11 feet tall, with blue skin and luminous yellow eyes and they all seem to carry bow and arrows and daggers.  These blue and tall but otherwise disappointingly human-shaped beings generally seem happiest when attending their frequent tribe-wide drum fests – with a terminally simplistic 2/4 beat rhythm that sounds like it might have been pounded out on cool Senegalese drums the Anglo orchestra bought in bulk.

These earthy aliens have a sacred, mystical, spiritual connection to the forest where they live; generally behaving like any nature-loving tribe the Europeans successfully decimated a little over a century ago in North America.  In a complete creative hiatus, at one point nature is even called a “mother”.  Why not a father, or brother, or just skip the nuclear family reference to nature entirely?  The descriptor ‘Mother Earth’ is so unoriginal, it ranks up there with Bless You and Dot Com.

Although 2 hours and something like 40 minutes, you can easily sum up the movie in one phrase: “Dances With Wolves”…but with pterodactyls you can ride.

Basically – Marine makes contact with natives through project financed by aggressive and ethics-challenged Big Business company.  Marine plans on helping his financiers destroy said natives.  Instead, he inadvertently falls in love with natives in general, and one curvaceous native in particular.  He then becomes the enemy of his former bosses, ultimately leading the meek, dumb, dark-skinned simpletons to victory over superior white man.

I haven’t decided if this REALLY tired theme of the White Male swooping down into a primitive race, seeing their genuine good, and then becoming their Great Savior is completely racist.  Some are saying it absolutely is.  I don’t really think that was the intent.  I just think it was lazy writing by a white male who deep-down believes that white men are still the best hope for the world.  That they still run it, ultimately.  But it is possible that white men really don’t have much to offer the world anymore – that we’ve had our time and made our mark.  Maybe it’s time for some non-white, non-men to run the countries, write the laws, own the companies and save fictional worlds.  Maybe the white boy has done about all he can.

Big Business takes a major hit in this movie.  It gets portrayed as the denizen of all Evil in life.  That said, it’s Big Business that has paid for every iota of scientific discovery that has occurred on Pandora.  The science taking place on this moon (and taking place on our earth) is an elevated form of existence, no question, but in both worlds it mostly exists because of Big Business, either directly or through taxes.  Scientists – and artists – need to accept the fact that to live in that enlightened world of thought and wonder and possibility depends on their benefactor’s mundane ability to sell widgets.  Big Business is rarely genuinely evil.  True, figuring out when to inject some profit-endangering humanistic principles into a business plan does takes some skill and is occasionally gotten wrong. But for the most part, if business didn’t make the poet, at least it feeds him.

The actual “avatar” is a living being made to look like the aliens, but controlled by the mind of a human.  The human links to the avatar neurologically, so it can only be controlled by one specific human.  Thus, the human lies in a coffin-like body-pod that connects him/her to their specific avatar.  Upon falling into a coma in the pod, the avatar wakes up and the mind of the comatose human controls it.

Soohh...who gets to clean this thing?

The doc in me couldn’t help but get hung up on this part of the movie.  First, all humans need to sleep.  But since the avatar wakes up as soon as the human “sleeps”, and since controlling the avatar is a conscious process, the human never actually does sleep.  For some evolutionary reason I can’t fathom, REM sleep is the foundation of all life.  This inconvenient fact defies even the mighty pen of James Cameron.  By the end of the movie, after staying awake vicariously with the characters, I felt like I’d been on call in the hospital for days on end (felt like I was back in residency again).

Also, the human lays in this coffin thing for hours and hours.  At the least, he’s gotta pee himself on a regular basis, to say nothing of the inevitable bowel movement here and there.  Plus, the main character’s avatar hooks up with the sexy female alien.  Depicted as the first consummating night of an eternal love bond – thus likely a multicoital affair – envisioning the scene (and smell) inside the pod after this particular night left me a bit squeamish.

As mentioned, the power of this movie is in the visuals.  It is a “looker” many times over.  But the general message is tired, probably slightly racist, and denigrates the U.S. Military (or at least leads the audience to exult in the widespread slaughter of American soldiers/mercenaries).  That said, perhaps our culture really should take the main theme of the story to heart.  After all, we DID decimate the Native American culture, and based on my experiences on the Crow Reservation in Montana, I’d say we continue to.  We’re also strikingly obtuse in our dealings with tribal cultures in the Middle East today.  Listening to people from a different culture – rather than melting them with daisycutters and circling drones – has some merit.

But I do wish the movie had added a little post-modernism into the mix and eschewed the evil-good idea altogether.  It didn’t have to pit the American Axis of Evil (big business + U.S. Army) against a pristine tribal culture practically perfect in every way.  Historic Native American tribes were often duplicitous, aggressive, thieving and hateful (many still are today).  They rarely trusted each other from tribe to tribe and may have been just as irresponsible had one tribe attained the raw power that the U.S. Government currently has.  The Arab tribes we’re tangling with recently have a litany of faults and cobwebby dark corners too.  But they are also a just, priceless, sacred, honorable people.  This dichotomy exists in virtually every race in our world.  Americans seem to hate this complexity in our fiction – it’s easier to hate one thing and love another and then watch them duke it out.

Yeah, YEAH! Die lame-oh Americans! Wait, didn't an American make this movie?

Thus, the conflict in the movie could have been between two parties filled with faults and frailties but ultimately imbued with genuine honor, honesty and a respect for the rights of others.  Standing between them is something they both deeply need and want (trees, mineral ore…whatever).  In life, conflicts almost always boil down to two parties who both have blood on their hands, but both are essentially good, honorable…and in the right.  e.g., Palestine wants the land, Israel wants the land, both have been evil at times, both have been angelically good at times, and each have some form of legitimate claim to the exact space of real estate.  Stick that conundrum in your avatar’s virtual peace pipe and take a deep drag, nature-brother.

Depicting this nuanced world may have weakened the sense of righteous rage as the Army went Operation Flatten Everything.  It may have lessened the gloating release when the Ultimate Bad Guy finally met his ignominious end.  But it would have made a better movie.  It would have made the written story as complex as those fantastic visuals, and created a worthy counterpart to such a sparkling, wondrous vision.

Where’d They Go?

For those wondering where all the blogs have gone – I was on a once/week or better output for over a year – I’ve been distracted (this is not newsworthy).  Lately, the particular distraction has been my novel (this, maybe, is).

Yes, like every 3rd human on planet earth, I’m writing a book.  And one not all that creative, I suppose, since it’s basically “Star Trek” but with minimized people in a tiny ship inside a human body.

Same Thing...Just Smaller

Entitled “The Journals of the Micro Project,” I started writing the book waay back during my first year of med school to help me survive…med school.  Anatomy and physiology, in particular.  Then I just kept going, as I kept taking more classes.  Then I started writing the story to help me make sense of my feelings about religion and international politics (since we were living in Israel), how the American social order relates to dreamers and idiosyncratic personalities…and even how I feel about the city of Jerusalem.  Yeah, that all got in there.  Possibly some funniness and mildly-believable sexual tension stuff too.

I knew about the likes of “Inner Space” when I started my story.  But since I was using it to help myself understand and remember facts about medical science, I didn’t care about any sort of “hook” or “unique voice” or “poetic angle” so important to selling fiction.  I wrote it for me…not to foist on the rest of the world.

Then I started hearing the cha-CHING of literary greatness when I learned that the average novel makes an author less than $5000.  I figured ‘Daaang, I gotta get me some o dat action!”  Immediately, I began working on crafting a novel that everyone would like to read and pay, oh, 2-3 bucks for.  By ‘everyone’, I suppose I’m referring to Jr. High super-dorks with a left brain so big and a right brain so atrophied they walk in left-leaning circular arcs all day.  But so be it!  Friends are friends, even if they eat Captain Trilithium for breakfast.

Suddenly, things like verbs, quotation marks, PLOT, coherence and originality actually mattered.  Whoah.  Pressure.  So, I put a lot of work into all the mechanic stuff during residency, usually at the Bayview Deli in downtown Olympia.  The manager there gave me permission to hole up and write all day.  Sitting in that cafe, looking through giant bay windows onto Puget Sound, studying its many moods – from glistening to tumultuous, from deathly still to rollicking and granular, from green to blue to silver to explosions of orange and red and purple – remains one of my life’s favorite memories.  And that 2nd floor of the Bayview Deli remains one of my favorite places…making a respectable run at the Armenian Tavern in the Old City of Jerusalem.

As I sat there, pondering what kind of Eternal Being could possibly drum up the idea of a vision like the Sound, the distant snow-capped Olympic mountains and all the glorious splendor of trees, hills, clouds and wind that make up the southern edge of Budd Bay, I figured I was writing a freaking MASTERPIECE.  Move over, Bill’s Faulkner and Shakespere.  Make room for the New Guy.  Who wouldn’t write a masterpiece when surrounded by such divine poetry?

The guy's on a throne...how'm I supposed to compete with that?!

But, like a tire iron to the face, I learned only recently about a similar story written by Isaac Asimov, which was based on a movie screenplay.  I guess it was written in the ’50’s – when all anyone cared about were those evil Commies – but aside from that political angle, my story apparently bears many similarities (I am mortally afraid to read his book, lest I find that all my plot ideas have been used up).  So, turns out that more than one person on the planet has, at one time or another, imagined what it might be like to travel around inside the human body.

If you want my opinion, he’s a damn inconsiderate un-original jerk, Asimov.  Depending on your definition of “time”, Asimov pretty much totally ripped off my idea and then went back to the 1950’s and wrote the killer app (we’re talking sci-fi here…it’s an arguable point).  And really, how many ideas did that guy use up on his stuff, anyway?  Couldn’t he have left at least a science fiction crumb for anyone else?

Oh well.  By the time I learned about the Asimov thing, I was too far in to quit.  So, tired drivel though it likely will turn out to be, I’ve been putting some of the final touches on the book.  All 150,000 words of it.  It’s all I do with my spare time.  I get home from work, play with kids, help with the dinner/bed axis, try to give eye-contact to anyone who is talking, chill in front of the T.V. for a bit, then I attack the book till 12 or 1 every night, even when I have to be up at 0630.  The result? A sadly neglected blog, baggy eyes, and a book that now needs professional help (arguably, like its author).  Once off to a good editor (bro, you’re up!), I suppose I’ll get back to some regular blogging.

But until then, dear SW101 nation, bear with me as I pursue this 8-going-on-9-year exercise in being told, “Don’t give up the stethescope, Dr. Delusion”.

8 Pigeons? I’ll Check the Regs…

I love urban legends:  The one about the killer calling the babysitter from inside the house, or the acne that turned out to be a quivering pod of spider eggs.  You know, all those.

akBut my favorite is the one about how you can cause pigeons and seagulls to explode by giving them Alka-Seltzer.  I’m serious.  EXPLODE.

This myth is cool for the science-fair, medico-extravagance of it.  But I also harbor a fairly pathological grudge against seagulls.  Sure, their winsome cry carrying on the breeze hearlds the nearness of the endless sea.  Thousands of poems and stories and paintings concern themselves with these ocean-going fowl.  But I lost all romance toward the seagull when a GIANT group of them ate an entire bag – including the bag – of Chips A’hoy cookies while my buddy and I were surfing once.  I’m STILL looking forward to eating those cookies, and that was 8 years ago.

Why do they explode?  Apparently, birds have a one-way alimentary tract, which means they can’t burp.  Give them something effervescent, all that gas has nowhere to go aaaaand – POW! Alice, straight to the moon.

You can understand, then, why my favorite patient currently is a guy who actually tested this one-way-no-burp-POW! theory.  For all my grudges against the birds, I’m still too much of a softy to actually blow them up.

Not Jake, though.  He went for it.  And still doesn’t feel bad about it.

He went with pigeons – same class as seagulls, if I was the ornithologist in charge – and trying out the theory got him kicked out of the Army.  ‘Course, he tried it on 8 birds at the same time.  After he stuffed them into his commanding officer’s new Chevy Tahoe.

“So, it really works, then?  They blow up?”

“Yeah, it works.”  He said, looking bored and chewing on a cuticle as I nearly wept with laughter.

“They ALL exploded in your commander’s car?”

 

2 pigeons
Uugggh, did you eat a bunch of those little white crackers too?

Suddenly he perked up, eyes sharp and intelligent, “Nah, not all of ’em.  Some just shit all over the place.”

Imagining his commander’s reaction the next morning after finding the most colossal mess of all time, just brightens my day every time I think about it.

 

By some miracle, this guy got away with his life after that episode.  More miraculously, after getting CHAPTERED out of the military (basically a court-martial without the court or jail), he got back into the Army just a few years later. “On a wavier for bi-polar disorder, in remission.”  He said with a wicked smirk.  “Needed a paycheck.”

I can only imagine the ever-positive recruiter.  “Oh, well, 8 pigeons?  Only 8?  I’ll check the regs…there’s probably nothing in there that expressly forbids entry into the military for blowing up birds.  No problem, man.  I’m sure we’re good.  Now, I can’t promise you a bonus, you understand..”

Now he’s on his way back out of the military, via my unit.  He’s wry, filled with black, intelligent wit and flat-out hates authority.  I’m not sure I’d call this a mental disorder… but in the Army, a guy like this is nothin’ but stark-raving nuts.

Of course, once he gets bored…he’ll be back.

 

explosion
POOF!