SB Videos

A GREAT collection of short videos about the Santa Barbara lifestyle:

Santa Barbara Movie Tours

Can you tell that I'm getting excited about the move? :)

SB / Golden State of Mind

A very cute series, well done.

SB Red Tile Tour

Bubu's Plum Wine

Today we bottled our own plum wine. The recipe is a secret, but the basics of it involves fermenting plums & plum-cots over about a 6 month period. We tried a little before bottling the rest and it is very tasty indeed.

Inpatient Digestive Health

Yesterday started a new rotation: Inpatient GI / Digestive Health. Will likely be a very challenging month. Pancreatitis, Liver cancers, Crohn's disease, Peptic ulcers, Diverticulitis . . . you name it, we see it. I think it'll be tough, but manageable, and a good learning experience. Days start between 6 - 7 AM and sometimes go until 10 - 11 PM. But some days are a little lighter.

Will write more later . . .

Inside Santa Barbara (part 5)

Methamphetamine

A powerful video on the effects of methamphetamine use. It cuts off at the end, but I think this is the best one on the net.



A brief summary of a recent patient encounter I had with a polysubstance abuser.

Ms. A is a 27 year old white female I recently had as a patient. She had a long history of drug abuse, including Heroin, Cocaine, Club drugs, and Amphetamines. She presented to the hospital with diffuse body aches, restlessness, high heart rate, an increased WBC count (usually a marker of infection), no fever, and a history of several weeks of nausea with occasional vomiting. In the hospital she was hysterical, crying loudly and sometimes writhing in pain and rocking back and forth. The initial differential diagnosis was broad, but high on the list for me was opiate withdrawal or possible (viral) infection. She was tested for influenza, blood and urine cultures were sent to rule out an infection of her body fluids, and a urine drug screen was sent. She was negative for all things tested for except her urine came back as positive for Amphetamines.

This young patient was on daily Methadone (a long acting opiate) via a Methadone clinic for prior Heroin addiction, reportedly in remission. Certainly a requisite for participating in such a clinic is that you are otherwise drug-free. During my initial interview with her she completely denied any past or current drug use. It took the urine drug screen, some detective work, and further interviewing with her to tease out the extensive drug history. And in all likelihood she came to the hospital with the knowledge that she could likely get a "fix", or opiate pain medications (at taxpayer expense) by putting on just the right act. Or another way of looking at it is that she was truly in "pain", but this pain was somatization of the psychological and physical stress she was putting her body through with administration and withdrawal (when money or supply ran out) of street drugs, often laced with dangerous impurities.

I did my best to rule out any fixable medical conditions, got the Substance Abuse specialists at the hospital to come see her, kept her comfortable while she was at the hospital, and then sent her on her way. Before she left I gave my best shot at an inspirational / motivational speech about the dangers of drugs and how she had much good life ahead of her. I'm not hopeful it sank in, as this patient looked to be pretty deep in the hole.

Sir Hugh Lloyd-Jones

"The Greeks were not tolerant of the well-meaning idiot." --Sir Hugh Lloyd-Jones, great Classics scholar who passed away today. I met this knighted gentleman once when I was a boy in the UK, when my father was a visiting Classics professor at Oxford University. Love this quote. Full obituary here.

Inside Santa Barbara (part 4)

Breaking the news

The past couple of weeks have been pretty challenging. For some reason a dark cloud has been hovering over my area of the hospital and I have gotten several patients in a row with new diagnoses of lung cancer. This is all the more odd since we have a dedicated Hematology / Oncology service, still these patients have been coming to me of late on the regular Medicine wards.

It's quite tough to break the news. I won't ever forget Mr. P, a 55 year old white male with no previous medical history, a totally healthy guy who came to me with swelling of the face and neck. He had been experiencing for the last month or so increased swelling of his face and neck, particularly when leaning over e.g. when he would tie his shoes. He had also noticed some new intermittent shortness of breath. He came to the hospital to check it out and we did imaging which showed a significant "soft tissue" mass in his right lung. This mass had been likely growing for quite some time and was now almost totally occluding the Superior Vena Cava (SVC), one of the major veins that returns blood to the heart. He actually had significant "collateralization", which means that small accessory veins around the SVC had picked up the slack from the occluded big vein over time. This "SVC Syndrome" clearly accounted for his neck/face swelling and shortness of breath symptoms.



I recognized the possibility of cancer right away and had the tough job of breaking the news to this patient and his wife, who is a health care worker herself. This patient as I mentioned was totally healthy before. Had smoked cigarettes for 30 years but had totally quit 5 years ago. I explained to them sensitively and clearly what I thought was going on and what further testing we needed to do -- in this case we proceeded with a bronchoscopic biopsy of the lung mass. I got to know the patient and his wife quite well over the next several days, and was with them as they learned that the mass was in fact Adenocarcinoma of the Lung, spoke to specialists in Hematology / Oncology and Radiation Oncology, and set them up for all their future care needs. The prognosis is not good, but it was very fulfilling to be able to be there with these very pleasant people, answering their questions and helping to ease their very difficult transition into dealing with a new diagnosis of cancer. The wife gave me a big hug on the patient's discharge day, and I have been continuing to follow the patient's progress via the electronic charting. I hope his available chemotherapy and radiation therapy options, while not likely curative treatments, will at least allow this patient to lengthen his amount of quality life left and allow him to die with dignity and on his own terms. Oncology is a tough field, I'm glad that I didn't go into it, as I think that I do have a pretty high degree of sensitivity (though I can be kind of cold sometimes) and the weight of sharing in people's new cancer diagnoses over years and years would be pretty tough. I was glad though to have had the opportunity to participate in this gentleman's care and to have made a positive difference in his life.

Clemency

Mr. C is a 57 year old african american male prisoner with a history of hepatitis C liver cirrhosis who presented to the emergency department with complaints of abdominal pain, diffuse bony pains, nausea, and loss of appetite. After pan-scanning Mr. C it became evident that he had widely metastatic cancer. Given the history of Hepatitis C and the prominent masses in his liver as well as a lab test called AFP which had rapidly doubled, it was thought that he had a type of Liver cancer called Hepatocellular Cancer. A biopsy of his Virchow's Node (left supraclavicular lymph node) confirmed my suspicions. The imaging showed likely metastases to his rib cage, spine, hip, adrenal glands, and spleen. This was late stage cancer, associated with an extremely poor prognosis. Mr. C probably had less than 2 months to live, and I had the tough job of telling him his diagnosis and likely prognosis. The attending physician and I decided to try to put a silver lining on this bleak grey cloud by petitioning to the judge to award Mr. C clemency, so that he could leave prison and spend his remaining days on earth with his family, including his young grandchildren who he had not yet gotten to see much of at all. I made numerous calls, and faxed over official paperwork to the judge's office stating that death for him was "imminent". There wasn't too much that we could do for Mr. C medically, but I did feel good to have helped him and his family in this small way.

Inside Santa Barbara (part 3)

Small to Big

This year scientists at IBM have been able to actually create the smallest photograph -- of a single molecule pentacene -- using an atomic force microscope (AFM). It's actually quite amazing as you can see the hydrogens jetting off the corners of the six-carbon rings. I copy the photograph below with the other universe bookend . . . the butterfly galaxy photo courtesy of the Hubble Telescope. Can your eyes from these pixels fathom the extremes of big and small?

Naturalization ceremony

Kangkang's naturalization ceremony, which coincidentally was also on our 5th wedding anniversary: 9/9/09. The stars are aligned.

Hammer paged

Being hammer paged is the phenomenon during intern year where your pager goes off every 1 minute. While on the phone & putting in orders into the computer for one patient you are getting paged about the next, and then pages can stack up pretty quick. Having an organized system for dealing with being hammer paged is key.

Inside Santa Barbara (part 2)

Inside Santa Barbara (part 1)

American Thinker Blog: A doctor responds to Obama's NYT op-ed

American Thinker Blog: A doctor responds to Obama's NYT op-ed

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Just say no

Today I had to tell a patient that I wouldn't give her a prescription for more pain pills. While this patient, a 52 year-old woman with atypical chest pain (i.e. NOT a myocardial infarction or angina) was in the hospital I put her on Morphine to manage her chest pain. This was appropriate given the severity of her pain and the fact that the initial workup did include acute coronary syndrome (i.e. a real deal heart attack). However, when arranging her discharge she asked for more pain meds and on research I found that she had already been prescribed a month supply 1.5 weeks ago . . . so likely this was drug-seeking behavior and I could not in good conscience double cover this lady . . . despite the fact that she told me I was "the best doctor she had ever had" . . . which may have been more attributable to her learned skill of successful drug-seeking behavior than to my skills as a physician. There's a dose of Richmond, VA reality for ya.

Butterflies

Some photos taken at a Butterfly exhibition at Lewis Ginter Botanical Gardens in Richmond, VA:

Night float

Working the night shifts at the Cardiac / Coronary ICU. Day starts at 7:45 PM and usually ends 9-10 AM this next morning. The part that feels weird is coming back to work the same day you left . . . I am though starting to get used to coming home and getting some sleep during the day. Which is tough to me because I think I have a sensitive Suprachiasmatic Nucleus. Whaa??

We think that the day / night circadian rhythm in humans is regulated by sunlight hitting the retina and triggering signals to flow down neurons to the suprachiasmatic nucleus (SCN), a small area of the brain located in the hypothalamus. The SCN in turn causes the pineal gland (another brain structure) to dole out certain amounts of the hormone melatonin. Melatonin levels in your body peak at night and get low during the day, and are involved in creating your proper sleep / wake physiologic balance.



So the bits of sunlight coming past the shades in my bedroom during the day is kind of messing with me a little. But I'm adjusting. Wonder how much the flip side -- sitting in a dark room all day as a Radiologist -- will affect me . . . think I should probably make sure to eat lunch outdoors every day to trigger the SCN / pineal gland (and take care of sunlight-derived vitamin D production too!)

Buddycare

The latest crisis in the health care world: our cat "The Buddy" has been vomiting for several weeks straight. He's still eating, drinking, pooping normally, he just vomits out partially digested feeds 1-2 times per day. The vet initially thought it was a stomach bug and gave him an antibiotic shot (Flagyl, I think). This didn't help. I was wondering if he might even have pain-induced vomiting from a kidney stone. Sweewawa took him back to the vet today. Turns out cats don't usually get kidney stones (get bladder stones instead). Got an xray of The Buddy (a process which I hear hey enjoyed immensely) which is quite cool to see! I've included it below.



Some things to point out that are fun to see --> you can clearly see the spine along the top of the image going to join with his hip / rear legs on the right, and you can see the tail leaving the spine. You can see the thin kitty ribs along the left side of the image and the dark area with the thin white lines is his lungs with vessels. To the right of the lungs in the image is a bright (white) area that is his kitty liver (not kitty litter). The loopy loops in the middle are his intestines, and you can see air (dark color) and stool (mottled whiter color). Apparently (I wouldn't have picked this up from my own Radiology training) this pattern of air / stool in the intestines is consistent with some serious hairball buildup. So he's on some oral treatments (special food & some tuna-flavored laxative) that will help him with this. So $275 later we have a correct diagnosis and an appropriate treatment . . . I hope. One thing, I was glad that the diagnosis arrived at was hairballs -- something completely out of the realm of what I learned in medical school and beyond. So I have an excuse for not arriving at the diagnosis before the vet :)

US Health Care is top notch

An interesting report was prepared by a senior fellow at the Hoover Institution and a professor of radiology and chief of neuroradiology at Stanford University Medical School by the name of Scott W. Atlas:

http://www.hoover.org/publications/digest/49525427.html

Not a doctor

Beware the High Cost of Unintended Consequences

Beware the High Cost of Unintended Consequences

still going strong

Still going strong in the Cardiac ICU. 30 hour shift (with no sleep) from Fri --> Sat. Then starting night shifts on today --> Thu. It's pretty intense. Have also already encountered many interesting ethical issues. Whether or not to continue life support in a patient who is brain dead . . . how much care to provide for patients who are illegal immigrants . . . how to handle patients whose own reckless lifestyle keeps landing them back in the Emergency Department or ICU . . . the list goes on and we see these cases every day.

One great piece of advice passed along to me by a really excellent resident: always assume a test you're ordering will be negative (or an intervention you are ordering won't help) and know what you'd do next. In other words, always be thinking one step further down the chain. It's an essential skill in chess and is equally important in inpatient wards. You don't take that pawn with your rook just because the move is there . . . you do it because affects your opponent's next move, which sets you up for the next move, which affects your opponent's next move . . . which sets you up further. The person with chest pain who looks like he's having a heart attack but the cardiac enzymes you ordered are negative and the EKG is non-ischemic . . . always gotta have a "what's next" in mind . . .

Death certificate

Today had to pronounce a patient dead. Quite an experience. This was a 47 year old african american male with a past medical history significant for hypertension and cardiovascular disease who had suffered a cardiac arrest. His heart had stopped for unknown reasons, he was resuscitated by EMS personnel, and brought to the hospital where he was started on Arctic protocol. This is a relatively new medical advance whereby we cool the blood of patients with recent cardiac arrest, bringing down their overall body temperature, with the intention of trying to save brain. In some patients it works, in this patient it did not. He likely had just suffered to much of an anoxic (no oxygen) brain injury from his arrest. So after rewarming him from the Arctic protocol, he was found by Neurologists to be brain dead. Still he remained on a ventilator, and we were keeping him "alive" with machines and fluids. Once we confirmed his brain death then the tough decision had to be made to take him off the ventilator. We discussed the medical course and the plan at length with his family. It was quite tough for them. This man was still relatively young, I think it was quite hard for them to let go, even with the knowledge that he was essentially already dead.

So with about a dozen family members around, we prepared to withdraw the ventilator support. We kept only IV fluids and medications to prevent him from having seizures or pain. Then we removed the breathing tube, and this young patient slipped away quietly into the day. Without the ventilator his brain did not tell the muscles of his diaphragm to keep breathing. He took no more breaths, so slowly his heart ran out of oxygen and it too stopped beating. I watched this process on the telemonitor, while trying simultaneously to be there in a caring way for the family. They cried, in fact they sobbed quite loudly. The emotion in the room was palpable. But in this scene I still had to do my job. I confirmed that he had in fact passed away, by feeling for pulses, examining his pupils for any response, and listening for any breathing.

He had passed away, and after consoling the family some more, I went to fill out the required paperwork, including the death certificate. Felt kind of weird, to have experienced as a 3rd year medical student the joy of helping to deliver babies. Now I had completed the other bookend, and had officially declared the end of life. Being a doctor really does mean being a part of the whole life process from beginning to end.

CICU

First day of Cardiac ICU. Wow. It's as intense as I thought it would be. Within hours of arriving I was helping with a "Code". That means cardiac arrest, the real deal with chest compressions, shocks, the whole nine yards. The rest of the day was House-style rapid-paced differential diagnosing on multiple patients at once. One thing about manning the CICU . . . you can never claim that it's boring. Hours today: awoke at 4:30 AM, shower/breakfast/headed to hospital, back by 9:30 PM. Not much time for much else besides eat and sleep now . . . back to work same time tomorrow morning.

Just beat it

I was really struck with a patient who I encountered while manning the Pulmonary clinics this week. This 65 year old gentleman had been hit by four separate cancers and had beat them all. Throat, Lung, Prostate, Colon. Definitive treatment completed, still going strong. He tells me, "If another one pops up, you cut it out and I'll beat it again." What gutsy determination! This guy credits the fact that he's still alive to his attitude and willpower. I think it's quite possible he's stumbled on the power of the mind . . .

Patent-able idea?

Today, on the spur of the moment, came up with a draft of an idea for a medical device / method for helping to cure patients with Bronchopulmonary Fistula (BPF). I've gotten some good feedback on the idea already and may move forward with testing / patenting / etc. It actually felt pretty neat to turn my creative side on today, even if this doesn't result in an actual patent or my name on a device . . . Cheers, Dr. Kowawa

So Much to Say

OK, so a lot has been happening. So chronologically and briefly . . .



"Pull" went well. Spent two days wearing the Inpatient Digestive health hat. I happened to have seen a boatload of patients with liver problems. Most frequent patient was a 60ish male with a history of alcohol abuse or hepatitis infection who presented with liver cirrhosis and the complications that accompany it -- for example ascites, or fluid in the belly. The liver produces proteins, and proteins such as albumin help keep the fluid part of blood (plasma) inside of the blood vessels. Low protein --> fluid seeps out of the vessels into the belly. One guy I saw had gained 19 lbs of fluid to his belly in 1 month. So we tap it . . . and drain it off. And replace the proteins via IV . . . and do lots of other stuff. The experience was incredibly fast paced, pager going off constantly, balancing several things at once, but it was a great learning experience. This kind of busy-ness is the quintessential intern experience . . .



On Friday got up at 5:15 AM, got ready, went to the hosptal, and didn't get home until 10:15 PM. On returning sweewawa and I had a late dinner, and then I got an email from my Mom. Turns out Dad had a freak fall -- ruptured both quadriceps tendons while doing his normal walk on the trail near the local high school. No trauma, just a sudden snap and then both legs were flexed as he fell to the ground. Without the balancing force of the quadriceps the muscles of flexion worked unopposed. To make matters worse as my poor dad struggled to get up a bunch of hornets stung him repeatedly. It must have been awful!! So he was taken by ambulance to the hospital where I was born, and by the next day (Saturday), after XRays and MRIs a orthopedic surgeon had gone in and re-attached the tendons to the patella using sutures and metal hooks. Quite an ordeal.

So during all this time I was doing my homework. It's exceedingly rare for someone to have bilateral rupture of the quadriceps tendons. Typically one of those rare individuals will have a underlying condition -- kidney failure, diabetes, prolonged steroid use, recent fluoroquinolone (an antibiotic) use, lupus . . . my dad had none of these things. But my Mom told me incidentally that he had recently been started on a Statin, the leading drug used to lower cholesterol. And I had an inkling in my mind that I had learned in med school or out in practice that there was this VERY rare side effect of tendon problems in Statin users . . . and looked it up. It's not an official adverse event listed on the drug info, but there have been case reports of people with tendonitis and tendon rupture on the drug. So I'm intrigued and have been learning all I can about this. I may write this up for publication.

My parents were just getting ready to leave for a trip to Europe, followed by a year of working in England. Now all the plans have to be postponed / modified as my Dad goes through rehab. It's all pretty hard on him -- he definitely isn't enjoying being pretty much totally confined to the bed for most of the day. Who would like that? I really hope the recovery is complete and as fast as can be -- and I'm trying to be supportive emotionally and from a physician standpoint . . .



So since that I've headed back to Pulmonary Consults at the Veterans hospital. Stayed late this evening. Got to do a lot of interesting stuff. Did my first ever emergent flexible bronchoscopy. Briefly, had a patient who had gunk (yes, that's a medical term) in his airways and couldn't breathe. The arterial blood gas numbers and portable chest radiographs were starting to look screwy. I used a long scope to traverse the tunnels of the bronchi (lung airways), then suctioned it out. Problem solved, very rewarding to practice that kind of medicine.

Dems health care plans

Pulled!

Got the page today, I got pulled! This means I'll be leaving Pulmonary Consults at the veterans hospital and heading back to the main campus for the Inpatient Gastrointestinal / Digestive Health service. One of my colleagues got sick and I've gotta cover. Which means much more work. Blah. At least it should be interesting. I'm probably going to be pulled for the next 4 days, which also means bye bye weekend . . .

Today I had a patient with Chronic Obstructive Pulmonary Disease (COPD). In the process of taking his medical history he starts to tell me about getting shot in the back of the thigh. Being a veterans hospital patient I assume he's going to tell me a war story . . . but it turns out he was at the receiving end of the bullet as he was climbing out of a second story window. His girlfriend's husband had come home a little earlier than expected . . . Bam! He told me that was their last "date". Love the stories you'll get at the V.A.

Cheers, Dr. K

Ayn Rand's Objectivism

"Pull"

Tomorrow I begin two weeks of "Pull". I'll continue with my normal duties as a Pulmonary Consult at the veterans hospital, but will be on call 24 hours a day 7 days a week if needed elsewhere at VCU or the VA. If another resident gets sick, I cover for them. This means that one day I could be in the Cardiac ICU, one day covering clinics, one day back at Pulmonary Consults, and one day on the Wards. Should be an interesting couple of weeks, filled with a variety of types of medical encounters. I look forward to the challenge.

Dr. Kowawa

Santa Barbara, CA

Another interesting youtube vid I found about SB:

Lung doc

I consulted on a 65 year old patient who came to the veterans hospital with longstanding cough but who had recently started coughing up blood. This nice gentleman had smoked for many years but had kicked the habit 10 years ago. We took Xrays and then CT scans and found tumor and lymph node involvement in his central chest and lung area which had spread around his main airways and around the pulmonary artery (the one that connects the heart & the lungs).

Cancer. In a guy who had tried to do the right thing, had kicked the habit. In a guy who at 65 years old still had a lot of life ahead of him. It was tough talking to him and his wife about his likely diagnosis, and the tests we needed to do to confirm it. He and his wife asked a lot of questions about prognosis, how tough the treatment would be, what were his options. I really felt for them during our discussions. They were searching for something to hold onto, something to help them make sense of the mystery, a life raft to guide them off the sinking ship, but there wasn't much to do but wait. I tried to be clear and realistic, empathic and patient. I think it helped a little.

The next day we did a bronchoscopy, the procedure whereby using a long-tubed camera we could look directly at the tumor and take biopsies. The visual evidence confirmed cancer, and a short while later the Pathologist sent the report: Squamous Cell cancer of the lungs. At this stage in my career I haven't yet become desensitized, so the news did affect me. I am going to strive to do my best to be there for this patient and his wife and to help them through this tough time of turmoil and turbulance.

Dr. K

Global Warming bill must be stopped

Click below for an excellent read on the Global Warming bill aka Cap-and-trade:

David Limbaugh : Cap-and-Tax: Government vs. America - Townhall.com

Week 2 begins

My second week of internship began today. I am really enjoying Pulmonary Consults so far -- quite a fun and relaxing way to begin the year. Today I just had one patient, and the rest of the day I spent researching pleural effusions and practicing reading / interpreting pulmonary function tests. I've heard it described before that Ward and ICU months are analogous to "systole", or the contraction phase of the heart cycle, while electives are "diastole", or the relaxation phase. My heart beats a little slower and I'm a lot calmer when I'm on "diastole". Great way to begin the year. With all this extra time and minimal stress I'm making sure to fit exercise and extra studying into each day. Looking forward to the rest of this week . . .

Independence Day

One last song of the day to end about a year-long tradition

Song of the Day: Hallelujah - Jeff Buckley

Just woke up from a 5 hour nap. Spent the weekend (Fri eve --> Sun morning) doing two night shifts at the Veterans hospital. While I wished I had had this time off to do fun things with my July 4th weekend, on the other hand it did feel kind of good to be working for our veterans on the Independence Day. After all, our veterans have sacrificed so much to keep our freedom and independence from tyranny a reality.

Each night the entire inpatient medicine ward was covered by two housestaff -- myself and a resident. The way we split up the duties, I did "cross-cover" (managing all the patients on the floor) while the more experienced resident handled new patients that came in during the night. This meant that I was managing up to 28 patients at once -- quite the challenge! I put my best effort forth and am very proud to say that everything went very well. Most times getting paged means making small changes to medication orders or adjusting fluids / electrolytes / or oxygen requirements. I felt I could handle 80-90% of the issues on my own with my knowledge gained to date in medical school and beyond. For a couple of the more complicated issues -- for example when a patient who recently had a liver transplant and was on immunosuppressants suddenly developed fever / chills -- I rapidly formed my own opinion of what I _should_ do but called the more experienced resident to make sure. The nurses are also often an excellent source of info, as they see the same patterns day in / day out.

Last night I only got about 1/2 hour of sleep, curled up in my green-blue scrubs in the intern call room, clinging to a pager on vibrate mode to wake me up at a moment's notice if a patient should suddenly "go south". While the lack of sleep was a little painful, it did feel really special to be awake and ordering lab tests, drugs, therapies, checking up on my patients, taking a focused history, doing portions of the physical exam -- all these things on my own in the middle of the night in a large hospital -- with the simple purpose of guarding the health of these veterans until the day shift team arrives. It was the least I could do on Independence Day weekend for those who guarded the country in Vietnam, Korea, and beyond.

Day 1 complete

I survived my first day of internship, and thankfully so did all my patients . . . all 1 of them. Turns out that Pulmonary Consults at the VAMC is going to be a pretty easy way to begin what will be otherwise a very challenging year. I kind of wish I had this "vacation" rotation a little later in the year once I'm more burned out, but that's OK. I plan to spend some of my extra time studying, preparing for the harder rotations, and staying in good physical shape.

Today I saw a 74 year old tetraplegic veteran with Congestive Heart Failure (CHF) who had previously been having some trouble with his breathing. Chest X-ray showed fluid in his lungs so starting a couple of days ago we gave him some diuretics to pee off the extra fluid, and put him on some pulmonary therapy in addition to medications for his heart condition. Today, much improvement showing blood oxygen saturations of 100% without any supplemental oxygen. Yay! It was certainly rewarding to see this veteran feeling better from a lung perspective, even as many of his other health issues are not fixable. I was very glad to have my first case as an MD being one that showcased health IMPROVEMENT. I'll do all I can to make that a theme for the year . . .

Dr. K

Let the fun begin

I'm done with a week and a half of orientation and am very excited to start officially working as a doc tomorrow. The nerves are definitely firing a little faster today . . . I think I'll be running around a little scared the first couple of months. But that's probably a good thing -- I plan to channel that extra energy into making sure I provide excellent care for my patients. Just hope I don't have to run any codes early on in the game . . .

So I plan to make as many (short) posts this year as possible, just to give myself a record of what the year was like and to hopefully provide for others some entertainment and insight into the life of an intern.

One thing I'm going to _try_ to maintain this year is a semblance of life balance. I plan to keep up with exercising, hanging out with my sweet wife as much as possible, and occasionally finding time for all those little things I like to do on the side -- reading, playing guitar, snapping photos, romping around in nature, etc. The key for me is balance. I plan to work my butt off this year, study a lot (for USMLE Step 3 but also just for lifelong learning-sake), but also maintain my self -- including those parts outside of the realm of the hospital.

Cheers,

Kowawa, M.D.

A Day in the Life of an Intern

Today started orientation for my intern year. I plan to attempt to make quick posts this year under the Label "Day in the Life", as a way of recording some of the tidbits of what makes up the dreaded year of the medical intern. Favorite quote from today's (dis)orientation: "We're going to do all we can today to make this process as painful as possible." Whoops, think they meant "painLESS" . . . or did they?

One change that began today -- no more parking "down the hill" in the A lot. For four years I've had to trek up a ginormous hill every morning, passing over smelly I-95 on the way, sometimes facing extremes of cold, heat, or rain . . . now, with the MD degree I get privileges -- get to park in the D-deck ("D" for doctor?), which means a covered walkway straight to the hospital, no hill. Aaaaah . . . the good life.

Favorite books

All-time favorite books I've read:

Zen and the Art of Motorcycle Maintenance: An Inquiry into Values
by Robert M. Pirsig



Godel, Escher, Bach: An Eternal Golden Braid
by Douglas R. Hofstadter



The Mind's I: Fantasies and Reflections on Self & Soul
by Douglas R. Hofstadter



The Chronicles of Narnia
by C.S. Lewis



The Hobbit
by J.R.R. Tolkien



The Hitchhiker's Guide to the Galaxy
by Douglas Adams



The Collected Dialogues of Plato



The Complete Pelican Shakespeare



Miles Davis, The Autobiography



Tao Te Ching
Translated by Man-Ho Kwok, Martin Palmer, and Jay Ramsay
Calligraphy by Kowk-Lap Chan



Brave New World
by Aldous Huxley



Fahrenheit 451
by Ray Bradbury



books to read / re-read in future:

Journey to the West
by Wu Cheng'en (Author), W.J.F. Jenner (Translator)



Atlas Shrugged
by Ayn Rand



The Analects of Confucius



The Book of Chuang Tzu
Translated by Martin Palmer with Elizabeth Breuilly



The Doors of Perception and Heaven and Hell
by Aldous Huxley



The Digital Photography Book volume 1
by Scott Kelby



The Digital Photography Book volume 2



Jean Christophe
by Romain Rolland



Stalking Microbes
by Richard P. Wenzel, M.D.

Sea Shell Curtain

Salvo, NC Sunrise

451 to Atlas

Song of the Day: Atlas Shrugged - Jeff Sipe

Quote of the Day: "The zipper displaces the button and a man lacks just that much time to think while dressing at dawn, a philosophical hour, and thus a melancholy hour." --Beatty, from Ray Bradbury's Farenheit 451

Thought of the Day: Just finished Ray Bradbury's Farenheit 451, what a wonderful book. The book that pumps you up about reading books. Set in the future, in a time and place where books are banned and government censorship rules. The firemen of the future, including main character Beatty, set fires instead of putting them out. Their most popular target: those curious thinking rebels who still keep books in their hidden home libraries contrary to the rule of the land. Solution: burn the books, the houses, and sometimes the book-readers themselves.

In this future dystopia, government censorship means no literature, no teachers, no creative individual thought. Its replacement is 'the family' which in actuality is more like mass entertainment. 'The family' is our current TV and youtube culture combined and on crack. The hapless populace assemble in their parlors, which are rooms with full-wall media screens where fast moving images of cartoons, soundbite sensationalist news, and cheap pulp fiction are offered like an all-you-can-eat buffet for convenient in-home standardized mass consumption.

The themes of the book, written over 50 years ago, still run quite true. How far are we from this picture today, where the population is more concerned with who will be the next American Idol than with the often destructive policies of our short-sighted politicians? The elected leaders love our pre-occupation with professional sports teams and mind-numbing reality television shows. No need for overt censorship in this age as the populace is content to ignore the goings on in Washington unless it is an election year and only if the complex news is filtered down to catchy slogans like 'Change' and 'Hope'.

After finishing 451 I immediately cracked open a new novel, Ayn Rand's Atlas Shrugged. In this sprawling work Rand details her own philosophy, dubbed Objectivism, and asks the question: "Who is John Galt?" The Song of the Day references the work it it's title. Not sure of the connection, but it's a pretty song. I'm already enjoying the book immensely and will likely post on it as I read more.

Cheers, Dr. Kowawa

Yummy breakfast

Blog turns 1!

Song of the Day: There Is No Greater Love - Coleman Hawkins

Quote of the Day: "To love someone deeply gives you strength. Being loved by someone deeply gives you courage." --Lao Tzu

Thought of the Day: Dr. Kowawa the blog turned 1 yesterday. I've enjoyed this first year of posts and plan to continue on. This past weekend celebrated the marriage of my sister & Brad. Congratulations to them, may they have a happy lifetime together! The Song of the Day was part of the outdoor wedding ceremony, played by the great Charlottesville trumpeter John D'Earth with Pete Spaar on bass. The ceremony was beautiful and the weekend at Mont Fair farm was enchanting.

Cheers, Dr. Kowawa

Porcelain Vase

Sweewawa & I have made several trips to Busch Gardens this spring, and as part of the trips have been making pottery at one of the shops. Below see the amazing flower vase Sweewawa painted, with a poem in calligraphy on reverse.

Backcountry camping

Below is the link to the three day circuit we chose:

Big Run, Doyles River, and Frazier (PDF)

Memorial Day Weekend

Fun, fun, fun! Today Sweewawa and I head out for a half day at Busch Gardens before heading West to Crozet, VA for a BBQ with old friends. We're all packed up to for the camping trip to begin Saturday morning though Monday afternoon. Can't wait, will update the blog with some photos on our return. Cheers, Dr. Kowawa

Planning camping trip

Song of the Day: Dock Of The Bay - Otis Redding

Quote of the Day: "He who hath many friends hath none." --Aristotle

Thought of the Day: Today have spent much time planning a two-night, three-day camping trip for Memorial Day weekend with Sweewawa. Planned out our circuit hike, our menu (cooked solely by stove, no open fires allowed in Shenandoah National Park), and our gear. I expect it will be a fun time of tranquility, exercise, picture-taking, and philosophizing.

Cheers, Dr. Kowawa

MCV Takeoffs

The following is a clip from MCV Takeoffs, which is a humorous film made by fourth year medical students at the Medical College of Virginia about the trials and tribulations of med school. In it my classmate Leslie Brown and I poke fun at the things we're taught in our "Foundations of Clinical Medicine" course. This particular scene was quite well received when the film was screened at the historic Byrd Theater in Richmond, VA last Wednesday. Hope you enjoy it too! Cheers, Dr. Kowawa

Graduation from medical school

Songs of the Day:

Weird Fishes - Radiohead

My Way - Frank Sinatra



Quote of the Day: "The mind is not a vessel to be filled but a fire to be kindled." --Plutarch

Thought of the Day: Today completed the second day of graduation ceremonies from medical school. The songs of the day are two that are dear to me. Weird Fishes is a Radiohead tune I really like, and is one I have listened to again and again during my years of studying. For some reason it seems even more special to me now that I have graduated. The second song is a tune made most famous by Frank Sinatra, My Way. Dr. Collins, one of the founders of the Human Genome Project, was the commencement speaker at the VCU graduation. At the end of his commencement speech he did a brilliant modification of "My Way", shown above.

After four years of near-constant, hard work I am done! I matched at my first choice for my desired specialty, Radiology, and am feeling on top of the world. All my work has paid off, and I am humbled and deeply honored to have earned my M.D. degree. I look forward to the next years of providing excellent care to my patients and continuing my studies of Medicine and Radiology.

Cheers, Dr. Kowawa

Ricercar

Song of the Day: The Musical Offering, BWV 1079 - Ricercar a 6 - Johann Sebastian Bach

Quote of the Day: "If there is any religion that would cope with modern scientific needs it would be Buddhism." Albert Einstein

Thought of the Day: Just finished reading Godel, Escher, Bach, An Eternal Golden Braid. What a brilliant book! Can't say I understood every concept in the 777 pages, but I definitely enjoyed the book immensely. This book is intellectual exercise, but Hofstadter has a wonderful sense of humor so it's fun. The last chapter ends with a 6 part dialogue that re-explains some of the author's methods and mirrors Bach's masterpiece 6 part fugue that concludes the Musical Offering. I would absolutely recommend this book to anyone interested in music, philosophy, mathematics, or religion who is looking for a challenging, intellectual read.

Ceci n'est pas un message

Song of the Day: Dream - John Cage

Quote of the Day: "How can you tell if your own logic is 'peculiar' or not, given that you have only your own logic to judge itself?" --Douglas R. Hofstadter, from Godel, Escher, Bach

Thought of the Day:

My thoughts these last couple of days have been with the people of Santa Barbara, CA as the wildfires continue to blaze. Fortunately there have been no deaths but some firefighters have been injured and there has been substantial loss of property. May the blaze be contained soon with minimal further damage.

Of late have been continuing reading Godel, Escher and Bach, and am on the final chapter. This has been an extremely rewarding, though quite challenging, read. The quote of the day is a really interesting one from Hofstadter. Love this loop of questioning. The Song of the Day is from John Cage, whose work is frequently mentioned also in the book. The pic at the top is from Magritte, who challenges viewers of his works to question the reality of representations or symbols. In this piece he highlights that the reality seen through the window is represented on the painting, and the viewer takes another step back to see that this representation is itself a painting on a canvas. Which is itself also a further two-dimensional reality-representing symbol, the one the viewer is witnessing. Take it back a step further by interpreting the whole visual concept a la the philosophy of Descartes . . . Here is a quote from Magritte on this work:

"I placed in front of a window, seen from a room, a painting representing exactly that part of the landscape which was hidden from view by the painting. Therefore, the tree represented in the painting hid from view the tree situated behind it, outside the room. It existed for the spectator, as it were, simultaneously in his mind, as both inside the room in the painting, and outside in the real landscape. Which is how we see the world: we see it as being outside ourselves even though it is only a mental representation of it that we experience inside ourselves."

Tao Te Ching

This weekend decided to do a 56-hour fast (apples & tea allowed) and to re-read / study the great classic Tao Te Ching. First, wanted to share a link to the actual edition that I am using, which I think is excellent for several reasons. First, it is a beautiful hard-cover book with very tasteful illustrations. Second, according to Sweewawa the translation to English is favorable to some of the other versions currently in print. I would strongly recommend this version to anyone who is interested in purchasing the book or checking it out from the library. You can get it from this link to Amazon, or at the time of writing this version is available at Barnes & Noble, believe it or not in their Bargain books section!

Tao Te Ching
Translated by Man-Ho Kwok, Martin Palmer, and Jay Ramsay
Calligraphy by Kwok-Lap Chan

Here is a brief outline of the timeline of Chinese philosophy:

•The Classical Age (6th century BC-2d century AD)

–Confucianism (Confucius, 551-479 BC)
–Daoism (Lao Tzu, 6th century BC)
–Mohism (Mo Tzu, 468-376 BC)
–The Yin-Yang School (founder unknown)
–The School of Names (Logic) (Hui Shih, c. 380-305 BC)
–Legalism (Han Fei Tzu, d. 23 BC)

•The Medieval Age (2d-10th centuries BC)

–relations & conflicts between Confucianism, Daoism, & Buddhism

•The Modern Age (11th century AD-Present)

–Neo-Confucianism (incorporation of Daoist & Buddhist elements in an overall Confucian perspective) (Chu Hsi, 1130-1200 AD & many others)
–20th century impact of Western philosophies such as Pragmatism & Marxism

I would like to highlight some of my favorite passages of the work and offer some comments.

Introduction

    The translators / editors emphasize that the Tao Te Ching was not written solely by its supposed author, Lao Tzu. Rather it encompasses texts which probably cover 800 years. This is a crucial point in my view. Another interesting point made in the introduction is that in many ways the Tao Te Ching represents an opposite view from K'ung Fu-tzu (Confucius) philosophy but in some ways Taoism and Confucianism are very similar.

    The book is made up of 3 sections. The first consists of Chapters 1-37 and is the Tao, or "the Way". According to the translators this section contains the core of Tao Te Ching's message. The second part consists of Chapters 38-70 and is the Te, or "the Virtue". This part plays a supportive role to the original message of "the Way". The third part the translators interpret as a "Coda", Chapters 71-80. In this section a lot of the themes presented in the rest of the book are reiterated. It is arguable that the quality of the text declines for this last section.

Chapter one



"The Tao that can be talked about is not the true Tao."

    I love the humble way the book begins. Right from the start the author acknowledges that one cannot truly represent the purity of Tao via finite words with their inherent limitations.

"Everything in the universe comes out of Nothing."

    It is interesting how this statement has parallels in the modern science of Big Bang Cosmology. According to the Big Bang theory, all the mass contained in the universe now, trees mountains moons stars and all, originated from a single point of miniscule (or no) volume containing infinite (or all) the mass.

Chapter two



"Beauty and mercy are only recognized by people
  Because they know the opposite, which is ugly and mean."

    This is such a powerful concept. Lao Tzu has a special appreciation for the slip side of the coin -- the "bad and ugly" -- and sees their value, in a way, as on par with "the good". This is a tough concept for Westerners to get, as we in religion and culture often hold "the good" on a pedestal while sweeping "the bad" under the rug or dismissing it solely as the realm of the devil. One of the challenges I hope to meet in studying Taoism, Confucianism, and Buddhism is to learn how to acknowledge the good and bad present in all things while still striving to accomplish what I perceive as "good" in my actions.

Chapter four



The Tao " . . . smooths round sharpness
                      and untangles the knots."

    Such a beautiful quote. In physics and science there is the concept of entropy, or disorder. The second law of thermodynamics is an expression of the universal law of increasing entropy, stating that the entropy of an isolated system which is not in equilibrium will tend to increase over time, approaching a maximum value at equilibrium. This means that the universe is not unlike the room of a child, which gets messier with each passing day. I see this concept of increasing entropy present in the rounding of sharpness and the untangling of knots. But note though that often smooth jewelry is considered more "perfect" and desirable, and that hair without knots is actually considered neater or more ordered, though it may in fact have a higher entropy value. I love it that this quote can be interpreted in opposite but equally profound ways. Another really neat concept is that of planets. It is thought that all planets and moons probably started out as quite irregular shapes but the forces of air resistance and gravity over great periods of time caused them to become basically spherical.

Chapter five

"Heaven and earth are like a pair of bellows:
  they are empty, and yet they can never be exhausted."



    How can something come from nothing? What is so meaningful about emptiness and nothingness? The Tao Te Ching explores these questions again and again. I love the choice of words to end the quote -- note the dual meaning of "exhausted" as tired out but also contributing to the image of bellows "exhausting" or emitting puffs of air to fan the flames.

Chapter seven

"The sage guides his people
  by putting himself last.

  Desiring nothing for himself,
  he knows how to channel desires.

  And is it not because he wants nothing
  that he is able to achieve everything?"

    I really appreciate the last lines of this passage from a utilitarian perspective. One of the nagging thoughts that has in the past drawn me away from continuing studies in Tao and Buddhism is the sense that while it is beautiful and profound it lacks utility in everday life. In my life I don't really just "go with the flow" but rather I am always actively working and struggling to carve out a straight path towards my goals -- for example becoming a great Radiologist. This is a little different from the free spirit who wanders the earth and experiences that which comes his way. I love talking about vague concepts such as "Nothing" and "the Way" but do sometimes appreciate a tip of the hat towards the practical value of studying a particular philosophy.

Chapter eight



"Water, you know, never fights
  

  it flows around
                               without harm."

    I find this to be a beautiful way of describing the concept of pacifism without suggesting that it is a weakness. Note the photo is one I took at Lushan mountain, near Sweewawa's hometown in Jiangxi province of China.

Chapter nine

"You may amass gold and jade in plenty
  but then the more you have, the less safety . . . "

    This is sage advice on the dangers of gluttony and greed. Note also that this is an example of good and bad being equally contained in all things. Newton's third law is that "for every action there is an equal and opposite reaction." This is yet another example of how Tao concepts are often mirrored in science!

Chapter eleven

This is one of my favorite chapters so far, and I think this particular translation is excellent! Here's the whole of the chapter:

                                Thirty spokes on a cartwheel

              Go towards the hub that is the centre

- but look, there is nothing at the centre
and that is precisely why it works!

If you mould a cup      you have to make a hollow:
it is the emptiness within it that makes it useful.

In a house or room      it is the empty spaces
- the doors, the windows - that make it usable.

They all use what they are made of
to do what they do,

but without their nothingness they would be nothing.

**************************************************

    I love the concept that it is the emptiness, and space that makes things useful. Empty space is also a really important concept in music. Often it's the notes you leave out that truly make a piece of music beautiful. This concept is exemplified masterfully in the Miles Davis composition "In a Silent Way". Miles is really good at creating space in his music, and the space is what makes the tune "something".

In A Silent Way - Miles Davis

Interestingly, Miles once was quoted as saying: "Don't play what's there, play what's not there" which I feel to be the perfect yang to the empty space's yin.

Chapter twelve

"The five coulours
                                 blind the eye -

The five notes
                             deafen the ear . . .
The five tastes
                            deaden the mouth

[ . . . ]

The sage [ . . . ] is guided
                                       by his instinct

and not by what his eyes want."



    Reading this I'm drawn back to my readings of Descartes, who believed that true sense perception was more dependent on the mind than the body. He argues that sense can fool, as in the case of watching a candle melt. Is "candle" a liquid, solid, or a fire? The only true understanding of its nature is arrived at by realizing the senses are just hints or clues about what is true . . . and using the mind to connect the dots. Descartes says "[P]erception . . . is neither a seeing, nor a touching, nor an imagining . . . [r]ather it is an inspection on the part of the mind alone."

Chapter thirteen

"If you can put yourself aside -
  then you can do things for the whole of the world.
  And if you love the world, like this
  then you are ready to serve it."

Sage advice especially for ultra-competitive and ambitious me.

Chapters fifteen - nineteen

These chapters talk about what it takes to be a good ruler. An interesting concept described is that the best government is one that is not seen at all:

       "The highest form of government
  Is what people hardly even realize is there

[ . . . ]

  And the people stay happy
  Believing that what happens
                                                     happens, naturally."

  

    First, I definitely don't take this to mean that the people are being deceived or that the details of governing are being hidden from public view. Rather, the Tao Te Ching in my view suggests that good governing should be more like the laws of nature, mysteriously and silently telling the trees which way to grow and the rivers how to flow to the sea.
    How does this concept relate to modern politics? It's my view that free market capitalism with wise & minimal regulation fits well into this picture. A mountain spring will trickle down via tributaries to the river and then the sea, provided you let it. The forced welfare state, in contrast, oppresses people by taking them out of their natural state. The "benevolent" ruler in a welfare state is very visible, and those receiving aid are felt drawn to leave their own natural forces of survival and self-betterment to fly like moths towards the new artificial light.

Chapter twenty

"Is there really much of a difference
  Between being angry and pretending not to be?"

As Shakespeare would put it "be true to thineself." I believe it to be one of the most important lessons there is in life.

Chapter twenty-one

(Note the accompanying photos are ones I took at Lushan Mountain in China (near Sweewawa's hometown) of a shrine to Buddha.)

  This edition / translation of the Tao Te Ching is one Sweewawa and I picked partly due to the fact that it overall depicts very well in English the original intent and beauty of the Chinese text.  However, the translation is by no means perfect.  This chapter is, in my view, one example of the imperfection of the translation.  To illustrate my claim I quote first the translation of the chapter in its entirety followed by an alternate translation by Sweewawa.

  From these two versions you can catch a glimpse of how radically different translations of the Tao Te Ching can be.  The difficulty lies in the fact that a very literal translation of the text will be clumsy and much of the desired meaning would be lost due to the fact that the English-speaking reader will lose subtle cultural references and other subtleties of the language.  So for a great translation a certain amount of creativity is required.  But there also is a danger in being creative of straying away from the intended meaning.

  The ninth line of the book's translation is "I say so, and I can prove it!"  This line when I first read it caused my hair to stand on end and I read on with great interest.  This is quite a bold claim contained within a book with groundings in religion and philosophy  . . . but after finishing the chapter I was disappointed.  "How do I know the Tao is the root of all being? . . . Because I know this."  I never would have asked for such a thing as a proof that the Tao is the origin of all things, as this is, I think, such a undefinable and unprovable concept that if one believes one must only hold based on faith.

  Sweewawa's translation speaks to me much more.  "God" or "Tao" are words and concepts that have been around for eons.  Just that is in a way a "proof" that there is something real behind the words . . . "From the Ancient time until now, its name has never perished."  But this is not a proof in the sense that you can say "I can prove it!"  Sweewawa offers the translation "At the bottom of the dark abyss, there is an essence.  The essence is so real, you can rely on it."  I do believe or "rely" on the idea that there is a "God", "Tao", or "Creator" who exists outside the universe and is the source of all things we know.  This concept is in a sense obvious to me, but yet I realize it is absolutely unprovable.  This is the beauty and difficulty of the "faith" concept present in many religions.   You cannot prove it, but you rely on it.      

Book translation:

The Body of The Tao

                                       is a mist beyond your eyes.

Tao of No Body,

                              and yet within it is All Creation.

Like a seed in the dark, and a dim light

     And from it, comes everything.

Root, stem, leaf . . . its essence is in everything.

Everything is born from this Tao

                                  I say so, and I can prove it!

From the beginning of time until now

the Tao is eternal because it is Creation.

How do I know the Tao is the root of all being?

Because

                 I know this.

Sweewawa's translation:

The biggest virtue obeys nothing else but Tao.
  Yet Tao reveals itself in an obscure way.

Behind the fleeting sceneries, there is an image.
  Behind the vague phenomenons, there is an object.
    At the bottom of the dark abyss, there is an essence.
      The essence is so real, you can rely on it.

From the ancient time until now, its name has never perished.
  It is the origin of all things.

How do I observe the beginning and development of all things?

    Because I know Tao.

Chapter twenty-four

"The kind of person who always insists

  on his way of seeing things

  can never learn anything from anyone."

This is great advice about the benefits of keeping your eyes, ears, and mind open.

Chapter twenty-five

  This chapter contains language which paints "Tao" as a very "God"-like being.  In it the Tao is described as "Mother of Everything", "greater than everything", "Tao is Great", "It is greater than Heaven, Greater than the Earth, Greater than the king."  I found it incredibly interesting (and satisfying) to see that Lao Tzu (and the other authors) took this stance on describing the Tao.  The Tao, according to them, is not just everything itself but is the source and master of everything.  This hierarchy is one that resonates with me personally and jives with the basis of the Christian faith to which I am accustomed.

To be continued . . .