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I recently visited the Galapagos (more posts and pictures coming soon).  During that trip I brushed up on some of my Darwin knowledge- in a lecture on board, with some books in the ship’s library, and reading The Voyage of the Beagle on my Kindle. I just got back from a very different trip (visiting family in the UK), but again I managed to brush up on some Darwin, this time by visiting the place where he lived, worked, and died- Down House.

 

Down House, the home of Charles Robert Darwin (1809-1882) for the last 40 years of his life, is in the village of Downe in Kent.  Here Darwin conducted many experiments, and wrote most of his scientific work (On the Origin of Species by Means of Natural Selection (1859) being the most well known).  I am certainly a Darwin enthusiast (some might say a Darwin stalker…), but I expect that even those who have only a mild interest in Darwin, history, evolution, or science would enjoy a tour around this historic site.

 

Down House is located in the village of Downe (the Darwin’s kept the traditional spelling after an “e” was added to the village to distinguish it from the county Down in Ireland), and it has had a number of renovations since it’s initial construction in the early 1700s.  The Darwin’s acquired Down House in 1842, when Darwin and his wife (and first cousin) Emma (nee Wedgewood) wished to escape the hustle and bustle of London with their growing family (at the time they had two children and were expecting a third).  Darwin, in his characteristically frank style wrote, “It is a good, very ugly house, with 18 acres.”, though I think many today would disagree with this assessment!

 

Down House as it is today, with a very excited tourist.

Down House as it is today, with a very excited tourist.

 

Over the course of his 40 years at the house Darwin enlarged it not only for his growing family (he and Emma had ten children, though only 7 survived to adulthood), but also for the comfort of his servants.  Writing to family he said “It seemed so selfish to make the house so luxurious for ourselves and not comfortable for our servants “. One of Darwin’s many interesting (and noteworthy) traits was his humanism.  He was an avid abolitionist (a disagreement with Captain Fitzroy on this subject almost got him kicked off the Beagle), a kind “master” to his house staff, a loving and involved father (an anomaly in Victoria times), and supporter of the humane treatment of animals.

 

Today the name Charles Darwin calls up images of a great scientist, a deep thinker, and a major contributor to human knowledge.  However, this certainly wasn’t the future his family imagined when Charles was a youth.  As a boy he received a classical education at Shrewsbury School.  This was not an education that paired well with young Charles’ interests of beetle collecting (then a national craze), chemistry, and shooting.  His father, a respected physician, is reported to have said “You care for nothing but shooting, dogs, and rat-catching and you will be a disgrace to yourself and all your family.”.

 

After his mediocre performance at Shrewsbury School, Darwin was sent to Edinburgh to follow in his father’s footprints and become a physician.  Alas (or fortunately, for the future of science), Charles could not stomach the brutality of surgery in the era before anesthesia, and he returned home after less than two years.  He was next sent to Cambridge to earn a degree so that he could enter the clergy (entering the clergy was a common career path for men from good families with a penchant for natural history).

 

While Darwin did complete his degree at Cambridge, he never went on to study for the clergy, as he was recommended by a mentor to accompany Captain Robert Fitzroy on the Beagle. Darwin wasn’t the first young naturalist recommended for the job (he actually wasn’t on the boat as the naturalist, though he did later rise to this position, his “job” on the ship was to act as Fitzroy’s companion- a gentleman that a captain could talk to amongst a ship-full of burly sailors).  While his father did not support this decision he did eventually let young Darwin (he was 22 at the time) depart on this adventure at the recommendation of Charles’ uncle Josiah Wedgewood.

 

The expedition aboard the Beagle was meant to last two years, but it stretched into a five-year endeavor.  Darwin’s observations during this travel were instrumental in shaping his thinking and his future.  It is rather fascinating to realize that Darwin’s 5-year, around-the-world journey aboard the Beagle was the only travel he ever undertook.  He returned to England in October of 1836, married in January of 1838, and in September of 1842 took his growing family from the strictures of London to Down House where he would spend the rest of his life.

 

Once at Down House, Darwin preferred to correspond with friends rather than travel back and forth to London.  He was a prolific letter writer- spending the equivalent of thousands of pounds per year on stationary and postage.  While it does seem that Darwin was a bit of an introvert, this insular life was largely a result of ill health.  Once an active and lively young man with a penchant for exploring and shooting, he was plagued with illness after his return from the journey aboard the Beagle.  His symptoms, which were present in varying degrees for the rest of his life, included a number of GI problems, palpitations, and extreme fatigue.  There have been many theories about this illness, ranging from Chagas disease to Chronic Fatigue, including lactose intolerance, Crohn’s disease, and psychosomatic disorders.  Whatever the cause, this illness debilitated Darwin, and at Down House he developed a schedule around his symptoms- working when he could and resting when he must.

 

The Sandwalk at Down House, also sometimes known as the Thinking Path, was where Darwin would walk three times a day (health permitting).  There is a walk down around the property with a loop in the woods, and Darwin would walk laps on the circuit deep in thought.  He would kick rocks from one side to the other to keep track of his laps, as his mind was usually on matters other than his number of "reps".

The Sandwalk at Down House, also sometimes known as the Thinking Path, was where Darwin would walk three times a day (health permitting). There is a walk down around the property with a loop in the woods, and Darwin would walk laps on the circuit deep in thought. He would kick rocks from one side to the other to keep track of his laps, as his mind was usually on matters other than his number of “reps”.

 

Down house wasn’t only Darwin’s home, but also the place where he conducted many experiments – on pigeons, barnacles, orchids, and weeds- work that was instrumental in supporting his theory of natural selection.  Of course Darwin was not the first person to suggest that species were mutable, but he was the first to convincingly propose a cogent mechanistic theory and support it with various lines of evidence.  Both he and Alfred Russel Wallace appreciated the implication of Thomas Malthus’ commentary on populations- that sooner or later populations were checked by famine and disease- and both men independently came to the same theory of natural selection based upon the pressures exerted by nature.  However, it was Darwin who first wrote about the theory (though he did not publish it) and who collected extensive evidence to support the theory.

 

The Hot House at Down House.  A collection of orchids and carnivorous plants are maintained here.  This is where Darwin hypothesized that the orchid Angraecum sesquipeda was pollinated by moth with a long proboscis.  This was discovered to be true, 21 years after Darwin's death.

The Hot House at Down House. A collection of orchids and carnivorous plants are maintained here. This is where Darwin hypothesized that the orchid Angraecum sesquipeda was pollinated by moth with a long proboscis. This was discovered to be true, 21 years after Darwin’s death.

 

The Kitchen Gardens.  Not much going on this time of year, but in summer these beds are full.  This is where Darwin did experiments on pin-eyed and thrum-eyed primroses.

The Kitchen Gardens. Not much going on this time of year, but in summer these beds are full. This is where Darwin did experiments on pin-eyed and thrum-eyed primroses.

 

The remnants of some of Darwin’s experiments can still be seen at Down House.  His hot houses (heated by composting manure!), where he maintained large numbers of orchids and carnivorous plants, are still maintained, as are the large kitchen gardens where he studied primulas.  A reconstruction of “The Worm Stone” that Darwin and his son Horace used to study the action of worms is in the garden, and English Heritage, who maintains the house, continues to dig experimental weed plots similar to those that Darwin constructed to study the succession of plants.

A reconstruction of "The Wormstone".  I was being optimistic when I took this pic, and hoped that I wasn't actually taking a picture of the septic system...

A reconstruction of “The Wormstone”. I was being optimistic when I took this pic, and hoped that I wasn’t actually taking a picture of the septic system…

 

Throughout my visit to Down House I was overcome with a feeling of awe.  I grew up with a deep respect and affection for Darwin- my father is a huge fan, to the point where my brother’s middle name is Darwin.  Being the second born I received an equally nerdy though significantly less well known middle name- Lyell.

 

Charles Lyell was a geologist (I actually wrote about him briefly in my first blog post!) and a well-respected scientist.  He was a mentor for Darwin, though it took him a while to come around to Darwin’s theory of natural selection.  He eventually did, and it was Charles Lyell and Joseph Hooker who presented Darwin’s and Wallace’s papers On the Tendencies of Species to form Varieties and On the Perpetuation of Varieties and Species by Natural Means of Selection to the Linnean Society in 1858. It was a thrill to see Darwin’s portrait of Lyell in his study, as well as various volumes of Lyell’s books in locations throughout the house.

 

Visiting Down House certainly increased my understanding of this great man, and also increased my respect for him.  He was a humble man, a hard-working man, a loving father, and a great mind.  He was also a troubled man- plagued with illness, profoundly concerned by the implications of his theory, and deeply scarred by the loss of children he loved.

This is a picture of Downe Church (not mine) where Darwin would walk every Sunday.  Darwin lost faith in religion after the death of his first daughter, and while he would walk his family to church on Sunday he would not enter the church.  This is where his wife, Emma, is buried (Darwin is buried in Westminster Abbey).

This is a picture of Downe Church (courtesy of wikicommons) where Darwin would walk every Sunday. Darwin lost faith in religion after the death of his first daughter, and while he would walk his family to church on Sunday he did not enter. This is where his wife, Emma, is buried (Darwin is buried in Westminster Abbey).

 

Darwin’s work on natural selection is a classical example of the scientific method.  As a naturalist, especially during his time aboard the Beagle, he made a number of observations.  These observations led him to a hypothesis (natural selection) that he then researched extensively.  He was not purely a “great thinker”, who came up with a theory, but also a patient and meticulous experimentalist who painstakingly showed that species were mutable through pressures of nature.

 

Sometimes in science, medicine, and certainly in the paleosphere we get stuck on an idea or a theory.  We latch on to something that just “makes sense” or fits in nicely with our current way of thinking, and we start to accept it as fact.  Seeing how hard Darwin worked to build evidence to support a theory, which on an intellectual basis was so obvious, reminds me how important it is to not stand on theory alone, but to work diligently towards better understanding through rigorous science.

 

Though sometimes controversial in the US, Darwin is well loved in the UK.  He had a distinguished funeral at Westminster Abbey and is interred near the monument for Sir Isaac Newton.

Though sometimes controversial in the US, Darwin is well loved in the UK (and is featured on the ten pound note). He had a distinguished funeral at Westminster Abbey and is interred near the monument for Sir Isaac Newton.

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Merry Christmas!

 

Christmas isn’t for everyone, and Christmas as a Christian Holiday vs. an excuse for rampant consumerism seems to be on the decline, but it can be a truly wonderful time of the year.  For my family it’s a time of good music, good food, and spending time with people that matter.  Unlike many who spend the holidays with large gatherings of extended family, it’s just my parents and me in this country, so we don’t have large family gatherings (of our own) to attend.  However over the years we’ve been adopted by friends who include us in their family celebrations.  We’ve now been celebrating Christmas day with these friends for well over a decade!

 

Different things “make it Christmas” for different people.  For some it’s Grandma’s cookies or hanging a special ornament on the Christmas tree.  For others it’s a specific Gospel reading, or a certain Christmas song or carol.  While I’m not sure it’s what “makes it Christmas”, listening to King’s College Choir (Cambridge England) Festival of Lessons and Carols is a wonderful Christmas tradition.

 

Here is the 2010 Festival

 

 

Christmas music is always a reminder to me that natural selection is everywhere.  The Kings College Festival is always a lovely combination of old and new. It starts with “Once in Royal David’s City”, a carol that has been around since the mid 1800s, and includes other traditional pieces as well as some modern compositions.  Some of the modern stuff is great, and will be carried on by future choirs for generations to come, others will disappear into the archives- deemed “not quite good enough” to make it into the hallowed halls of “Christmas Greats”.

 

The old carols that we still sing today have gone through many rounds of natural selection- I am sure there were plenty of carols written in the 1800s that aren’t around today, but the ones that have made it this far are good- they hit a chord with the listener, whether the listener is religious or not.  They fire our neurons in ways that make us want to hear them again, next year, and for generations to come.

 

Natural selection is still ongoing.  It’s the reason “In dulci jubilo” has been around for over 600 years and “Funky, Funky, Christmas” is (hopefully) on it’s way to obscurity (though it will perhaps be immortalized on youtube).

 

 

And now- since I can’t think of any sensible segue from “Funky, Funky Christmas”, I will just make the following bold statement:  I bet Jesus didn’t have asthma.

 

I bet he wasn’t allergic to peanuts either.

 

I’m not here to debate whether Jesus existed, but I do think it’s worth thinking about the fact that anyone who WAS born in a stable is probably on the way to a robust microbiome and an appropriately occupied immune system (i.e.- not over active and causing asthma and allergies).  Since he was a vaginal delivery, lived in an age before antibiotics, and was exclusively breastfed (no formula 2000 years ago!), I expect Jesus had an admirable gut flora indeed!

 

And with that, dear readers, I wish you a happy (and merry) Christmas!  In an effort to reduce the quantity of unnecessary objects in our lives, my family has taken to the philosophy that Christmas gifts should be “Consumable, or the best gift ever”.  As such, I am looking forward to trying a nice new olive oil and balsamic vinegar, an interesting piece of cured meat, some lovely dates from Dubai, and a tasty looking bottle of tequila… Merry Christmas indeed!!

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“Doctor! Heal thyself!”

 

Those were the words of the orthopedist as he entered my room in the Emergency Department.

 

Two weeks ago, while taking a break from working on residency applications, I decided to go ride one of my horses.  Alas, as I was leading him and his pasture-mate to the barn they spooked and one of them literally jumped on my foot.  I’ve been around horses for decades (eek!), and have had my toes crunched many times, but I immediately knew this time was different, not least because he had landed on the side of my foot not my toes.  The pain was instantaneous and overwhelming, I was doubled over and hyperventilating within seconds (at which point I realized that the horses hoof had actually torn my leather boots- let this be a lesson to ALWAYS wear boots around horses, a lesson I’ll admit that I haven’t always followed).  After taking a couple of minutes to catch my breath I hobbled to the barn, optimistically hoping I’d still be able to go for a ride.

 

Once in the barn, with the horses secured, I pulled my boot off and had a quick palpate. One good squeeze and I knew I needed to make a trip to the hospital for some X-rays. *Sigh*  This was NOT how I had planned to spend my evening!

 

A little later, at the community hospital, the X-ray tech snapped a few angles.  I asked if I could see the films before hobbling back the waiting area and immediately spotted two, slim, hypodensities in my 4th and 5th metatarsals.  With an expletive, I pointed to one of the lucencies. The tech tried to reassure me that it wasn’t anything significant: “just an artifact” because there was a similar line in the adjacent bone…

 

After the Physician’s Assistant examined me in fast track, he went to go check out the X-rays.  I asked if I could take another look, admitting that I was a med student (and currently on rotation in this community hospital for my sub-internship!). When he came back to pull the images up on the computer, he let me know that he and the ED doc agreed that I did, indeed, have non-displaced fractures of the 4th and 5th metatarsals.  There wasn’t really much they could do, but the orthopedist was coming into the hospital to see a couple other patients and if I was willing to hang out for half an hour he’d take a look at my images as well.

 

They don't look like much, but those two little lines are really cramping my style!

They don’t look like much, but those two little lines are really cramping my style!

 

Half an hour later, the cheery orthopedist came in, chatted with me about my future plans in medicine, and told me to follow up with him if things got worse instead of better.  I headed home with a walking cast, crutches, and a few Percocet.

 

This was two weeks ago, and while my foot is by no means “fixed” it is certainly getting better.  Hobbling around to take a shower the first morning was rather excruciating, but the walking cast was my saving grace in the hospital and I’ve been able to do more normal activities without the boot with time (though I think I may have pushed my limits last night heading into the city for a book release party and am paying for it today- on that note, definitely check out John Durant’s book The Paleo Manifesto).

 

So why am I writing this, other than catharsis? (It’s perfect fall hiking weather and I’m out of commission- boo.)

 

Healing takes time.

 

With things like a fractured bone people know this, but sometimes we (“we” the public, and “we” the medical community) seem to forget that healing takes time.

 

There’s no denying that I am “into” preventative medicine.  However, as much as we can try and prevent injury and illness- something is bound to happen.  In that vein, I don’t think preventative medicine is only about avoiding problems, but encouraging a physiology where healing is promoted.

 

I’ll admit that I’ve been frustrated at times in the hospital when my stable patients have complained to me on morning pre-rounds that they had a horrible nights sleep because someone was taking vital signs every couple hours, and the phlebotomist came for morning labs before 5.  Vital signs are vital for the management of some patients, but others would benefit much more from a good nights sleep. Of course, making the decision that your patient needs sleep more than monitoring is not an easy one- no one wants to find that their patient is hypotensive on morning rounds and not know when the problem occurred, but for some patients the risk seems quite low.  On my neurology clerkship I remember thinking that what many of our stroke patients needed most was a good night’s sleep.

 

I recently read, at the recommendation of my favorite cardiologist, the book Cutting for Stone.  It is amazing, in many ways. I particularly loved a short passage that talked about the success one person had in improving women’s recovery from fistula surgery.

 

Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence.  ‘I owe this to Shiva,” she said. ‘He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks…. We work on strengthening their legs, getting them moving.’…

 

‘Can’t get them to walk after surgery if they won’t walk before.’ Shiva said.

 

When I was on my anesthesia clerkship I saw how hard it is to manage a “sick” patient, and how easy it is to intubate and anesthetize a healthy one (a complicated cardiac patient vs a young ortho patient, for example).  On surgery, you see how well some people tolerate surgery and how poorly other do- how some heal quickly while other seem incapable of healing.  One’s underlying “health” certainly affects one’s ability to heal.

 

This is one of the many reasons I like primary care.  A good primary care doc makes everybody else’s job easier.  They can keep their patients healthy and out of the OR and specialist’s office, and if misfortune strikes, a patient in the best of health is almost always set up to fair better (the only example that I can think of where this is not the case is the pandemic flu of 1918, where the robust immune systems of young, healthy, adults was actually their demise).

 

Injury and illness, at some level, are inevitable.  A healthy lifestyle and good genetics can go a long way to keeping you out of the hospital, and they can also go a long way towards helping you heal if you do find yourself in harms way.  As the Dos Equis man might say “Stay healthy my friends.”.

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It’s been a busy month since my last post.  I’ve studied for and taken the United States Medical Licensing Exams (USMLE) Step 2 CS and (on Friday) USMLE Step 2 CK, two parts of what most people know as “the boards”.  I’ve attended and spoken at the 2013 Ancestral Health Symposium (AHS) and moved out of the apartment I lived in for the last 18 months.  I’m also half way through my “Acting Internship”, a clerkship most medical schools call a Sub-Internship, where I basically function as an intern (a first year medical resident).  I’m doing this rotation at a local community hospital and I’m really enjoying the atmosphere, personnel, and patients.  The hours are long, but not as long as for many of my classmates doing acting internships in Internal Medicine, Surgery, and Ob-Gyn (mine is in Family Medicine, the specialty I am pursuing). Applications for residency programs go live in just over a week which finds me struggling to write (for the fourth time) a personal statement that embodies me

 

Needless to say, things have been hectic , and the last month has been a touch overwhelming at times.  I’m certainly looking forward to some downtime after I finally complete my remaining med school requirements (just 8 more weeks!), have my residency lined up, and am able to catch my breath. 

 

I really shouldn’t complain.  Even in the last, relatively crazy, 6 weeks I’ve still had some good times.  The week of AHS in particular was one for the books.

 

I’ve written before about destinations and journeys.  The destination for AHS was clear- Atlanta Georgia- but the journey I took to get there wasn’t what you might expect. 

 

Many, many, months ago, when the location for AHS was first announced, I made a rather rash statement that Atlanta was almost close enough for a road trip.  While I had no real intention of road tripping to Atlanta, my longtime Twitter friend @PrimalRush (henceforth known as James) said he was keen to tag along for the journey.  At the time I thought an actual road trip was unlikely (it’s a good 13 hour drive and airfare isn’t that expensive), but as the time got closer I realized I would regret turning down the opportunity to create an excellent story (those that know me know all too well that I’m a fan of adventures and stories). 

 

Since I took 4 weeks off from school to prepare for the boards and attend AHS, I was able to take some extra time travelling to AHS.  About a week out, I vaguely mapped a path to Atlanta, made plans to pick up my Canadian travel buddy from the bus stop, and hoped for the best!

 

Three days before we planned to pull into ATL, James and I hit the road with camping gear, a cooler, and a tank of gas.  After making a stop at one of my favorite butchers to fully stock our cooler, we made tracks to Shenandoah National Park in Virginia.  We travelled the length of the park on Skyline Drive, stopping about midway to camp for the night. 

 

At times, we were in the clouds driving on Skyline Drive.  Driving the length of the park added a few extra miles to our trip, and certainly slowed us down a bit (the speed limit is 35mph and you can't help but pull over and ogle at the views), but it is certainly worth it!

At times, we were in the clouds driving on Skyline Drive. Driving the length of the park added a few extra miles to our trip, and certainly slowed us down a bit (the speed limit is 35mph and you can’t help but pull over and ogle at the views), but it was certainly worth it!

 

Without going into detail, our time in Shenandoah involved meeting some mushroomers who confirmed my Chanterelle (and Chicken of the Woods) identification, cooking a truly excellent camp dinner (with Chanterelles), having a run-in with a slightly disgruntled ranger, hiking part of the Appalachian trail in the dark, pitching a tent in the dark, waking up and breaking down camp in the dark, and then scrambling to a 360o viewpoint to watch the sun rise.  When we were finally able to tear ourselves away from our solitude and sunrise we hiked the couple miles back to the car and made tracks through the rest of the park and onto our next destination in Mortimer North Carolina.

 

A delicious addition to our dinner (good thing I had some Kerrygold butter in the cooler!)

A delicious addition to our dinner (good thing I had some Kerrygold butter in the cooler!)

 

I'll take this over dehydrated rice and bean camp dinners any night!

I’ll take this over dehydrated rice and bean camp dinners any night!

 

The view at dawn from Bearfence mountain.

The view at dawn from Bearfence mountain.

 

It was certainly worth waking up at 5, and hiking in the dark, to watch the sun rise over Shenandoah.

It was certainly worth waking up at 5, and hiking in the dark, to watch the sun rise over Shenandoah.

 

How could I resist?

How could I resist?

 

Mortimer North Carolina holds a special place in my heart.  One of my longtime friends has a family cabin in Mortimer, and I’ve twice travelled with her for an escape to the mountains and the beauty of Wilson’s Creek.  Mortimer is also home of Betsey’s Ole Country Store an establishment owned by my friend Bruce.  The address to Betsey’s is a little deceiving- let the record show that “Highway 90” is a gravel road where you need to pull over to let oncoming traffic pass. 

 

Anything I say about Betsey’s or the owner/operator of the establishment, Bruce, would sound like a paid advertisement, so I’m not going to even start.  What I will say is, if you want to visit a beautiful part of North Carolina- visit Mortimer. And if you visit Mortimer- visit Bruce.  He’s got cabin rentals, inner tube rentals, and more knowledge of the area than you’ll find anywhere else.  If you ever find yourself that way, tell him Victoria sent you… Seriously!

 

With Bruce’s back yard as our home base (he is a gracious host), we put in many miles of hiking, had numerous dips in local swimming holes, and managed to spot some of the Perseid meteors.  It was hard to tear ourselves away in order to make it to Atlanta on schedule (we actually didn’t make it to Atlanta on schedule because we opted to take a morning hike before we hit the road).

 

Betsey's. "Peace and Love, Y'all"

Betsey’s. “Peace and Love, Y’all”

 

Putting in some miles in Pisgah National Forest...

Putting in some miles in Pisgah National Forest…

 

I was keen to keep my socks dry, and I did! At least for the first half of the hike (darn slippery rocks)...

I was keen to keep my socks dry, and I did! At least for the first half of the hike (darn slippery rocks)…

 

My new favorite swimming hole, at the top of Gragg Prong fall.

My new favorite swimming hole, at the top of Gragg Prong fall.

 

The reason we didn't make it to Atlanta on schedule- I had to introduce James to one of my favorite spots- Big Lost Cove.

The reason we didn’t make it to Atlanta on schedule- I had to introduce James to one of my favorite spots- Big Lost Cove.

 

It goes without saying that Atlanta was a big change of scenery in comparison to the preceding few days.  I actually didn’t see much of the city, save for the inside of the Sheraton Conference center, a few of the fine dining establishments, and Boyd Eaton’s gorgeous house where the presenters dinner was held.  Prior to the official start of AHS, a number of the Physicians and Ancestral Health docs got together for a brief meeting.  It was great to catch up with these like-minded Docs, and I was reminded, again, how refreshing it is to spend time with people who share passions and interests. 

 

AHS itself was fantastic, save for a few AV snafus. I thoroughly enjoyed some of the plenary talks: namely Nassim Taleb’s antifragile talk, Gad Saad’s talk on The Consuming Instinct, and Geoffrey Miller’s talk on Sexual Fitness (not talking about “reps for time”).  I was a bit surprised by Mel Konner’s and Boyd Eaton’s talk on the history of modern “paleo” diets, where they repeatedly said that our modern diet is much higher in saturated fat and lower in polyunsaturated fat than historic diets… I find it hard to believe that any diet that contains modern vegetable oils has anything other than an excess of polyunsaturated fats. 

 

There were many excellent talks over the course of the conference, and it was often hard to pick which talk to attend out of a very tempting schedule.  I look forward to catching some of the ones I missed online when the videos are posted.  On that note, my talk on Dietary Fats and Fatty Liver Disease, went well.  When the video becomes available I’ll try and post it here!

 

As much as I enjoyed the various lectures, workshops, and posters, the highlight of AHS was catching up with friends and making new ones.  There is quite a vibrant online community of those interested in evolutionary and ancestral health, and AHS can sometimes seem like the interwebz in 3D.  As someone who would happily trade days of online interactions for even brief face-to-face encounters, AHS was a social occasion that refilled my tanks and renewed my enthusiasm. 

 

Back in May, on the Wilderness Medicine elective in Utah, our instructors expressed that one of the goals of the elective was to “stock good memories” for the rough times that were to follow in residency (all but 2 of the 12 students would be starting internship in the next month).  I still have quite a bit of time until I start residency (though the march towards June of 2014 soldiers on), and my goal between now and then is to bank as many good memories as I can.

 

Stashing good memories (and looking for Hobbitses).

Stashing good memories (and looking for Hobbitses).

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I’ve been hesitant to write this post.  This blog is certainly not a travel blog, and it was never intended to be a place where I posted my exciting travels (and to be honest, during the final years of my PhD and third year medical school I didn’t really have any exciting travels to write about).  That being said, I can’t help but post about my adventures in Moab.  If my antics encourage just one person to get outside and enjoy time in the great outdoors, I will consider this post a huge success…

 

Moab…

After completing my Wilderness Medicine Elective, I opted to take two weeks of vacation time (4th year medical students can get a rather absurd amount of vacation time if we play our cards right) to recoup, relax, and since I was already out west, spend time in Colorado with my best friend.  With over 100lbs of luggage to lug around, I managed to sweet talk my best friend into picking me up in Salt Lake City (where my elective wrapped up), instead of hopping a plane to Denver.

 

My best friend is a good sport about road trips (I suppose she should be, as I once drove 28hrs straight with her when she moved cross-country to Colorado), and she was happy to come pick me up, suggesting that we route our trip back through Moab for a bit of outdoor adventuring before heading back to Colorado.  I didn’t know much about Moab before I got there, but I knew Arches National Park was right next door and that the desert portion of my course was in Canyonlands National Park, so I thought it might be fun to swing back through and at least check out Arches on our way back.

 

That was before heading west… Once I met and talked with the river guides who work out of Moab and spent a “transition” day there between the river portion and the desert portion of the Wilderness Medicine elective, I was counting down the days until I would be back.

 

Moab is a stunning place- the rock formations and geology surrounding the town are truly “other worldy”, with the red rock shaped by time and weather into precarious and beautiful structures.  There is also a LOT to do in Moab for people who enjoy the outdoors.  The Colorado River can be enjoyed from rafts, boards, boats, or the shore, there seems to be a new hike for every day of the year, biking (mountain and road) is king, and the weather in May is wonderful for camping (sans-tent, for those-like myself- who are so inclined).

 

There are plenty of places to stay in Moab, but being on a budget and having spent the majority of the prior 3 weeks sleeping outdoors, I was more than happy to camp in Moab.  There are many campsites with RV hook ups, tent sites, and amenities such as showers, but I’m a fan of primitive camping.  Fortunately, for those in the know (or those who get the scoop from knowing river guides), there is plenty of dispersed camping to be had in spots around Moab.

 

view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

The view from one of our camp sites up off Klondike Bluffs, about ten miles north of town.

 

We spent out first morning in Moab getting coffee (“That Paleo Guy”, Jamie Scott, would swoon at all the coffee spots in Moab) and sorting out plans for the next couple days.

 

Wicked Brew- home of a mighty fine shot of espresso

Wicked Brew- home of a mighty fine shot of espresso

 

After a morning in town we headed out for a hike at Fisher Towers.  This hike, while popular, is a bit off the beaten track (at least in comparison to the tourist heavy hikes in Arches National Park).  The rock formations are stunning and the plant life was beautiful. This place is popular for rock climbers, and it was breathtaking to see them atop the tallest towers.

 

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

Fisher towers- if you go on this hike, make sure you get on the proper trail… we ended up scrambling quite a bit looking for a trail on various dead ends when we erroneously got started on a “photograph trail”.

 

“The Titan” is the tallest structure at Fisher Towers, and is very striking.

“The Titan” is the tallest structure at Fisher Towers, and is very striking.

 

 

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning.  Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!)

Alas, I seemed to have a knack for attracting rain on this trip… As we rounded the turn at the top of the hike, we were greeted by storm clouds and a flash of lightning. Needless to say, we made a rapid retreat (I did learn about lightning strikes on my Wilderness Medicine course, but like almost all aspects of medicine, the best solution is prevention, prevention, prevention!).

 

After our hike, we headed back towards Moab, making one stop at a local vineyard and a detour down Onion Creek Road.  If you are around Moab and have an AWD vehicle (or are comfortable taking your vehicle through multiple stream fords), definitely check out Onion Creek Road.  If you’re really lucky, one of the dispersed camping sites might be open and available (we didn’t have any luck on that front).

 

My best friend is an avid paddle boarder, and she’d contemplated packing her paddle boards down to Moab for us to use on the Colorado River.  It seemed that renting boards in Moab was a much better option, so after making some inquiries, we ended up renting two inflatable boards (Badfish MCIT) from Canyon Voyages, strapping then to our car, and driving them up river to our drop-in point.  We’d scouted the river the day before and had decided to drop in at Take-out beach and to get out at Lion’s Park: a ten-mile paddle downstream (with my friend opting for the hitchhikers shuttle after parking her car down at the pull-off site. Pro-tip: carry your PFD (personal flotation device) and catching a ride is pretty easy).

 

Boards- Ready for adventure.

Boards- Ready for adventure.

 

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming.  I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.

While a road parallels the Colorado River the length of our ten-mile paddle, the trip was still very calming. (Though I’ll be honest- I went through our lone rapids and a couple of the choppy fast-water sections firmly on my knees.)

 

The rest of our day was spent driving out to Dead Horse National Park, seeking out dinosaur footprints (yes really), cooking dinner at our campsite, and then meeting up with a new friend from my Wilderness Medicine Elective- one of the river guides from my travels down Desolation Canyon.

 

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

I can’t tell you if they’re Therapod or Sauropod footprints, but they were pretty cool!

 

As much fun as the previous two days had been, the real adventures began when we started hanging out with a local… My river guide friend was just back from another long trip down Desolation Canyon, which meant that he had a bit of time off before heading back to the river.  The next morning he took us on a hike up to Cable Arch, an arch off the beaten track on an unmarked trail.  Our drive out to the trailhead took us past quite a few petroglyphs, including one that I found very interesting.

 

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth.  Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting.

The birthing rock- my picture isn’t the best, but this petroglyph seems to show a breach position birth. Some readers may remember that I’m interested in “traditional” positions for giving birth, so I found these depictions particularly interesting. (Here’s a better picture.)

 

An arch all to ourselves… something you seldom get in Arches National Park

An arch all to ourselves… something you seldom get in Arches National Park

 

Not another person for miles...

Not another person for miles…

 

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

Scrambling up and down rock faces is a lot of fun (and an excellent work out)…

 

After a relaxing lunch in town, we headed up to the Sand Flats for an afternoon adventure of rappelling.  I’ve never been rappelling (save for the ~15’ rappel we played with up in the alpine on the Wilderness Medicine course), and I’ll admit that at the top of our first descent I was more than a little nervous.  However, as I lowered myself into the slot canyon (into an area aptly named “the medieval chamber”), my fear was replaced by exhilaration.

 

Rappelling down into the "Medieval Chamber".

Rappelling into the “Medieval Chamber”.

 

The second rappel, off a natural bridge, landed us at the focal point of a somewhat well travelled out-and-back hike.  My best friend went first, and her adventures were well documented by some of the sightseers below!

 

Kate, headed down off the natural bridge

Kate, headed down off the natural bridge

.

The next day found us rappelling again, this time in Arches National Park.  We were truly spoiled to have a local show us yet another awesome spot, for while we left our car in a crowded parking lot, we quickly backtracked along the road and scrambled up a rock fall to find ourselves isolated atop a large mesa.  Hundreds of feet above the other tourists below us, we spent much of the morning relaxing above Arches, in our own world, away from any other visitors to the park.

 

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually we settled down to soak up the sun, talk, and relax.

Above Arches- We spent quite a bit of time wandering around the top of the mesa, but eventually settled down to soak up the sun, talk, and relax.

 

Above Arches- I’m not sure the scale comes through…

Above Arches- I’m not sure the scale comes through…

 

After an hour or so of basking on the rocks, we started our descent back down into the canyons.  This (again, unmarked) path took us down a number of small descents before finally putting us atop a 100’ wall down to the canyon floor.  The rappel was a rush.

 

Can you find me? Hopefully the scale comes through now!

Can you find me? Hopefully the scale comes through now!

 

My best friend and I did plenty of other things in Moab, including taking a drive and some hikes through Arches National Park. Arches IS stunning, but after getting an insiders-tour to some stunning and relatively unknown-to-tourists spots, hiking along crowded groomed trails to ogle at postcard views lacked some luster.  I don’t mean to sound snooty, and I hope it doesn’t come across that way, but I think my favorite moments of this trip to Moab were the moments with friends around bonfires, scrambling up rocks, and quietly taking in all that our surroundings have to offer.

 

After more than a month away, I am finally headed home to New Jersey.  I am heading home physically tired but psychologically refreshed.  I have always believed that nature is *good* for humanity, but I have never experienced this goodness so intensely as in the last month.

 

Through the wilderness medicine elective, my trip to Moab, and then a Memorial Day Weekend camping trip in the mountains of Colorado, I have experienced many different environments.  A big part of experiencing these environments, to me, is learning to be present in the moment- to quiet the mind of all the banality and drama that so easily catches us and to really appreciate what surrounds us.  In the hustle and bustle of normal life this skill takes practice, but it is practice that pays back in dividends on the principle that nature satisfies a deep and primal part of our humanity, and we should seek it out and absorb it whenever possible.

 

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

Memorial Day Moonrise over Twin Lakes in Colorado- Not sure I can think of a better way to end the day…

 

Find your people, find your places, and enjoy the moment…

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1-year Blogiversary

 

It has officially been one year since I started blogging (1 year and 4 days if you’re being exact).  Starting blogging as I started third year medical school was probably not one of my smartest moves.  Third year medical is tough, mainly by being incredibly demanding of your time and sanity. All the same, I’m really glad that I finally started putting words-to-website and getting some of my thoughts out there for others to read.  Blogging is something I had wanted to do for a while, but wonderful people though they are, I think my parents might have disowned me if I’d started writing a blog before I’d finished writing my thesis!

 

Starting blogging during my clinical years has led to a couple things. First- I haven’t been able to put the requisite time into a number of the topics I originally wanted to write about (though I plan to get to these topics eventually!). Second- I’m surprised by how much I want to write about clinical situations and my general experiences on the floors. Together, this means that my blog is slightly different that I had initially imagined and that I have a long list of potential future blog posts (as well as a folder on my desktop with a significant number of “started posts” that may never see the light of day or the glint of a readers eye).

 

I sincerely want to thank everyone who has joined me over the past year on my blogging journey. I deeply appreciate that you take the time to read my musings. I really enjoy getting comments and I apologize that I sometimes get too caught up to reply to all the thoughtful responses.

 

I also want to thank everyone who has shared my blog and my posts.  I’ve had a couple big days when some rather “big shot” bloggers have shared my posts (most recently Mark Sisson gave me a big bump when he shared my snuggling post in last week’s “Link Love”) but I really appreciate (and am humbled) that readers like my posts enough to share them on facebook and twitter . One of the fun elements of having a blog (at least for those with a significant nerdy streak) is keeping an eye on the statistics generated by your blog host… more on that later!

 

Exciting News…

 

I’m very excited to announce that I have been invited to speak at the 2013 Ancestral Health Symposium this August in Atlanta.  I attended the last year’s conference in Boston, and am excited to be speaking on one of my favorite subjects, lipids and liver, at this year’s event.  Tickets are already on sale for society members and early registration starts for non-members on March 15th. The symposium sold out the last two years, so if you plan to attend make sure you reserve your tickets early!

 

In addition to giving a talk on liver and lipids, I’ll also be heading up a panel of ancestrally minded physicians.  The details are yet to be settled, but with a panel including Dr. Emily Deans (of Evolutionary Psychiatry), Dr. Anastasia Boulais (of Primal Med Ed), Dr. Jacob Egbert, and Dr. Don Wilson, I’m sure there will be some interesting discussion exploring how to use ancestral and evolutionary thinking in a variety of clinical fields including psychiatry, hospitalist practice, physiatry, and ob/gyn respectively.  More details to follow!

 

Fun with Stats…

 

As I mentioned above, one of the joys of having a blog (at least for those of us with a nerdish interest in numbers) is keeping an eye on the blog’s stat page.  In addition to showing me which posts are popular and why, it also shows me the search terms that navigate people to my page.  “Principle Into Practice” is a popular google search that navigate people to my page.  Some of the more obscure ones are a little more puzzling (and amusing).  Here are some favorites:

Help me, I’m dating a medical resident

– “Dating in medical school”, “dating a medical student”… some variation on this theme is one of the more popular phrases that gets people to my blog, no doubt linking them to this post . I’m sure that’s not the kind of dating advice the googlers were looking for- sorry!  As for actually dating a med student? Good luck… the first two years are probably more “dating friendly” as the schedule (at least at my school) is quite flexible, but my experience with third year is that your time is generally spent in the hospital or sleeping.  Date a med student at your own peril- they will undoubtedly want to practice physical exam skills on you and they’re probably a bit short on time for making much of a relationship. Also, if you think dating a medical student is bad, I can only imagine the horror that is “dating a medical intern”. Their schedule makes a med-student’s schedule look like a walk in the park!

Can you burst your appendix by eating a lot of pickles

-Umm… no

Can you get out of the country if you have c difficile

– Actually, a lot of people are walking around with C. diff in their system. Problems arise when you have an overgrowth, at which point you probably can’t be anywhere too far from a toilet… (and you need prompt medical attention)

Victoria Principle nude

-This web-surfer undoubtably went away disappointed…

 

Asparagus therapy and human parasites

also

C. diff and asparagus

-I got nothing…

How to sleep during medical school

– My answer? As much as you can, whenever you can.  Refer back to “dating a medical student” if you’d like.

What speciality [sic] in medicine combines clinical practice and evolutionary theory

– I’m not sure, but if you figure it out, please let me know! (Actually, as I’ve argued before, I think there’s a need for an evolutionary perspective in ALL fields of medicine, though perhaps some have more opportunities for evolutionary thinking than others.)

 

Most search terms guide the seeker to appropriate pages, and I hope that my posts enlighten and entertain.  Many of my favorite posts, some of which are also my most popular posts, can be found here on my “Favorites” page, if you’re ever looking for some interesting posts you might have missed!

 

A final thanks….

 

I said it before; I’ll say it again.  Thank you to everyone who reads, shares, and/or comments on my blog.  It’s been a fun year of blogging and I’m looking forward to more posts, speaking at AHS 2013, and continuing to interact with readers, friends, and those who share an interest in ancestral health and evolutionary medicine… and also those who are curious about dating in med school! 🙂

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It’s currently the time of year when the Student Affairs personnel at my school people are rallying the troops (third year medical students) to start thinking about what we want to be when we “grow up”. It’s early days yet, but the words “personal statement” seem to inject fear into my classmates. I guess most of them don’t write a blog for a hobby…

 

I haven’t started to write a statement yet, and I’m sure it’ll be an angst filled experience when I finally get down to it, but mulling it over got me thinking back to the personal statement I submitted when I first applied to medical school.

 

I was not a traditional med-school applicant. I was not “pre-med” (a major I would discourage anyone from pursuing) and I had never shadowed a doctor nor shown any interest in a medical profession.  I had a broad interest in all things scientific. I took the MCATs on a dare and did well enough to consider applying to medical school.  My love of science made the MD/PhD route intriguing to me, so I decided that in addition to the PhD programs I was interested in I would also apply to a few MD/PhD programs.

 

A couple weekends ago I was up in Boston and enjoyed a dinner with Kamal Patel of Pain Database and others. It was an enjoyable evening, and while discussing the merits and perils of being a med student I somewhat jokingly suggested to Kamal that I should dig up my old personal statement and post it on my blog.  He thought it seemed like a great idea (surprisingly, alcohol was not involved in this discussion), so now that I’ve had a bit of downtime I’ve dug it up and given it a look over.

 

In hindsight, I seem a little overenthusiastic (so many exclamation points!!!!), but generally I think that my enthusiasm for life is genuine.  One of the closing lines is something that I still deeply believe. In fact, it is a sentiment that comes through in the name of this blog.

 

I believe that the practical application of knowledge is the most rewarding result of study and curiosity.”

 

 

Even 8 (eek!) years ago, I wanted to put principles into practice.

 

Without further ado…

(Unedited, except to abbreviate the names of the professors I worked with)

_____________________________________

 

Until a few years ago I could still see the remnants of my first “experiment” in my garden every spring: red tulips growing along the fence line of the vegetable patch. As long as I can remember, I’ve been asking questions and trying to figure things out. The directions on a pack of tulip bulbs told me to plant them six inches deep, six inches apart. But at five I had to ask… why? Luckily I’ve been blessed with equally inquisitive parents, so my father indulged me, and the next day we were digging holes ranging in depth from one inch to two feet. The next spring I waited expectantly. Somewhat to my disappointment, they all came up! That wasn’t supposed to happen! Only the next year did it become clear that six inches seemed about optimal for a perennial show.

 

My quest for understanding and knowledge through experience has been a lot of fun, taken me many places, and introduced me to many people. As a child I would spend days in the woods and fields around my house exploring and trying to understand nature. When I wasn’t out adventuring, I was home reading books; I was amazed at what there was to learn! When I first started riding horses it was hard to find me away from barns, vet offices, or anywhere else I could learn about horses. While this led me to compete at national quiz competitions, I have most enjoyed becoming a thoroughly knowledgeable horse person. I apply what I know to working with my own horses and those of others, and enjoy teaching and helping local kids and even adults with general equine knowledge and veterinary care.

 

I particularly enjoy teaching others about polocrosse, an exciting combination of polo and lacrosse. I started playing on my first pony, a well-trained, athletic pony that did everything I asked her to do. When it was time for me to get a bigger horse, I looked at a number of horses that were ready to play, but eventually decided to buy a young ex-racehorse with a lot of potential and very little training. At times it was hard to watch my peers get better so quickly on their well-trained horses, and at times I thought I should give in and get a horse that was ready to play, but the challenge excited me, and I stuck with it. After four years of hard work, a lot of sweat, a few falls, and occasional bouts of anguish, I’m proud to play on a horse that I brought to the game on my own, and I know that I am a better rider because of the experience.

 

Now in college, I still can’t learn and do enough. I have joined a number of groups on campus, and am on the executive boards of the campus-wide Programs and Activities Council, the Biochemistry Club, and Alpha Zeta, a co-ed honors/service/social fraternity. Going to a large state school, I have had the opportunity to take a wide range of classes that apply to my major, my interests, and things that just seem neat! During the fall of my freshman year I became SCUBA certified so that I could travel to Little Cayman during the winter break to study coral reefs with a marine geologist. I was so enthusiastic that she invited me to apply for a summer internship studying the reefs around the island. I applied, got the position, and spent two weeks documenting species diversity, morbidity and mortality of coral around the island.

 

A fascination with Moorish architecture and Picasso’s Guernica, and a desire to test my Spanish on its home ground, led me to drag my mother to Spain. My basic grasp of the language and her ability to rent a car made for an incredible trip. For ten days we traveled in the south of Spain, seeing architecture and experiencing the culture. Similarly, a fascination with Guinness Stout, Ireland, and the Irish led me to take a youth-hostelling trip to Dublin. These and other trips have heightened my curiosity and driven my desire to see and experience more of the world.

 

During college, the curiosity that my parents initially encouraged when I was a child developed into a desire to do scientific research. In addition to the coral reef project, I am glad to have had several other exciting research experiences. I was fortunate to receive a Center for Bioinorganic Chemistry summer grant to work in the laboratory of Dr. GZ on the biodegradation of aromatic hydrocarbons by Pseudomonads. Another year I got funding to study the incidence of Lyme disease in mice and their parasites along a rural to urban transact in New Jersey in the laboratory of Dr. MS. I am now conducting my senior thesis work in the toxicology lab of Dr. LW, studying the effects of 2,3,7,8-tetrachlorodibenzo-p–dioxin, an environmental contaminant, on developing fish embryos. The curiosity that once inspired me to plant rows of tulips has brought me to believe that medical science is the most exciting and dynamic field I could hope to enter, yet I am hesitant to devote my life purely to lab work and research. I believe that the practical application of knowledge is the most rewarding result of study and curiosity. I want to enter the medical field to combine my drive to discover and understand with my love of people, and become a doctor working at the frontiers of clinical science.

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When I tell people that I’m interested in evolutionary medicine, I sometimes get the response “Evolutionary medicine? Or the evolution of medicine?”.

 

I’ll admit, I’m actually interested in both, but my interest in Evolutionary Medicine is much stronger than my interest in the history and progression of medicine, though this subject can be rather fascinating.  I’ve listened to a course on the history of medicine, attended some extra lectures, and occasionally pick up a book to indulge this interest, but as a third (soon to be fourth, in 2 weeks!) year medical student, I generally have a hard enough time trying to make sense of our modern medical practices without spending too much time thinking about medical history.

 

Sometimes, however, the evolution of medicine plays out right in front of your eyes.

 

Today I took the end-of-clerkship exam for my obstetrics and gynecology rotation.  I actually enjoyed this clerkship a lot more than I had initially anticipated (a good thing, as I am increasingly thinking that I will pursue a residency in Family Medicine, which includes obstetrics).  I found myself a lot more enthusiastic to go to the OR to scrub in than I was during my surgical clerkship many months ago (it’s amazing what a year of clinical medical education will do to you).

 

This clerkship was split into a number of portions: labor and delivery (L&D), night float, women’s health clinic, maternal-fetal medicine (MFM), reproductive endocrinology and infertility (REI), gynecology, and gynecologic oncology… Quite the smorgasbord! On night float and L&D I would frequently end up in the OR to scrub in on a cesarean delivery, on gyn and gyn onc I was in the OR daily for a range of procedures from small biopsies to extensive tumor staging cases.

 

Major advancements in surgery include the discovery and utilization of anesthesia (Imagine being awake and able to feel everything in surgery! Better not, actually…), and the acceptance of germ theory (for which we should thank John Lister (1827-1912), namesake of Listerine!). Many other discoveries, techniques, and inventions have changed the practice of surgery, but these two are biggies.  The third, looming, problem that needs to be addressed is the perturbation of cytokines during and after surgery, but that is a story for another day!

 

An interesting progression of surgery is the way in which surgeons gain access to the abdomen and pelvis. Traditionally, as one might imagine, the easiest way to visualize and manipulate the internal organs was to do an open procedure, literally cutting a person open to directly access the area to be operated. In the 1980s, gynecologists started to train in a new technique- laparoscopic or “minimally invasive” surgery- in which a small camera is inserted into the abdomen (which has been inflated with an inert gas to create space*) so that surgeons can visualize the internal structures without opening the belly. Instruments can be introduced into the abdomen through small incisions, and organs and instruments can be manipulated inside the body** and visualized on a screen.

 

Initially this technique was used for only very small procedures (such as a tubal ligation, “having your tubes tied”), but as surgeons became more proficient, the complexity of the cases that could be performed in this manner increased.  The utility of this technique was recognized, and in the 1990s, general surgeons started to train in laparoscopic techniques.  Now, many surgeries, both gynecologic and general, are performed laparoscopically (somewhere along the way, urologists started using this technique as well).

 

To be a good laparoscopic surgeon takes a lot of time and training. Cut yourself a 31 or 42 cm stick and imagine trying to do small and precise tasks with the end, which you can only visualize on a screen. Now imagine you have to dissect out delicate pieces of anatomy, correctly identify them, preserve or remove tissue accordingly. As a student on the gynecology service, there was really no reason to scrub into “lap” cases (though they were generally good cases to observe, since the screens make the procedure easy to follow), but on surgery I would sometimes scrub in and occasionally be allowed to steer the camera or “bag” a specimen for removal (really, the resident would drop the sample into the endocatch bag, but they would generally act like it was a great triumph for the student!). It all looks fairly easy until you actually have your hands on the instruments and have to find your way around the belly (or if you’re the med student with the camera, make sure the surgeon is seeing what she wants to see!).

 

Once you are proficient with laparoscopic techniques, there is a lot you can do. One of the fellows on the Trauma service was a specialist with laparoscopic techniques, and he could “run the bowel” (visualize it from end to end) more rapidly laparoscopically than many surgeons could do open.  Getting proficient, however, takes a lot of time, especially if one is to master skills such as laparoscopic suturing.

 

Many gynecological and general procedures are now done using laparoscopic techniques. If you have your gallbladder or appendix removed, it’s likely you will have a “lap-chole” or a “lap-appy”, and the offending part will be removed with only a few small incisions visible.

 

In the last 10 years (I think), there was been “the next step” in laparoscopic surgery… the invention and utilization of a laparoscopic robot.  I should be clear that surgery is still under the control of a surgeon, and no one has “robot surgery”, but the “latest and greatest” (though is it really?) advancement in surgery is “robot assisted laparoscopic surgery”.

 

In robot cases, the abdomen is accessed similar to a traditional laparoscopic case, except the various instruments are subsequently attached to a robot, instead of being wielded by surgeons (though an assistant was needed at the patients side in the cases I saw to swap out instruments and to suction).  Using “the robot” allows surgeons a lot more precision and accuracy, and according to one of the surgeons I observed, you become proficient much more quickly on the robot than you do with traditional laparoscopic techniques.

 

Is it progress? 

 

On my week of gynecology, I witnessed the same surgery (supracervical hysterectomy) done open, laparoscopically, and with a robot-assist.  Some cases, due to the underlying pathology or anatomy, must be done open.   If the uterus is too adherent to other structures or if there might be malignancy that could spread if not removed in one piece, open surgery is probably the best option.  All things being equal, recovery from an open procedure is much longer than for the other options.

 

When it comes to laparoscopic surgery, robotic surgeries can potentially accomplish much finer tasks than general laparoscopy with significantly less blood loss (the robotic hysterectomy that I observed had an estimated blood loss of 20cc- they probably take more at your annual physical).  The laparoscopic case I saw also had minimal blood loss and was accomplished very quickly- the surgeon has decades of practice under his belt.

 

So- is this the evolution of medicine? Will robots fill every OR, and will the best surgeons be those who spent many hours as a child (or as an adult, as often is the case) playing video games? (I had to have a quick google, which resulted in this.).

 

Who am I to say? I’m just a MS3.97 (yes I calculated), with no great knowledge of surgery.  All I can say is that the progression of medicine is amazing.  We (generalists, specialists, surgeons, and other health care practitioners) have amazing technology at our fingertips. We have access to impressive diagnostics, powerful drugs, and amazing technology that allow us to diagnose, treat, and definitively fix disease.  But we must be judicious. Diagnostics and treatments (pharmacologic and surgical) have consequences- some big and some small.

 

Sometimes the question shouldn’t be “what type of surgery”, or “which drug”, but rather “is surgery necessary?” or “how will treatment help” (I don’t think the cases I described above were unnecessary, but Obstetricians/gynecologists, because of the horrible state of medical-legal affairs, often seem to err on the side of doing too much and/or acting very quickly).  We can do amazing things with medicine. Contrary to how this may sound, I’m not acquiring medical knowledge with no intent of using it. Rather, I think that those with medical knowledge have a responsibility to help patients decide what is the best option for them– physically and personally. At least that’s the kind of doctor I want to be…

 

But hey- we have some pretty cool tools out there to help us when we need them!

 

courtesy of wikicommons

A surgical robot- Courtesy of wikicommons

 

*It’s amazing how laparoscopy can pervert your perception of anatomy. When the abdomen is pumped full of gas it looks like organs are flopping around with lots of space, when in reality everything is rather tightly packed during day-to-day living.

** I write abdomen or “belly”, but I generally mean abdomen and/or pelvis.

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This one isn’t exactly “evolutionary medicine”, but it sure is a smart, cheap, and (in my experience) unheard of little tip for shortening hospital stay (and thus cutting the bill) for some surgery cases.

Surgery comes with innate risks. Bleeding and infection can occur with any surgery, but operations that affect the bowel come with additional risks and concerns. One frequent complication of abdominal operations is postoperative ileus- a temporary paralysis of the intestinal tract after surgery that is usually related to the degree of surgical trauma and bowel manipulation.

When you are part of the surgical team, an important part of post-surgical care is keeping track of the workings (or lack thereof) of the patients’ digestive system. A typical morning check-up on a patient might go something like this:

“Hello! How are you feeling this morning?” (This exchange usually takes place around 5:30 in the morning… Anyone who says “good” is obviously bluffing!

“Sleep well?” (I think I may be the only student that cares about this question.)

“Any pain?”

“And have you had a bowel movement? No? Ah- have you passed any gas? Above or below?”

Yes, when you enter the world of medicine, the taboos of normal conversation (indeed, many social graces) are quickly forgotten.  Gone are the tendencies to giggle when someone says “fart”. Instead, the return of a patient’s bowel function can become a celebrated event amongst the team.

Post operative ileus is likely caused by a number of factors, including increased sympathetic activity (the fight-or-flight side of our autonomic nervous system) which overpowers the parasympathic (the rest-and-digest) system, as well as inflammatory mediators.  Additionally, some of the drugs that are used before, during, and after surgery may also inhibit bowel motility [1].

Ileus can delay patient recovery and increase the length of patient hospitalization, which leads to greater healthcare care costs. So how can we decrease ileus?

There is some evidence to suggest that therapies such as early postoperative mobilization (getting up and walking) and early feeding may decrease post-operative ileus [1].  I’m particularly interested in early post-operative feeding, which seems to come with a host of benefits in comparison to “NPO” (nil by mouth) that is common after surgery.  In fact, in a meta-analysis of 11 studies including 837 patients, early post-operative feeding significantly reduced the risk of any type of infection and reduced the mean length of stay in the hospital.  It also reduced (though not statistically significantly) the risk of anastomotic dehiscence (the breakdown of the site where bowel was sewn together), wound infection, pneumonia, intra-abdominal abscesses, and mortality. The down-side of early post-operative feeding is that the patients have an increased risk of vomiting [2].

But is there a way to get the benefits of early feeding without the risk of vomiting? Is there a cheap and easy way to increase the rate at which bowel function returns?  It appears the answer is yes, and it is incredibly cheap and easy: Gum.

Gum chewing works as a type of sham-feeding that promotes intestinal motility. It seems that chewing gum causes our brain to pass the signal to our stomach that food is on the way. In normal volunteers, gum chewing stimulates gastric secretions. In patients, gum chewing appears to wake the GI tract up more quickly than if their mouth stays idle [1].

A meta-analysis of 9 trials including 437 patients showed a reduction in time to first flatus (the medical term for fart), time to first bowel movement, and reduction in hospital stay in patients in treatment groups versus controls. The treatment groups chewed sugarless gum at least three times a day for 5-45 minutes starting on the first post-operative day [1]. While early post-operative feeding seems to offer a number of benefits in comparison to fasting, it can be poorly tolerated and only taken in small amounts. Chewing gum is a method of sham-feeding that stimulates bowel activity, without the possibility of vomiting or the limited intake of food seen in some patients.

I have heard surgeons at our University talk about the data regarding early-feeding. I have not heard anyone talk about the benefits of gum chewing.  The data is out there, but unlike pharmaceutical interventions which have drug-reps proclaiming their benefits, simple interventions such as these are not widely promoted.  Who would benefit from promoting this information?  Even if every hospital ward in the country started stocking gum, I doubt the gum-makers would notice an uptick in their bottom line- this isn’t exactly a high dollar intervention. In fact, the meta analysis suggests that chewing gum can reduce the length of hospital stay by a mean of approximately 2 days at the average cost of $0.60 per patient [1].

It is important to mention that many of the studies included in the meta-analysis were conducted in Africa, where the risk of complication and the subsequent length of stay are much higher than in the US.  While on my surgery rotation, I saw some patients go home less than 24 hours after having their appendix removed. One paper from 2006 shows that the mean hospital stay after appendectomy at a teaching hospital in South Africa was 10.6 days [3]. Indeed, much of the primary data that I read about surgery in the developing world leaves me cold.

Laparoscopic surgery (performed through small incisions in the abdomen and visualized with a small camera), means that simple procedures such as the removal of an appendix or gallbladder can be done with minimal trauma and scarring. In developing countries, these operations are still done with open incisions, in operating rooms that lack many of the most basic tools necessary for good surgical care.

Angela’s recent guest post has inspired me to think more about the great disparities in health, disease, and medical care in the developed and the developing world.  As I read more about surgery and medical care in Africa, I realize that even the simplest of interventions can have a huge impact on health care, especially in developing areas. This was also brought through in Atul Gawande’s book The Checklist Manifesto, which I read recently.

It is unrealistic to think that hospitals in developing nations will be equipped with cutting edge technology to perform minimally invasive surgery any time in the near future. Such technology is expensive, and it requires surgeons who have been trained to use it (not to mention reliable sources of electricity to power the equipment).  Yet simple solutions, such as post-operative gum chewing, can offer serious benefits that should not be ignored [4].  And if I find myself on the other side of an early morning post-op check-in, I know I’ll be requesting something to chew on*!

*It should go without saying that this post is not meant as specific medical advice, but as an exploration of a potentially useful therapy that doctors should consider. If you find yourself on the wrong side of the operating table, work with your medical team to get yourself on the road to recovery ASAP.

 

1.            Noble, E.J., R. Harris, K.B. Hosie, S. Thomas, and S.J. Lewis, Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg, 2009. 7(2): p. 100-5.

2.            Lewis, S.J., M. Egger, P.A. Sylvester, and S. Thomas, Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ, 2001. 323(7316): p. 773-6.

3.            Ayoade, B.A., O.A. Olawoye, B.A. Salami, and A.A. Banjo, Acute appendicitis in Olabisi Onabanjo University Teaching Hospital Sagamu, a three year review. Niger J Clin Pract, 2006. 9(1): p. 52-6.

4.            Ngowe, M.N., V.C. Eyenga, B.H. Kengne, J. Bahebeck, and A.M. Sosso, Chewing gum reduces postoperative ileus after open appendectomy. Acta Chir Belg, 2010. 110(2): p. 195-9.

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Waste not, want not

As my part of the country battens down the hatches as Sandy approaches (all the businesses in my town have boarded or taped their windows and sandbags line the sidewalk), it seems appropriate to write about nature.

The changing of the seasons is always a beautiful sight here in the northeast US.  Early in the year, greens and yellows of spring welcome a new year of growth and productivity.  The banner at the top of this blog is a picture taken in my parents’ garden of aconites, a flower that blooms in February when the rest of the world is still brown and gray.  Now, in the throes of fall, the changing of the seasons is obvious in the reds, yellows, oranges, and browns of the changing leaves.  When you see the cycle of the seasons, with trees budding and leafing out in the spring only to see the leaves turn color and drop 6-months later, it can seem a little wasteful.  So much growth, only for the trees to be bare once more.

But what is waste, in nature?

One of the arguments frequently used against the eating of meat is the toll that animal waste takes on the environment. The run-off of nitrogen-laden (not to mention antibiotic-riddled) water from large-scale feedlots can wreak havoc on waterways and land (though it bears mentioning that run-off of nitrogenous fertilizer from crop land can be equally detrimental).  In a non-industrial setting, however, is “waste” really such a problem?

On the contrary- in a more natural world “waste” is not a toxic hazard, but rather an important part of life.  I snapped this picture at a farm near where I grew up. For as long as I can remember, this land has been “hayed” (in our area, farmers usually make 2, sometimes 3, cuttings of hay per year). In the last couple of years this land has changed hands, and now belongs to a vet with a great interest in grass-fed meats (as well as quality horses). The fields that have been farmed for vegetative crops will now be home to livestock… Just look at what their waste has done!

Animal impact: “waste” = growth

Look inside the fencing. See those dark green areas where the grass is particularly lush (and extra long)? THIS is what nature does with waste: nature turns waste into growth.

This land was productive as crop-land (you can see in front of the fenced land that part of this property is still in hay), but I suspect that with the return of animals to this land the grass will actually grow more, not less.  Hayed land can be (and should be) replenished with potash (for potassium), lime (to maintain an appropriate pH), and nitrogen (in some bioavailable form to help plants grow) to compensate for the nutrients being continually removed by the cutting and bailing of hay. While many farmers slack on replacing the more expensive lime and potash, most put down nitrogen to help the grass “pop” so they get a good yield (biomass). Putting animals on the land reduces (or eliminates- once the soil is replete) the need for added fertilizers, as the grass is not being shipped off the property as hay, but is rather being cycled right there on the property into biomass (beef) and fertilizer.

What our modern, industrial world sees as waste is really part of a natural (not to mention efficient) cycle…

This isn’t just true with animals.  I recently took a lightening visit to go hiking in the mountains of North Carolina. With a surprise 3-day weekend on my hands (my out-patient medicine preceptor was sitting for the boards), I couldn’t say no to a last minute invite.  With views like this- I’m very glad I said yes!

It was almost the perfect time to visit, with leaves seemingly changing colors in front of our eyes. The palette of fall colors was stunning, and led to an enjoyable arts and crafts session of the patio of my friend’s cabin while enjoying a post-hike cider.

Nature- embrace the rainbow

In the woods, these leaves lay where they fell (save the ones I carried back or the few the chipmunks and squirrels use to cushion their nests).  Again, it can seem like a dreadful waste, until you realize that this process, which occurs every year, feeds the insects, grubs, fungi, and molds that turns these leaves into rich topsoil to encourage new growth.

One childhood family activity that I remember was raking leaves. I somewhat fear that the advent of leaf blowers has replaced good old-fashioned rakes (and more importantly, good old-fashioned leaf piles that were great for jumping in!), but whatever the mechanism of collection, leaves are generally not abided in our modern world. While I take no issue with clearing leaves, it pains me to see leaves bagged up and put out to be collected as “trash”. There is definitely an increase in people composting “yard waste”, but the name, again, shows how people see the world and nature- a progression, not a cycle.

A bit of google-mining suggests that the saying “Waste not, want not” can be attributed to Benjamin Franklin (1706-1790), but it is nature that best embodies this philosophy.

(Stay safe out there- all my fellow northeasters in the path of Sandy!)

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