Saturday, June 30, 2012

Bowen Island - SVGiri - Journal day 3

At anchor in Mannion Bay off Snug Cover, Bowen Island. We left Vancouver Thursday and todays' Saturday. It rained most of the day.  We've been reading.  I just finished James Patterson's I, Alex Cross.  Great mystery thriller.  Was making some headway with One by Seife.  The Patterson soon was calling to me though.  Boat reading on a rainy day.  Laura made eggs and hashbrowns.  Later I made minestrome soup for lunch. I also made Rosemary Zuchini Olive Tomato Beef Stew.  Lying around reading and eating seems appropriate for a rainy boat day. Every 15 to 20 minutes Gilbert jump on one of us and licks our face.
For a great break in the day we fed the visitting geese.  At another time I got out the crab trap from the lazarette and took this out with the dinghy. It's now about a hundred yards offf the stern in 45 feet deep water trying to catch crabs with cans of dog food, brands that picky Gilbert doesn't like.  He loves Little Caesar but turns his nose up at the the no name brand just like it.  Hopefully the crabs aren't dog food connosieurs.
I just got back from taking Gilbert for a walk on the beach.  I've been rowing.  A change from the motor and excercise I need. The boat is a whole lot of exercise. Climbing in and out of dinghys, even starting motors , the out board and the little Honda generator, takes exercise.  Good living this.
I'm not expecting a terrorist attack or car chase out here.  I'm resting up for another day or two of this high speed living.  Oh yea, I showered. That was an event. I took the 5 gallons can off the deck and added it to the 50 gals we're carrying.  Maybe I'll get the water making working.  Everything seems a major effort then it gets done rather spontaneously. If you 'd asked me if I wanted to take the dog ashore an hour ago I'd say, no way, but then I finished the novel and we were off and running. Things get done that way on a boat. All about timing.
I had a nap earlier. I may be due for another.  My dad at 93 is the real master of napping but I'm thinking it's good that I'm starting training earlier.  It's just a cycle.  Or a boat.  Colin likes to say that we're designed so that if we just let go everything rights itself like a sailboat that's been knocked down. You let all the rigging off and the boat rights itself.  SomethingIMG 1201 about surrendeIMG 1205r to win IMG 1203in tIMG 1206here to.  Hallelujah IMG 1194

Bowen Island - SV GIRI - Journal

Yesterday the sun shone. I was up early thanks to Gilbert's wet alarm clock. I fixed the speedometer by pulling out the through hull sensor and cleaning the propellor blades.  I hate that moment between pulling the sensor bung out and replacing it with a plain bung. Water is spouting into the interior of the boat until the fumbling hands stop the inflow. Then when the sensor is cleaned the same procedure recurs with that sense of panic as water pours in for those exciting moments.
After Laura's delicious egg bacon sandwich with hashbrowns I lifted the new light weight dinghy over the side.  The outboard is only a 4 hp but I felt I could use a lighter one of those.  Assembled Laura and Gilbert, with Gilbert in his life jacket, headed to the Union Steamship wharf in Snug Cove.  There we went ashore to Gilbert's utter delight. He frolicked off leash with a few other dogs and shit on land twice.  We had our little doggy bags out to stoop and scoup in this pristine tourist park where dogs are really supposed to be on leash.  After I found a light knapsack, folds into a pocket pouch, and a water proof cellphone container Laura Gilbert and I headed up the dark and mysterious Dorman Trail. A kind of mini mini mini Grouse Grind.  A sort of walk really with a little uphill motion.  Great ferns
After it was back to the boat for more gruelling hard core mind muscle work out novel reading.  Then I made some Chicken Cacciatore on Linguine to much appreciation from Laura who ate from her plate while Gilbert cleans the pans and pots with enthusiasm.
Before bed we watched a couple of episodes of Netflix tv Jericho watching Jake have another rough day dealing with the corrupt post apocalyptic corporate power vaguely California like.  Texas comes off looking good at this point. No mention of Canada whereas lots of Americans ironically were hoping to be let into Mexico.
This morning it's raining. Heavy.  I don't have alot of motivation. If I was hip slick and cool I'd have the sails up and be coasting up Howe Sound in the very light winds, youthful and vibrant before the mast.  I'd vaguely thought maybe I'd go to Keats Bay this weekend but it's raining and this is a lovely anchorage.  Maybe another coffee. I might put out a crab trap or go fishing. But it's raining. The fish like the rain.  I'm really enjoying this book "One - decoding the universe" by Charles Seife whose book Zero I consider one of the all time greats of science explanation, right up there with Kuhn. I'm also reading a Patterson, Alex Cross detective book.  That's alot of work and even getting up on deck to get the generator going again to charge the battery operated device seems work. I could run the engine and charge this laptop that way.  The main batteries are just fine with wind generator and solar panels and little draw except the freezer and water pumps.
It's all so very challenging.  I'm overwhelmed with toIMG 1188IMG 1183IMG 1184ugIMG 1182h decisionsIMG 1186IMG 1187.  I did light candles this morning to brighten up the place.  A little more coffee and book time. I've thrown Gilbert the ball alot and rough housed with him.  The choices though seem unbearable.  Stay, lift anchor, go where, walk around deck, read, maybe shower, I shaved, that was a major committment to the day, maybe have breakfast, then a nap. Can't forget the naps.  Helps one think about what to do or what not to do.

Friday, June 29, 2012

Mannon Bay, Bowen Island -Journal

Praise the Lord. Jesus is born.  I just read the opening chapters of Bill Johnson's, When Heaven Invades Earth.  Mark who worked with me a couple of years was enamoured by Rev. Johnson's writings.  Now I can't remember who the other person was who spoke so highly of him.  Yet the book has sat a year on my shelf at least waiting to be read.
It talks of miracles.  Living a supernatural life in Jesus' name.
I plod mostly.  I struggle from day to day.  I carry the burdens of world upon my shoulders and my body aches with pains I imagine Job knew well.  I am chronically frustrated by the Herod's of authority.  I fear at times Caligula is reincarnated in Washington. I long for Marcus Aurelius instead.
Yet here I am enriched by every day of living sitting in a sailboat in a little bouncy bay off Howe Sound. This is the sailboat I've winter sailed solo to Hawaii in.  It's restored since my extrarordinary friend, Tom and I sailed back from Hawaii breaking the mast  at night, a thousand miles from shore,  when we feared we'd not be able to continue under our own steam yet did so by jury rigging a Spanish turnkey.
I'd asked for help that time. Using a satellite phone to Eric I got advise from all the resources of Vancouver and beyond.  Life's like a space ship at times.  All I have to remember to do is call home.  Earth this is me, help.
That's been the story of this last month. Moments of panic followed by prayer followed by asking for help.  I had the lump on my face that didn't respond to the normal doctor self help like squeezing, picking, self prescribing antibiotic cream and hydrocortisone.  My friend George, better known as 'the poet", otherwise named Dr. Chalmers thought I should let Dr. McAlistair look at it. Now that the dermatologist, this wise and kind gentleman with endless years of experience wrestling with just such wiley demons of vanity as unknown fascial lumps. I felt 'safe' again.  The mounting fear had been halved just talking with George about it.
The unexpected tax bill, shocking and disturbing as it was, once would have thrown me into a paroxysms of paranoid conspiracy theories, but this month did no such thing. I spoke with my accountant, a fine gentleman indeed, and then with my bank manager. Scotia bank has been as helpful to me as Bank of Montreal was so helpful to my parents for many years.  They want to make money by ensuring that you're making money.  So suddenly there was an easy solution.
I'd just bought a car, a lovely little Mazda miata, because I've been riding motorcycle year round mostly to save money, a bit to be macho, and partly because the traffic of Vancouver is so horrible with bike lanes and lack of parking that my truck is no longer an option for that increasingly effete city of lulu yoga lotus butts.  I ride an off road motorcycle in winter and a Harley in summer. I'd skidded on wet leaves and road oil evading psychotic BC Budd smoking drivers to crash. So I had stopped riding my Harley in winter. I'd limped most of a year after that event so was riding a Ural Sidecar Motorcycle with knobby tires but it  was killing my back this winter since I rolled my ATV hunting last fall.  Come to think of it I when I couldn't get the ATV off me and cougars were following my blood trail and my rifle was broken in the roll, I'd felt less confident about life then.
This last year of constant rain and cold was trying my patience so I opted for the sports car.  But I hadn't sold the Ural yet.  Partly because I hate to part with it. It's an amazing Russian machine based on the German war machine that BMW created years past. A classic that has never yet been improved on.
That's why the tax bill caught me by surprise.  That and my penchant for studying things that are relevant to psychiatry and health care rather than studying money and stocks.  I always believe God wants me to be the best doctor I can be and that if I want to make money I could focus my attention on that and save fewer lives but be a whole lot richer.  It's an either /or calculation for me because to date other than my brother I've found that people who promise to look after a doctor's finances are more likely to take the money and run.  Money managers as we learned in the latest of too many diabolical corruptions of the world financial situation don't take a Hippocratic Oath.   The impression we are left with by the media of Goldman Sacs is that the whole upper management was on cocaine with whores cleverly convinced that the hard working citizens of America would bail these banksters out with old age pension funds and whatever was left of once proud and strong America before the dirty got downright despicable.
If Jesus reighed on earth all would be rich beyond on our wildest dreams.
Now the fact is I am. I just forget it. I've been poor so that I went with out food and was hungry and without an apartment. I've been punished for marriage while all those who didn't marry but did break up took no financial or moral hits.  Collectively the girls are celebrated for divorce more than they are for marriage while I've had my share of the state and courts in my bedroom and heart. I nonetheless am blessed to have a kind and beautiful female friend who remains with me despite my antipathy to the rape of the courts of marriages and family.
Oh I am such a self pitying resentful nihilist if I don't keep my lizard brain in check.  I pray most days all day just to block out the fear and anger. Whenever I look at the media I hear the rant of incompetence in every authority structure yet personally I find most people are doing their best bumbling along. Especially the folk I know in church. They're good people.  There are lawyers and bankers and doctors and car sales men there and they'll doing their best like me to be less sinners and more saints.
I've had pneumonia this month.  I did the antibiotics. I have this chronic sinusitis which just waits for the Vancouver weather to give us one day of sunshine then ten days of rain.  I wonder all the time if I wouldn't be better back in the freezing world of Winterpeg where I grew up and the annual winter temperatures killed off all bugs and the occasional human as well.  I know I love Arizona and would be glad to be in a dessert where breathing is best for my nose and lungs but that said I've so many friends here I have grown to love and cherish.
I don't think ever before have I so appreciated the people in my life.  I simply love my friends. They are people I so admire men and women whose lifetime of accomplishments amazes me. They have such great senses of humor too and whenever I am with them I feel enriched to the depth of my being.  I suspect I might make others elsewhere but I really don't want to leave them here only because I can't breath and keep getting colds.   A small price to pay.
I 'm overworked and over stressed.  I haven't had a year of work without having to address the micromanagement of an administration that personally destroys more than it creates while doing everything in it's power to serve it's own interest.Yet, don't I sound like the media when I think like this.  Yes, they have been more wrong than I am and I have been more sinned against than sinning as Lear might say but I don't have their jobs, as fat assed and cushy as they are are, so I really don't know if they are doing cocaine with hookers as their decisions appear.  I'm rather narrowly focussed and over react to the heavy weight of excessive parasites living off the work of others.
But this year, this last month, faced with a criminal who wanted to kill women in the womb, a veritable Chinese government type, suing me,  I just carried on.  I know I'm doing God's work healing .I know I work 12 hours a day for the betterment of my fellow man. I see the proof of my work in the successes where success is impossible. I know how hard my work is and yet I go and if I don't think about the future and worry about my declining healh and aging body and fear of no pension and the rape of pensions and the abuse of the elderly I'm okay.
I'm okay if I focus on today.  I'm okay if I forgive the authorities which demonic at times are probably simply reflections of my own unhealed aspects of self.  I am in heaven when I can love hell.  I loved the play in which Jesus visitted Hell and the devil and his friends simply didn't want heaven. That's my impression.  I want the joy of love over the delight of lust but then that like most things of civilization it's an acquired taste.
 My animal brain is always at the door. The wolf howls when I least expect it. I pray each day to keep the lizard and the wolf at bay. I loved the imagery of Ghost Rider with Nicholas Cage. It spoke to my inner struggles and made me want to get back on the Harley and lose some anxiety at high speeds on the open highway.
Here I am in my sailboat. I had the fuel system fixed this winter so I wasn't certain if I'd have any problems when I filled up. I wasn't certain I'd have enough fuel on board to get to the fuel dock. I wasn't certain how the engine would run. There's a need for new seals on the stuffingless stuffing box.  I rely on pumps to keep the water levels down in the bilge when I 'm driving along. Jim does good work but so often I've had work down and only found out that there was a mistake when I'm in high seas. The new exhaust sheared off twice with vibrations once in the strait at night with storm warnings and another time just leaving dock.  Black smoke coated the whole of my interior cabin so that it took thousands of dollars to clean up the resulting mess to what is really my downtown apartment home.
I understand my friend leasing a car and renting a house and never getting involved in the maintenance or concerns of ownership. My empathy for patients difficulties with second hand cars, roofers, cable repair men and mechanics is solidly based in experience.  The more I live life the more I've been able to encourage the suicidal to carry on inspite of the hardships and frustratons.
I want to know God more and more. I want to be with God all the time but right now a person who I helped by lending a whole lot of money too when they were in a desperate crisis has turned out to be  a party boy, and it's months of broken promises while I know they've never yet been weaned from their mother's tit and would shame a father by their lack of industry and responsibility.  I hate myself when I  help others and err in generosity.  Like giving those two women who were recovering alcoholics a job only to have them steal from me and try to destroy my patients and the ministry of medicine.  I have personally lent tens of thousands of dollars to those in need and never been repaid by them. I thought that over time these 'takers' would 'give back' but I see now that they with  decades  past haven't given back to me and haven't given back to others either .I live in a country with a whole lot of people still living in diapers expecting the adults to care for them while they party or 'do their own thing' claiming any excuse to simply care for themselves.  I am appalled to realize the abuses of Greece and realize they're like Quebec and so many others around me who simply don't believe they should 'work' while they clearly want the product of others labours. Some even consider their 'vibes' are worth more than others 'vibes' and yet won't care for others in a material way.
I remember the musician who took so much money from me.  There's a joke that goes what's a musician without a girlfirend, homeless.  Art is like a two year old giving poop to its parents.  These infants insist on seeing their poop as priceless but boy if you ask them for money it's a whole different equation. Of course there's good art and bad art.  There's a whole lot of good in all of us in fact.
I feel badly because I've sewed seeds repeatedly in barren ground. I am the eternal optimist. I'm a spiritual chieerleader. I take in strangers and give them a home and they steal from me. I give people work and they steal from me. I work three jobs and find that the other person is playing at the computer claiming that 'surfing' the internet is really important.  I'm a bloody accredited researcher and I don't have time to do this because I'm working to pay the rent.
That said I take for granted all the great things that people do for me. I've worked with the best and right now am truly blessed with the people I'm working with. How come I focus on a hurt rather than celebrating the kind things that go on all the time. Last night I was stung by a mosquito and thought of that rather than focussing on the warmth in the cabin, the good company, the great NetFlix series Jericho and the wonders of being in outdoors BC at anchor in this incredible creation of centuries of engineering and design.
When I say pay the rent I'm really talking about office overhead and  this glorious boat that's got me here .
I lost the rpm meter crossing Howe Sound last night.  I watched it begin to bounce about then slowly die.  I thought the engine was cooked.  Because the bottom is full of crap and I paid the tax man and the little shit didn't pay me back the money I lent him I haven't pulled  the boat up on land to fix the shaft leaks or scrape the bottom and put new zinks and antifowling paint on. I'm only making 3.5 knots rather than 5 knots.  The engine is working hard just to get me going that fast. There was a wind coming out of the sound.  It was night and I'd put on the steaming lights.
Laura gets anxious. We talked about all the other women in my life and the extraordinary near death experiences that they had coming along for the ride. Tom and I've talked about this.  He's lost girlfriends after they've been out flying with him. He told me he'd found out last year in flight that his air speed indicater was wrong wired. He was having trouble flying an antique plane through the mountains against a head wind and thought the only saving grace was that he was alone and there'd be no witnesses or complaints if he crashed in the mountains.
I think all the women I've know,  except Laura whose still game,  are home somewhere on a couch in the suburbs watching tv and recovering from the trauma of knowing me.
I explained to Laura that the Coast Guard were 5 minutes away.  Further, I'm a member of CTow the marine equivalent of BCAA. One of those great guys would tow me into port if I called.I"ve a half dozen means of seeking help, radios, flares and cell phones.  Help is right here. It's a whole lot different than when I was alone in the Pacific or even off the coast of Mexico or up by Alaska.    I don't at all think an engine problem in protected waters is a major concern. I've been knocked down in 40 foot seas at the outset of a hurricane scurying for safety with my tail between my legs.
I told Laura about Sherry and I surviving Devils Hole north of Desolation Sound when the dope smoking diesel mechanic left a screw out of the oil pan after the overhaul. A whirl pool suddenly began to open behind us like someone pulled the bathtub drain plug . At the same time freak high winds coursed down the channel ahead of us impeding our forward mothion. Poor Sherry was at the helm with the Yanmar engine running full open throttle while I was pouring oil in the overheated diesel one step ahead of the growing leak. If the engine had stopped we would have had gone under to our deaths in minutes.   Now those were  desperate times.  But not this night. This was just a nuisance.
It turned out it was just the RPM meter and not the throttle or the engine.  I checked the gps and we were making headway at a constant rate even though the rpms were fluctuating on the meter but not by the sound of the engine.  I obviously have sails and I could have put those up and sailed on to the harbour.  I even have a dinghy and motor so could have hopped ship with Laura and Gilbert, cursed my beloved bitch ship one last time, left it to it's fate in the sea, gone ashore to never set foot on a boat again.
But it was just an RPM guage that was done in.  The speedometer was clogged with undergrowth so I didn't have that to help.  The prop shaft is producing a veritable hose of water too so I became worried with low rpm guage I'd picked up something on the prop. The mind goes into overdrive thinking of all the possibilities.
It's never perfect.  My boat becomes perfect into the second third week of steady cruising but these weekend jaunts and holiday exercusions are always full of surprises.
At least the anchor worked when we finally got into the Bowen Island bay. A whole lot of crab traps made that simple task difficult. Nowhere to anchor either because of the welfare scows that are floating Safeway shopping carts.
I'm actually fairly happy in the rain taking two tries to set the anchor.  I realized that only moments before I thought my engine was going to die.  Of course such a thought is coupled with thousand dollar repair bill and having days of workmen on the boat and life disrupted with 12 hour days of patients and no where to escape the chaos. I moved into my RV for a couple of months while repairs took that long this winter.  I was so thankful when the work was finally done and I could return to my boat.  Only one major curse. The refrigerator was turned off yet again. This has happened with workers on the boat a dozen times. This time I only lost a pound or two of venison from the deer I shot in the fall. It's a million dollars an ounce but how do you explain that to a person who is doing their best keeping you afloat.  Years back I had a worker forget to close the through hull so returned to boat filled with water the pumps not turned on  toilet leaking.  These same people who charge more than I make complain if surgeons leave pipe wrenches and hammers  in their brains and forget to suture wounds closed. The gall!
I've known thousands of miracles on this boat.  This boat has been Gods' way of trying to convince me it's okay. Don't panic.  This too will pass. Jesus loves you.  Every fear and trouble I could imagine has come and gone on this boat.
It's still here and I'm still here.  Gilbert my dog is sleeping in my bed.  The ferry comes by early and I was woken by the tossing about with the big waves that come into the harbour.  The door to the head flung open and I saw that I've had a half dozen 'fixes' to address the problem of it flying open. There's evidence of such 'fixes' everywhere.
The Mazda was second hand. The only new things I've had in years is a computer and an ATV.  New things break as often as things already worn in.  I know all the trouble spots on this boat.
I remembered that the rpm guage once went out before because there was a short on the ground. I'll look at the wiring today. But it's 30 years old so maybe it's the guage itself.  We're all getting old.  There's wear and tear.
In my heaven the wear and tear isn't happening. Everything that is supposed to be lubricated is.  Especially joints.
Last night my back was in spasm.  The ATV roll took it's toll.  I feel a whole lot better now after at night at anchor. Every molucule is massageed by the motion.
I have this great new propane stove. There's a thing of celebration.  I got this installed last year and it's a marvel.  Yet in my self pity and worry I so quickly forget about the glory of this or the new wind generator I put in to replace the old one that hadn't done much good for years giving me only a watt or two or power when it was supposed to be putting out a whole lot of energy. The old solar panels have been a joy doing double duty for years.
I worry about the wiring.  Jim re wired the batteries for the new wind genny and I'm not sure if I've got the switches the way they should be.  It's not an issue for today since I have the diesel engine as generator but given the shaft leak I can't afford to be without battery to the pumps. I'm watching the battery indicator jump which means that something is siphoning power. I'll get up and look to see what that may be eventually.
Everything on a boat is conservation and ecological. I get tired of the 'activist's and all the talkers who go on and on about the enviromment but refuse to accept it's the city dwelling activists with all their hot air that are a principle cause of global warming. I'm out here self sufficient and using wind, solar power and diesel as needed with my own sewage dispoasl unit and all mamer of environmentally friendly 'stuff'. It's 'work'.  It's expensive and it's not just ranting and raving and sounding good. It's actual living in that world.  Talk is cheap.  My friend gave me a button that said of beware of stupid people in large crowds.
I forgot to ask Laura to bring some elk I store in the little freezer I bought and have at her place. I've deer in the freezer at work. This weekend I hope to catch a salmon.  It's not been snce I was out last August that I've caught fresh fish.
I miss country living. I 'd like to garden again. They say you can have chickens in Vancouver. Now that my cat Angel died this month, mavbe I could consider chickens on the boat. I can just hear Angel in heaven say, now that I'm gone you have such an idea!
I dream of working in the country again and maybe commuting part time to the city.
I applied to work in Chilliwack and Abbotsford but the administration said they didn't need pscyhiatrists or addiction doctors.  I think that means they don't need me. I gained a really bad reputation as a whistelblower stopping the unnecessary killing of patients by administration a decade or so back.  The patients were glad to be alive but they don't count.  Health care administrators never forget and never forgive. They're putting all doctors on gag orders, their solutions to all problems, lie, deny and cover up.   The one thing that's guaranteed is that administration sticks together.  There I go again. The political animal lizard brain just jumped in.
God wants me where I am doing what I'm doing. The fact is I'm enjoying it immensely just working too hard. I've no health care or benefits and if I get sick I've no compensation.  All day long I see people who are off work with insurance companies paying for them and I think of my own insurance package I pay for myself which barely pays the overhead if I'm not working.  In Canada with over 50% of the country government employed in some way and the rest working for companies no one really understands the small abused private businessmen. The governemnt in it's act of hostility against doctors put our gross incomes on the front page. My colleague has a half dozen doctors and a dozen staff working for him so he was shown has earning millions and the media never took the time to clarify that Mr. Smith , this surgeon made less than the hospital administrator or that I as a doctor make less money than a nurse by the end of my career given the loss of income that 12 years of education did.
See how quickly the poor me brain steps in.  Suddenly out of nowhere the gratitude and celebration of God and good memories of battles won and days lived are high jacked by this monkey mind that wants to self pity and feel vengeance.
There 's a 'child within for sure but ones a really bad little kid and the other is the good kid. Bad kids are loud and obnoxious and it's a lot of discipline and work and maturity and wisdom to get to hearing and keep hearing the wee small voice inside.
God is that wee small voice.
God is everyday I've been alive getting me through that day I might otherwise have died. I am alive today only because God is 100%.  My higher power is what gives me life and years.  I've got to shake off and ignore all the problem thinking and catastrophising and awfulizing.
I've got to remember  the Third Day song "There's a light at the end of the tunnel."  I was listening to Third Day when Tom and I were limping along through storms in the Pacific and just this spring I got to see them in concert in Langly. Isn't that a miracle.  God be praised it is.
The very breath we breathe is a mystery and a miracle.
I'm going to have another cup of coffee and try to keep the glass half filled at least. IMG 1170IMG 1179IMG 1171IMG 1173Thank you JesIMG 1169IMG 1181us.

Thursday, June 28, 2012

Who do you defer to, Doctor?

I was asked the question, "Who do you defer to, Doctor?" by a lawyer in a court case.  It caused me to pause.  I was being asked about the care of my patient.  I was a generalist, a specialist and a sub specialist.  I knew that the lawyer seemed to consider some 'hierarchy' applied to doctors as it presumably does among lawyers and certainly is a matter in the military.
It probably pertained when I was an Assistant Professor at the University too.
But it wasn't relevant in that way to clinical medicine.
I said, "I don't defer to another doctor, unless he is willing to take responsibility for the patient and assume full accountability."
Indeed, that's what clinical practice is about. It's all in the relationship.
I thought about the question overnight.  Clearly I defer to God.  I defer to authority in a governmental sense but in regards to patient care, again it's different.
The lawyer asked specifically about someone who is high profile in the court system.  I found that interesting because again clinically the lawyer couldn't grasp that 'big guns' and 'little guns' weren't a matter of much substance in my clinical world.
I do have a constellation of characters who I admire and respect and would on specific questions seek their advice and probably accept this though in the end it would be a consultation. In a consultation I can disagree and go my own way with greater risk and responsibility once I'd asked for advise and chose not to follow it.
I have a host of doctors, though fewer as I've grown in years and experience, who I consider have more specific experience than I do in a particular area.
I am a psychiatrist in the general sense but am a subspecialist in the area of addiction with certification and extensive experience.  I routinely seek advise of colleagues who have more experience with a particular kind of patient. I have a half dozen doctors who are certified in addiction medicine, some of them psychiatrists even, but I don't think of them as 'superior' to me.  I think of their individual training as comparable in many instances as mine but think more about them in terms of numbers of cases diagnosed and treated.  I also think of their outcomes and most importantly the complexity of cases.
One fellow is particularly good with heroin addicts, but of two doctors I know one is more experienced with abstinence while another is more experienced with harm reduction therapies.  Another doctor has far more experience in sex addictions than me and there is one character locally and another in the next province who know more about gambling addiction than I can ever hope to know. Yet I don't think any of them know more about 'addiction' and the diagnosis and treatment of addiction than I do in my addiction psychiatry work.
In my psychotherapy practice I have subspecialised in trauma and especially with those in recovery, the 'dual diagnosis' group and don't really know another psychiatrist who shares my particular approach to this group, a mixture of 12 step facilitation, dynamic spiritual therapy focussing on the anxiety and isolation components.  I know others who work with a similiar population but their particular approaches to treatment are often different but I think they may get similiar results.
I have another niche where I am commonly sought for advise and that's where patients have major medical problems coupled with psychiatric disorders. The psychopharmacology of this subset of patients is particularly difficult.  Patients with head injury and an anxiety disorder or depression and a seizure disorder, kidney disease and psychosis.  These are a particular group of patients who I found that a colleague was also commonly seeing and I've benefitted from his specific insights.
I don't 'defer' to these colleagues in a 'deferential' sort of way except one lady doctor who has specialised in the treatment of pregnant patients with psychiatric disorder.  And come to think of it I would defer to her and do. It's an area of psychiatry that I really have limitted experience to hers.  There's definitely some areas in psychiatry in which I probably do 'defer' now that I think of it but they're areas like that.  Child psychiatry and Geriatric Psychiatry. The latter is a subspeciality area that requires more training certified geriatric psychiatrist would see far more patients over 75 years old than I do. Right now I only have a half dozen in my practice and may have seen less than a hundred in my lifetime.  In contrast my female colleague in geriatric psychiatry is not only a great clinician but she's my age and has being seeing old people as long as my other colleagues has been focussing solely on children.
So yes I do 'defer' in these cases and would surely and do surely defer to other specialists outside my own area of specialization. Hence I'm forever deferring to orthopods, surgeons, cardiologists, endocrinologists, rheumatologists, and urologists etc.  There are however some areas of overlap in neurology for instance. I do defer to neurologists commonly but there's some areas where my own experience and expertise cause me to feel that the area of overlap might be more in my peculiar bailiwick than that of a neurologist. This is true for pain specialists and occupational health specialists.  There are little overlapping territories where I acknowledge that the two of us might have equal expertise despite coming from wholly different backgrounds.
The matter of responsibility and accountability is always at play. There are commonly alot of 'adjunctive' players in the field but when the ball is dropped I'm very much aware of whether I'm going to be stuck holding the ball.  Alot of people who refuse to carry the ball really want to tell you how a ball should be carried. I'm more aware of these with age and experience.  Monday morning quarter backs and and arm chair philosophers.
The question was a good one. Lawyers are astute and I am thankful for the questions they raise and the opportunity their questions give me for self examination and further learning.  When personally I've need a lawyer I've been rather deferential to him or her though know that in the end I'm going to be the one who is ultimately accountable.

Tuesday, June 26, 2012

Machine Gun Preacher

I loved the Sam Childs movie about the Christian orphanage in East Africa.  Kony and the LRA account for 400,000 murders and 40, 000 child abductions. The children are raped, beatten, sold as sex slaves and forced to be children soldiers.  Sam is a real life ex convict ex addict ex junkie trailer park gun toting  biker gang member  The story tells of his finding Jesus with his ex stripper wife.  He meets a preacher from Africa and decides to visit Northern Uganda and South Sudan eventually building an orphanage for children rescued from the depraved "LRA - Lord's Resistance Army".  His construction worker skills, people knowledge and gun and gang skills all contribute to his becoming known  as the "Machine Gun Preacher".  When the orphanage is attacked and he has a price on his head for stealing future child soldiers he fights back with bullets.
The screen play is written by Jason Keller, director Marc Forster.  Gerald Butler plays a mean and fully believable Sam Childers.  The beautiful grounded Michelle Monaghan plays his wife Lynn Childers.  The filming of the people of his town in America and the people of Africa is amazing.  So much character and such a hopeful story in a terrible crisis.
When Constantine made Christianity the religion of the  Roman Empire he did so because the Christian soldiers were the greatest of the day. It was mainly Christian soldiers who fought the Nazi terror.  Jesus physically threw the money lenders out of the temple. He taught peace but his message of 'turning one's cheek'  was not unliimitted.  Not all Christians were born to be martyrs and certainly not all Christianity is about milk toast values.  While I admire the peaceful Mennonites and Quakers I am glad that Sam Childs is saving children from the armies of Kony by fighting force with force. God uses each of us according to our skills.   A great man said that for evil to grow all it takes is for good men to do nothing.  Sam and Lynn Childs are definitely doing something still.

Monday, June 25, 2012

Thank you, Lord

Thank you, Lord, for the sunshine. Thank you for the air we breathe. Thank you for the water  and blue sky. Thank you for the gentle breeze. Thank you for Gilbert, the dog companion. Thank you for friends. Thanks you for their health and wellbeing. Thank you for family. I wish they were nearer.  Thank you for the ocean and galaxy. Thank you for perception. Thank you for win win. Thank you for love. Thank you for upholstery. Thank you for motor vehicles.  Thank you for transportation. Thank you for this body. May it be rewarded with health and well being.  Thank you for commerce. Thank you for communication. Thank you for the mind. Thank you for feeling. Thank you for taste. Thank you for this coffee this morning and my harley davidson mug.  Thank you for the MacBook Air. thank you for the light and the darkness. Thank you for colours. Thank you for sounds. Thank you for smells especially the smell of wood smoke.  Thank you for sails. Thank you for fireworks. Thank you this city, province and government. Thank you for my church, Lord. Thank you for 15 years of sobriety today.  I am thankful for the via negativa and the spiritual path that comes with sacrifice and fasting. Thank you Lord.

Sunday, June 24, 2012

My Psychiatrist Doesn't Listen to Me

I've heard this said about myself as often as I've heard it said about colleagues.
There was a time when people could go to a psychiatrist and he would spend 50 minutes apparently "listening". I have tapes from my own psychoanalytic therapy series with patients in which I literally speak only a few words.  I listened and I listened very carefully.
This 'therapy' was found not to be beneficial for most people.  The public health funding system no longer provides funding for psychoanalysis because it was found most beneficial with only a certain selection of patients and commonly those very same patients could well afford to pay for this intensive in depth therapy.  Psychoanalytic therapy in which a person is seen weekly for roughly 10 to 40 sessions is still utilized and it's "evidence based" efficacy was well documented In the Ontario book, Standards and Guidelines for Psychotherapies, editors Dr. Paul Cameron, Dr. John Deadman, and Dr. John Ennis.
Over the years selection criteria were developed for the "listening therapies" which in contrast to new standard therapy, Cognitive Behavioural Therapy, is more like a typical tutorial.
More often than not though a patient who says his psychiatrist doesn't 'listen' to them is really saying 'my psychiatrist' doesn't 'agree' with me.  I am routinely called the 'non listening' psychiatrist when I tell people
1) Abstain from alcohol, your alcoholism is killing you.
2) Stop doing illicit street drugs.  They are causing your insaniety. They are not the solution.
3) Your partner isn't the problem. You are the problem.  You picked him/her or you trained him/her to be the way they are today. Leave them or change yourself so they can change.  But remember you take yourself with you and your likelihood of poor mate choices increases with the number of failures.
4) You are ready to return to work and work is generally good for mental illness.
These are the most 'offensive' things that I routinely have to tell people and when I do they become ballistic and routinely 'fire' me, and always say I don't 'listen'.  The person commonly figures that the way I will 'agree' with them, especially the painful marijuana addicts, is if they have enough time to 'convince me'.  They see their role on 'selling me' on their 'sickness'.
There were studies on long term and short term therapies and they found that whether you waited weeks or months to tell a person to return to work who would benefit from work, didn't matter.  Even with a strong 'therapeutic alliance' an alcoholic is going to reject you when you ask them to 'change' their behaviour.
Hence, Motivation therapy, with Prochaska's Stages of readiness.  Modern therapies are expected to identify what change is required and then assess when the patient is in the precontemplation, contemplation, determination or action phase of therapy. The limitted resources of society sponsored therapies are then used realistically and appropriately.
Today most people who see a psychiatrist are a very different lot than the ones who saw a psychoanalyst in the past. Today the psychiatrist is part of the medical model and providing 'specialist consultation' similar to a neurologist.  Most psychiatrist may not even be psychiatric psychotherapists and only be psychopharmacologist.
In the glory days of psychoanalysis, the rich paid hundreds of dollars a day 5 days a week for years to suffer through a very tortuous process of self discovery. It wasn't counselling and it was indeed very effective for those highly selected motivated individuals who were willing to invest that much money into their growth personally.  It wasn't found to be very effective in the prison population and of limitted value in those areas where patients were 'sent' rather that 'came' to therapy. It was also more effective when patients paid for their therapy rather than having it paid for by third parties.  The higher the education and the younger and more successful a person was before entering psychoanalysis the more likely the outcome would be positive.
I spent years 'listening' to patients, have hours upon hours of taped sessions where I say only a few words but this is not with patients who have addictions.  The analysts collectively considered alcoholics and addicts as 'untreatable' by the 'listening' therapies though there was progress made when these were done in 'group therapies.'  Transactional analysis remains a successful group therapy and Games Alcoholics Play remains a true classic.
Modern therapies are specific to the patients 'condition', personality disorders often benefitting from a socratic dialogue more than insight therapy, for instance. Supportive therapies are most effective for patients who have regressed to where they are having problems with self care, maintaining work or relationship. 12 Step faclitation therapies are talk therapies which are most effective with impulse dyscontrol therapies.
Cognitive Behaviour Therapies include home work, writing and behaviour assignments. They're not dominated with the patient talking but rather focus on the patient 'doing' things differently.
Today the patient who gets better is the patient who 'listens' as the model of psychotherapy is based increasingly on 'psychoeducation'.  The learning of 'social skills' is evidence based today. Freud's work and the early psychoanalysts in general were 'explorers' . They were like the 19th century biologists who were 'observing' in hopes of understanding. Today thanks to the psychoanalytic work of years specific therapies have been developed that are themselves evidence based.  Focus has moved from diagnosis, which thanks to the early explorers is much better established with tools such as ICD 10 and DSMIV tr than ever before, and more focussed on therapy.
I don't need to listen a person tell me for 6 months about their appendicitis symptons anymore than I need to "listen' for 6 months to a person tell me about their life of woe and self pity before I can prescribe not only medications which if taken have a 80% success rate but also therapies which are equally effective today. In combindation biopsychosocial therapies are more effective than ever before and the treatment of psychiatric illness is approaching the success of physical therapies in those who are capable of 'listening' and taking direction.
Noncompliance with medical regimen or nonadherence to therapy can run about 30% in the physical disease population but as high as 80% in the psychiatric disease population.  It's important that the psychiatrist 'listen' to what patients are saying but they may today be more interested in why the patient didn't follow through with last week's recommendations rather than discussing ad infinitum the blaming of mother for lack of breast feeding.

Nativity of St. John, St. James Anglican Church

I've been sick for weeks.  Dx'd skin cancer, bronchitis, pneumonia, resolving, waiting biopsy, legal threat from an pro abortion father when I supported the pro life mother condemned by the courts for the healthy child Monday morning quarterbacks always knowing better how the past should have been played. , unsuspected tax burden and failure of those who I'd loaned money to to repay their loans while continuing to party irresponsibly, and work, so much, with so little support from a government that promises but takes away.  I've been sick.  I wanted to stay in bed coughing up green phlegm, pounding headache, all joints anching.
But when patients tell me they were too sick to see a doctor or go to hospital, I confess, I consider it an oxymoron.
I'm a sinner and Kiekegaard described life as "sickness unto death'.   Being sick I needed to be in church more than in bed.  An evangelical minister friend says there should be neon signs up on churches shouting 'sinner emergency' and  'soul sick' wards manned 24 hours a day.  .
So I went.  I was glad I did.  The incense had me hacking but probably it's healing power helped get the chunks of evil out of my lungs.  I had to leave to get some cough syrup from the car before coming back to join Laura and Gilbert.  The congregation at St. James is a delight, so many loving people.  From all walks of life, all ages.  A fascinating collection of humans who I'm so thankful I'm able to be a member with.
Father Mark Greenaway-Robbins sermon was especially good. He challenged us all to think of the threats to Christianity that are present today, listing  secularism, individualism, the rise of radical Muslims, the wishy washy watered down lotus land Buddhism and more. But he said he thought the most important one was Christian Hypocricy.  He then took us through the Lord's prayer and asked us each to consider how well we were doing this week individually.  As usual I feel extreme guilt when it gets to the part of forgiving, being the most unforgiving person in the world.  I could see though that those around me were snagging on other parts of the Lord's Prayer.  Like do we really want "thy kingdom come' when it means the first shall be last etc.
So there I was arrogant about dragging myself to church only to see that my sin of pride remains strong despite my own best efforts.  Then Father Mark Greenaway-Robbins talked about authenticity and used as a very odd analogy a 'stick of rock' candy from his childhood in England.  Given the neighbourhood he had to clarify that his comparison of that rock to God was not as the neighborhood 'rock' comparison might be.  Indeed even through the discussion of hypocricy he had us all laughing though when he got into the description of this candy cane candy without the hook and how it was good through and through he had the kid in us all wanting the candy more than the analogy.  The message was made though.
It was good to laugh and we all sang hymns and joined in responsive readings.  We shared the peace and by the end of the service felt no longer alone.  Communion had brought us together again.  Gilbert even met a friend, a puppy who was new to the church but as happy to see Gilbert as Gilbert was to see him.
As a child I remembered most the martydom of St. John's, his  head on a platter  as the request of a girl..  Today his importance as the bridge between Old and New Testament was emphasized.
 I was thankful to be at St. James Anglican today. I'll start another week now working on being a good Christian and maybe even becoming more forgiving with supreme effort.  Alternatively, I'm thankful for the Grace of God which can heal even a sinner such as me.

Thursday, June 21, 2012

Netflix TV

I've just watched the first season of Jericho on Netflix tv. I've been sick so I've had time lying about and enjoyed immensely the ability to program my entertainment with this brilliant series.  No commercials.  Easy download. I love Netflix.  Cheap at $8 a month.  I've loved tv series I bought in DVD but the cost of $40 or more a season was relatively prohibitive.  That said, Sons of Anarchy was well worth the price when we got it at Sturges North and watched it in the RV rainy nights after a Harley run.
When I first got Netflix a few years back the selection of movies was limitted and I only watched a couple before dropping out.   I've seen a lot of movies over the years being somewhat of a movie buff.  Tuesday 1/2 price movie at the theatre was a regular event some years.  Now it's only the movie that's a must see big screen event like the recent Men in Black that gets me out to the theatre. Some movies are cultural events and seeing them early in the first week at the theatre allowed one to be able to talk about them. Woody Allen films were like that a few years back.  Then there's Kidman's Australia which really needs a truly big screen to appreciate it.  Australia is that big a country.  Otherwise we like to stay at home with the dog and watch DVD.
I'd watched an episode of Jericho on tv and never watched it again. The commercials disrupted the 'flow'.  However, watching the series over a week has been like reading a great book .  The characterization, the sub plots and sub stories have all been so alive this way.  I realized too that commercials have caused television story telling to have to be 'dumbed down'.  Jericho has alot more happening than alot of the mainstream tv. Ironically lack of commercials can kill a tv series but equally commercials can kill a great tv show.
Thanks to netflix I'm reviewing tv series I've not 'caught on' too because without the commercials complex character stories like Jericho are really extremely intriguing. The fast pace thriller aspect is maintained without the interruption too.
I'm hoping that tv series and movie series find a better way to 'make money' to make the money they deserve.  The acting and writing of these has never been better.  Other venues seems to have sorted this out.  I don't mind paying the monthly rent for this sort of quality. I imagine however all manner of things that could of gone the 'commercial' route like 'educational lectures' at Univeristy interrupted every 5 to 10 minutes by a jingo.  Maybe with the health care crisis surgery can interrupted for a 'word from the sponsor'.  I recently had the experience of a video commercial board over a urinal and thought while I missed the opportunity for my own thoughts I preferred commercial in the washroom to commercials in my livingroom.
Just as Frank Lloyd Wright asked that architecture consider the environment it was in  an ahead of his time ecological consideration,  high quality marketting really needs to get on board with better ways of selling without abusing the potential 'customer' the way commercial disruptions of entertainment have.
Netflix  is a  great antidote.
I don't have much time in my schedule for tv or movies as is.  I suspect though I watch at least a couple of hours a day of some sort of entertainment making me one of those roughly 20 hour a week sorts.  Perhaps that's a lot by some standards, less by others.  Whenever I'm sick though or recovering from an injury or overworked tv series and movies are a favourite distraction and entertainment.
Thanks to Netflix though I can better program the content - indeed I could watch more 'discovery' channel easily if I was so enclined. Frankly I do watch a lot of history and science material but nothing beats a good tv series for 'comfort food enjoyment'.  Jericho did that like Friends and Tudors did it, like some of the HBO mini series have too.
Probably having watched so much Jericho this last week I'm a little post apocalyptic and more attentive to the BBC news about world terrorism.  Certainly Sons of Anarchy didn't affect my desire to do crime, if anything it made me more against it, but it did affect my desire to ride my Harley.  Just seeing the bikes on the open road was invigorating. "Friends" always takes me back to medical school days,  nostalgia of student friendships that is always enjoyable. I appreciate the friends I have today more as a result of the relationships depicted in the Friends series and in Seinfeld too.
Netflix lets me choose the tv I want to view.  I confess, if I'm eating alone at home, I prefer to watch tv , a half hour, rather than watching a movie which can have me infront of the screen for an hour and a half limitting the available choices for the evening after that.
I like that it's on my laptop too.  My Mac Air is just fine for viewing.  The Apple cube and tv seemed over priced and didn't have what Netflix has in comparison.

Sunday, June 17, 2012

Basal Cell Carcinoma - a doctor's self report

I squeezed the 'pimple' on my face a couple of times and just blood came out. I picked the scab. It was hard not to pick at it.  For a couple of weeks I used antibiotic cream but nothing changed.  It seemed a mm or two bigger.  A month went by.  I was going for dinner with  a friend who is a great family physician. I did the thing doctors hate people to do.  I'm a doctor. I know how rude this is.  But I did it anyway. I'd made my own diagnosis.  I wouldn't want anyone to know I was scared but I was 'uneasy'.
"What do you think this is?" I asked.  He was concerned.  Only the coffee and bread had arrived at our table.  Chez Michel, the fashionable Parisian West Vancouver restaurant.  Only a couple of tables taken this early in the evening. No one close by.  Beautiful view of English Bay.  Daylight savings. The sun still bright outside.
"Stand up and let me look at that  in the light." Skin is best viewed in bright sunlight.  I moved so he could position my head. He's taller than me.  A big man.  A doctor who served the far north for years in his youth.  A doctor's doctor. His practice as full of the rich and famous as well as the common man.  He doesn't differentiate when it comes to people. "All God's children'.  he says.
"It looks like basal cell cancer." he said finally as we sat down to eat our rolls.
"That's what I thought." I answered.
"It's hard to be certain." he said.  "It's raised with the typical edge."  We talked some more about what to do. Matter of fact.  We're friends. Both doctors. He could see I was concerned.  I could see he was concerned. I didn't want to worry him more than necessary.
"Aldara" is a new antineoplastic cream. You could try that.  Can cure basal cell carcinoma by enhancing your own immune response."  he told me. I'd not heard of this.  But that night on the way home from the meeting we'd attended together I drove to an all night pharmacy and got some. $400 for 23 treatments. I've not got extra health care coverage.  Self employed I pay for everything myself.  If I'm sick no money is coming in.  Worse these days, there's  no one  left to cover my practice.   I know the constant daily stress is getting to me.  My fingers were shaking when I put the first dab of cream on my face.
The first appointment with a Canadian dermatologist was given as 3 months away.  I thought the cancer could have entered my brain by then or I'd be psychotic.  Without the cream I'd not have slept thinking about this foreign alien thing gnawing up my face.  Basal Cell is also called 'rodent cancer'. That day I asked a couple of doctors I worked with what they thought.  As doctors we all like looking at physical disease. Improves our skills of recognition. Besides they'd been looking at me already discretely wondering what that thing was on my face.  They too thought it was basal cell carcinoma too. Can't be sure. Need to see a dermatologist. I'm clinging to a thread now that it's just a bad blemish.  My friend phones a good old boy and he'll see me the next week. There's a cancellation.  We phone back the first dermatologist and cancel the original appointment.
I suspect I'll survive. But I'm prone as anyone to catastrophise. Sometimes looking in the mirror I consider fascial mutilation of the cancer itself or the possible surgery. Surgery is usually the answer. . Other times I think of the rare case of metastases. They're not supposed to but I imagine myself the exception that proves the rule.  
Mostly I hope it's not that but now I'm sick with the flu like symptons the Aldara can cause.  It's a minor concern but I don't feel well. I go to work and care for others but I don't have a whole lot of hope myself.  It seems too that in the Canadian culture the sick are brutalized and  marginalized. Show weakness and this society hits you harder where it hurts. Canada is a culture that caters to the rich. I'm thankful that I can afford Aldara.
"Have you had that looked at? Doctor?" a patient points at my face.  "Oh yes, it's taken care of .  Just a little infection,  I'm putting cream on it."   I can't say Cancer. It's not Cancer. It's not the big "C" word.   It's not the modern leprosy.  People still back away from people with cancer despite all the education and science we know today.
I think how I used to work on television. I have to confront my own vanity.  I think what's important about a face. I wonder how much money my fairly okay face till today has made me.  I've felt sorry for those born with deformity.  Genetic deformity diseases and now I'm going to have an Acquired deformity disease.I think of Leonard Cohen's song,  with the words, "I want a new face, one not covered up in shame and pain".  Something like that.
 I imagine a hole in my face. I don't want anyone to know but then I tell my patients its best to share.  We live in walls here frightened of the advantage people take of the sick and suffering. Only the psychopaths and sociopaths seem to thrive. It's all about corporate economics today.  The sick are less valuable. The beaurocratic "in" words are abortion and euthanasia.  Doctors committed to healing are marginalized.   I'm becoming cynical with fear.  I have to pray more. As the Third Day song goes, "There's a light at the end of the tunnel."
"Did you not wear sunscreen?" a friend asks.  I tell him yes.  I'm fair skinned , a sailor and an out doors man.  And I've always worn sunscreen. But the question is like one that Job in the Bible was  asked by his friends.   I reply  " Personally I think I've got cancer because I masturbated."   We both laugh.  He's Catholic so he knows that is the root of all evil.  
My nurse friend says I should look on the bright side, "Maybe you can get a face lift thrown in."  I imagine myself with half a face lift, all the Canadian health care would provide. I'm the old geaser then in the nursing home with half a turkey neck.
It's silly. I'm not thinking very sanely.  I wall the thoughts off during the day enjoying the distraction of routine but at night I'm alone with my fears.  I wake from sleep seeing the pictures I've seen in textbooks and the faces of patients I've seen working overseas.  The time moves slowly.  I am a patient. Patients must have patience.
It's nothing really.  Just a little lesion.  I'll be okay.  I'm thankful for Aldara.  Even if it were just a placebo I apply it religiously and think it's working. It's keeping me sane at least till I see the dermatologist.
In Bellingham USA a dermatologist will see you next day for $150.  It's a small price to pay but then if I cross the border as a patient I couldn't return here as a doctor in good faith.
IMG 1162I pray more.   Anxiety is a measure of one's distance from God. Cancer is that which you can say in no other way.  My family physician friend is a poet. Maybe his dermatologist friend will have a way with words.

Miracle Cure - the book

Harlan Coben has done it again. This intriguing  thriller is an extraordinary story of gay killings aimed to stop research into a new cure for AIDs.  Sara the beautiful television news reporter and her celebrity model sister Cassandra team up with Mike a basketabll hero in helping Harv their researcher doctor friend find out whose behind the rash of gory deaths.  The motive at first seems plain to Max Bernstein the pencil chewing New York detective  but as doctors and nurses die and healthy people go missing there's much more at stake.  Especially when the sleazy televangelist is raising money saying Aids is todays plague of Egypt.  Chemistry and sociology mix with Coben's endearing characterizations.  I couldn't put it down. But then I've read all of Coben's books.  He's a heavy hitter against anti semitism and any kind of discrimination that makes a person miss seeing the truly entertaining human in all of us.

Saturday, June 16, 2012

Angel - obituary

DSC 0096
Angel died last night.  Laura, Gilbert and I were watching tv. She was lying on the couch beside me. Suddenly she shot up and fell down quivering. A minute passed while I  ran my hands over her, her eyes glassy, tongue lolling to the side. I felt her heart beat stopping as I held her.  Then I got on pants to go to the Vet but picked her up again and realized it was over. . She was definitely dead.  Suddenly.  Sadly. Tragically.
I was numb.  Laura suggested we put her in a blanket. I did.  Then cleaned up the feces and pee.  14 years old and apparently a cat 'stroke' or cerebral bleed. It was like she'd been electrocuted but there was no electricity.  There was no life in her either. We set her in the blanket gentle on the couch at the back of thesail boat. That's where we'd laid together in storms crossing the Pacific Ocean
In the night about 3 am I checked her. She was stiff. This morning I put her outside  in the cockpit under the bimini out of the rain.  Gilbert my dog came up with me.  He sniffed her nostrils for the longest time.  They always greeted with rubbing noses.  Now he nudged her with his snout.  He was anxious. He'd never known a friend to die.
 I'm an old timer at that.  Heavy with death.
But he's a little dog and she was like a big sister or mother to him.  I called him back in.   I can see he's confused by death.
They would chase each other up and down the dock together. He'd chase her, little paws pounding after her quick clawed lightening flight till she'd suddenly turn and hiss, the two stopping in a dramatic stand off. Then he'd run away with her chasing along beside him till she'd pass him and stop. Suddenly she 'd be sitting there licking herself, nonchalantly,  acting like she'd not even been racing. She'd however be just a little smug.  He'd want to have another match but she'd won and she'd ignore him as he'd put out his fore paws arse in the air and bark at her to go again.  When he'd least expect it she'd take off and the whole caper would replay.  He could do it all day.  But she'd bore easily, suffer cat ennui, and leave him to return to her academic study of  the nearby birds.
I always knew she'd liked to kill a seagull or better still one of the Canada Geese that climbed up on her dock and sunned themself. She'd tried to not let on that was her dream especially when she could sneak up close to them as they stood on the dock.
When I'd had the boat (ship)  over by Stanley park she'd escape the dock and take to the trees. Later she'd come back in the wee hours with song bird feathers caught in her fur.  She was a great birder. She brought me mice home too at times. Little treats to remind me how clever she was.  Gilbert adored her.  He was so amazed at how fast she'd go up a tree or climb the fence in Laura's backyard.
But mostly she'd like to lie on the bed or couch and preen herself.  The minute I lay down anywhere though she was there lying on my belly.  This beautiful half calico half siamese majestic feline who would purr constantly telling me all manner of things  about her day.
I remember her as a kitten in the Vancouver Pet Store on Broadway at Laurel.  I was living in a studio apartment near Oak and walked by the pet store on my way to my Broadway and Granville medical office.  She was there in the cage rolling around tumbling with her siblings.  I think it was a day or two I stood watching her in the window before I went in and stood watching her inside.
"Is that the one you like?" the animal loving owner said.  'You can hold her. you know"
She picked this little bitty bit of fur and personality  put her in my palm.  Game over. I was in love immediately. I lifted her up and she snuggled my neck, purred and purred as she looked me in the eyes and said very distinctly, "You're going to be my human, now."  And I was.
I called her Angel forgetting that Satan had been one. She was certainly angelic most of the time but could be terribly mischievous especially with paper around .She never knew that some of the papers she scratched and spread about were most important in a human sense.
I'd missed my last cat, Moon for so many years.  Now here was another making a mess of my well ordered sterile bachelor life.
The pet store owner was a mensch. She got me everything I needed.  The old Jewish landlord in my little building had already told me he loved cats.  He oohed and ahhed when I showed him Angel too.  "She's a talker, " he said.
Cats Only, her special vets, took the best care of her and even kept her for a week at a time when I'd fly back to Winnipeg to see my parents. They told me how everyone loved her and as everyone knows Cats Are Us know their stuff when it comes to cats.  Angel was special.
It's hard to believe that was 14 years ago.  A year or so later I'd get my sailboat back. Angel and I would move aboard. That became more her home than mine.
Winter was bad one year . She was short haired and didn't like the cold. I'd leave her in the boat with the heaters on but when I came home at night the boat would be ice cold and I'd find her quivering in my open sock drawer, her favourite little cave.  This happened repeatedly before a neighbour told me the boat owner across from me was a psychopath who'd wait for me to leave and then steal my electricity unplugging my high power cable and plugging his boat in instead.  I spoke to him softly later that day and he never did it again.  Thereafter Angel was warm.  And I always thought it Christian of me to let this bottom feeding inhuman scumbag live another day.
Some years later I'd get the white scotty.  Angel didn't take to him immediately but a day later when she woke up she seemed to think he must be hers.  I watched her little eyes seem to say she was going to give up catnip and Toms forever if this was what that wild life landed her with. After that she was like his mother and tolerated all manner of abuse from Stuart as he grew up. His favourite past time on the boat was to drag her about with her head in his mouth while she'd retaliate by sitting on the table where he couldn't get at him but she could claw his little white butt whenever he went by.  At sea they'd chase each other around the boat, her long gliding leaps matched by his pounding short leg dashes.  I had netting to keep them both from falling over the side.
Those were my two companions through all the preparations I was making for off shore sailing again. Those two were with me too when I headed out from Victoria in November on my way to Saipan where I had a job waiting.  Everyone knows you don't sail to Hawaii in winter.  Summer sailing is a breeze but winter sailing is a horror. I was knocked down three times in high winds and 40 foot seas off the mouth of the Juan de Fuca when a surprise hurricane hit the coast.  It was supposed to pass by but obviously didn't.  Angel was down below in her sock drawer while Stuart was inconsolable below so stayed leashed beside me in his yellow life jacket.  I remember when we were knocked down the second time and the sail was in the water and great waves were crossing over the boat his leash broke and he was going away from the boat, his little feet paddling frantically. I was harnassed in myself and holding onto the steering wheel when I lunged and grabbed his jacket hauling him to me as the keel went back down and the boat righted itself again in a mighty swirl.  I tied him in again  but could tell he was as frightened as I was after that.
When I got back to land and made it into the protected harbour of Neah Bay I dropped an anchor in the bay, exhausted. Angel appeared then coming above deck to see where we were, tweaking noses with Stuart then telling us at great length about her discomfort in the sock drawer below.  As long as she had her sock drawer thought to go to she was fine in any inclement weather.  Let the boys take care of matters above and she'd make an appearance after all the fuzz was over.
When at night we were sailing in storms and the boat was like living in a washing machine she'd venture out to cuddle beside me in the stern berth I'd made where I could keep an eye on the GPS and radar dozing and getting up every hour to check the horizon.  She'd lie on one side of me with little Stuart on the other side.  I had pillows all around to protect us from the chaffing and bashing that went with the rough seas.  The autopilot kept me on course with only the storm sails up.
When it was sunny and we were sailing along in the glorious trade winds Angel would  be an arial gymnast trapezing along the boom or climbing up to sit on the radar post high above the passing ocean water.
She smelt Hawaii before all of us.  She and Stuart went to the bow sticking their heads out on either side sniffing the winds  a day or more out from the islands.  It would be a half day at least before I'd pick up the scent of the island fragrance.  How rich and earthy and sensual an experience that was after 20 some days at sea, including Christmas. It would be 25 days at sea before we'd drop an anchor off the Big Island.
I was late for work and left the boat in Hawaii flying on with Angel and Stuart first to Japan then to the Northern Marianas Island.  She was allowed in the cabin with me and was a favourite with the girls sitting in the seat behind me.  She lay on her side and purred as the stewardess stroked her belly.  A jet setter cat indeed.   Stuart was quarantined in Saipan so I had to visit him daily for a month or so before he joined us in the new apartment.
Angel however moved into my beautiful 2 bedroom condo with me .I'd was so lucky to get this fabulous suite  above the Commonwealth of Northern Marianas Hospital.  Angel made this our home spending hours chasing geckos that loved to hang out on the wall just above her highest leap.  When Stuart joined us there was a whole lot more chase and even further for him to drag her about by the head.  Not something strangers thought funny but I'd come to take as normal since he never hurt her and she seemed to bounce right back with a swat to his nose and more chasing around the hard wood floors with fur sliding turns more entertaining to watch than the Nascars. It did mean that her head was often wet though.  This however was her world. She loved Saipan. She loved the heat.  I was fatigued like the Scotty who had to be kept shaved but she was in her siamese element .  I felt sorry when I had to bring her home. She'd so enjoyed it and loved more when Laura visitted having another human to boss about.
When Stuart was poisoned by the stoners whose urine I refused to pass as clean in their bid for government jobs, she was bereft for days having lost her child and best buddy.  We were both sad at Stuart's loss.  The South American doctors dog was killed for the same reason.  A new corrupt government was taking over and my friends said our lives were being threatened because of our integrity.  Mom was ill in Canada.  I'd come to work in Saipan when the ruling party were the friends of high integrity I'd come to cherish and admire.  Dog dead. Mother sick in Canada. Politics.  I came home though I'd loved to have stayed with Angel. It was hard leaving friends and paradise but I was so glad to be back in Canada and closer to my parents.
Back in Vancouver Angel  became the Lady of the high rise apartment I had in the West End overlooking English Bay.  There she'd stop my heart a couple of times getting out on the balcony only to do a high wire act over to the neighbours balcony where she'd lay in wait for a pigeon.  I could just see her taking a triumphant leap followed by a 15 floor "oops' purr while claws clung to equally disappointed pigeon. I got her back and put up netting to stop her from bolting over there if she outsmarted me getting out the sliding door.  Despite her inability to get at the pigeons who nested on the deck she was very happy here.
But when a couple of years later I sailed the boat back with my friend Tom she was again in her element,  mistress of the GIRI, sea cat extraordinary.
When ever work was being done on the boat she'd visit Laura and her cat Tiffany. These two now old ladies, Tiffany and Angel,  would hiss at each other.  When Laura and I would return from a jaunt with Gilbert we'd find them sitting across the room from each other on high ground daring the other to try to get the mouse that never crossed between them.  With Gilbert back they'd join forces and sometimes both would swat his butt at the same time when he got between the two of them on the bed trying to get closest to Laura or me.
Chicken night was Angel's favourite.  She slummed on Whiskas and always had to have her special Fancy Feast can. She didn't like turkey and she didn't like tuna unless I'd caught it fresh when she was more than happy to join in on the barbecued feast.  But Chicken night was when I'd bring home a barbecued chicken from Safeway or Save on.  It started with just her, then it was her and Stuart and finally Angel with Gilbert. I'd be sitting on the boat with one little furry body one one side and the other on the other side. I'd be watching some video movie while together we'd all make our way through this incredible feast. A piece for you, a piece for you and a piece for me. Naturally Stuart and Gilbert just the same,would try to get Angel's piece after wolfing their's but she'd stand her ground nibbling daintily then hissing at the dog before finishing up and looking at me for more.  So whenever I came home with chicken I'd have a cat around my legs and a dog jumping up and down and there'd be no peace till the movie was on and the chicken was being partitioned about.
She was a singer too.  Whenever I'd bring out my guitar and sing a sea shanty or hymn I'd immediately have this little furry body sitting beside me belting out Siamese cat harmonies with little concern for human concepts of melody. She just loved to sing and it was always a joy for me to have my sad solo become a robust duet.
Angel had been back on the boat this last month.  She was happy as I've ever seen her.  The boat was her home.  We were all here that night.  Gilbert her child and best friend, Laura and me.  I'm crying now. But then I cry easily sometimes. Silly really. I'm tough as nails about alot of things.  Not this though.
I'm going to miss her. Angel, Cat of cats. The little house cat with the heart of a lioness and soul of a cheetah.  Singing Sea faring cat extraordinaire!

Saturday, June 2, 2012

John Rauls and Academic Fame

My friend is a philosopher who lectures college students.  She gave me a copy of John Rauls decades back. I duly read it, mostly because she is extremely beautiful and worried she'd quizz me about it at sometime in the future.  When I'm not reading about neurochemistry and Higgin's particles I'm more often than not reading theology.  I liked that Rauls said to paraphrase, justice is to social institutions what truth is to the individual.'  I've always liked the 'as above, so below' connection between macrocosm and microcosom. I just didn't realize that John Rauls, Theory of Social Justice would become so important. It was written in the 70's and I read it in the 90's and today I learned it's one of the most cited of social philosophers.
I've had this experience with individuals before. I read Harvard's, George Vaillant's book on the Grant Study, wrote to him a very appreciative letter in the 70's long before I knew he was one of the 'grand men' of our age.  I was just delighted that he corresponded with me and later I had the opportunity to meet him, a truly wise and remarkable man, a few years ago.  I read Thomas Kuhn's, "The Structure of Scientific Revolutions' a few years after it was published in the early 60's .  Today paradigm is a garden variety word thanks mostly to his book.  I read Turing early in my interest in computer programming when I was writing in Basic and MS Dos long before I cursed program language realizing I could speak swahili, punjabi, mandarin and spanish if I had devoted my attention to learning living rather than techno language. I still enjoy learning spanish but will likely die before I ever  learn swahili. There is simply not enough time for learning all one wants to and so much interference in the study of what really matters.  
Recently I read Jared Diamond's first books and happened to share the tastes of the world as that great genius has also gone on to acclaim he deserves.
When I travelled I used to carry a copy of the Bible and I also had a copy of Plato. I enjoyed in my 20's  reading the discussions  of Socrates.  Over the years I'd routinely read three texts, one about some aspect of sociocultural world, from the  arts , a scientific text, which might be from any aspect of science, medicine or psychiatry, and finally a novel which commonly discussed matters of importance in the other fields.  I've loved the writings of physician writers like Michael Creighton and recently Daniel Kalla.
I loved Love in the Ruins and the Joshua Tree.  I've loved those books that spoke to our times and culture, like Robertson Davies trilogy.  Obviously reading Thomas Mann's Magic Mountain was an insight into asylums, tuberculosis and the human spirit just as that other nobel prize winner Magister Ludi caused consideration of meaning as much as Victor Frankl's writing does.  Recently I was reading an economics text, a physics text and an evangelical theology text side by side getting relief from them by reading the antics of Flashman by Macdonald as he boisterously raced through the hot spots of history.  Most of the ideas of science fiction a hundred years ago and even only 50 have come to pass.  I laughed because several of my patients were called insane for thinking exactly the same way as  characters out of a William Gibson's novel.  I thought meeting these exotic creatures some of my colleagues should get out more.  Not at all insane by global standards but definitely beyond the mindset of Georgia and Howe.  
An old friend, the father of my dear friend, before he died told us how he'd supported himself in the latter years. He'd had very little or modest returns from all the best stocks and investments. However he chose to invest in an obscure company because he thought what they were up to was rather brilliant. This man was a scientist in chemistry himself but chose to buy stock in this obscure little start up.  "It was called IBM. It's provided more returns than all the other blue stocking stocks put together and allowed us to live as we did after retirement." he told his son.
I feel like I've invested well intellectually.  There's a kind of 'social justice' in that.  It's the truth.  John Rauls was a good read even if my brilliant and beautiful friend never asked me about it later.  But today as his name has achieved an even greater popularity I am thankful to her too for recognising gold in the dross.

Brain - Behaviour Relationships

Depression and Cognitive Complaints Following Mild Traumatic Brain Injury, by Jonathan M. Silver, MD, Thomas McAllister, MD, and David B. Arciniegas,MD (Am. J. Psychiatry 2009 :166:653-661 is a truly elegant paper discussing this subject from experience with detail. It's an essential read for anyone treating pateints with depression and mTBI.
What I am essentially copying here is from Table 1 in this paper. I have seen this information elsewhere and it's standard in neuropsychiatry and behavioural neurology texts.  Like everything else in this paper it was presented here in a readable and easy to comprehend and clinically useful way.

Structure                     Function                           Consequence of Injury                                      


Reticulothalamic system    Arousal                    Impairment of Counsciousness

Reticulocortical system       Arousal, facilitating cortical activity         Hypoarousal,  inattention, impaired information processing

Hypothalamus        Autonomic,, neuroendocrine,                   Dysautonomous, thermoregulation problems, altered feeding behaviours,
                                                    Circadian, some lower level social           endocrine dysfunction, sleep wave cycle disturbances, pathological affect
                              functions                                                        (laughter and anger)

Ventral forebrain             Cholingeric supply to medial and             Impaired information processing in multiple cognitive domains, neo cortical areas                                         particularly attention, memory, and executive functions


Entrorhinal-hippocampal Complex        Multimodal informationa filtering                Impaired sensory gating, attention, working memory and
                                                                      Declarative memory, some aspects of        declarative memory
                                                                      Attention and working memory

Amygdala          Generation of contextually relevant           Affective placidity, Kluver-Bucy-like presentations, alternatively
                                                                       emotional and social behaviour                   anxiety

Anterior/Polar cortex              Semantic memory, semantic aspects        Disturbances in semantic memory, functional communication
                                                                        of language, sensory limbic integration    impairments, impaired sensory-limbic, facial, social and emotional
                                                                        face recognition, social and emotional      processing, impaired social/empathic function
                                                                        processing, "theory of mind"


Ventral frontal cortices       Comportment, control of primitive              Disinhibition, irritability, emotional dysregulation, agitation, aggression
                                                                        ("limbic") behaviours

Anterior Cingulate cortex         Motivation                             Apathy

Inferolateral prefrontal cortex          Working memory                                          Working memory impairments

Dorsolateral prefrontal cortex             Executive function                                         Impairments in complex cognition, including executive control of attention,
                                                                                                                                                    memory, language, motor planning, as well as sequencing, set shifting
                                                                                                                                                     abstraction, judgment, insight

White Matter                                                 Connections between cortical areas         Impaired cognitive, emotional and behavioural functions, supported by
                                                                           particularly in frontal and temporal           affected white matter, slow, inefficient information processing.
                                                                           areas, facilitation of information

My columns got smunched by the editor so it's best to go to the paper. The rest of it is an excellent and must see read.  I've just listed these areas to show where the lesions are being deliniated in a beyond Broca way that's clinically relevant.

This is geographical presentation but then there are the neurochemical transmissions with both facilitating and dampening process.  Coupled to this is the endocrine modulating effects and the fluid these systems sit in, a kind of 'soup' which is affected by quite a variety of spices in addition to sometimes being affected by heat or cold.