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The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project

The Mardi Gras Mambo

Picture 031.jpgPerhaps you have already seen it. The close-ups of drunken faces, the whooping and hollering, the tossing of the bead and the bearing of the breast. The crowded, raucous, filthy Rue de Bourbon, full of Mardi Gras revelers. Then the cut to the footage of decimated houses, ruined neighborhoods. Finally, the face of a blonde, always blonde, news correspondent, beautiful and ever loquacious, saying, "The drinking and the partying of Mardi Gras goes on, even as thousand suffer . . . "

Here is a word from someone who has seen at least 20 Carnivals: Bourbon Street is not Mardi Gras. For the hundreds of thousands of natives who attend Carnival every year, Mardi Gras is not a drunken, naked orgy. It is a family and cultural celebration.

The French Quarter is the smallest part of Mardi Gras. The parades, and the celebration, begin on Napoleon Avenue, 5 miles away, in a residential neighborhood, and move through the lovely oak-lined  St. Charles Avenue. St. Charles is the home of family Mardi Gras, and here you will find the streets crowded for miles with families, their children included, barbecuing, dancing, singing, and enjoying the holiday. Mardi Gras, for New Orleanians, is a celebration closer to Halloween or Christmas in its cultural importance than it has ever been to the foolishness seen on Bourbon Street.

Some people who have never been here, or even a few who have, have trouble believing this. These people are making the same error people make who think soap operas are real -- they are not looking hard enough, and are assuming what they can see is all that there is. New Orleans was the home to 1.3 million Americans before Katrina and just over 1 million now. If New Orleanians were the authors of the debauchery that goes on in the Quarter, we would all have died of AIDS or alcoholic cirrhosis years ago. We make our lives here, and our lives are just as family-oriented and spiritual as anywhere else. Mardi Gras is family-friendly and peaceful. If it were not, we would not have celebrated it for 150 years.

Picture 027.jpgMardi Gras is the fusion of the three great religions of Southeastern Louisiana -- Catholicism, music, and food. It would be an exaggeration to call it a religious holiday, but it certainly retains echoes of its original purpose as the big blowout before the austerity and prayerful fasting of Lent. In New Orleans, you will see the same faces going to church on Ash Wedneday, the day after Mardi Gras, as you saw on dancing on the streets the day before. The religion, music, and food are everywhere, and the three are never separated for long.

People in New Orleans take food and music very seriously. If you ever come to visit, you can test this theory. Stop any person on the street and ask where you can get the best gumbo in town. In the 20 minute lecture that follows, you will hear a litany of famous and unknown restaurants and dives, including Brennan's, Galatoire's, Clancy's, R&O's, Mandina's, the list will go on and on. This is a city devoted to the simple pleasures in life. It is not interested in excess. Excess requires too much work, and drains away the pleasures of the moment. New Orleanians live the the moment, enjoying each day for whatever delights it may yield. This may not always make life as productive as it can be, and sometimes as a credo it is short-sighted. But it is not destructive. An important side effect of this pleasure-of-the-day mentality is that it spurs people to keep things as they are so they can be enjoyed again and again. This attitude is incompatible with the tourists' desire to burn the candle at both ends, and thus to destroy the substance of living. Mardi Gras is a celebration of constancy, not of extremes.

Perhaps more than any other city in the United States, New Orleans has taken care to preserve its social structures and organizations. Sometimes this means time seems to pass us by, but that is the flavor of our town, and something that every tourist immediately senses, whether he goes to Bourbon Street or not. City life is centered around numerous neighborhoods -- Uptown, the Garden District, the Irish Channel, Treme, Mid-City, Carrollton, the Lower 9th Ward -- and each neighborhood is in turn organized around local watering holes, restaurants, and churches. Music, food, and Catholicism.

The Mardi Gras Krewes that so famously march down the streets of the city are nothing more than neighborhood social clubs gone public with their good will. Rex is an Uptown organization, Endymion originally hails from Mid-City. There is a Krewe of Mid-City and of Carrollton. Zulu, the largest African-American parade, is from Treme. Folks in the French Quarter (yes, the Quarter is a real neighborhood) host the Krewe the Vieux.  My old neighborhood of Chalmette birthed Gladiators, Aphrodite, and Shangri-La.

The histories of these Mardi Gras organizations erase any doubt that they are local, rather than tourist phenomema. Almost all of them run charitable funds. Thoth plans its route to pass near homes for the elderly and infirm -- it is sometimes known as the "Krewe of the Shut-ins." Many Krewes, especially Choctaw, Grela, Jason, and Sparta, sponsor children's causes as part of their mission.

It is this peculiar link between religion and fun that makes New Orleans go. Churches hold communities together, and are the social backbone, and Carnival arises from them. No faith and no community, no Mardi Gras. In the last few weeks there has been a great outpouring of grief over the decision of the Archdiocese of New Orleans to close St. Augustine Church in the old African-American neighborhood of Treme. Communities here die very, very hard, which is why the dislocation of Hurricane Katrina has been so difficult to bear.

So, when you watch the news reports and the ads for "Girls Gone Wild -- Post-Katrina Edition" remember that the faces you are seeing are the tourists, not the residents. The residents are the ones off to the side, laughing at the goofballs the tourist flights have brought into town. The residents have their own party, separate from the tourists, there in full view for anyone to see, but subtle enough that the hurried eyes of the media usually miss it.

Happy Mardi Gras, y'all.

For other takes on the "other" Mardi Gras, see the New Orleans Times-Picayune here, and Slate Magazine here


First Pellet

I have been reading here and there about President Bush's plan to turn over contracts at 6 U.S. ports (including the Port of New Orleans) to a company based in the United Arab Emirates.

As with most public issues, once you get below the superficial discussion on the airwaves, the matter appears less clear cut than the pundits would have us believe.

Yes, two of the 9/11 terrorists hailed from the UAE. And yes, the UAE was the site of some terrorist money-laundering prior to 9/11. But since 9/11 the UAE has been cooperating with U.S. intelligence, if the White House is to be believed. Dubai has also been allowing the U.S. Navy to use its port for its Persian Gulf operations. This is not a small thing, given the current climate in the Middle East.

The ports contract appears to have been a carrot offered to the UAE for its help. In this sense, the contract was a good political move. Building up trust and mutual support with Arab nations is a very important foreign policy goal, especially now.

The problem is that it was a poorly chosen carrot. Of all the contracts the US could have offered the UAE, a ports management contract is certainly one of the dumbest choices, considering America's current security concerns. Why not let Dubai sell hot dogs at Giants' stadium? Or put them in charge of a truck stop on the Jersey Turnpike. Anything but put them in charge of a port.

As a former resident of New Orleans, though, what offends the most is the way President Bush immediately went to the defense of the UAE when the controversy erupted. He as good as told his opponents that they were racist for opposing the contract. The only reason people are attacking the contract, he argued, is because the company is Arab-based.

I wish he exhibited such passion when he talks about the Gulf Coast. Here is a president who feels so strongly about prejudice against an Arab nation that he is willing to go to the mat for them. He has never, ever shown such determination to rebuild the Gulf Coast after Hurricane Katrina.

It is not as if Louisiana or Mississippi have not been loyal supporters. Both states went for Bush in 2000 and 2004, and both went for Bush, Sr. in 1988. And even more maddeningly, the Gulf Coast has almost as great an oil reserve as the UAE has (77 billion barrels vs. 91 billion barrels). We supply 15% of America's crude, which is more than the UAE supplies.

Any respect I ever had for George W is gone, all gone.

Second Pellet

I was dismayed to read that the Commonwealth of Virginia is trying to pass a law making it illegal for doctors to ask their patients about handguns in the home. This proposed law has been written as a response to recommendations by the American Academy of Pediatrics to ask about handguns as part of a routine review of patient safety in the home.

Critics of this policy complain that it is obtrusive and politicizes the doctor-patient relationship. It is tantamount, they say, to doctors discouraging private gun ownership.

Maybe so, but is threatening to revoke a doctor's license the solution? I have asked all kinds of private questions of my patients, such as: Do you have sex with men? Have you ever cheated on your wife? Do you use cocaine? How many abortions have you had? When you laugh do you pee on yourself? Asking about firearms cannot be any more intrusive than any of these questions.

It bothers me that this nonsense comes out of Virginia. I lived in Virginia for 11 years, and have strong feelings about the place. Virginia is the home of George Mason, the father of the Bill of Rights, not to mention George Washington, Thomas Jefferson, James Madison, and James Monroe. The House of Burgesses, founded almost 400 years ago, was the first democratically elected legislative body in the Western Hemisphere. With that pedigree, one would think that the Commonwealth would be more careful than to enact a law that so clearly runs counter to the spirit of the First Amendment.

Kevin, MD has further discussion about this topic here.


How I Spent Last Weekend

DSCN1433.JPGThey dogged me interminably. Those niggling bean counters, the ones in charge of the world and of my destiny. All I wanted was a license to practice medicine in Mississippi. They wanted a copy of my diploma, as if such a piece of paper qualifies as proof that I completed medical school, and more importantly, learned something in the process. I thought, naive me, that a valid license in another state, a verification letter from my residency program, a valid DEA certificate, and an active listing with two medical specialty boards would be proof enough. Hardly.

The problem: I left that piece of paper behind when I evacuated for Hurricane Katrina. My diploma was somewhere in what was left of my flooded home.

I tried to order a new copy from my medical school, but that would take 12 weeks. So, after explaining repeatedly that my diploma was lost, and after getting letters every single week for 2 months straight saying that I had to produce it, I gave up and decided that I would try to extricate the thing from my ruined home, come what may.

One fine Saturday morning, my wife and I set out for our old home in Chalmette, LA. We took with us the tools I knew we would need to prove unequivocally that I am a well-educated American Medical Graduate -- a hammer, a shovel, a set of screwdrivers, plumber's boots, and an ax.

The trip through New Orleans has changed significantly since the days right after the storm. The city is now well divided into the quick and the dead, the boundary between recovering communities and struggling ones snaking thought the city like the sharp line of dry gangrene on a withered limb. Those areas that have survived the storm have consolidated into spaces of vivacious activity, while those most heavily hit remain sagging and crushed, almost as they were in August.

Our neighborhood was showing some signs of life. A few of the houses were now gutted of flooded material and stood empty, stripped inside to the bare studs. The FEMA-supplied trailer, ubiquitous in recovering areas of the city, was rare but nonetheless present. This meant a few people were moving back in, and starting to rebuild. There was maybe one trailer on every block -- not many, but a start.

Our street was still blocked by a house that had been swept off its lot on the back street of our subdivision. It sits intact, slab and all, right in the middle of Bradbury Drive. Our new neighbors.

Before we went into our house we paused to look at the maple tree in our front yard. It was under 12 feet of saltwater for 9 days, and stood up to 140 mph winds. Most of its branches were stripped away, but there it stood, breathing green leaves in defiance of the surrounding devastation. The only living tree on our block, it is a symbol of nature's immortality if there ever was one.

Then to work. First, to get some light in the house, we pried the plywood we had used to board up our doors and windows before the storm off the front door and a back window. We moved in. To get the front door to open and close freely, I had to shovel away about 6 inches of swamp mud in our foyer.

Our door had a large hole in it near the lock, a calling card left by the National Guardsmen who broke the door down in the days after the storm. They were looking for dead bodies, and to let us know they found none they kindly left the number 0 spray-painted in hot orange on the front of our house.

My diploma, we knew, was in the utility room. In preparation for the storm, my wife took a number of important items and stored them there, some inside the clothes dryer and some wedged between the washing machine and the wall. She was thinking of wind damage rather than flooding, and the tiny utility room was the most secluded room in our house. Unfortunately, when the water rose the washer and dryer floated up and resettled against the door, wedging it closed. The water rose all the way to the ceiling, soaking it and causing it to collapse, which left a layer of insulation and sheet rock on top of everything. Getting the diploma out would not be easy, which was why I put it off for so long.

The door was immobile, so I went at it with the ax. In a few minutes it was in splinters and I was inside the room. Next, with a shovel I was able to clear away the sodden insulation and sheet rock and took a look around.

Under the washer I spotted a stack of what looked like picture frames. The first one I tried to pick up came apart in my hands. I recognized it as a commendation from the French government to my mother's great uncle for distinguished service in the French Army during World War I. Under that was my residency certificate. Also soaked, and falling to unreadable pieces as I tried to peel it up. And under that, there it was, my medical school diploma. Carefully I was able to separate it  from the muddy floor. I lifted it up, and my wife extended her hands to receive it. She quickly carried it off like an OB nurse whisking off an afterbirth.

In a sweep of the house we recovered a few dishes from the kitchen, and most of our wedding china, which was filthy but remarkably intact. Piece by piece we carried everything outside, and lined the items up on the driveway to dry.

Across the street, our old neighbor, Mr. Jim, was home. The 77 year-old Korean War veteran was slowly stripping moldy sheetrock from his walls and carrying the pieces out to the street. A huge pile of debris stood in front of his house. It looked like his flooded home had retched up its guts, the pile of rubble a mound of vomitus on the sidewalk. He had set up in an RV about a half a mile away and was living out of it, renting a small parking space next to an old shop that had power and, in the American entrepreneurial spirit, had converted its parking lot into a temporary trailer park. His wife sat in the front seat of his pickup, patiently watching us through the windshield. She had lung disease, and he didn't want her coming into the house to breathe the dust and mildew.

There was at least a ton of debris in front of Mr. Jim's house. He had moved every bit of it by himself.

Like the good neighbor he always was, Mr. Jim stopped to talk. He planned to strip out his home and then wait to see how things developed. If there was enough activity in the neighborhood, he would eventually sell or rebuild. Like all of us, he was waiting to see what would happen. None of us want to put money into our houses and then be the only person on a block of abandoned houses. So we all wait in community limbo, to see if a critical mass of citizens returns to make repairs worthwhile.

Mr. Jim had news about Mr. Brian, his 75 year-old next-door neighbor and the inhabitant of the house directly across the street from ours.

As he spoke, I remembered the last time I saw Mr. Brian. It was August 28, the morning before Katrina. We were packing up our car to leave town and Mr. Brian walked across the street to speak to my wife.

"I have never left for a storm before, but I'm leaving now," he had told her then. My wife had asked him if he thought the Mississippi River would overflow. "Oh, no," Mr. Brian had said. "The water is going to come from that way." He then pointed down the street in the direction of the levee facing the 40 Arpent canal, then 17 feet high but today only a nubbin.

Mr. Brian left his home that morning, and died during the evacuation. Mr. Jim said he heard it was pneumonia. The story Mr. Jim heard was that during the evacuation Mr. Bryan got sick with chest congestion and fever and that his family was unable to find him a hospital.

That would be ironic if true: He had lived 4 years across the street from a doctor (me) and then died because he couldn't get appropriate medical care.

As we stood there talking amid the ruins, a tourist bus cruised around the corner. I had heard that visitors to the city were taking tours of the disaster zone, but so far I had not seen it.  I took a certain grim pride in knowing that my neighborhood had made the National Registry of Devastated Places. Maybe we should apply for National Monument status.

The sun was hanging low; time to move on. We collected our now-dried stuff from the driveway. Back at my mother-in-law's house later that day, we had everything spread out in the grass again. In the cool January air, as the daylight failed us, we hosed down all the dishes to get the swamp mud off and then put them away in the garage.

Before I went to sleep that night, I had a vision. I saw my wife and I preparing a dinner at my new house, with FEMA director Michael Brown and Homeland Security Secretary Michael Chertoff the honored guests. We were serving them food on our wedding china, the plates that had soaked in the equivalent of sewer water for nine days. Naturally we hadn't bothered to wash them very well.

My tattered diploma came back to our new home in McComb in the back seat of our car. On Monday I made a photocopy of it, and impishly sent the faded image to the bean counters.


TV Head

Maybe I have too much time on my hands, but I worry about how much TV my children watch. My wife and I try to restrict it, but on the occasions when we are both too tired and too busy to fight with them, they have amazed me with their voracious appetite for video input. They could watch from 7 am to 9 at night, every day, without complaint. Sometimes I wonder if they would forgo food for another round of “Thomas the Tank Engine” videos.

In the morning before I go to work, I will observe them sprawled out on the sofa, the steady stream of cool light entering their eyes and massaging the tips of their neurons, stimulating novel neuropathways never heard of when I was a toddler and our one black and white TV was only on a few hours a day. They sit there, almost motionless, and I wonder how that plasma screen is reshaping their little brains . . . .

My mind goes ahead forty years. My daughter is alone in a dark room. Over her eyes is a helmet with a visor that projects video images directly onto her retinas. She has a pair of the latest Virtugloves on her hands, the latest in virtual sensory perception with propriceptive enhancers. In those gloves she manipulates a $3 million pistol-grip joystick (inflation has been a problem in the last 40 years) molded precisely for her hand and no other.

She sees a black field of space. She is in a space ship flying though an endless cyber-cosmos. A small star appears ahead of her, and rapidly grows to become a huge green blob. She eases up on the joystick, searching the surface of a strange planet. Finally she spots what she is hunting for – a narrow crevasse in the surface. She pushes on the stick and glides in.

The inside of this planet is very different from the placid outside. There are electrical currents, like bolts of lightning, traveling everywhere. In a few places she sees these currents tangled up in vast storms. She is careful to avoid them – a single glancing contract and her mission may be over.

She accelerates, knowing she does not have much time, twenty minutes at the most. It took her ten minutes to get this far, so she will have to hurry. She accelerates her ship, rapidly and deftly dodging the currents of electricity that seem to be everywhere. She has never been inside this planet before, but she seems to have a familiarity with every one of those currents, every pathway.

She dives deeper. In the distance she sees what she was looking for, a volcano deep under the crust of this strange world. This volcano is very angry, spewing hot red magma for what seems like hundreds of miles. When the magma meets the electron streams, it throws their controlled flow into chaos, creating more electrical storms.

To get to the volcano, she must fly directly through one of the magma flows. There are only 2 minutes left, no time to hunt for an alternate approach. She thinks she knows enough about the electron streams to dodge them by memory. Through a hot mess of pulsating magma she flies, first darting up then down. She can see nothing; now she is flying on pure muscle memory. The magma clears, and she is right on top of the volcano. Her index finger moves to the trigger, and she delivers a volley of laser bullets into the gullet of the volcano. She waits. Too much ammo could cause surface damage, opening up the volcano rather than closing it.

The magma slows down to a trickle. Three more bullets, no more, no less, she decides. She is exactly right, and the flow stops completely.

Now she reverses her ship, rapidly weaving her way back out to the surface, almost exactly retracing her every move. This is the easy part. The computer has tracked her path exactly, so mostly she just follows its prompts, but on occasion she will make corrections because the virtual terrascape often shifts ever so slightly.

A moment later, she is again hovering over the surface of the green planet. The flight timer reads 18:54, not bad for an emergency procedure.

An overhead fluorescent light comes on. My daughter stands up, and flips her visor up. She blinks at the temporary harshness of the artificial light. The room she is in is empty, except for her chair and equipment. She strips off her gloves. Through a window facing her chair she can see a man lying anesthetized on a surgical table. One side of his skull has been removed, exposing his brain, and a huge robotic arm with a tiny probe on the end is moving away. A second arm supports the cut-away section of skull, and loads up a staple gun to fasten it back into place.

The door opens, and a young woman dressed in white scrubs steps through. “That was brilliant work, doctor,” she said. “You were able to cauterize that intracranial bleed without having to cut through a single major neuro tract.”

“Oh, don’t thank me, Deborah. Thank my dad,” she replies. “He is the one who let me watch all that TV when I was a baby.”


All the Confusion That's Fit to Print

This afternoon, Reuters news service is reporting that Harry Whittington, the man accidentally shot by Vice President Dick Cheney, has now suffered a heart attack. The story states that the attack occurred “when some of the birdshot migrated close to his heart.”

The AP reports it this way, ''Some of the birdshot appears to have moved and lodged into part of his heart in what we would say is a minor heart attack.''

I doubt that there is any malicious intent in these stories, or in the statements coming from the hospital in Corpus Christi that they are based on, but they are erroneous. A “heart attack,” or myocardial infarction, occurs when one of the arteries in the heart suddenly occludes, causing the death of cardiac tissue. This, clearly, is not what is happening.

A buckshot could only cause a myocardial infarction if it severed a coronary artery while passing through the body, which would mean death in minutes, or if it came to rest directly on top of a major coronary artery and occluded it, which is about as likely as a flipped coin landing on its edge and staying there as neither heads nor tails.

What may have happened is that the pellet lodged close to the heart, resulting in local irritation (called pericarditis), and that inflammation has aggravated an underlying heart problem, thus giving the patient symptoms. The problem with this theory is that it is me speculating. It is impossible to know unless someone involved issues a more accurate statement.

Why does it matter? It just makes me wonder: If I can pick up errors in medical reporting as often as I do, how many errors am I missing when I read topics I know nothing about?