The Bitter End

They called me to your room, I saw you for myself

I saw you, and my self was torn

Who you remind me of, I dare not say

The consequences I dare not see

Your habit, got the best of you

But you of it, have the worst end

And they will be there, to hold your hand

Your loved ones, till the bitter end

Themselves miles more torn than me

Written for a dying mother...

It all starts with a nodule...

We are taught by life to greet people with courtesy; always smile and say something nice, always ask how people are doing. You enter a sick patient's room on the morning rounds and say something like: "Hello sir, how are we doing today?", and hope for some optimism and a smile in return. Try doing that on the oncology wards. On a few of my first patient visits on the oncology floor, I was caught off guard by a 38 year old patient with a body torn up, on the inside, by a uterine cancer. Now in the terminal stages of her disease, N. answered my question in a way I was never ready to handle.
- Me, entering the room for the first time, smiling: "How are you today Mrs. [...] ?"
- Her, stating the obvious, pointing at her distended, asymmetric, diseased abdomen: "Well, how do you think I'm doing?"
Realizing the retrospective absurdity of my question to a woman with a mass the size of a basketball inside her, and many other little ones scattered around her frail and broken body, I froze for a second, and nodded, with my stupid, embarrased smile still stuck to my face, and proceeded to interview and examine her, gathering a few pieces of information to write my stupid little note in her chart.
How? How can you be pleasant to a dying person? I'm still learning here... perhaps learning that oncology is the single most impossible specialty for me to work in. Oncology, cancer, that indiscriminate, slow killer that catches persons and tosses their bodies around for seeming ages.
Cancer means you see your patient on Friday and think he's doing a bit better:
- Mr. H, a nice and unfortunate old man: "Thank you doctor for coming to see me, it makes me stronger"
and then you go away for the weekend and on Monday you hear the news that Mr. H passed away on Saturday, his son's wedding day. They tell you that Mr. H's son had been pushing since thursday for a discharge so that his father can die in his hometown, and to kindle a glimmer of hope that his father would get a chance to see his son get married, even if he has to feel this fatherly pride in a wheelchair. No such luck.

It's too much for me to handle. Too much to see this losing battle day in day out, too much to see so much suffering. Too much to see so much harm coming from what started as a small nodule, a small blip on a chest radiograph... Not for me.

Hey what's up??

What's going on? I don't understand... Why is it that one day everything in your life is going wonderfully, just to turn completely around the next day without you having the slightest clue that anything has happened?

Why is it that those things you are completely oblivious to one day seem like insurmountable obstacles the next morning?

What happens to people overnight?

What in the world gets into people sometimes?

How do you manage, for the first time in your life, to end up alone at some random bar on a Thursday night, sipping on a glass of scotch and asking yourself all these questions?

I wonder...

Why am I so disappointed?

What Happens to Time?

When Monday morning kicking off another day's work seamlessly morphs into a Monday morning kicking off another week. And while you're trying to think about it, why not? another month flies out the window and next thing you know you're left sitting on a metaphorical curb, head cradled in your hands, wondering what you've accomplished, if anything, during that hectic October you've just leaked ever so unsuspectingly.

Or when you meet your new pediatrics resident for the night's duty and realize that his father was actually the pediatrician who followed, treated, and probably terrorized you through the better part of your childhood, 0-18 years of age. In a puff of smoke.
Such a shame how far that apple falls from the tree... but I digress...

People are always afraid of losing time. Time, time, time.
"We're late, we need to hurry!" Of course. Time is gold.
"I'm growing old, look at these wrinkles" says she, in her mid-late 20's, dripping of youth and beauty as she speeds down a wrong way road to her plastic surgeon's office, stone-coldly ignoring all pleas for a healthy and graceful maturity that's still far far away.

But why? Why should I be so preoccupied with time, when the harder I try to save it, the more acutely aware I am of my helplessness toward it? Why can't I be less attached to that Monday? or to that October, or to that year that October has ruthlessly dragged down with it for the 28th time? And why can't I look back at my great 28 years in this world and smile, instead of looking just ahead, terrified of turning 30 in 2 years?
2 years. More like 2 Mondays, 2 more weeks, 2 more Octobers; it's all the same. Maybe that's why...

Meet me back at that curb...

Days in Memory...

August 13, or the last of it was

In a fortnight, let there be life!

And I can't help it, but I ask

What if this had been let unroll

It is but today, that I realize

What you and I have brought to bear

What you have given me

No other has

And for that indeed

I love you more

For L.

Glass Inferno...

Faqra, Lebanon - July 2010

There's something mesmerizing about glassware photography. I find wine glasses to be a beautiful object to photograph, especially in a dark environment.

This unedited picture was taken on a beautiful windy night in Faqra, Lebanon; a half-empty, half-full glass of wine, backlit by a raging barbecue fire. With the aperture wide-open, a slow shutter speed of some 2 odd seconds allows the wind-stricken flames to merge together in an apparent explosion, and leaves the core of the fire appropriately overexposed. It could be criticized for hand shaking during the exposure, inevitable at these slow speeds, which is evident from the smeared contours of the glass and reflections.  Sure, a tripod would have made this a better picture,strictly technically speaking, but as I've learned, it is photographic imperfections such as this one that so often seem to add a little something to a photograph. Something raw and unexpected, something beautiful. In this case, a nice snapshot of the way I was seeing that night after the few watered down glasses of wine that preceded this one...

Is it just me, or...

Well it is obvious that everything in this country is getting more and more expensive by the day. Restaurants, Pubs, Night Clubs, Beach Resorts, nothing is spared from exorbitant prices rising at exorbitant rates. But what's been pissing me off lately is that as this happens there seems to be a concomitant slow but steady decline in the quality of all services provided! Here are a few things off the top of my head:

- The beiteddine festival: Have you ever bought a soggy, hyper-salted, minuscule Saj man'oushe for 7,000 LBP [~5 USD]? if you haven't, please take a long drive to Beiteddine and do so at the entrance, where the monopoly of saj has blown the prices right off the chart. And whether you like it or not, and no matter what you order, you are getting the "Amira" specialty man'oushe because the lady who makes them will MAKE you. just go there and you'll know what I'm talking about.

- Beach resorts: Jiyyeh and Jbeil alike, the amount that a nice enjoyable day at the beach will set you back is sizable! 20-30 $ entrance fee, 15-20 $ for a quick bite at their restaurants managed by some of the most incompetent people on the planet, you're talking at least 40 $ for some sun! More if you feel dehydrated and feel like getting a cold drink. Sun beds line the pools in almost all resorts and renting one will set you back another 20-30 $. Oh and did I mention the "bouncers" at the entrances? apparently they're concerned about the male:female ratio and won't let single or groups of men in... PLEASE! It's a !@#$ing beach resort!

- Restaurants: How much profit do you want to make? selling a 500 LBP bottle of w ater for 5,000 LBP is just ridiculous. Selling teabags for 7,000 LBP is even worse! We had dinner last night at Beib el Mina at Byblos. Some of the nice usual Lebanese mezze like Tabboule, Hummus and Baba Ghannouj, followed by fries and 3 fish dishes, with a few cokes and glasses of wine. Good food, good times, crappy service as usual. The bill? 850,000 LBP [566 USD] for 16 people. I didn't even feel like I'd just had a meal. Ridiculous. And it's like that everywhere.

- Pubs, Night Clubs: Always with the 30 - 40 $ minimum charge. Always with the dinner requirement to get a decent table. And most of them do not inform you until you receive the bill and can't believe your eyes because you've just had a 35 $ glass of Red Label, a 750-cL bottle of which costs no more than 13 bucks at your local minimarket! Did I say a glass of Red? I meant a glass of ice, with a scent of whiskey for you to fantasize over. That's not a night out, that's a JACK!

It seems to me that going out in Lebanon, especially this summer, has become more of a hassle than a pleasure. Factoring in the indescribable Lebanese traffic and all of its associated road rage, or the heat if you're unlucky enough not to have A/C in your car, followed by the ridiculous return you get on your hard earned money, I'm becoming more and more of a fan of house parties and dinners, and I cannot stand the sound of the word Jemmayze when my friends call me up to go for a drink...
Going to the beach is no better.

Blind Item...

I've been waiting for 25 minutes for a 4 and a half minute YouTube video to load. It's half way there. Fingers crossed... I might take a break or a shower in the meantime... 512Kbps my @## :)

The Latest in Iranian Barbarity

"At that time it should have been finished. They should have punished her only once. Her documents say she is innocent. She paid for the crime five years ago." - CNN Article

This is one of the desperate cries of Iranian citizen Sajjad Mohammedie Ashtiani as he struggles to save his mother, Sakineh Mohammedie Ashtiani, from a stoning sentence imposed by he courts of Iran for alleged adultery.

Le Cirque Invisible

My first visit to the Beiteddine Festival today was just fantastic. I was lucky enough to be invited to attend the act put together by Victoria Chaplin (Charlie Chaplin's daughter) and her husband, French actor Jean-Baptiste Thierree in "Le Cirque Invisible" or "The Invisible Circus".
I have to say I was deeply impressed by their performance.

In a fine example of equilibrium, a rapidly alternating mood was established between the sheer quirkiness and light humored spirit of Jean-Baptiste's ludicrous but seriously amusing skits, and Victoria's more enthralling acting prowess; the audience never seemed to get enough, and wanted more, of both extremes. The show was an interspersion of skits by either actor alone; Jean-Baptiste Thierree lightens up the mood by playing a few magic tricks to funky music, and as he leaves the stage, Victoria Chaplin strides in with her more poetic and graceful performance.

She simply graced the audience with a masterful display of fluid, stepless movement and manipulation of props ranging from the simplest umbrellas to some of the most intricate mechanical devices I have ever seen on stage. Her fluidity in motion and her fixed expressionless face played perfect partner to an immersive musical score, a fantastic wardrobe, and precision lighting, in the creation of a truly psychotropic performance that left the audience hypnotized. Victoria's uncanny resemblance to her late father went beyond her facial features, with her beautiful acting and showmanship speaking volumes of Charlie Chaplin's legacy. With her 60 year-old body performing like a young athlete's, she made easy work of cable walking and some truly insane gymnastics and contorsion art to stun the audience even harder.
I had gone to Beiteddine expecting nothing more than a 'circus' and I was pleased to attend the fine act of precision choreography that is Le Cirque Invisible. Don't miss it.

A Piece of Heaven...

Nahr Ibrahim, Lebanon - July 2010

... On the coast of North Lebanon... Psychedelic isn't it?
Hey P. :)

FIFA Match Officiating a Disgrace...

I wonder how the FIFA won't release their death grip on the traditional refereeing, whose honest mistakes are changing the course of the entire world cup. We've seen many, many mistakes; England's goal against Germany, Brazil's double handball ending in a goal scored... nothing too far out of the ordinary.
But seeing Italian referee Roberto Rosetti admit to the Mexican players because he knew that the goal scored seconds earlier by the Argentinians was an offside play, and apologize to them because the FIFA wouldn't allow him to change his decision...
Seeing this and how players earn free kicks, penalties and get their rivals booked or sent off by sheer drama school acting at this level of the game is just something that I can't understand...

Get video refereeing and a clean game for everyone.

Vuvuzelas, or Hitler's Tantrum

The interminable background buzz of a trillion bees is just getting too annoying!
If Adolf Hitler complains of this...... I loved the ending.



...

I thought it was cool at first, but as I watched more and more games, the headache grew! During yesterday's game between Denmark and Cameroon, there was this shot of the crowd and this huge group of Danish supporters. They were cheering and flailing their arms and flags around while there was a lone african fan in their midst, standing there, completely still, a Vuvuzela pressed against his pursed lips. Makes you feel like shaking the life out of him until that thing of death falls out of his death grip!!

Join bloggers's quests to get these annoying horns banned!! lol

Will Play for Tips

Hamra, Lebanon - June 2010

A pleasant sight and sound near AUH, where all we see all day are abused children begging you to give them money or buy lottery tickets. 

I have to sing for me to live

a job for me is out of reach

so come on by and hear a tune

I will sing for a bit of tips

The Farce that is Lebanese Telecom...

"No one has noticed, but the Lebanese government is writing yet another chapter in the endless mockery of our rights as private citizens and social entrepreneurial agents of progress and change. The state is extending censorship over the remainder of our liberties into the last frontier of freedom – the internet and its supposed neutrality." - Imad Atalla, for the Daily Star on June 08, 2010.

Apparently Ogero is enforcing the Telecoms Law that bans VoIP (Voice over IP), the technology that enables internet users to make voice calls for reduced rates, and sometimes for free (IP to IP).

Sidewalk in Hamra

Hamra, Lebanon - June 2010

This is a response to "Sidewalk in Achrafieh" Posted on Blog Baladi a few days a go. I said I'd have a pic of sidewalks in Hamra for comparison... well here's what I was talking about...

Try negotiating the parked vehicles and avoiding the garbage juices on this lovely piece of Hamra property... Square footage pricing? Let's not mention that...

Stay tuned for sidewalks with construction material and bulldozers... Coming soon!

The ER Delivers...

Bring it ER, Bring it Med IV... That was the closing sentence in my Beginning of the End post. Excitement and ambition.

I have to say that today, the ER delivered. Today, I couldn't help but think that what was happening was some kind of response to what I wrote and felt a few days ago when I was just starting out...
The ER never faltered, even in the med III ER rotation, in showing us how little we knew, and how completely unprepared we can be for handling situations and patients beyond our qualifications.

A Primitive Cranial Nerve... Did you know about this?

I can't remember what I was looking for exactly when I stumbled upon a research paper for a cranial nerve that I had absolutely no idea about. For those of you who aren't that medically inclined, here's an intro.

Cranial nerves are nerves that arise from the encephalon. They are responsible for many reflexes and control of many automatic functions, such as gaze coordination, taste etc...
There are 12 cranial nerves (CN), numbered CN I-XII in the order that they enter or arise from the brain. If you're interested, here are the known Cranial Nerves:

The Beginning of The End...

Tuesday June 1st, 2010, the first day of the last year of Medicine. Med IV starts today. Med IV means we're getting close.
I hope it turns out as good as Med III.

Starting out in the family medicine rotation. It turns out i'm first in line (with a colleague) for a PM shift in the ER lasting 7 hours (4:00 pm - 11:00 pm) on the very first day. Rough start!

Blogging from the ER lounge (Where I love the Air Conditioning! Just FREEZING!), I just finished seeing a patient with an elbow injury. First thing that came to mind: I miss the ER! I miss the speed with which things were done; I miss the frantically scribbled less-than-one-paragraph-long notes on board-charts. The patient I just saw was triaged, seen by an attending orthopedic surgeon, 2 residents, and myself, taken down to x-ray and back in just under 20 minutes. As comparison, consider that an out-patient case takes about 2-3 hours to be handled.

I miss it. I do.

Bring it ER! Bring it Med IV!

I want my M.D.

I Sang You to Sleep...

Creed - Lullaby

Lyrics

Hush my Love now don't you cry

Everything will be all right

Close you eyes an drift in dream

Rest in peaceful sleep

If there's one thing I hope I show You

If there's one thing I hope I show you

Hope I show you

Just give love to all

Just give love to all

Just give love to all

All my love in my arms tight

Everyday you give me life

As I drift off to your world

Rest in peaceful sleep

I know there's one thing that you'll show me

I know there's one thing that you'll show me

That you'll show me

Just give love to all

Just give love to all

Just give love to all

Let's give love to all

Let's give love to all

Just give love to all

Let's give love to all

Just give love to all

Let's give love to all

Embarrassing Incident Turns Into Funny Encounter

There are few, very few, situations that are more embarrassing than having your fly break open while attempting to answer nature's multiple calls in a public restroom. Because what usually follows such accidents is you having to spend the rest of the day wondering how obvious it is, who's looking, and, if it's your first time, thinking to yourself "wow, the breeze, it's real!!" - especially if you're stranded like I was. Well that's what was going on in my mind on tuesday, anyway. At the Saab Medical Library at AUB, I was relieving myself in one of the stalls. And then it happened. It happened because I was too stubborn and somehow put too much force and - I'll spare the details, if you don't mind - I ended up hearing the sound. And then I knew... I thought "uh oh!"

More intriguing cab rides...

It's not everyday that I get to go around Beirut in a cab. In fact I've gotten so accustomed to driving my own car that all of the chaos surrounding our notorious public transport system had evaded my memory. When you have your own car, you just forget about the adventure that it is to get a cab driver to drive you from point A to point B, and all that's in between.

... Until your car stays at the dealership workshop for 4 days for repairs and maintenance (And yes I see the trend, thank you).

I got a call from the guys at the garage asking me to come and pick up my pride and joy, ready after a long absence.

The trip from AUH to the Sin el Fil workshop was uneventful. But it was the return trip that was all worth while! I picked up my car and parked it in the Galaxy mall parking lot (Coming back to Hamra or Bliss and searching for a safe parking spot is a no-no after 10:00 AM), and took a serial 2 cabs back to AUH. My car parked in a safe underground parking away from direct sunlight, I was happy, smiling, and satisfied with the workshop's job well done.

(1) - Galaxy - Tayyouneh

I hailed the first cab and in the ceremonial "la wein?" (where to?) conversation, I said "Tayyouneh". The cab driver laughed and appeared annoyed, and whined "ma ele jlede ya zalame halla2 kenet bel tayyouneh!" ("Oh come on man! I can't be bothered, I was just there for cryin out loud!") Surprised, I smiled and said "OK... it's your call, I'm not making you do it!", thinking to myself: "is this for real??". The guy finally told me he'd drive me to the end of the street for free and go home for lunch. On the way he found 2 more clients going to tayyouneh, so he looked at me and happily congratulated me saying "wejjak kheir ya habibe!" (something like good karma). I ended up reaching my waypoint and the driver ended up making an extra LBP 6,000 before lunch.

(2) - Tayyouneh - Hamra

The second cab driver was less of a pleasant ride. As I leaned toward the pasenger side window and said "Hamra", I noticed that he was staring at my lips. It turned out he was deaf, and had impaired speech, probably as a result of his deafness. I couldn't help but overhear the conversation between him and the passenger who sat in the front next to him. The story had it that he had lost his hearing in an explosion sometime during his childhood. He had burn scars on what was the better part of his body to show for it. And then, in an all-but-subtle segue, he went on to talk about how he had just lost his 20 year-old brother to a Heroin overdose. And before I could wrap my head around that, he looks at me in his rear view mirror and mumbled words I couldn't make out, but he made it clear by acting out a drug user's needle prick. The passenger then told me the whole story he had heard. The driver was trying to figure out how to get his two other brothers off the drugs before it was too late. What a shame.

After this humbling reminder of my pre- driver's license days, I got to AUH on time, with lots to think about.

Good karma? Bad karma? I couldn't tell anymore.

Is Your Jar Full?

Link to original article here.
Is Your Jar Full? When things in your life seem almost to much to handle, when 24 hours in a day are not enough, remember the mayonnaise jar......and the beer. A Professor stood before his philosophy class and had some items in front of him. When the class began, wordlessly, he picked up a very large and empty mayonnaise jar and proceeded to fill it with golf balls. He then
asked the students if the jar was full. They agreed that it was.

So the Professor then picked up a box of pebbles and poured them into the jar. He shook the jar lightly. The pebbles rolled into the open areas between the golf balls. He then asked the students again if the jar was full. They agreed it was.

The Professor next picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else. He asked once more if the jar was full. The students responded with an unanimous "Yes."

The Professor then produced two cans of beer from under the table and poured the entire contents into the jar, effectively filling the empty space between the sand. The students laughed.

"Now," said the Professor, as the laughter subsided, "I want you to recognize that this jar represents your life. The golf balls are the important things - your family, your children, your
health, your friends, your favorite passions - things that if everything else was lost and only they remained, your life would still be full. The pebbles are the other things that matter like your job, your house, your car. The sand is everything else - the small stuff." "If you put the sand into the jar first", he continued, "there is no room for the pebbles or the golf balls. The same goes for life. If you spend all your time and energy on the small stuff, you will never have room for the things that are important to you. Pay attention to the things that are critical to your happiness. Play with your children. Take time to get medical checkups. Take your partner out to dinner. Play another 18. There will always be time to clean the house, and fix the disposal. Take care of
the golf balls first, the things that really matter. Set your priorities. The rest is just sand."

When he had finished, there was a profound silence. Then one of the students raised her hand and with a puzzled expression, inquired what the beer represented. The Professor smiled. "I'm glad you asked. It just goes to show you that no matter how full your life may seem, there's always room for a couple of beers."

Did You Know...

... that all the blinking you do in one day amounts to having your eyes shut for 30 minutes?

... and that in a lifetime the average person spends over 25 years SLEEPING?

Gets you thinking doesn't it?

Southpark: Too Far This Time?

I stumbled a cross this bit of news on CNN (Read News Article) reporting that Southpark creators Matt Stone and Trey Parker might have gone too far on one of their notorious skits on religion and major religious figures, by allowing one of their episodes to feature Muslim Prophet Mohammad wearing a bear suit.

"This is a show, after all, that once painted God as a gap-toothed rhinoceros-monkey, portrays Satan as a simpering milquetoast and regularly features Jesus as a superhero -- the kind who's not afraid to ignore the peaceful teachings of the Sermon on the Mount to smite his opponents. The show has mocked Jews, Catholics, Mormons, Scientologists and atheists, among (many) others." - CNN

I have been a fan of Southpark for years and years so this really caught my attention because, while I found their fun poking at religion and its figures was witty, hilarious, and as bold as one can imagine, I've always wondered when and how it would get them in trouble (and I'm laughing as I write this!).
So here it is! "Revolution Muslim" a radical Islamist organization and movement based in New York City that advocates the re-establishment of a structured Islamic state, terrorism in both the US and in democratic countries around the world, the removal of the current rulers in heavily Muslim populated regions, the destruction of Israel, and an end to what they consider 'western imperialism' - Wikipedia -- Is it just me, or does it sound a bit odd that this group would be based in NYC??? Excuse my digression! -- has taken offense at the portrayal of their prophet and has released a 'warning', or so they called it, to Trey Parker and Matt Stone, reminding them of the murder of Theo Van Gogh, who was killed in 2004 by an Islamic extremist. Among his works was "Submission, a short film about abuse of women in Islam. The release included pictures of Van Gogh's dead body. According to the group, however, this was in no way a threat but a mere warning of what might happen as a consequence of the airing of the episode.

I can't help but laugh at the wonderful work of the makers of Southpark. Of note was one representation of almost all religious figures in a group gathering, with Prophet Mohammad covered by a black square with the word "CENSORED" contrasting in white.

I am not sure about the repercussions of this and what they can be, or if any other movements with more power have taken more serious offense than Revolution Muslim. And if they have, how different would the reactions be in NYC as compared to the Middle East? I am also wondering about freedom of speech and how it applies in this case! How can groups be allowed to run around threatening people who don't live by their values?

Video From CNN

Thank You Ayaan - You are the first Muslim I have ever heard speaking with such objectivity.

Blind Item

I snapped this photo of the Lebanese Norwegian Cultural Week poster...
A funny twist!

What's Lebanon's Stance on Slavery and Racism Again??

So here's another lie us self-righteous Lebanese tend to force feed ourselves. We don't condone slavery. We turn our backs to racism. Right?

Think again...

To your right is a nice classified ad for the exchange of a 1991 Dodge for a Sri Lankan domestic worker.

Please read No Maids in the Pool.

[Edit:This is to clarify that the classified is NOT in a Lebanese paper].

What more do we need? how much more disgrace, how much clearer does this picture need to be for the Lebanese to just shut the hell up and realize that we are probably the most self-absorbed, superficial, and prejudiced (oh yeah the list goes on...) people on the face of this planet?

I can only try and say how dumbfounded I was when I saw that classified. And in light of the no maids in pool article I can tell that it's only a matter of time before we find a few like these in our Lebanese media.

I really thought I'd have so much to say about this matter, so much to talk about and criticize, so many questions and so much eloquent rhetoric. Instead, I have only speechlessness, disbelief, and shame. I am ashamed of my country, ashamed of being Lebanese. This shame is growing by the day, exacerbated by the fake, smug, and holy stance that the Lebanese take on these and other matters.

Lebanese people are a friendly, welcoming, and humanitarian people. Or so would the media say. Of Course they do not tell you the whole story. I will stop here, too disgusted to continue writing.

Modern Medicine and Cruelty... The Positives?

Read Cruel Discussion and Modern Medicine.

I've talked and talked and rambled on about the disillusionment one stands to feel during one's progression in physician training over the years. My avid readers will remember the "Ladies and Gentlemen, Your Future Doctors!" 'saga'. If you don't, check out Part I and Part II. (Does time fly or what?).

Anyways in the second part I go on about how you lose this sense of idealism, this cleanliness, if you will, that people commonly associate with medicine. Now some one and a half years down the line, this incident comes and reshuffles my perception of the world of medicine and what it all stands for.

In the OPD (Out Patient Department) we care for patients on a visit-to-visit basis. It is usually the least expensive form of healthcare, and so inevitably we get to see the less fortunate patients who are paying petty fees for consults with doctors in a high-ranking hospital. The ramifications of this, which I will save for another -long- post, and the experience of such 'encounters' sometimes shakes you to your core. The socioeconomic aspect that we never really come to face on the ward floors with high class (I hate to say it) patients is a rude awakening to say the least. So one of my last patients in the OPD Pediatrics rotation was K. an 11 year-old boy whose chart (We view charts before meeting with patients) said that he had growth failure. As I read more and more pages, and came across more and more test results and differential diagnoses, I got to the note that was written when K. had last visited the OPD clinic. At the time (some 2 years ago) he was diagnosed with Laron-type dwarfism. In brief, Laron type dwarfism (also Laron Syndrome) results from a mutation of the Growth Hormone receptor, and a subsequent Growth Hormone insensitivity leading to failure of growth due to severe IGF1 deficiency (IGF1 mediates the action of Growth Hormone).

The Visit

K. walked into the room and I immediately saw his prominent foreheaed (typical of the syndrome). To me he looked like a 4-5 year-old toddler, physically, and somehow even though I knew about his condition, I was still dumbfounded when he greeted me with a noisy low-5 followed by a firm handshake worthy of a grown man. Or when I heard his 11 year-old voice and his 11 year-old vocabulary. Or as I saw his 11 year-old movements manifest in a 4 year-old body. His 11 year-old self confidence, assertiveness, and demand of autonomy also struck me as he insistently forbid his mother from answering my questions for him. I think I've stressed it enough, it was one hell of a surprise, despite the fact that I knew about it.

K. was without a doubt the most pleasant patient I've had during this rotation. He had a persistent contagious smile that revealed a set of run down, crooked and decay nibbled teeth. He made jokes, played with my stethoscope, and everything else he could find in the room. The whole interview and physical exam took place in a light atmosphere and in the best possible conditions. NOT to be soon forgotten.

Of The Sadness of Reality
One promising modality for the treatment of Laron Syndrome is recombinant IGF1 (marketed under the name Increlex in the U.S.), which can bypass the action of GH on its deficient receptor, thereby restoring growth satisfactorily if treatment is initiated in a timely fashion.
Sadly, Increlex is unavailable in Lebanon. And apparently it is a very expensive drug, which as you might have concluded makes it a problem for an OPD patient struggling to pay even the LBP 10,000 OPD fee.
As documented in K'.s chart, K.'s mother was told about this treatment when they had last visited OPD. She was also told that it was not available and that there was no way she could afford it even if it were. She was coming a couple of years after that visit in the hope (in her own words) that "Dr. N had something new for her and her son".
- Dr. N: There still are no significant efforts to market the drug in Lebanon.
- Mother: Oh.
- Dr. N: As I told you last time we are trying but your son's condition is so rare that it's hard to find proper treatment here. And the expenses would be just impossible.

Dr. N once again sent K. and his mother home empty-handed. I could not tell whether the expression on the mother's face was one of disappointment, helplessness and resignation, or of expectation.

My Reactions and Thoughts

I was deeply saddened by this outcome and for a brief moment I felt helpless and ashamed that we had to send a patient home after telling him in no uncertain terms: "there is a drug for what you have, we're sorry but you just can't have it". So what are the issues here? I mean after stepping out of that personal, humane, human, emotional roller coaster ride of a first reaction, what are the circumstances that need to be discussed?

We hear a lot every day about how medicine has been commercialized to a degree where incidents such as these are possible. We also hear about how shameful it is that medicine is a financially driven institution. And what we hear most are the sad individual stories such as the one I've told you in my long and by now surely boring account. But what is the bottom line? If anyone knows me they know I'm a bottom line kind of person. So what is it in this case?

Well the bottom line, stripped of all emotion, all sentience, and all humanity, is a sad realization that money is and always will be a major, major factor in the drive for research of all kind. Putting all of this baggage aside, a patient is buying a product (in this case a drug that is the result of years and years of expensive research and trials), in order to use that product for personal reasons.

This is how impersonal and desolate the bottom line of modern medicine has become. And to me that's all that matters because there simply is no point trying to discuss how and why it comes down to this. So is it correct to assume that my disillusionment has surpassed all the good that medicine has brought and is bringing to this world? That in the end it can be boiled down to a simple transaction between a care provider, a pharmaceutical company, and an ill person?

The answer is a resounding NO. To me there is always a positive side to this. One positive side that will not be affected by the source of motivation of pharmaceutical companies, is that no matter what happens, medicine will always strive toward a common goal. And that common goal (besides, of course, the financial rewards) being what it is, which ranges from the curative eradication of disease to the palliative nature of the most trivial of pain medication, I can confidently say that medicine does more good than harm.

Sure, unfortunate patients will benefit less than others and K. here is a prime example. But if we consider the long term outcome of the situation, we are hard-pressed to see that had there not been this monetary incentive for research, Increlex would have probably never seen the light of day! But the bottom line is that it HAS. As a result of this, we HAVE a drug, it IS helping SOME people and maybe one day this drug WILL be available to everyone. I will go out on a limb here and say that an inevitable period during the life of this drug (and this applies to all drugs and forms of medical treatment or diagnostic tools one can think of) when it will be administered in a discriminate fashion among patients is only an obstacle, a hurdle that we will overcome in our drive toward global availability and affordability of the drug. This situation now is better, in my humble opinion, than not having any drug at all, and I would be surprised if anyone argues otherwise.

Sad. But true.

Brilliant Recap on Religion

Came across this skit by George Carlin on religion and its shortcomings.

I know some of what he says may be a bit disrespectful and his language might be a bit raunchy. But look past this and you'll find a good argument. And a funny one!

I somehow identified with Carlin on this one. I was never a believer. Since childhood, and since I could remember having any sense of logic and my own opinion on a few things in life, I just couldn't get myself to accept the dogmata of religion. There always seemed to be just too many discrepancies, to many dissonant axioms for me to just believe blindly. And let's face it, blind faith is the requisite in this department.

So what Carlin says in this skit summarizes (very briefly) my views on religion.

One thing though is that I've always been sincerely respectful of people's beliefs, as I've said in earlier posts; what drives me out of my mind though are people who use the 'faith argument' in discussions to try and convince people of the validity of the God Theory and all that it entails. These are the only instances where anyone will hear me badmouthing religion (and not spirituality).

Yesterday was holy Thursday and I tagged along with milady and a few friends for the traditional 7-Church visit. "This isn't tourism", smiled L., who was all too aware of my views on the matter, "you should have some thoughts, maybe say an informal prayer here and there!"

The thing is, there were many, many thoughts entering my mind at the time. At every church visit, every time I walked into a church since I was a kid, I would start thinking and thinking. Wondering, asking myself questions. Questions and thoughts about how people seemed taken and immersed in their belief, and the sense of their trance-like state. Every time, the experience is touching to say the least. And every now and then, I felt like one or two of my thoughts were of my family and loved ones, and these were the thoughts that I felt were somehow 'emitted' or 'sent off' without me necessarily wanting them to, in some raw and random hope that someone really is up there. But... you know the rest. These feelings and thoughts never consolidated into anything more powerful and for me, I don't know. I guess something more compelling will have to happen for religion to have a better chance with me. Don't ask what.

So please for those of you who will view this video, don't be outraged and blinded by a few bad words and scream blasphemy!

Cruel Discussion and Modern Medicine

Overheard at the OPD Pediatrics Clinic between physician and a patient's mother.

Mother: What can we do Dr. N?

Dr. N: There is a new and effective drug for what your son has. But it's too expensive. Neither you nor I can afford it.

Mother: So what's the solution?

Dr. N: ..........................................

P.S. I will elaborate on the case soon.

The Snail

Shweifat, Lebanon - March 2010

"The snail he lives in his hard round house,

In the orchard, under the tree:

Says he, "I have but a single room;

But it's large enough for me."

The snail in his little house doth dwell

All the week from end to end,

You're at home, Master Snail;

that's all very well.

But you never receive a friend."

- Anonymous

A Late Rite of Passage

Walking on Bliss street had never been such a complicated task, what with all the 10-year old –or less- mendicants and lottery ticket ‘agents’ or shoe cleaners. For the longest time I felt annoyance at the heavy task of brushing off these pesky and persistent solicitors that seemed to be after nothing other than your money. The annoyance not circling around the money itself, but about the ethics and principles of discouraging the presence of alms-askers and the associated child abuse and whatnot; let me not digress and wander off into these treacherous discussions for now.

So one of my tricky walks along the famous street, while I was looking for that after lunch cup of coffee, got me to Epi D’Or. -Don’t let the name “Epi D’Or” fool you. Fancy name for a place that’s affectionately and more commonly called “Abou Naji”, the little store across the street from the AUB main gate-. Waiting for my coffee, I get elbow-tugged outside by an as-yet unknown figure who turned out to be one of Bliss’ seasoned shoe cleaners

. “Here we go”, I thought to myself. But then, all thought processes angled at getting rid of that annoyance were instantly stopped by the cleaner’s marketing skills… “Eza ma 3ajabak ma tedfa3 wala lira!” Translation “If you don’t like my work don’t pay a dime!”

Said in a convincing and confident tone, these words made me think ok what the hell? My shoes were dirty, hadn’t been cleaned in a while and a good buff would do no harm! So I told the guy to do a good job and he got to work. I have not seen hands move so fast. The sound of swishing as his run down piece of tissue carved through the air and onto the now polished leather told the tale of a shoe cleaning veteran with years of training!

All done, shoes shining, and face smiling as M. took a few snapshots of the event, I was thinking about the going rate on a premium job like this! So I thought 3,000 LBP. M. frowned in disagreement and so I gave him 5,000 LBP.

In retrospect, seeing how his face lit up as he tugged on that bill and all the good wishes for prosperity and long life I got at that time, I know I overpaid! But I would do it again and pay the same price!

But hey. An honest living, a job well done, make me rethink my stance on the good shoe cleaners out there! This is one rite of shoe-cleaning passage not to be soon forgotten!

Drafts from the Past

For a few days now, I'd been wondering how to get back on the blogging track. For me it's one of those times when you have a lot to write, but not enough time. So much to write you can't just cram it into one post and expect it to make sense... So I thought why not see what I had been up to before my unjustified hiatus...

Here's to fishing a few drafts from the past, a few posts that were never posted. Figured we'd go from there!

August 22, 2009 - A Med Student's First Patient Crush

"Well here it is. It finally happened... It had to, I guess it was only a matter of time. I guess it's always only a matter of time before any med student gets infatuated with one of his patients. I had to check on a total of 6 patients yesterday, and these include two patients from my previous post.

So after a long on-call day at the hospital, I get beeped for my last admission of the day. I thought to myself, "here we go. One more intestinal obstruction or jaundiced patient and I'll be on my way..." And so I got to 7 South. I saw Dr. K (one of our residents) and R. (a visiting student from Syria) at the end of the long hallway leading to the desk. As I got closer, I started hearing tidbits of what they were saying, and the little that I could put together was "She's status post whipple procedure in 2007".

When I heard this, I tought "ok, here comes another 90 year-old... [end of draft]"

September 26, 2009 - Enraged Med Student Slays Many in Elevator Frenzy.

"What is wrong with people? What is wrong with Lebanese literacy? what is wrong with normal psychomotor and cognitive development?

You're probably wondering why I'm asking these questions... Well let's see. In order of appearance and respectively, here's what they... [end of draft]"

November 6, 2009 - Some Will Never Learn...

"Ever wonder why you seem to keep making the same mistakes... [end of draft]"

December 24, 2009 - Wandering Attention, You're Welcome

It's 2 am and I'm awake, wondering what it is that drives the seemingly coincidental encounters, the apparently arbitrary events, large and small, that seem to just explode in apparent randomness until they inevitably crash back together and make up that mess that we call life... [end of draft]

I had been thinking about a few of these posts, the few worth posting, that is, and wishing I had posted them when I remembered more of what made them worth writing. But I have to say that while a bunch of fine-script details are lost to hazy recall, some memories are tenacious and come out vividly as soon as they are elicited.

Like L., my 26 year-old patient with not only the most intriguing and sorrow-inspiring medical history and problems, but also with the most unforgettable face and big blue eyes and out of this world sweetness one could imagine. One of the many patients I will never forget.

Or that insane feeling I get everytime I get in the elevator at AUH and people start pushing and shoving to get in before anyone has a chance to get out. When they look in at some of us 'elevator insiders' and ask: "Going up?" with that bewildered look on their faces! And finally, when stuck in a packed elevator for 10 floors with a stop at each and every single floor with agonizing slowness and the same sketch of pushing, shoving, and moronic questions, the nice feel of less-than perfect hygiene: the 9 out of 10 people with breath odors prompting the eloquent question: "WTF???" and let's not forget the 8 out of 10 people with body odors worthy of wildebeest! I used to think about that frenzy every day! "LOOK OUTSIDE YOU MORON! THERE'S A LARGE ARROW POINTING EITHER UP OR DOWN! AND GUESS WHERE THAT !@@#$% ELEVATOR'S GOING!! AND TAKE A GOD!@#$ SHOWER AND BRUSH YOUR GOD AWFUL TEETH!" Oh that felt good!

As for the last two drafts, I can't seem to remember what I was on about. I'm sure it would have been interesting though!

Ok so there was my flashback. My way of dotting the i's and crossing the t's paving the way for a few more memories fished from the past as I catch up.

Back after a long absence!

It has been a long time since my last post. And to my few interested readers I apologize :)
Stay tuned for updates on my Gynecology and Pediatrics rotations.

Lots to catch up on! Coming soon

Cheers.