Bryan Biologics

I had the opportunity to fly home to Minneapolis for a quick weekend to see friends and family.  My sister is heading off to Galway, Ireland to study abroad for the whole year and my intern year schedule might cramp my style in getting to go visit so it was great to be able to say goodbye to her.  We got a little tennis in as well to shake the rust off.

The family gathered for a few meals and also to take the 2011 Christmas card photo…spoiler alert: here’s a sneak peek.

What a crew.

I also got to watch a little of the Pine Tree Apple Tennis Classic in White Bear Lake to cheer on some of my friends.  I usually love playing in the tourney but got in a little too late on Friday night to be able to play “for the children.”  I did get to enjoy the annual Narr afterparty with subsequent tippy cup, had to shake the rust off there too.

The weekend concluded with a terrific dinner with friends at Ingrid and Pete Schwingler’s condo.  All in all a nice whirlwind tour.

Despite a missed approach into the Santa Barbara runway due to late night fog, United got it done the second time around and I made it back.

On to the standin’.  I have been rocking the standing desk since moving into my place in Santa Barbara and I don’t think I’ll ever go back to sitting for work.  It is killer for improving my posture and I never feel sluggish after working at the computer.

It has to be better for you

Plus, Thomas Jefferson stood for work as well, so it’s got to be the way.  I am reading Billionaire’s Vinegar which is about an extraordinarily expensive bottle of wine that Thomas Jefferson supposedly owned.  Through reading the book, I’ve been amazed at how TJ shaped the wine collecting  and growing environment in early America.  The book has been an interesting read and I recommend it to anyone interested in wine collecting.

The Jefferson Standing Desk

Even the ER at the hospital has some standing work stations, I’m all over those when they’re available.  I’m wrapping up my last week in the ER and will post my thoughts on the experience soon.   The big finish will be a trip up to Monterey this weekend to see my Aunt and Uncle, attend some wine events, eat great food in Carmel, and compose myself before beginning my first week of working overnights in the ICU.

As my brother Andy says, “There’s no reset button on intern year” and I have to say I’m loving it…

Having been home, I’m shocked at how many people actually check out my thoughts and musings on this blog.  Please let me know how you’re all doing and leave me message in the comments!

In just the first month of being an intern, I’ve already had the curtain lifted from my eyes in different situations.  I wanted to document my thoughts and memories about the “frequent fliers” of the resident service.

It’s 3:30 in the morning, my pager goes off, then my cellphone, the resident saying we have an admission in the ER.  But, not to worry, he’s a “frequent flyer” and we’ll have it done in no time.  The resident also tells me that, as an added bonus, I’m going to learn how to manage diabetic ketoacidosis (DKA).  So I get my stuff together and wander up to the ER, wondering how the resident knows that it will be a routine DKA admission without ever seeing the patient.

Little did I know, the 23 year old, Type I diabetic who is also a drug addict and alcoholic has had over 100 ER visits in his life.  He has no insurance so he always gets the stellar care of the resident service.   Reading old dictations, the story is almost the same as a month or two ago…drinking a gallon of whiskey a day, stopped taking insulin, in ER with messed up metabolism.  I dictate almost an exact replica of the last H&P, start some fluids and insulin, and wait for labs.  My resident and I talk about just how many interns this same patient has taught how to manage DKA insulin, fluids, and labs…and I get frustrated and depressed.  One guy, refusing to take his insulin, drinking, and lost in the world has a bill of probably over $50 million for ER visits, ICU admissions for DKA and insulin drip management, attempted inpatient alcohol treatments, and medications.

We managed to reverse his DKA over the course of a few hours in the ER, preventing the use of an ICU bed.  He denied any help with his alcohol use and we sent him on his way after a meal.  I would go on to take care of him about a week later in the ER, with the same problem again.  I wonder if every new intern will have a chance to learn to manage DKA with this “frequent flier?”

There are many other stories of the “frequent fliers” of Cottage, teaching interns to treat DKA, endocarditis, alcohol withdrawl, etc.  From my first month I can recall a few special patients.  There was the man with no colon and only some small intestine left who enjoys milk so much that he drinks 120 oz of it each day.  Nevermind that this causes his GI tract to flow like Niagara Falls into his ostomy bag, severely dehydrating him and pickling his body.  Best part is, he refuses to learn to change his ostomy bag or stop the milk because he just loves Cottage living so damn much!  I did learn to work up chronic diarrhea, and my “frequent flier” made a new friend…

Frequent fliers are the perfect example of the system’s reactive approach to healthcare.   The same problems are solved over and over again. However, what I’ve learned is that the reactive nature of healthcare in the US is not always the fault of the system, but it is what the patient population demands in many instances.  Until we find a way to motivate, alter behavior, and bend will, the healthcare system must react to the decisions, however harmful, of the patient’s we aim to treat.

I’ve finished the first month of internship and I think I ascended the major portion of the learning curve.  Half the battle was learning the system; how to fill out the orders, notes, dictations, etc.  I had a great experience and really enjoyed the team I worked with.

In my program, teams include two interns and two seniors (2nd or 3rd years).  The schedule is rigged so that you admit new patients pretty much every other day with an overnight shift and a long call shift (7am-9pm) every 6th day.  I had good days, horrible days, and mostly a mix between the two.  The one horrible day involved being on “short” call, where you take the new admissions from 730am until 230pm.  Somehow, I managed to “cap,” getting 5 new admissions in that window.  So much for “short.”  However, despite 80 hour weeks, I still got out and enjoyed Santa Barbara to the best of my ability and have established some “go to” hot spots.

I’d like to document some of the experiences from the first month of wards that had an impact on me, for one reason or another…

First, I realized I was spoiled by the electronic medical records (EMRs) available in Minnesota.  Though none of the systems I’ve used at Fairview, Park Nicollet, HealthPartners, or Abbott, including the Epic “Solution,” are user-friendly and an ideal solution; but writing notes and ordering things by hand is horrible.  The typical admission involves going through the vitals and old dictations on the computer, then seeing the patient and taking scratch notes while they talk with you, moving on to writing a History & Physical note on green paper, then writing admission orders on white paper, finally ending by dictating the note you just wrote from the green paper into the telephone to some service located who knows where.  So many steps…so much inefficiency, it drives me nuts.

I’ve honed my process so that I take my memory and notes from talking with the patients directly to the phone, do a “stat” dictation, then print that out instead of chicken scratching onto the green paper.  I think I’m going to work on photocopying some generic, standard orders that I can use on multiple admissions in the future as well.

Most EMRs, let you set up standard H&P’s that basically write themselves, incorporating medications, past medical history, and any other data already in the chart.  All with no need for dictation.  I guess this is good and bad…some of those digital H&P’s can get pretty skimpy on actual substance with Epic “blowing-in” pure worthlessness.  It continues to boggle my mind that I can go to a friend’s Facebook page and within 1 minute figure out what they had for dinner, who they’re dating, where they currently live, the music they’re listening to, etc. but we can’t get a solid EMR that presents data in a way doctors need and want.  Something has got to give….IT will set us free.

This is already long…now with more time to post, I’m going to break it up into two parts.

Up next…”Frequent Fliers,” “look and you will find,” and Santa Barbara hot spots…

BrainStorm Cell Therapeutics, an Israeli company formed around technology developed at Tel Aviv University, has entered into an agreement with Massachusetts General Hospital (MGH) and the University of Massachusetts Medical School (UMMS) to test their NurOwn product in clinical trials for the treatment of Amyotrophic Lateral Sclerosis (ALS).

NurOwn, which was granted FDA Orphan Drug status, involves putting patients’ own bone marrow through a proprietary process that drives the differentiation of the marrow cells into unique nerve-supporting cells that secrete factors responsible for neural system growth, repair, and survival.  One of those factors, Glial-Derived Neurotrophic Factor (GDNF), is thought to be extremely important in the pathophysiology and potential treatment of ALS, also known as Lou Gehrig’s disease.

ALS is a progressive, fatal disease characterized by motor neuron loss without an identifiable cause.  It is hypothesized that a lack of neuronal support factors leads to the “dying back” of neurons and subsequent loss of motor function for patients.  BrainStorm believes that once marrow mesenchymal cells complete the NurOwn processing, the now-differentiated glial cells will secrete protective factors such as GDNF and Brain-Derived Neurotrophic Factor (BDNF) that could ameliorate or even cure the disease.

Dr. Robert Brown, the professor of neurology known for discovering the first gene linked to familial ALS who will be leading the trials at UMMS, stated: “Professor Cudkowicz (MGH) and I are delighted to join forces with BrainStorm to prepare for BrainStorm’s first human clinical trials in the United States. We are hopeful that together we may achieve a breakthrough for the treatment of people suffering from ALS. This trial will be conducted after receiving all necessary FDA approvals and in parallel with the human clinical trials that are being conducted by BrainStorm in Israel in collaboration with the Hadassah Medical Center.”

Despite several companies attempting to create nerve-supporting cells that secrete GDNF and other neurotrophic compounds, BrainStorm is among the first to do so without the need for fetal or embryonic stem cells and without including genetic engineering steps that may increase the risk of cancer in treated patients because of an unstable genome.

The NurOwn process may also be leveraged towards treatment of other debilitating and fatal neurologic diseases such as Parkinson ’s disease, Huntington ’s disease, and Alzheimer’s Dementia.  You can learn more by viewing Rasheda Ali, an advisor to BrainStorm and daughter of Muhammed Ali, speaking about the potential of BrainStorm’s technology here.

UMMS Press Release:  UMMS, BrainStorm Cell to Collaborate on ALS Trial

BrainStorm Press Release: BrainStorm Signs MOU for Collaboration

So I’ve finally settled in since arriving in Santa Barbara.  The little Jetta was packed to the brim for the trek.  I said goodbye with a family sendoff from our Caribou in Edina on Sunday morning around 9am and drove until around midnight, stopping in Rock Springs, WY.  The day was really uneventful and I listened to some great audio books.  I was exhausted by the time I got to Rock Springs and I was happy to crash.

Anthony Bourdain’s Kitchen Confidential made the time pass really quickly.  I loved the book and it was interesting to see the many similarities between medical training and becoming a chef.  He really lets you know what it is like training to cook and made some thoughtful points.  One that stuck out was that for the majority of the people that prepare our food at restaurants, cooking is not an art but a craft.  I always viewed cooking as an art, mixing and matching flavors to hit all the taste buds.  However, he makes an important distinction, pointing out that the best line cooks can reliably pump out many, many meals each night without really thinking about the recipe given them.  Experimentation with flavors is discouraged for everyone but the executive chefs; the cooks can even lose their jobs for trying something fancy.

That really struck me because, as medical students, we always heard about the “art of medicine.”  Our  attending would make a unique care decision because of their gut instinct, chalking it up to this infamous “art.”  The patient id splendidly and the attending smiled at the team, winking, saying we all have more time until we’ve learned the “art.” Anyway, I realized how the current system and coming changes to the system, especially in primary care, will make the docs craftsmen instead of artists.  Not only that, it will penalize “art” much like they do in the food business. The sheer numbers of patients that are going to have to reside in the US system will ensure the need for “line cook” docs.

I’ve already seen it happening with Evidence-based medicine (EBM), emphasis on the BM.  Guidelines are drafted by a committee of 15 to 20 experts, the guidelines are then spewed to the line cooks, each happy to be paid for following the rules with each and every patient.  Just like most recipes are fine and fill you up no matter who prepared them, most guidelines get the job done.   But if only that doc had thought before prescribing that statin because your LDL was 141.  Or if the line cook just thought before initiating insulin therapy on every diabetic with a Hgb A1C >9.   Cookie cutter medicine/EBM/line cooking gets the numbers through, but man, we probably miss out on some masterpieces from thinking, “artist” docs in the form of significantly better lives for patients….
Anyway, Anthony Bourdain made for good thinking and an interesting listen on that first day.

I left around 9am the next morning and drove until midnight again, reaching San Jose, CA.  The day included a bs Nevada speeding ticket and a monster rock to the windshield.  Needless to say,  I fell into a dingy Motel 6 bed, woke up with bites all over my legs, showered, and got out of there.

I stopped to see my friend Ben in Palo Alto and was able to visit the Stanford Entrepreneurship Accelerator which was cool to see. I also stopped at my Aunt’s in Monterey on my way down to Santa Barbara.  Having been here for two days, it is goin to be a good year…

More to come on the amazing property I found through Craigslist, my new pets, and the guesthouse I’ve outfitted for the year…thanks for reading

I love the idea of blogging….But I definitely crashed and burned with my first attempt. Last post March 23rd.  At least it was in 2011.

I have decided to give myself the benefit of the doubt, concluding that I set myself up to fail with too limited a scope.  I can’t contribute to a consistent nutrition blog.  Content was tough to come by and there were so many people who were more dedicated than me.  So I’ve decided to reform the blog into more of a stream of consciousness database that will document the start of my life as a medical resident in SoCal.

It’s a time of pretty big change for me.  I’m leaving my family, friends, and the place I’ve called home my whole life.  I’m excited/nervous, but I want to have a place to document the journey and let people follow along.  I hope to do a little nutrition, medical education, humor, tennis, radiology, and foodie life for everyone too.  In other words, it’ll be a reflection of me, my life, and what I care about….as best depicted through the interweb.

The journey starts tomorrow, 32 hour roadtrip from Minnesota to Cali.  I’ll let you know how it all starts off.

Please read, comment, ignore, whatever…I hope it’ll be better the second time around.

It’s been a bit crazy as the Match concluded.  I haven’t focused on posting with so much else going on.  But….

I saw a recent study today that warranted a short post, as it is about Intermittent Feeding (aka Intermittent Fasting, IF).  I am fascinated by IF because of how it can quickly change the metabolic environment in prediabetes and obese individuals.  In addition, a new study points out why IF might be better then traditional daily dieting.

“Intermittent versus daily calorie restriction: which diet regimen is more effective for weight loss” is a review article that looks at a variety of diet studies to evaluate the effectiveness of two methods of dieting.  The first method is traditional calorie restriction, limiting the total number of calories eaten each day anywhere from 15 to 60% of normal intake.  This was indirectly compared to IF, which is alternating days of eating as much as you want with days of eating nothing or very little (up to 25% of normal caloric intake).

The review study by Varady found that the two methods were equivalent in the amount of weight lost (in pounds).  The cool part was that the IF regimen preserved lean muscle mass much better than the traditional diet.  People on the traditional caloric restriction diet lost 75% of total weight lost is fat and lost 25% of the weight in fat-free muscle mass.  The IF dieters lost 90% of the weight from fat with only 10% of the weight loss coming from lean muscle mass.  This is incredibly important as the lean muscle mass makes up the majority of our basal metabolic rate (BMR).

BMR accounts for >80% of all calories burned every day and is colloquially called the “metabolism.”  So you can see how traditional dieting is almost shooting yourself in the foot, for every 10 pounds lost 2.5 of that is lean muscle mass.  With that lean muscle mass, BMR and “metabolism” drops, making you eat even less calories to loss weight further.  IF allows you to lose weight while maintaining BMR and metabolism.

In addition, people reported that it was “easier” to follow the IF diet and having a day to eat until full was better than tea-totalling each and every day.  I can agree that it is much easier for me mentally to just have one day to eat what I want and then take a day off.  It is much easier for me on diet days to know that I’m not eating rather than trying to eat only a little bit of something.  Finally, I think IF is in concordance with how our bodies and minds were made to think about food.  Humans and other omnivores were made to go periods without eating, hence the liver and gluconeogenesis.   I feel zeroed in and sharp on IF days and it helps me concentrate.

The authors do not suggest why IF may preserve lean muscle mass in the article.  I suggest it may be the action of glucagon, lipoprotein lipase, and the activation of glycogenolysis.  A 24 hour period will not put you in ketosis, burn muscle for fuel, or result in a significant cortisol spike.  I think a day without food is perfect for stressing the system just enough to put you back in metabolic homeostasis while honing insulin sensitivity.  In addition, the refeeding window that occurs every other day probably plays a large role in maintaining muscle mass because the calorie deficit is not constant, allowing the necessary repair/reload of muscular tissue to occur on the ad libitum feeding days.

I encourage everyone to try IF if you are trying to lose a little winter weight, I would be interested to hear if you find it easier than dieting on a daily basis.