VIRESTORM CHAPTER 4

Thank you all for your patience. As you may know I began writing a novel,  Virestorm, a couple of years ago and began to publish it on the blog. Despite my failure to post for a while I do have some more chapters to publish. For those of you new to the blog or need a refresher the first three chapters can be seen on older posts in this blog. If anyone is having trouble accessing them please let me know. Please enjoy Chapter 4


September 9, 2001 NYC
Text: Alex, meet me at luggage, can’t w8 2 c u. Dad
Reply: Ok me 2

“Hey hon, I feel like it’s been forever!” Alex runs up to her dad, long blond hair

swinging back and forth, a sparkle in her blue eyes.

“I know what you mean, Dad. Hey, Hi Kimberly.” “Hi Alex!” Kimberly and Alex

embrace with a hug. They all turn, grab their bags and head for the taxi line.

“Well you two, I think it’s about time to share a little fun in the Big Apple. Last

time I was here was about fifteen years ago. I hear the town has changed a lot. Still a bit

grumpy but cleaner with a lot less crime. So you ladies want to chance the subway a little

this trip?”

“Sure Dad, just, you know, don’t be cheap the whole time.”

“Hey you, I may resemble that remark but I am very sensitive to teasing.” Alan

shows an exaggerated pout. “Ok, here’s the itinerary. I got us a place right near the Trade

Center and financial area. Today we can take one of those double decker tour buses.”

Alex let’s out a groan. “Come on Alex, it’ll be just a couple of hours and gives us the lay

of the land. Tonight we’re on our own. Tomorrow I have tickets to “Phantom” for the

matinee and we can walk around Time Square after. Monday my meetings start and you

guys are on your own.”

Alex, anxiously asks “So when do I go shopping. I promised everyone in Tampa

that I would check out the styles and bring a bunch of things back.”

Alex had moved with her mom to Tampa Bay a year ago and she still felt like

she was caught in some bizarre time warp. Every time she saw her dad she sensed an

opportunity to enhance her wardrobe. Being a complete daddy’s girl had worked well to

her advantage and Alan’s medical practice had been doing well lately anyways. Kimberly

usually went along but sometimes the manipulation would make her cringe. Just now the

look in her green eyes suggested that Alex was just about to cross the line. Alan caught

the look and to smooth things out decided a little diversion was in order.

“Ok, I’m sure we’ll all have plenty of time to spend your father’s hard earned

cash. How about we check out the town first?”

They all headed into the awaiting taxi and started toward downtown Manhattan.

About thirty seconds into the ride Alex pulled out her cell phone and began dialing.

“Hey Tony, so we’re here. What are you up to this weekend? Uh huh, sounds

cool. No, my dad has planned out the first two days to do a bunch of touring and shows.”

Leaning into the phone and whispering, “I’m gonna try and get hold of my cousin and see

if she can save me.”

“Hey Alex, is your mom ok with you using the phone here?”

“Yeah dad, Tony’s on the same carrier, the whole things covered”

Alan and Kimberly rolled their eyes toward each other and Kimberly leaned in

to Alan’s shoulder. As usual he was sitting in the middle, between his two girls. The

weekends always started out this way. He would try to keep both girls feeling like they

were equally important. Eventually, they would push him to the outside and the two girls

would start sharing secrets and giggles. That was perfect to Alan, but he still relished the

attention and jealousy he triggered during those first hours.

They arrived at the hotel, unloaded and rode the elevator to their room on the 44th

floor overlooking the Brooklyn Bridge. They all unpacked, the girls traded time in the

bathroom and changed for the days travels. Once all were ready, Alan grabbed the travel

books, they went to the subway and began to navigate the underground maze.

“Ok Alex, I want to show you this stuff so if you decide to take off on your own

you’ll know what you’re doing.” Alan went over the subway map and showed Alex

how the trains were color coded and numbered and lettered. He explained the uptown

downtown directions and what to do if you get disoriented. Kimberly leaned in to hear

the explanation as this was her first time to New York City as well and she had plans to

check things out without Alan. She also had overheard Alex’s reference to her cousin and

figured she might be on her own on Monday and Tuesday.

Next, they were off on the Metro. Exiting 49th Street they quickly found the tour

buses. They found an available open double decker and headed to the top just as Alex let

out a groan of embarrassment. Kimberly turned and gave Alex “the eye” and they move

on to find some seats. Alan breathed in the warm late summer air as the tour bus headed

down the street. Landmarks were progressively identified and the history of each area

was explained. Kimberly was jotting notes into the guidebook for later revisits. Alex

leaned over the bus and pointed out the various shopping areas that enticed her. After a

while she looked at her father and asked, “So how much longer dad? I thought you said

we could get out and walk around.”

“Yeah Alex, but the rides only two hours and you have all weekend to walk

around.”

“I know, but there are some places here I really want to check out. Like how are

we going to find these places again. Can’t we just get off the bus and walk around? You

know dad I didn’t meet you here just to get stuck on tour buses all day long.”

Alan knew exactly what the issue was. He could see Alex’s look, she was

beginning to pout and her voice was starting to whine. Obviously, there was something

Alex wanted and she couldn’t relax. She had been like this since she was little. In fact,

Alan knew this was really a trait she inherited from him. Once an idea was in his head

he couldn’t relax until it was dealt with, purchased, resolved, whatever. Now Alex was

starting to act the exact same way.

“Hey Alex, here’s the deal. Stick with me on this bus for forty five minutes more.

I know exactly the place to go to. I promise you’ll love it. If I’m wrong you can control

all of the plans for tomorrow, no questions asked. Deal?”

“Fine.”

The bus continued the tour through the village, into Soho and Chinatown and

began to work its way uptown again. Once they crossed Fifth Avenue Alan called to the

girls “Time to go,” and the three departed. They took a turn uptown and Alan marched

them right into Saks, then Tiffany’s and then Burberry. Alex’s eyes were the size of

billiard balls. She went through the racks at Saks, tried on jewelry at Tiffany’s and

compared the purses at Burberry. After two hours of intensive comparison shopping

interrupted by brief calls to her supervising girlfriends in Florida she began to smile

again. Alan made sure to keep Alex from spending all of her money, reminding her

that there was a long weekend ahead and every store she went into would be a new

opportunity.

“Remember Alex, you have the high end traditional things around here, but

tomorrow were going to walk around the Village and Soho and those areas are trendy and

edgy. Just keep control, check things out and most of all have fun. Heck, hon, we’re in

New York. Now I just have one thing we have to do today. I’ve been wanting to do this

since I booked this weekend. Follow me.”

The three headed out and Alan walked them toward Central Park. As they got

there Kimberly new exactly what was on Alan’s mind. Alan checked out the horses

and chose a horse and carriage dressed in beautiful floral bouquets for a ride around the

park. They settled into the carriage, Alan in the center, and they rode through the park

on this stellar fall day. Halfway into the ride the driver took a photo of the three of them

on Alan’s digital camera framing the horse and carriage and its three passengers. The

two girls with their heads on Alan’s shoulders and in the background the sun breaking

through the leaves on the trees.

Time for Renewal

I haven't posted in nearly a year. Why? I ask myself. I believe that I became depressed by some of my own observations regarding the field of medicine. So many changes and such a big machine to work within that it is easy to become frustrated.

So, yesterday I'm walking on the beach with my wife Cynthia and my daughter Elizabeth and I'm talking about how difficult it is sometimes to get pleasure from work. But, what's strange is I enjoy treating peo ple and solving their problems so why am I missing out on the pleasure of what I do? What I realized is that I need to spend more time talking about what I enjoy in medicine and less of what is both frustrating and nearly impossible to change. Therefore, what I plan on presenting in this blog is recollections of patient challenges and successes and to share the stories of what I experience on a daily basis. And I will mix in some of my other projects with some more chapters from Virestorm and any other unique and interesting stories I can summon. Of course I will be careful to protect anyone's privacy, names will pseudonyms and the stories may have some minor changes.

A very pleasant 60 year old woman with gray streaked hair and a kind smile arrived in my office with a 7 month history of dizziness. She couldn't roll over in bed without spinning and she was off balance with any rapid motion. She had no relief with antivert, a common vertigo medication, and she had been seen by her primary care physician several times. When we talked she was only a little frustrated by the persistence of her symptoms. She seemed to have accepted her condition as a given factor of aging.

On exam she was completely normal except when I rolled her over onto her right side and laid her down rapidly she had sudden and very intenese dizziness and I could see her eyes rotating. Slowly her symptoms subsided. While she was laying still I explained that she probably had a disorder called benign paroxysmal positional vertigo also known as BPPV.
I explained to her that some of the fine crystals in her ear that were part of her balance sensor that detects motion had broken free and landed in one of her three semicircular canals. The treatment was a physical maneuver performed in the office called the Epley Maneuver. She told me that someone had previously tried a maneuver without help but she was willing to give mine a try.

About 30 years ago Dr. Epley gave a talk I attended. He showed a video of these very fine particles under magnification floating around in the canal where they were wreaking havoc. He showed us his method of treatment which involved slowly rotating somebody like a marshmallow on a skewer. It was this treatment I took her through.

I did the maneuver a couple of months ago and didn't hear from her again. She showed up in the office last week finally for her recheck. She didn't explain what took her so long to follow up but with a big smile she told me she was cured of her dizziness. That she hadn't had another problem again from the moment she left my office that day.

Survival of the Little Guy

I wonder if I will be the last independent practicing ENT doctor in my community. Over the past years I have seen a continuous onslaught of changes all of which are targeted to benefit large corporations but are a burden to my little three man group. I know these changes aren't only impacting me but also any small group of doctors trying to negotiate the web of insanity.
Will we survive the next ten or twenty years?
I hope so because I am certain that the one advantage a small group has is the ability to target our care to the individual patient. When we see a need to slow down and go down a different path we can do it. If a new treatment or algorithm comes out we can make the change right away. No waiting for the corporate office for review and approval. If a patient has a complaint or a compliment it goes right to the top. No hierarchy of people between the patient and the doctor.
So why am I so concerned?
Crippling new regulations are being passed by our state and federal governments every year. For me to really comply I would need a full time attorney and a medical consultant. Obviously, us small guys can't afford that. For example, Medicare decides they want us to switch to sending in your prescriptions electronically. No problem, we spend the money, buy the software, retrain our staff and we're doing the job. But that isn't the end. They want me to prove to them I am doing this. So back in 2009 they ask me to submit a letter to them on every patient I see Medicare or not with a special code. I do this. Then in 2010 they decide to change the code. Now in 2011 I think they are changing again. By the way, do they tell me this? No, they wait until November to send me a letter that I might be doing things wrong but they don't even tell me what it is.
Hmmm, how does the little guy survive?
How about a little bit of ridiculous? The State of California has a law that I need to return a call to you within thirty  minutes. Sounds reasonable doesn't it? How about if you're calling about your prescription refill while I am in the emergency room saving someone's life. Which should the priority be? Hmmm.
Even better, they have a law on the books that I have to see patients within fifteen minutes of their appointment time. What if the patient is late, am I still in trouble? Hmmm, how about a penalty if our legislators don't pass a budget within fifteen minutes of deadline? Sounds reasonable to me.
So why is this worse for my little group than the big guys? The big guys can hire people to make sure the i's are dotted and the t's crossed. Meanwhile, they watch us little guys suffer.
What will happen when the last of us closes shop? I guess independent businessmen have been suffering this fate for decades. Maybe a few of us will figure out ways to survive. Maybe we can find a way to team up, but you can imagine trying to have a bunch of independent people agree can be a challenge. Meanwhile, the geniuses in Washington, D.C. and Sacramento are going to paint themselves in to a corner. Because without us little guys to push around the big guys are going to fight hard for their interests. And you can guess who will win that battle. Just look at how the banks have controlled our economy. Well guess what? Health care is 16% of our gross national product. That's a mighty big tail swinging the dog.
What can we do?
I'm open to ideas, tell me!

Drugs Alcohol our Kids and Their Brains-Some Answers

I have been under the impression for a long time that our kids issues relate to how we raise them and counsel them and whether our family life is stable and supportive. But, now I have a completely different view. I just returned from a trip to Virginia where I attended some amazing seminars that finally gave me answers as to what is going on in the heads of our kids.  I believe that what I learned needs to be shared so that we all understand our kids better and can do a better job helping them survive into adulthood.

There are two gentlemen from Duke University, Aron White and Jeff Georgi, who have studied adolescent behavior and have shed a lot of light on what is going on in our kids heads and why it seems behavior has been changing over the past several decades. If your like me you've been scratching your head when you look at today's young adults. They look more mature than we ever did. Thirteen year old girls sometimes look like mature woman. On the other hand even at age eighteen or older they seem lost regarding their future. They have a hard time committing to work or school and me and my friends constantly complain that today's kids seem immature compared to our generation.

Well guess what? They are! And, there is science to prove it and this science makes everything make sense. My goal is to give you a synopsis of what these two men from Duke taught me last week and using some of my own inferences I want to help us all to understand our kids and how we can help them make good decisions.

First, we need some definitions. Puberty is the physical changes we experience that turns our bodies from child like into an adult with adult sex characteristics that enable us to reproduce. These changes include our appearance with hair growth, voice changes, breast development, menstreuation, etc.
Adolescence is the changes our mind makes that moves us from childhood and dependence on our parents to adulthood with independence and the ability to raise our own families. Adolescence is characterized by anxiety, loss of interest in family, a need to develop a pack of friends, desire to experiment, boredom, lack of insight of the future, etc.. Particularly interesting is that during adolescence our ability to learn and remember is the best we will have in our entire lives and simultaneously our brain is firing off signals that cause us to be impatient and anxious.

Is it just me or do we all remember our parents complaining that our generation seemed to be unfocused, lazy, reckless etc.? Much to my dismay I recall having very similar conversations with my friends about the current generation coming of age. So, is this because as we get older we get more critical or is something really going on here? Surprisingly, something is actually going on. Over the past 60 or more years the age of puberty  is getting younger and younger. Sixty years ago onset was around twelve years old in girls and now it is at age nine. Therefore, our observation that these twelve year old girls look like young woman and nothing like the twelve year olds when we grew up is actually correct. Ironically, while puberty is hitting at a younger age adolescence has been turning on later. The result is that sixty years ago adolescence kicked in around age twelve and ended around eighteen now it starts around age fourteen and doesn't completely end until close to age twenty-five. I'm not making this stuff up there are actually publications on this.

So, think about this, our kids look more mature at a younger age but their brains are less mature until an older age. Not only is their brain less mature but it is taking dramatically longer for them to emerge from this. The result is that every new generation is taking longer to grow up and act like the adults they look like.

Now I'm going to really scare you. A whole bunch of studies have been performed on adolescents regarding drugs and alcohol and the impact on their behavior and development. First, remember their brains are firing off the anxiety neurons so much that they feel anxious and at the same time very bored. As an answer they use alcohol or drugs which calms down those hyperactive neurons and this makes them feel really good. The effect is way more powerful  than it is on us adults. At the same time the circuits in their brain are trained to learn. So their brain hardwires in that drugs or alcohol will make them feel really good. At the same time they are imprinting that this is an activity they can share with friends and creates very positive memories.

Unfortunately, the frontal lobe of the brain, the part that lets us look into the future and anticipate the consequences of our actions is still incompletely developed. Therefore, they don't "see" that they could hurt themselves by their actions.  We all remember the feeling of invincibility we had as teenagers. This is actually a biological result of incomplete development of the brain.

On the  other hand, teens have a very well developed cerebellum which controls balance and coordination. Therefore they can consume far more alcohol or drugs than an adult brain and still walk and look normal. On top of this their brain does not get sedated from alcohol but rather stimulated. So unlike us parents who have a couple glasses of wine and want to go to bed our teenagers are ready to hit the town.

Some of us wonder if maybe we could help our kids by teaching them to use alcohol responsibly. Maybe they would learn moderation and appropriate behavior. We have been told for years that the Europeans don't have alcohol issues in their youth and there isn't an enforced drinking age there. Sorry, the research shows once again that our perceptions are wrong. The European teenagers have a much higher rate of dangerous drinking than Americans with double the rate of drinking to get drunk. Studies also show that teens who are introduced to "responsible" drinking in the home have a much higher likelihood of getting drunk as well.

The reason for this again points back to how their brains are developing. They have an enhanced response to alcohol with fewer side effects and a poor ability to foresee consequences. So, now we ask, What should we do?

We asked the lecturers this very same question. They were very clear. First of all, these guys aren't Puritans. They understand that alcohol and recreational drug use can be done responsibly. But, it can't be done responsibly until after someone has begun to emerge from adolescence around age 21. Therefore, they recommend that we do everything in our power to keep our kids from using drugs and alcohol. They even recommended routine drug screening or hair samples since it can show drug use 90 days old and the test can't be beat. They didn't say what age to start but I suspect probably in middle school.

This seminar was very enlightening to me because it basically killed all of my assumptions. I now know that my kids are maturing slowly and are very susceptible to the effects of drugs and alcohol and I should be vigilant in trying to keep them from using them. I will probably consider routine drug testing. I figure that if a test is positive it gives us a chance to talk about what's going on. And, preferably, if negative it gives my kids the excuse to say "no" when peer pressured.

What do you think? Have I presented anything here that might change the way you raise your kids?

Privatize Medicare? Why give up a cruddy system for certain disaster?

Everyone has heard the screaming on the Hill about Medicare. Should we change the system and if we do how should it be done? Paul Ryan made a risky and probably foolish move when he suggested phasing Medicare into privatized fee for service insurance. Everybody with a pulse is aware of the absurd salaries and bonuses paid to executives of insurance companies for successfully avoiding paying for care. So, obiviously, if we privatize Medicare we are throwing these guys a huge multitrillion dollar bone.

I suspect that unless Mr. Ryan has a special kick back set up he was suggesting this because he recognizes a truth we all wish to ignore. Private industry is not afraid to make decisions that government leaders lack the back bone to achieve. For example, it is well known that the final six months of life tally up about one half of the entire money spent on a lifetime of health care. No one in government leadership is willing to discuss this issue. I suspect that if Medicare was privatized the insurance industry would figure out a way to deal with this. The profit potential of reducing these costs is just too staggering.

On the other hand, if Medicare is privatized there probably wouldn't be any sympathy for the dying patients who desire care. By the way, I find it very curious that a Republican leader came up with a strategy of dealing with our elderly that would most likely result in a real death panel. For those of you who think that I am reaching a bit far I can tell you that only private insurance has subjected me to panels to evaluate whether a surgical procedure I would like to perform is appropriate. Medicare and Medicaid do no such thing. Instead they try to discourage procedures they don't like by reducing payments until the reimbursement is too unpalatable to consider performing.

I suspect if we privatize Medicare the incentive to make a profit will be so strong that patient care will be delayed as long as possible. Once the insurance companies have squeezed every last drop of profit they will abandon the model and beg the government to take over. By then we will have delayed so much care that just like failing to perform routine home maintenance we will be stuck with enormous expenses. So I do suspect certain disaster if we follow that route.

Despite this, I would like to thank Mr. Ryan for his willingness to at least discuss the Medicare disaster that is looming. I suspect that if we just raised the age when full benefits kick in and phase in an increase in copays and deductibles we can delay the disaster.

An even better idea is to reform the fee for service system. We need to put more responsibility with the consumer. I mentioned in a previous blog that physician compensation has not kept up with inflation. I also understand that Medicare cannot afford to pay physicians appropriately. But, the free market can. Currently, no matter what I bill a patient I am restricted to how much money I can be paid. Because of this, each year physicians are face with either leaving the Medicare program or in order to maintain income they need to perform a larger volume of services at ever decreasing payments. The upside is consumers get more services performed the downside is that for every dollar the physician generates in an additional procedure there may be associated expenses for facility fees, lab testing, etc. And, there will always be some doctors who bend the rules of indications for procedures and do things only to generate revenue. Those dogs make the rest of us look bad. Most of us just shorten our visit times and work longer hours to keep the revenue from sinking.

Perhaps we should allow doctors to charge what they feel the market can bear. Medicare doesn't have to increase rates they just need to allow the physician to pass those costs on to the consumer. They should require us to publish what our fees are so the consumer can compare. The free market will result in people reducing their usage of services if the cost is too high. They may travel to areas where cost of care is lower. Expensive hospitals would have to prove to the consumer that they are better. We could do away with the crazy red tape that Medicare uses to show quality of care. The consumer themselves would want to know who is the best for the money.

All this without a highly paid executive trying to transfer your money into his pocket. What do you think?

Virestorm-Chapter 2 and 3

Chapter 2

Lahore, Pakistan Farmer’s Market

Ten year old Ahmed runs through the market with his younger brother Mastouf close behind. Ahmed is laughing as he rounds the corner nearly sliding on the banana peels on the ground. He skids to a halt and Mastouf runs into him right in front of the bird cages. In front of the boys a cacophony of chirps and shouts break out among the chickens. The boys carefully look through the cages, like diamond merchants scrutinizing a collection of rare gems. The chickens are of various color combinations, some deep red, others white. Most of the birds look malnourished and weak. One is barely moving. Mastouf puts his small hand between the wires of the cage and gives the bird a poke. The bird barely moves and he pokes again. This time the bird breaks out in a riot of chirps and hisses and Ahmed yells at his younger brother, “Get your hand out of there! Are you crazy, that one looks sick.” Mastouf pulls his hand back out quickly and looks down at his feet. He is embarrassed that he disappointed his big brother. Ahmed can see it in his eyes and feels sorry. “Hey, don’t worry, I got a nice one here.” Ahmed shows his brother the big bird with bright eyes and a plume of red and yellow feathers. He gestures to the shop keeper who nods his ok and the boys take the bird out of the cage. “This one looks healthy, I think she can make us some good eggs. We’ll take her.” Ahmed reaches into his pants and pulls out a crumpled pile of colorful bills. He quickly concludes the negotiations with the shopkeeper and they bring the bird home in a burlap sack, squawking the whole way.

As soon as the boys get home they run in the door yelling “Mama we got a perfect chicken, she’s gonna make perfect eggs, come look!” Their mother poked her head out the door of their small one room home and reached over and took a look in the sack. “Perfect, my children, you have found us the perfect chicken. Now go get her into her cage and we can hope for an egg in the morning.” The boys ran in the front of the single room house and straight out the back into an alley. Against the house was a stack of rusty and empty cages. Just as they were getting ready to put the bird in, one of the neighbor boys strolled over. “So, what have you got there Ahmed? Going to give it another try? Birds can’t live here, it’s too dirty and cold back here.” Ahmed looked up at the older boy and just as he did he saw the boy’s younger brothers and sisters form into a large circle around him and Mastouf. “Well why don’t you at least let us see her?” Hesitantly, Ahmed complied and passed the sack around for all of the children to see. After the bird was given a complete tour of all six brothers and sisters Ahmed placed her into her cage with a small cup of corn and a tin filled with water. His mother stepped out into the alley, “Ok, the show is over, time to go home!” And she shooed the other children away.

Chapter 3

Ann Arbor, MI

Alex sits down at the counter of Angelo’s Café with her cup of coffee, in the background just audible over the noise of the small and bustling restaurant she can hear National Public Radio. She bites into her French toast as the news begins to unfold. “Today is the 1835th day since the President declared victory in Iraq. Three more service men killed by IED’s in Basra and scores of Iraqis die in a suicide bomb attack in central Baghdad.  The President says the surge is working…” Alex rolls her eyes. Fortunately, Angelo’s locally famous cinnamon raisin French toast makes the news more palatable. Angelo wanders over to the counter and smiles at Alex. He’s a large man, round with thinning gray hair. He smiles at Alex “More of the same, eh?” Alex looks up at Angelo, his white apron with the patches of grease stains, the warm brown eyes, and his thin gentle smile. “The candidates in this upcoming election don’t have a clue either, Angelo. This war is more ancient than our leaders will ever know and is more complex than they can ever comprehend. Anyway, too much misery for such a beautiful day. Take care Angelo.” Alex takes a look at the check, pulls some bills out of her wallet and lays the money on the counter. As she walks out she can overhear the newscasters, “President Ahmadinejad refuses to back down to nuclear inspections, President Bush irate and threatens action.”

Alex stands, looks out through the old wooden café door and steps out into the sunshine. Well at least today is a glorious spring day. The green leaves on the trees have that intense fluorescent green, the cherry trees visible across East Ann Street have blossoms and all the birds are shouting to their potential mates. Alex smiles to herself as she begins to think of her own potentials when a yell from behind stops her in her tracks. She turns to see her close friend Paula all laughs and giggles. “So, any plans for tonight? I thought we might check out the comedy show down at the union.” Paula has long brown hair, big almond eyes, and an infectious smile. She’s a little heavier than she would like but she this is offset by her generous figure which is on display in her tight low cut brown shirt. “Sure Paula, and are you going to finally stand up and try  out your routine, or do we have to wait for some talent scout to catch you trying your lines out in your bathroom?”

Paula has been a wannabe comedienne since the two became best friends in grade school. She has always been the funny one and Alex the serious one. Paula gives Alex balance and without her Alex would have easily lost herself after going through “the tragedy”. Fortunately, this best friend has always been by her side to cheer her up and keep her social. And Alex has done her part for Paula as well. Back in high school when partying was all the rage there were some close calls. If Alex hadn’t yanked her out of those parties and hadn’t pushed her Paula probably never would have finished high school, let alone been accepted to Michigan.

“Ok, I’ll come by around 7:30 and we can grab some food upstairs at Charlie’s before the show”. Paula smiles and with a twinkle in her eyes she takes off in the opposite direction, “Awesome Alex, see you then!”

Alex heads around the corner and into the Med Sciences building. The building was probably modern and clean looking when her dad was in school twenty-something years ago, but now the white-yellow exterior looks a bit sad and shabby under the watchful eye of the new gleaming University Hospital addition. She swipes her ID card and heads in. Medical students are scurrying around looking for labs and lecture halls. The smell of formaldehyde wafts out of the Gross Anatomy lab around the corner. Alex turns into the stairwell and begins her three story climb up to the microbiology floor. The stairwell railings are black painted iron and probably have their own microflora that could represent it’s own publication. She always avoids those railings, who knew what nasty critters had been innocuously carried out of a lab by a careless and sloppy assistant. At the third floor door she swipes her card again and enters the stained linoleum hallway to her lab. A finger print reader and she’s in. The whole thing seamed ridiculous. Ever since 9/11 they added security to all of the labs. This was before Alex’s time but apparently back then they did background checks on everyone, issued secure ID’s and fingerprinted everyone. Alex wasn’t quite sure what of value could have been taken from the Gross Anatomy lab that would bring terrorism to the hills of Ann Arbor but the laid back atmosphere in the labs was quickly replaced by apprehension and paranoia and more than one post doc left to go into a different line of work. Apparently the stress level had relaxed a bit and now the only labs requiring intensive scrutiny and security were those either working with infectious disease or those using radioactive substances. Both were present in Dr. Zack’s lab and so they gave him a secure floor. Funny thing was that any first year engineering student could probably outsmart the security anyways. Most of this stuff was off the shelf at Best Buy.

As Alex walked in she could hear the news again coming from Dr. Zack’s office. The news now was about Iran and nuclear weapons. The Americans were angry that the Europeans couldn’t get Iran to guarantee to stop enrichment and a lot of posturing was going on. The Vice President, “The Dick” as he was affectionately referred to by Dr. Zack, was pushing for a military strike. The Presidential candidates were split, and the lame duck president was equivocating. As Alex turned the corner she could hear Dr. Zack shouting at the radio. She stepped into his office and he smiled. Dr. Zack was true Ann Arbor. Raised by two Ph.D. parents he had been here all of his life. He was a certified genius and perpetually stuck in the 1960’s despite the fact he was about ten years old when they ended. He always has on a tie dyed shirt, a collection that would be the envy of Jerry Garcia. His wiry gray hair is tied back in a pony tail and he wears gold wire rimmed glasses. He had taken Alex under his wing a few years ago when her world collapsed around her and between Paula and him her ship has been slowly righted.

His blue eyes look Alex up and down and he smiles widely. “Well dear, ready for another day in the trenches? We have another sample of lung tissue from that most recent avian flu outbreak in Pakistan. We need new cultures set up and we need to do another trial for lethality and transmission.” Alex lets out a groan. This was going to be another marathon and there was a very good chance she would not make the show tonight.

Whenever the tissue came in from these Asian countries the shipping was usually very sloppy. Last time the specimen was fully rotted because the cooling packs leaked. Dr. Zack’s lab was one of only three in the U.S. entrusted with these cultures. There was a lot of pressure to identify what mutation would make the virus more contagious. The first lab to figure this out would get a lot of PR not to mention that they would be on the front line of the vaccine program. Even though Dr. Zack seemed like a mellow guy, he was an academician and he relied on grants. No product, no money. His last big success was over five years ago when he helped define the strain of virus that was causing Mad Cow in the US and was able to help the CDC trace the source to cattle from Canada. That little discovery put him in the driver seat for a while, but the departments of infectious disease and immunology were giving him a lot of heat lately for no recent breakthrough on the “avian flu”.

Alex starts to recall the lecture she gave to Dr. Zack’s medical students last term. She was in charge of power point slides in the lab along with just about all the other grunt work. After putting the presentation together Dr. Zack asked her to just go ahead and do the presentation. The whole idea was a bit unorthodox but everything about Dr. Zack is.

The first slide went up on the screen and Alex began the show. “Avian flu” so named because it is influenza virus that is endemic in the bird population but people have been dying from it for a few years now. The virus is scary because the mortality rate can be 80%. We have seen it mostly in Asia because the populations there live in close contact with birds. Every now and then a person or group is exposed to an infected bird, they themselves become infected and more often than not die. There isn’t any treatment except supportive care and no vaccine has been developed yet.

Historically, every twenty years or so, one of the viruses endemic to a different species mutates and enters the human population. Usually the sick, elderly and very young are quite susceptible and die. This is why a cure for the flu is so difficult. New virus types keep on entering the population. Even more scary is that about every eighty years a super flu comes out and kills huge numbers of people. That’s what happened in 1918 and therefore Dr. Zack, the CDC and military have been focusing our research on this bug because we think it is the best candidate for the next bad event.

After the forty minute lecture the students filed out. A couple raised hands with questions but most just quietly moved on. Alex remembers leaving the room, wondering if she was on the correct side of the podium. Her life would have been very different except for one very bad day.

A Great Return

I just returned from nearly two weeks in Mexico. I was fortunate to be able to spend such a long and vital time with my family. Usually when I return I'm afraid of what has happened while I was traveling. So, as per usual pattern I had a few anxiety nightmares a couple nights before my return home. The day before I awakened with a rapid heart beat. "What was Monday going to be like?"

I never know if on my return I will be crushed with disaster. The hard part about being a physician is the worrying. Before I leave I want everything tidy. All my patients in good shape. If anyone is sick or not recovering well from surgery I put in extra hours to get them straightened out. Luckily, I work with two excellent doctors that I have enormous trust for. Still, I don't want them to be upset that I left them a bunch of unfinished work. So, before this trip I had everyone in good shape. But, life is unpredictable and the healing arts are just that, art work. So, like I said earlier I get nervous before my return.

But this time was great. I walked in to my office and popped open my laptop to review all of my messages and patient files. Whew! No disasters. I made a few calls, updated people on their test results and renewed a bunch of prescriptions. Lucky for me Monday was a short day of paper work only. I wondered, "What will Tuesday be like?" Tuesday arrived and I started to see my patients. It seemed like everything was working. Everyone seemed to be in great shape. Postsurgical patients were healing, infections were going away, headaches and dizziness were better. A fluke? Nope! Wednesday has been the same. Everyone is doing great. New challenges arrived today but nothing I couldn't tackle. But best of all is that some of my most challenging patients are feeling better, happy and enjoying their regained health.

A great return! These vacations do more than just give me rest. I return with a new set of eyes and a fresh and energetic attitude. And the payback is great. It's hard to explain how much pleasure there is in seeing people responding to my treatment. Sometimes this is the greatest job and today is one of those days!