LITTLE THINGS ARE A BIG THING

At my last eye exam my eyes were unchanged in spite of several years with Diabetes II, which was diagnosed by an eye exam. The life of my eye doctor, however has been turned upside down, not by medical conditions but by the health business. He has left the big clinic where he practiced for years, just as my previous eye doctor left that same clinic and then left the town. This is not unusual. I have only a dim understanding of what is going on, but I don’t think I’m far wrong. Being a physician is no longer a profession: it is a profit-making enterprise and the docs are being squeezed and managed with the rest of us.

Obamacare is beside the point. Doctors have made a devil’s bargain to get rid of the burden of paperwork and other management chores. They have lost their autonomy. Some have lost their morality. Whether they have lost their skill is irrelevant since that’s not what counts anymore. In fact, the nature of disease and the protocol for handling it is has changed, esp. in the case of something chronic like diabetes. One monitors with tests, notes the results, and runs one’s finger down the list of prescriptions indicated, and that’s it. No wonder people are disintermediating their doctors by simply going to the lab for the tests. If the doctors didn’t have control of the prescription pad, why would we need them?

The science of “omics,” which is the goofy name for the study of how operating genetics run the body, happened upon something very fortunate. Their main “lab rat” is a Ph.D. whose entire genome is recorded and studied. Not just that but also an integrative Personal "Omics" Profile, or iPOP. The word "omics" indicates the study of a body of information, such as the genome (which is all DNA in a cell), or the proteome (which is all the proteins). Michael Snyder's iPOP also included his metabolome (metabolites), his transcriptome (RNA transcripts) and autoantibody profiles, among other things. They saw that he had a vulnerability to diabetes though no one else in his family had ever been diagnosed with it.

Then one day he caught a virus and that actually GAVE him diabetes II. file:///Users/maryscriver/Desktop/omics%20&%20viruses ScienceDaily (Mar. 15, 2012) The team watched and learned.

When I was at seminary, one of my classmates (a woman in her twenties) caught the flu and then she had diabetes I. That meant injected insulin and constant monitoring. I’m happy to report that she’s maintained well and -- thirty years later -- serves a church happily. One does not have to die of diabetes IF one can maintain the protocol, which is rigorous.

I’ve only been diagnosed a few years but thanks to Internet contact, mostly Dave Lull (the cross-pollinating librarian) and Jenny Ruhl http://www.phlaunt.com/diabetes/bio.php I’m able to stay in control with one metformin a day plus food changes. Since I live alone, I cut my intake way back, lost fifty pounds, eliminated sugar, most carbs, white bread, corn fructose, processed food, and so on. I’ve always eaten a lot of veggies, salad and nuts. I read a newsletter about foods that convert to sugar slowly -- it comes out of Australia -- and another sort of rah-rah column about getting exercise. (I don’t do well on that one.) The point is that I’m in charge of myself, though it has meant major changes. This town is in a place where people interact through food: benefit barbecues, pie socials, candy on desks, coffee and cookies after church, and so on. Restaurant meals are high sugar, high process, big portions. But I’m a solitary anyway.

Most people who have lived here all their lives and who are diagnosed with diabetes, esp. on the rez, either become dependent on meds or simply sicken and die. Changing the way they eat, the way they cook, the way they interact with family and neighbors is too much. They find it impossible to lose weight. The ecology is changing too fast for them to evolve.

When I went for a refill on one of my two prescriptions (my high blood pressure med), the big Medicare website said I could not have any more until April 4. The local pharmacy records show one more set of meds was sent to me than I evidently received. We can’t figure out where the error is. I’m going to take advantage of this to run an experiment: I’ll not take any pills until April 4 and I’ll record my blood pressure every day. Today it’s 134/79. If it starts getting too high, I’ll buy enough pills out of my pocket to last until April 4. Assuming I have the money.

The point is not my blood pressure. The point is that our ailments have become very differently envisioned. Dr. Snyder’s diabetes onset involved 40,000 genes, all interacting in unique ways. A look at the names of the researchers reveals many countries of origin and the study itself was supported by Stanford University, the National Institutes of Health, the Spanish Ministry of Science and Innovation, the European Union, the European Research Council, the Korber Foundation, the Fundación Marcelino Botín and Fundación Lilly and the Breetwor Family Foundation. Snyder undoubtedly caught his trigger-virus from his small children who interact with the other children of the Stanford academic community, people who constantly travel and host other academics.

Many of us know and admire medicins sans frontieres. Now we have (we always did) diseases sans frontieres with frequent flier miles. Most are not dramatic. (Fatigue, malaise) Many are antibiotic tolerant. Some have been triggered by our constant invention and ingestion of peculiar molecules never seen in nature, much less in bodies. So far our water here is nearly pure, off the Rocky Mountains and traveling underground about thirty miles to our aquifer. That may not last since frakking means injected unnamed chemicals into the ground. Our wheat crops, which are grown right up to the town limits, are genomically altered to be Roundup Ready, meaning high levels of herbicide can be applied. The pigeons that hang around the granaries in town are all gone. No one will say how they were eliminated. Our cancer rates are high.

Years ago I used to have a poster in my kitchen that said, “Faithfulness in little things is a big thing.” It’s attributed to St. Francis, who advocated being as basic and interwoven with nature as possible. I wonder whether there’s a gene for that. It would probably take more than a few.

TRACED ON THE RETINA

About a month ago around suppertime I got a phone call from my eye doctor. This was so disconcertingly unique that I couldn’t hear what he was saying for a few minutes. Even then, it seemed simply a call to see how I was doing because of having precursors to glaucoma: diabetes, a skewed visual disc where the optic nerve attaches to the eyeball, a mother with glaucoma, ocular migraines, and marked nearsightedness -- plus the fact that I developed holes in my retinas while I was in Saskatoon. Several years ago this was the doctor who could see I had diabetes because in the eye one can see a tiny sample of the circulatory system traced on the retina.

But I was alerted that something more was going on. I made an appointment which was yesterday. A week ago I got a phone call from office staff (which is not unusual) to confirm my appointment and also to tell me that the doctor had quit the Great Falls Clinic and would be found at a new address, a far more modest building than the GF Clinic’s architectural monstrosity. (You can see my bias already.) When I got to the office, it was in a state of chaos.

The doc had moved out sooner than he had expected, so he was in a small suite while waiting for a larger suite to be remodeled for him. The computers had not been delivered. A quick walk up and down the hall (looking for the ladies’ room) revealed suites in every state of deshabile -- newly vacated, half-rebuilt, and one or two actually occupied. The doc’s waiting room at that point (lunch time) was empty but the small space behind the check-in window was crowded with staff. I settled down to read magazines while the waiting room filled up with older rural guys, mostly overweight and full of quips at the expense of Democrats. This doc’s practice is crammed with people whose eyes have been damaged by constant outdoor exposure to intense sunlight with a high UV component. The best plant catalogues will list the UV resistance of the various plants because the high clear air lets so much of it through.

Again I had to INSIST that if they put lidocaine in my eye to put the glaucoma instrument against it, they must be prepared to wash the stuff right back out again or my eyes will swell shut. The allergy is on my file folder or should be, but most of my records are still back at GF Clinic. The tech again argued that I was wrong, I was being unreasonable, there was no record, etc. but in the end she did what I said. The exam was the fastest on record, done with handheld instruments, and showed that my eyes were unchanged. Perversely, I always feel as though I’ve wasted time and money when there’s no change!

BUT, in the past in other places, I’ve always asked for my prescription to carry in my wallet as a safeguard against smashed glasses. I also carry a spare, but I feel better if I have my prescription. Besides that, it is possible to order glasses through the Internet for a fraction of what oculists charge. As well, the selection of frames is much broader than any oculist could carry and what the oculists DO carry is always trendy, what will sell, so attuned to fashion-conscious young people. What I want next is “Harry Potter” glasses: round. I’ve been wearing an old pair of big-lensed glasses which is fine, since fashion is not a concern. The big lenses make enough area for “graduated” bi-focals so I can read and work onscreen without having to get a crick in my neck. The GF Clinic refused to give me my prescription. My doc, now making his own judgments, wrote it out for me on the spot.

This is all trivia. I am far more interested in what’s going on with these doctors and the Great Falls Clinic. Everything in Great Falls is driven by money and most of the money is concentrated in Malmstrom Air Force Base, education, and medical care. The aluminum and copper refineries are long gone as is the railroad. However, there’s a strong nexus of cultural centers: the Russell Museum, the History Museum, the Lewis & Clark Museum, the Children’s Museum, and many smaller groups. There is also a undertow of crime, though nothing like the major Canadian cities close to the border or, say, Butte, or increasingly Missoula. So far there is not the sudden influx of violent opportunists that are plaguing the northeastern oil patch, but there are way too many murders in the newspaper, too many child abuse cases, too much underground (sometimes literally) deal-making going on.

March is the month of ice breakup and often other shifts as well. Malmstrom is going from fighter planes to transport. That means the streets will be safer and the bars will not be quite so boisterous. (I always joke that Tenth Ave S is dangerous because half the drivers are jet pilots and the other half think they are.) The legal status of things like the big electricity generating dams is changing.

But medical is where there is always action, not least because of the McLaughlin Center for mouse research which does crucial work with knock-out genetics -- the protocols where mice are bred to be mutated and then tested to see what the knocked-out genes did.

At one point there were two major hospitals who competed against each other. Involvement in both the hospitals and local higher education was strongly based in religious orders which have shrunk over the years and finally found they had to sell out. In theory steps were taken to restrain monopoly, but the buyers soon found ways around that. A large pool of aging people with rich land-based estates, and absentee progeny who never came back after being sent to all the best schools, is a cash cow, as the lawyers have known for decades. Now, with mineral leases acting like cocaine, predators who can figure angles are thriving. Not so many are doctors as are medical administrators. I couldn’t prove it, I couldn’t point to individuals, but it’s just under the surface all the time. The newspaper is dependent on the huge advertising stream of the hospitals and clinics.

I interpret my eye doc as moving out of that context. He looks enormously stressed. His staff, operating practically out of each other’s laps and without the computers they need, was cheerful. They know something. They are looking at a bit of the economic circulatory stream.

THE NEW PORN

Reading about Caravaggio (“M -- The Story of the Man Who Became Caravaggio) plus the movie, as well as reading Jeremy Biles’ essay about J.G. Ballard in “Sightings” which is an automated essay that comes from the University of Chicago Divinity School, I’ve managed to make a lot of inchoate and troublesome ideas fall into place. (Don’t worry. My domestic life remains calm and regular.)

First of all, I begin to see how in Caravaggio’s day the main privileged class was high church officials plus a few landed individuals. Their markers of privilege were anything of great cost, including jewels and precious metals (hello, Cellini) and art but also human beings for sexual use -- ANY sexual use -- and also secrecy enforced with violence. The biggest power of all was to break the rules that were enforced on “lesser” folk. Ironically, someone like Caravaggio or Cellini, who paid no attention to the rules at least in part because they could make valuable things, were thus able to be “free spirits,” their own kind of power that exposed them to violence. These convictions persist, which partly explains our problems with priests and politicians today. And perhaps also explains the origin of our idea that all artists are somehow entitled to be untamed, exceptional, tantamount to geniuses.

So being middle class, as we know it now, came later. I wonder whether a case could be made linking it to industrialization: people coming in from the country and making it in the city Dickens-style, either through bookkeeping or through machine-enhanced manufacturing or small shops. These are pursuits that depend upon attention to detail, consistency, persistence, watching the clock. This could produce wealth, or has until lately. Part of being middle-class was limiting children to the number who could be educated, since skill was now the way to make money. Simple untrained child labor became less and less useful and therefore children were easy to abandon. Respectability then became linked with repression, so that extra sexuality -- with no birth control -- had to be siphoned off to disreputables whose lives didn’t matter. People became much more guarded and more easily discarded.

Economics in a city meant that the primary male was far more important than on a farm. In fact, he was SO important that a woman had to be very careful about choosing him and then commit to him utterly. The law conspired with this. Men owned women. (I just saw “Iron-jawed Angels” and highly recommend it: a lively contemporary interpretation of the securing of women’s right to vote.) WWII inflated the national image of men into heroes of nearly god-like proportions. I just watched “A Bridge Too Far” and was startled to see how many of our major movie stars in the Boomer generation picked up their images from this war story. It’s not one of those black-and-white gritty WWII movies, though there are there are included newsreels, and not the carnegraphic (new word -- isn’t it great?) post-Vietnam movies of more recent times. "Bridge" includes a lot of spectacular Technicolor blood and explosions, then a series of vignettes of wry, brave, handsome men. Little of the dismemberment that since become popular.

When birth control, women’s rights, and female economic empowerment, are in place, the previous system is pretty well sabotaged. The paycheck power that entitled Pa to everything is now at least undermined as Ma finds work as well. National cynicism and corruption follow the chaos -- don’t cause it. People feel that relationships won’t last, that jobs won’t last -- and they’re right. So everyone presses for the moment. And that means in sex, too. Now that having babies won’t kill women, they don’t mind having more sex. And Dad was kinda pressured until they invented Viagra. Now it’s a checkmate: no babies, no necessity for arousal, no game, no fun.

All along the way the sex that Victorians tried to keep under control had been leaking out, mostly as a matter of commodification -- mercantilism. Sex sells. Movies, newspapers, books, and so on. Guys look at gals in terms of how much money it would take to get her to come across. Gals -- did they ever stop -- size guys up according to their prospects for income. Ma and Pa get so absorbed in this that they forget all about the kids who DO somehow manage to come along despite every safeguard.

The bottom line is that culture loses meaning, power is gone, family loyalty evaporates except among those only a generation or so from the land like Hispanics or Asians. (Which gives them a big advantage.) The power to attach is weakened because, to many, jobs mean moving, so people abandon what they have if they see something better. Sex and drugs combined become a “kratophany” (another new word -- it means an experience of great power -- in this case, a fantasy) because both are so denied and confined and yet so saleable, so ubiquituous and yet (for some) so elusive. The two interact.

But that’s beginning to wane. Familiarity, maybe. Maybe an actual physiological shift from modern diet and chemical ingestion, actual gender blurring. Sex is now all over the place and we’ve explored every orifice. What was porn is now “erotic” or maybe just an “R” rating that everyone ignores. The discussion of it no longer needs to be in Latin -- all the kids say fuck. Violence and pain enter the mix.

But there’s another real porn now, something nice people don’t talk about: the limits of human life. Not just us as individuals, though that keeps people glued to their science news and helps to sell ridiculously high-priced and bug-ridden machines that often divulge nothing or very little about ailments. (We’ve nearly translated to a higher plane: from mechanics to techtronics -- except we still think in terms of industrial mass-production.)

We are beginning to realize that humans are animals with no privilege, that all animals have genetic drift and that outliers are always falling off the edges, that something so subtle as climate change or a virus can extinguish (HAS extinguished) whole species, and that there is no assurance that humans will even exist on this planet more than a few thousand years into the future. Thus the huge interest in religion.

“Do you believe in God” is just code for “Do you believe in Life after Death.” Spirituality is the feeling that one belongs, but also the conviction that something never dies.

The enormous power of AIDS to tap human consciousness is that it wraps up mortality and sex together, though one could just as easily catch some other virus and just as easily catch it through a blood transfusion or a needle poke. And yet AIDS has not captured the budget; it doesn’t get as much money as it takes to develop a cure. The power has no shape, no direction. It’s not yet personal. While the “grownups” were busy thinking up reasons to resist a cure -- like, won’t it solve the Africa problem by depopulating the continent? Won't it wipe out perverts? In fact, won’t it just solve the overpopulation of the earth by weeding out all the people we don’t much like? -- the younger people of the planet have been quietly growing “secret” layers of planetary culture. One is the response to the criminalization of drugs, which has acted just as alcohol criminalization did to web together gangs, dictators and opportunists in a new mafia that ignores national boundaries. (The total value of marijuana transactions alone last year is estimated to exceed the value of corn, wheat and soy combined.) Another network is the war profiteering, which is now morphing around to escape control by the new administration. Not much difference except they can’t be so out-in-the-open. I think the high tech network is about to be forced underground by efforts to control all this as well as the need to make money. The results won’t be pleasant.

So we’ve entered a world that the punk sci-fi writers have inhabited for a long time: post-apocalypse. A time when place is a labyrinth, survival is the goal, and humans are voluntary cyborgs. J. G. Ballard and T.P. Barrus have lived in this world a while. They can tell us about it.

THREE BOADACIOUS HEROINES

My three red-headed warrior women heroines through childhood and beyond were Isadora Duncan, Gene Stratton-Porter, and Lucy Maude Montgomery. Isadora, the free-spirited dancer; Gene, the indomitable naturalist; and Lucy whom I knew in her aspect as “Anne of Green Gables.” All three went head-long crashing into the world and all three had their melancholy moments. Isadora never lacked for eroticism and Gene never slowed for traffic. But Lucy/Anne was the prize, a minister’s wife no less. (Fictional Anne settled for a doctor.)

Now Lucy’s granddaughter has spilled the beans: Lucy Maude Montgomery killed herself at age 67. Hey, that’s MY age! (Isadora died at 50. Gene S-P died at 61. Both from automobile-related accidents.) Lucy had a lifelong struggle with depression and so did her husband, who died a year later than she did. (Isadora’s husband, much younger than she, also had mental health struggles which emerged in violence.) The granddaughter of Lucy Maude made her disclosure to try to break down the stigma of mental problems and promote programs that help those fighting for their very lives.

My problems have been more with managing paranoia and temper than depression. But my mother, some members of my father’s family, and my mother’s mother have all had to fight off what Winston Churchill called “the black dog.” When my mother, also named Lucy but “Lucy May,” first realized she was dying, I was sitting in the corner of the hospital room to watch over her. She said, “You’re sitting there like a “big black dog.” And I was. But it was as a guardian. Some say depression is a guardian against realities one cannot face, a relative to denial.

I first realized that my mother, the invulnerable, could suffer was one twilight when I was pretty small. I came in from the yard and found her in the near-dark weeping. I had never seen her cry before. Dumb-founded, I couldn’t think what to do except to pat her. She turned angry, which was her Irish Prot family’s way of handling most everything, and sent me back outside while she started supper. Though she denied that such a thing ever happened, I finally figured out she must have been just realizing that cancer would kill her mother. In those days cancer was hidden deeper than depression. It implied that a person deserved some awful punishment. I suppose mental illness is the same.

Later my mother and we kids went down to Roseburg, OR, so my mother could do her mother’s canning. Her mother was in a nursing home, but the canning had to be done. My grandfather must have tended the garden. Gardening of food was man’s work, but canning was not and my aunts, farm wives, were doing their own canning. We kids bedded down on quilts behind the sofa and my mother and her father raged at each other all evening. We’d left too quickly for me to remember to bring along a doll, so my grandfather got me to draw one on some thin plywood and cut it out with a coping saw. He was a skilled finish carpenter, often away from home so he could go to contracting jobs. His raging was mostly empty, meant to control rather than wound.

Both my mother’s parents were religious. “Pop” was a pillar of the Presbyterian church -- maybe more like a rumbling radiator in the church, always making heat and noise. “Mom” was at heart a Universalist Baptist and, since in Roseburg the two churches were next to each other, she would slip out during the tedious hair-splitting of the Presby sermon in order to hear about forgiveness at the Baptist church. I thought her name was Grace, but it was Ethel Grace. These are gender-assigned religious tastes: a man wanting structure and a patriarch; a woman wanting comforting and something more like a lover.

I don’t think suicide is always a result of depression, though both are theorized to be rage turned inward as self-destruction. I don’t know of any suicides in the family; at least no successes. I guess, like me, they figured if it were that bad they’d make the bastards kill ‘em. And in the meantime, not be held back by good manners! The secret of a suicide must be pretty depressing, a lead weight on a weary swimmer through life. I’m not much one for secrets: disclosure might be a good trait for a writer, but not necessarily for her family. Maybe Lucy Maude’s fictionalizations kept her alive and were far more satisfying to readers than an honest account of her life might have been.

Through some kind of alchemy, she managed to create a kind of Victorian/Japanese, weeping-willow melancholy, a sort of romantic twilight woven of white flowers among the pines along the dunes where memories of lost loves walked alongside and the breakers sighed in the distance. She did have a keen sense of the ridiculous, gently mocking what must have been the tyrants and cranks of any congregation. She lanced the abcesses of pretention and applied the antiseptic of Rachel Lynde’s astringent opinions, showing them for the conformist and class-based assumptions they were. It’s “face,” facade, appearances that form a cage as much as depression. Isadora and Gene might be said to have destroyed themselves by hurling themselves against the bars. Or were they endangered by leaving the constraints of convention? Did they really escape? Do we really have freedom now?

Some commentators have noted that the lives of women in previous generations were enough to depress anyone and there’s some justice in that. But we’re also far more aware of chemical, sometimes hereditary and sometimes industrially-generated, conditions that cause this state, and we have counter-chemicals that are often effective, sparing a lot of psychic pain and supporting functional lives. Still, we have far to go.

Will I throw out my three role models, since from here on I will have lived more years than they have anyway? Certainly not. Do I discredit them for not living in the same decades or the same geography as I do? I’m not repeating someone else’s life, I’m living my own. It’s their ATTITUDES, I’m after, their style.

THE MANAGEMENT OF CONSCIOUSNESS

The management of consciousness is a kind of oxymoron since most of what goes on in one’s “mind” is unconscious. If it is a mistake to speak of a person’s body-being as entirely separate from the “reality” out there in the physical world, what is it to face the fact that 90% of what we “think” we don’t even KNOW we think? It’s one thing to say that the “map” of the world can’t be entirely accurate without being a duplicate of the world, but what if most of the map is “folded under” where our conscious and reflective mind can’t get at it at all?

Beyond that, how can one exert intentionality if so much is not under intentional control? When I was small, my mother used to get very frustrated because I would not nap while my younger brothers and she were desperate to sleep. I can remember lying alone in the middle the quilt on her big bed, blithely kicking my heels and thinking big thoughts. “Go to sleep!” she would call, but I didn’t know how. And her frustration with me kept HER from sleeping.

Gary J. Cook and I have been talking about the management of consciousness because it is so vital to the business of war, hunting, religion, and writing. The old-time Blackfeet knew a lot about managing consciousness but a former student of mine, when asked what he’s been reading lately, tells me he’s rarely “in the mood” for reading. He feels it’s not his fault, that moods are not anything one can control. The world just kicks a person around like a soccer ball. (I can’t blame him much -- I’m rarely in the mood for exercise.) It seems to me he’s assimilated this idea from the modern world -- that it’s not an old-time Blackfeet way of thinking. Between humor and fatalism (that gambling asset) they at least managed their RESPONSE to what happened.

But now, with the fMRI studies that can see the places and structures in the mind where thinking actually takes place, a record of electromagnetic changes, we have evidence of the mapmaker at work that is entirely separate from what the person consciously thinks they are thinking. We discover that there are two memories, one of which might not correspond to the reality, and that a major mistake shows in one’s brain before one knows it was done. This is disturbing to us as we try to understand what legal testimony, what psychoanalytic interpretations and what sensational memoirs “really happened,” quite apart from the witness’s belief. We had thought such things were controlled by us “on purpose.”

I’ve been thinking about consciousness-controlling strategies. I read that if one is asked to remember something or preparing to create something, one should look quickly to one side and then to the other. They say this brings the two sides of one’s brain into harmony, which is helpful since we know that one side tends to be focussed on language and sequential, rational reasoning and the other leans to image, emotion, and creation. Of course, there are dozens of other subtle controls, filters and recorders in the brain all working at the same time, so maybe this little exercise is not quite so powerful as one might hope. I mean, what does this do to one’s amygdala? One’s hippocampus?

Here’s a list of “consciousness changers” off the top of my consciousness.

1. ENVIRONMENT
We know what happens to claustrophobes in tight spaces. Entering a space like a cathedral or standing before an ocean sunset will seize consciousness and memorably introduce a sense of transcendence. The vistas of prairie, the ramparts of mountains, may in themselves account for the persistent mysticism of the Blackfeet.

2. INGESTION
Food, of course, can change your mood. Way beyond the idea of “comfort food” or “brain food” is Michael Gershon’s amazing book, “The Second Brain,” which examines what it means that the neural network embedded in the intestines operates on the same molecules as the brain. When you say, “I have a gut feeling,” it is real and profound. Bad thinking can make you throw up or develop colitis. (Not ulcers -- they're caused by a "bug.")

Lack of food, fasting, was one of the ways the old-time Blackfeet altered their consciousness so they would have a vision. Lying in a dream bed, they neither ate nor drank for as long as several days, until they felt they had contacted an alternate reality.

Drink as in intoxicants. We know a lot about that, but even the temperature of what you ingest will change your state of mind, whether you need warming or cooling. All that English tea must preserve sanity in the midst of cold rain and mist.

Drugs -- legal or illegal molecules that drastically change the way your brain works. Daily we meddle with coffee, antihistamines, etc. and probably underestimate their impact.

Inhaling -- the tobacco factor with its paradoxical stimulating and calming nicotine. Incense in church may change your mood. Stores know to provide pleasant smells to make you relax and shop. Blackfeet used smoke constantly, as incense, as cleansing preparation, and for practical aims like repelling bugs or curing meat.

The strong associations with smell, which is produced by actual molecules lodging directly in the brain’s receptors, can trigger memory and mood (the Proust effect) more powerfully and suddenly than almost anything else.

3. MOVEMENT
Memories are also stored in gestures or movements: one person told about being seized by a memory of a certain stone-paved path because of his ankle being slightly twisted the way a particularly shaped stone always caused his foot to turn.

Many Asian disciplines are movement-based and act powerfully to control mood. Dance of all kinds is the same. For the Blackfeet repetitive rhythmic movements, extravagant movements as in fancy dancing, and movements that mimic well-known and often-observed animals, all three, contain states of mind.

4. SOUND
We all know what drumming can do for our state of mind: rev it up, focus, calm, summon memory, and so on. Music is highly dependent on associations: where one hears it, who is alongside (“our song”). One weeps, one laughs, one leaves quickly.

5. CONDITIONING
They say that if a child eats a vegetable three times, it will become palatable or at least tolerable -- IF you make the child feel good about it. A grizzly that finds food just ONCE is conditioned. Big X on the internal map. That’s what they think is there for the rest of their lifetime. If a cat does something three things, that’s their map from then on. At my house we do things on the cat schedule, because it’s so hard to change. One of the secrets to writing is to associate a time and place with the act, so that when one gets there, one’s inner being thinks writing is a natural act. That's the real meaning of "lucky hats" and "favorite pens."

In spite of all these strategies, and there are many many, and in spite of the power of some disciplines, like yogis who learn to control their breathing and heart beat, there are some times when the map is simply wrong but so intense or meaningful that mapping instruments in the brain cannot register the wrongness in spite of intentions. We call them mistakes. We call them psychosis. We call them dreams or visions. Sometimes we call them memoir. They are on the underfolded part of the map, the unconscious. They are part of what makes us human and causes us to need each other.

EMT BALLISTICS

The bookend to the reflective, careful ethics of the doctor blogs is EMT blogs -- that’s as in Emergency Medical Technicians -- first responders. The guys who jump out of the ambulance as it arrives and dash to the victim with a kit and a radio contact back to the emergency room in the hospital. They see everything, including things no one should see -- like deep insides splattered on outsides. But their attitude is far from somber and grim -- they are masters of bloody humor. Plus a certain amount of pent-up exasperation, if not real rage at the damage one person can do to another and at the constant abuses of the system by the stupid, the selfish and the hooked.

Recently an EMT in Boston was interviewed on “Here and Now,” a lunchtime NPR program. That was: http://urbanparamedic.blogspot.com/

Rocky Mountain Medic is one I check fairly often. His writing is a bit purple, very atmospheric, but then he’ll hit a sweet spot and be brilliant. Some day he’ll be a famous novelist -- I have no doubt. http://www.rockymountainmedic.blogspot.com/

Everyone’s favorite is http://ambulancedriverfiles.blogspot.com/ Partly, we love him because we’ve been with him through the problems of his very special little girl and the tragic conflagration of his marriage -- then his finding new love and losing forty pounds. This guy lives a dramatic life and he lives it in the SE US, which usually features in redneck jokes, sinister tropical mysteries, and TV shots of poodle-eating alligators in swamps. By the time Our Hero gets through walking us into unpromising situations like the last rotting room of a collapsing ancient hotel, making a hip-shot diagnosis of a four-hundred-pound alcoholic with a purple face and bloody vomit, intubating, hooking up lines, and somehow helping his partner horse the guy down the tilting stairs in a chair because a stretcher won’t fit -- and then the guy sits up in the hospital and cusses him... We’re there.

This man is a teacher of EMT’s and I’d pay for the classes even though I’m no EMT and have no intention of becoming one. He’s been asked to give a talk to EMT’s about bullet wounds. Before holding forth, he shows he is a good teacher by asking his readers for info and advice. This IS useful to me because I write and someone might shoot someone else in a story. (I hope that the ONLY time it’s useful!)

As it turns out, there’s a lot to unlearn. Most of the research has been done by firing guns into gelatin or a relatively small animal (dead or alive) while a camera runs and then analyzing the results. That means at least one medical fact has gone unrealized. The bullet makes one destructive “cavitation” (hole) through the flesh where the cells are outright destroyed, called “tissue crush.” But flesh is resilient and around that destroyed tunnel is a secondary enveloping tube of flesh that is “tissue stretched,” basically bruised -- maybe badly. The practice has been to use surgery to remove all the destroyed tissue and also to take out much of the bruised tissue around it, assuming that it can’t recover. More recent studies show that it CAN heal and rebuild.

There has been speculation about “sonic impact” but a doctor named Fackler, who has made it his business to investigate and reflect, points out that a lithotripter used to break up kidney stones generates much stronger sonic pressure waves without harming soft tissue.

Another main point made by commenters is that the gun doesn’t matter as much as the ammunition, the most dangerous bullets being those that expand or tumble. Except that one city EMT explained that if bullets explode and fragment in the victim, who is not likely to be the most pristine slice of life, then the greatest danger to the EMT is being stabbed by a fragment when inserting a finger to try to find out the path of the bullet. This means being exposed to AIDS, HepC, and other blood-borne disease. Therefore, he wears double gloves, and he reports that though they have indeed been torn by fragments, so far his finger skin was saved. In fact, fragmenting bullets are far more deadly than high velocity bullets, though velocity is a favorite preoccupation.

Not all bullets tumble. “Bullet yaw” inside the body is much more pronounced than “bullet yaw” during the flight trajectory. What happens inside depends on how soft the tissue is where the bullet hits. A bullet can be hot and burn tissue deep inside. A bullet that crushes flesh is not so efficient at killing as an arrow that slices it.

First-on-the-scene witnesses report that the movie dramatics of being thrown backwards by the bullet is against Newton’s Laws (unless the actor is wearing a stuntman’s harness) and likewise spinning is unlikely if not just silly, though five-year-olds dearly love to spin while they groan, “You got me!”

The most dangerous gunshots, they say, are the ones fired by an expert who wishes to kill and knows how to do it. In the argument about whether it is better to stop an attacker, to “drop him in his tracks,” as they say, by shooting him in the head or in the heart, the winning answer is to shoot him (well, or her) in the pelvis, so that locomotion is mechanically prevented. This is meaningful to me because one of my jobs in the Sixties was to shoot a gopher every morning to feed the eagle. I learned NOT to shoot them in the head because they had enough reflex left to kick themselves down their holes and I hated to put my hand in there after I pulled one out that we’d shot the week before. (I was the only one with a hand small enough to fit down the hole.) A gopher shot in the heart with a .22 is exploded enough to drop.

But a person trying to repair the damage doesn’t need to know what kind of gun or even what kind of bullet was involved, except from the point of view of solving the crime. Doc Fackler says the treating physician is much better off looking directly at the damage and evaluating it with no assumptions at all.

One looks for the exit wound but, remarkably, bullets may not emerge but rather lodge just inside the skin which is tough and stretchy. Also, things in pockets (wallets, watches, Bibles, love letters) can alter outcomes greatly. One soldier had a mini-mortar in his abdomen that would have exploded except that a fragment of his uniform was stuck in the striker, keeping it from making contact. In the old days, I once read, people worried about clothing lodged in the body because of infection, but antibiotics have greatly eased that concern. X-rays help enormously since they can show where the bullet is, whether it is fragmented, and what kind of bone damage has been caused. But that’s after you get to the hospital. It’s up to the EMT to get them there alive.

THE DOCTOR'S DILEMMA

Certain dilemmas of the personal conscience are more of a problem to highly effective people than to many others. I love to read medical blogs, not just the Googley medical advice, but the personal testimonies and questions. I find people among MD bloggers who are certifiably skillful, valued, and effective, as professionals are presumed to be, but also self-scrutinizing and disclosive on blogs far beyond what we are used to in people at this level. For instance, one doctor has shared on his blog (and I’m not going to link, because he has built a supportive community and I don’t want to mess that up) a situation that many of us will never face and honestly reported the emotional consequences to himself.

This man is a surgeon, especially skillful and successful with female problems, like breast cancer. He just gets better results with them and has had a rewarding practice. But he is a multi-skilled person and decided that he would retire a little early so he could pursue and develop other interests. A woman of his acquaintance (well, all right, friendship, but I’d guess that he ever met a woman he didn’t like in a protective and delighted way) needed a surgery of the kind he used to perform, but since he was retired, the operation was done by another surgeon who lost her on the operating table. More plainly, she died.

Now “our” doctor is left with a huge confused avalanche of feelings: did he have a right to retire when other doctors were not as skillful? If he had stepped out of retirement (which no one asked him to do) and had done that operation, wouldn’t he almost surely have brought her through successfully? But isn’t he obligated by professional duty and common sense to support the unfortunate doctor who “let her die,” if indeed there wasn’t some other detail of her case that wouldn’t have allowed “our” doctor to succeed either?

Where can he put his grief to keep it from turning into rage or self-accusation that has no hope of redemption? The next post after the one explaining the situation was of a just-snuffed red candle. To me it was a plain signal of suicidal thoughts. When challenged, the doctor referred us to the Wikipedia entry on ambiguity. So -- moral ambiguity. A very painful condition only alleviated by the removal of the conscience, which may cause the death of what? The soul?

I used to have a poster that advised one never to make comparisons between oneself and others, because others will always be either better than you (which might be discouraging) or worse than you (which encourages sneering). Rarely is anyone ever of equal competence, wisdom, and foresight. Anyway, how would you know? Who’s the judge?

Beyond that, when I was training for the ministry and talked about not being able to stop someone from bad behavior or save someone from making a bad decision, the excellent therapist I had at the time would bring me to a halt in a hurry. “How grandiose!” she said. “You’re the minister, NOT the God! You are not inerrant -- since you’re not Catholic, you can’t even claim to be the inerrant Pope and I expect you’ve noticed that he makes an error now and then. What makes you think that people’s lives are all about YOU and the help you give them?”

This doctor’s guilt came partly from him claiming an early retirement -- it seemed to him that the limit he set drew a line that excluded his friend from his care. If he’d known she’d need him, he might not have retired? What about the next friend? And the next one after that? Retirement might have slipped away entirely, so that he finally died slumped over one last person who absolutely could not be operated on by anyone else. And since he’s been retired a while, maybe his skills have gotten a bit rusty. Maybe he, too, would have lost the patient. No way to know.

Some people suggest that the concept of an all-knowing, inerrant, and limitless God came from our own craving to be that way. We can at least have a “Big Friend” in the sky who has the qualities we believe it. It’s easier than facing the idea that everyone makes mistakes, even us. I had a friend in the Marines in Vietnam who was sent to officer school. He said they taught him about “combat decisions:” when you decide something in the very moment of most intense dilemmas and then turn out to be right, which is quickly forgotten as the situation changes, or wrong, which is bound to happen. To hang on to those wrong decisions, beyond re-thinking and learning from them, is to corrode your ability to act and disempower yourself as a commanding officer. Professional effectiveness doesn’t come from never making a mistake, but from facing mistakes (if indeed that’s what they turn out to be in the end) and accepting the burden of having made them. When they are deadly, it hurts.

But this doctor didn’t make any mistakes. He didn’t even refuse a request to come out of retirement for the sake of a friend -- and there is a point of view that forbids doctors to operate on friends and relatives anyway, for fear of emotion clouding their judgment. His problem is not one of action or inaction, but of managing his own feelings about his friend and his skills. He might have heard of a friend lost in a small sailing ship and have had the feeling that since he was a much better sailor, if he had been on the trip, he could have saved the lost man -- but he had given up sailing in order to do something else, maybe become a pianist. There’s no sin to expiate, no bad decision to repent, just the terrific pressure of sorrow plus the corrosive game of “what if.”

I think attention in this situation is best paid to the terrific courage of this doctor in telling us what he felt as a human being. Maybe he was reaching out for comforting comments -- if so, he got them. The more Puritan might say that the duty of a professional is to NOT expose lay people to the anguish of those who deal in life and death. I disagree. We’ve heard enough about venal, over-proud, too-prosperous, self-serving doctors. It’s time to let us see that it’s not just the education, the salary, the social prestige that set doctors apart. It is the constant battle for clarity and effectiveness.