Don't mind the time gap

A little out of touch. It has been a busy few months, and now it's time to get back on track.

Traveled to the annual Society of Federal Healthcare (AMSUS) conference in St. Louis this month. I presented some research along with Dr. J. Whitcomb and J. Salazar as we looked at cardiac arrest data over a six year period. As a mentor, Dr. Whitcomb is the finest, collaborating with me on several small research projects before he retired, and is the driving force behind by current status as a PhD student...thanks John!
Was also able to re-connect with my old boss from Fleet Surgical Team Seven. He was the keynote speaker at the Navy Luncheon, and gave a presentation on the ground-breaking mobile ambulances he has created and sold both the Navy and Army on their utility. Having been awarded the Purple Heart and Legion of Merit and board certified in two medical specialties, Jim is a physician's physician. None better. He disclosed to the audience (this was something he initially had to be discrete about for professional purposes) that he, too, had TBI, and is not unlike many other Marines, soldiers, and sailors coming back from Afghanistan and Iraq. As one of a few role models for me through my Navy life, Jim is at the top of list. I have committed my PhD work to brain injury and could not think of a topic more worthy my time and dedication.

Death of Fischer 344

Spent a few Fridays observing Emil, an anesthesiologist turned researcher who is looking at the relationship between estrogen and its neuroprotective benefits. The specific breed of rat he is using is called Fisher 344. I am not sure how they got their name, but I'm sure they didn't come up with it on their own.

So far, we have talked a little about his science, and I have mostly observed him running experiments. Here's how this goes:

• The morning begins with anesthetizing our rat with Isoflurane.
• Next, the subject is rolled over with extremities taped down to provide a stable working surface.
• A femoral artery is cannulated to provide arterial pressures and is used as an injection site for medications.
• Exposing the trachea, Emil severs the trachea and inserts a large bore catheter, essentially performing a tracheotomy.
• That done, he finds the exposed carotid arteries, teases the vagus nerve off, and lightly places a silicon ligature on each carotid arteries. The vertebral arteries were already ligated the previous day.
• Turn over the rat, and it's time to build a "cranial window" to observe the pial artery. He needs to visualize perfusion into the brain so he can observe and measure the effects of cutting off perfusion to the brain and testing doses of estrogen to see how well the arteries "bounce back" after a traumatic insult.
• To build a cranial window, Emil "scalps" the rat and exposes the skull. With a dremel and some deft hands, he gently cuts a small rectangular window along the suture lines and oh-so-gently removes part of the skull. He literally builds a transparent window filled with sterile saline and is able to visualize cerebral perfusion via the saggital sinus and pial artery using a specilized microscope equiped with camera and video recording capability.

This is a three hour process, by the way. Not to mention the weeks of prep work involved: taking out ovaries, waiting for the natural estrogen effects to wear off, and giving controlled and specific doses of estrogen to finally run the experiements. You can say that each experiment builds up over time resulting in a clear expectation of learning something from each rat. Otherwise: what is the point?

Two fridays in a row we have had the same results. The first friday, we transferred the subject over to the video microscope to begin running experiments and I noticed the brain bulging out of the skull. Emil sees the same thing and says "Oh, this might be bad." As if you can understate rat problems. Dead.
This past friday I made the trip up to John Hopkins again. Same meticulous prep work, same 3-4 hour intense investment. Only this time, we moved the rat over and lost blood pressure. Emil starts troubleshooting the catheter right away and says a couple of "oh no's" as a pre-emptive strike against us. Catheter flushing fine, ventilator functioning and doing its job. Look down again, and rat eyes turn from black to a dusky grey. Emil again with the "Oh, this might be bad." I was not sure for whom he was referring, and did not ask. However, after a few frustrating exhales and futile "rat CPR", we watched as a few meager red blood cells moved sluggishly through veins only with the prompting of sad and depressing rat CPR.

Thus was the death of Fischer 344.

National Simulation Center

Simulation is 1. Imitation or enactment, as of something anticipated or in testing, or 2. The act or process of pretending; feigning.

The art of simulation has probably been with us for thousands of years. Early acts of simulation revolved around hunting parties, preparing for great festivals, and entertaining. Today, in health care, simulation is a big part of how we "practice" specialized procedures before a surgeon's hands ever remove an appendix or perform exploratory laprascopic surgery. We also use simulation to practice highly organized team approaches to trauma care and working together as a coordinated unit in the operating room.

Last Monday I had the opportunity to visit and tour our National Capital Simulation Center located in Silver Spring, Maryland. Considered a simulation center of excellence by the Agency for Health Care Research and Quality (AHRQ), the simulation center trains hundreds of medical students every year in "virtual" suturing, laprascopy, and manipulation of specialized surgical instruments as they prepare for a career in medicine.

I was interviewing with Dr. Gill Muniz, Deputy Medical Director of the facility to explore possible research opportunities in the future.

Possibilities

Dissertation possibilities, that is. Four topics to explore:

1. Inflammation and cytokines
2. Traumatic Brain Injury, of which I have a personal connection while working in Anbar Province, Iraq. Our combat engineers, B-321, were responsible for keeping Route Mobile and Route Golden open at all times as these were our logistical ground routes to Fallujiah and Taquaddumm.
3. Simulation. I am due to schedule a tour of the Capitol Simulation Center located here in Washington D.C.
4. Competencies specific to critical care nursing and readiness to deploy.

Working on the refinement and narrowing the focus over the next few months.

Nourishment

It's been three weeks and I have made a few observations I wish to share.
Observation #1: I have always been the active type. Running, walking, lifting, etc. However, the stress of the "unknown" has resulted in an immediate need to eat my way through those crucial weeks. That is going to stop now. It's time to get with the program. Back to running and biking. Daily. For as long as the weather holds out.
Observation #2: the pure discipline needed to sit and read for hours on end is staggering. Razor focus I crave, and flights of occasional concentration is what I have. Yesterday in the library was the first time I was really able to zone out and study meaningfully. Before that it has been a challenge. Is it time for another cup of coffee? Will it be OK if i go to two pots a day? Is this third diet Coke going to push me over the edge into early Alzheimer's?

Tonight I lead the discussion on Galileo and Courage in Science. My presentation is complete, and I just need to study and memorize some of the details. Galileo, faithful Copernicus follower skirting ever close to Vatican wrath for heresy, ushered in the scientific age of Mechanism where empirical observation and measurement reigned supreme.

Ill-Informed Subjects

USU wants a dissertation topic soon. This is mutually exclusive from the fact that I have no idea yet what I will do.

It's not to be taken lightly. My chosen topic will stay with me as I eat, study, breathe, and sleep for the next three years. A poor choice will haunt and taunt me without mercy and make my time seem better suited to purgatory.

Whether it is a good one or not: I have a plan. This week I contact a researcher across the street at NIH who is doing research with cytokines (immumodulators that affect cell to cell communication and play a big role in the inflammatory response and septic shock). I need to "get smart" about current cytokine functions and promise as we know it now. Additionally, I will be meeting with another full-time PhD student who has chosen traumatic brain injury (TBI). With both of these, I have personal investments and a high interest in furthering our knowledge of these two high priority and mysterious complexes. The third prong of my quest for suitable research topics will take me to the current labs running at USU. There are a wide variety of researchers here on campus already, and I plan to visit labs in the coming two weeks to get a feel for what is possible and what is out of the realm (and out of my league).

How this plays out is anyone's guess (mostly mine) at this point.

Unexpected Risks of Clinical Research

This weekend I not only answered "collapsing variables" for Stats, but read a chapter from Clinical Research regarding research risk. The chapter was written by Dr. , a long-time NIH researcher, who ended up mired in controversy regarding experimental nucleoside antiviral agents during the dawn of one of the biggest scare of the twentieth century: HIV and AIDS.

The chapter was formulated and refined over a decade and is modeled after a research lecture given by Dr. at NIH after his experience with having his entire program shut down for over two years while the FDA, NIH leadership, the Institute of Medicine (IOM), and congress all had their own independent full blown investigations into the unfortunate deaths of patients enrolled in this experimental phase III trial for hepatitis B (HBV).

Wednesday: meet with the senior Navy adviser on my proposed research topics. With only three years to earn, the dissertation process starts right out of the gate in the first semester. The expectation is that you have your topic and are performing the field of inquiry before December. No fooling around at this pace.

Grasping for Air

It's been two weeks and I'm trying to enjoy this Labor Day holiday with family.

Here's how this is a more difficult task than one would expect: I have time, but no real idea of how I should be managing it. Having just begun this process, I want to exceed beyond my expectations. Given this extraordinary opportunity, I have no time nor little patience with not challenging myself to reach my fullest potential.

Therein lies the problem: I want to read and study all the time, yet it not physically possible nor realistic. So I feel as if I am trying the impossible task of grasping for air with a pair of tweezers. It's all around, but not to be held in one's hands. With an afternoon open, I jump from reference book to reference book and assess the varied projects due this summer. Should I be reading Bad Blood right now? Will Stats be my weakness, so focus on nailing validity, central tendency, and collapsing variables now before it's too late? Or better yet, should I be studying the lecture powerpoints for the coming week?

Generator of RVUs

The end-product of a quick journey through the medical customer service continuum by Dr. Ed Gabriele. What started off years ago as "patient" has moved through a range of coined terms. Patient became the Client, and moved with the service revolution to "Customer". Finally, in this age of "too many patients and far little time to spend with them", we have simply moved to "Generator of Relative Value Units". And this is how we started The Philosophy of Science.

Pearls
"Think of those people who tick you off the most, because they are the shadow of you."
"This is process vs. content and training vs. the meaning of education."
"So Adam was created from the earth, and Eve from his rib. For anyone who cares to comment on the fact that woman came from man remember this: Adama is Hebrew for earth. Read: dirt. Where would you rather come from?"

Philosophy: Lover of Wisdom. To observe our journey of knowing. Humans are perpetually in the act of completion. Looking for "the garden" so to speak."
Jeung and Freud had it right: we continually long to know and to be.

"It is the mark of an educated mind to be able to entertain a thought without accepting it." -Aristotle

Giant Leap

It has been a week, and I can not believe they are letting me do this. The Navy, most generously, has allowed me to pursue my doctorate. Full-time. Full paycheck. I am a fortunate son.

Three classes this semester: Research Design I, Statistics I, and Theory of Science. I have an ambitious plan and lofty goal: document this mysterious process from start to finish.

It's 11PM and I'm just getting started. I am going to have to get back with you on the first post. Obviously, here is where that aforementioned lofty goal immediately flies off the track. Tomorrow is full of promise and a legitimate post.