Calling 911…

As the week draws to its inexorable end, and the drudgery of the week gives way to the expectant joys of the weekend, my heart beats a little faster, as I turn in, each Friday night. Rising at the break of dawn, while my fellow city-dwellers slumber, I spring into the crisp morning air, keys to my chariot in-hand, as I break free the bonds of reality, headed to my time machine – preparing to make the run to 88 miles per hour.

IMG_3095

 
Unlike it’s predecessor, a 1968 Porsche 912 with a mechanical starter, this evil car wakes up with a surprising alacrity and a deep rumble – resembling the growl of a rabid hellhound. Ensconced in a snug, but comfortable, sport seat, I inhale the unique smells of a 1980s air-cooled car. Warming up, the engine throbs like the strumming of Satan’s bass guitar and drums, while the reliable heating system (an antithesis to it’s laughable air conditioning) braces me from the morning chill. After 5 minutes, and an imperceptible rise in the engine temperature gauge (from freezing to above freezing, I guess), I step on a surprisingly light and familiar feeling clutch, as the 915 gearbox slots into reverse. From past experience and numerous stalls, I slowly release the clutch while feeding the throttle, and the car crawls backwards down my curved driveway.

Other than the otherwise preoccupied dog walkers, joggers and (now awakened) infants, strapped into their jogging strollers, nobody else witnesses the murder of an early Saturday morning calm, as the Beast trolls the slow roll down Wydown Boulevard. Interestingly, the speedometer (which seems to start at 30 mph) is not interested in informing us of the rapidity of our progress at this point, preferring to get involved only at speeds a car like this must be driven. Bouncing from rut to pot-hole to steel plate, I gingerly negotiate the minefield that has replaced Big Bend Boulevard in Clayton. My trepidations give way to excitement as I see the exit for the interstate approach.

With a nether-worldly yawn, she goes into Beast mode, as I downshift into second and make that curve onto the 64. Since the engine is not fully warm yet, I limit my enthusiasm to shift in the 4000 rpm range, as the car effortlessly catches up with traffic threatening to merge right. Matching the speeds of cars decades younger than her, the Beast trundles down the expressway as we wait for the engine to warm up, all the while shifting up quickly to fifth. Each exit on the westbound expressway holds promise of a new route to drive, each one a different neighborhood, a different story.

Today our jaunt to the Jaguar dealership in Creve Couer, accompanied by the dated “stereo” blasting period-correct 70s and 80s pop tunes, requires us to take the right hander onto the north-bound 270. We find ourselves trapped behind ineffably confounded drivers searching desperately for acceleration to merge, while evil expressway drivers try to merge onto the exit. A quick downshift to 3rd and a tap to the throttle, into a small window of expressway space – and our peril is past. Dropping my wife off at the dealer, as she deals with the travails of her afflicted SUV, I resume my sojourn in my now fully warmed up red demon.

This time, as I merge onto the expressway, I let the engine reach its full wail at close to 6000 rpm between shifts and rapidly reenter traffic. In comparison to many modern (and much faster cars) that I have owned, the sense of occasion and involvement with each gear shift is totally different. The same kind of buffoonery in my prior 2012 Jaguar XKR would have me in “arrest-me-now” speeds – albeit without the rush that the little Carrera does in very legal speeds. In many ways, it reminds me of my hyperactive 2008 s2000, idling at 2000 rpm and redlining at 8. Even as it settles into a cruise, the pounding whump-whump of its engine is intoxicating.

I pull off the expressway and come to a stop at a traffic light at the end of the exit and revel in the sonorous rhythm of the twin exhausts – waiting for the lights to change. The change to green and the clearing of traffic ahead of me, as the mall crowd turns elsewhere, invites another ride up the wailing wall of sound as I shift at the limit, through first and second. In all of this, I don’t miss my other modern cars’ ineffective and stupid traction control, electronic gear shifts (manual or otherwise), numb power steering or pretentious preening. With its yesteryears simplicity and brute force character, like the love of my life that she’s named after, this demon has stolen my heart too. No wonder, each Saturday begins by “calling Carrera (911)”.

On Southern Hospitality

I’ll admit, I haven’t had much time to experience the phenomenon I’m speaking about, but it was something of an epiphany to me, so I want to write about it anyway.

On the weekend after Independence day, our family made a road trip down to Nashville, Tennessee. The 4.5 hour drive wasn’t bad at all, as we have driven 17-18 hours (Philadelphia to Missouri) in a day. It was 2am Saturday morning when we arrived, and we settled in to sleep immediately.

Skipping over the events of the next morning, we arrive at Saturday evening. We were going our to dinner with my parents’ old friends. These people were incredibly kind, and you could tell just from talking to them that they were filled with a seemingly limitless amount of generosity.

We were leaving on Sunday morning, and as we were doing so I experienced something that has affected my perspective of life immensely. My parents were checking out while Raghav and I guarded the luggage. At this time, the two of us happened to be sitting next to an older man working away on his laptop. He seemed to notice us and took a break from his typing to have a conversation with us.

We talked for a short amount of time until my parents picked us up to head out. Right was we were leaving, the same man comes up and stops my mother just to tell her that he though we were very good kids. This struck me because that’s one of the nicest things anyone’s ever done on my behalf. I was even more surprised because I didn’t even know this man’s name, and he had no reason to come up to my mother other than pure generosity.

This event was pretty important to me because something like that really just changes your perspective of the world. Just when it seems you’ve got people figured out, they surprise you. It reminded me that for all the evil in this world, there’s just as much good. These small acts make a big difference, and it’s people like him who inspire me to be a kinder person.

I don’t know if that man at the Gaylord Opryland Resort will ever read this or know how much his actions that weekend meant to me, but I want to say thank you, to him and all the other people who do these kind things without expecting anything in return.

My Issue With ‘Crazy Rich Asians’

WARNING: PETTY, VERY PETTY

Okay, let me get this straight, I have no problem with the movie itself. This is extremely frivolous, if you didn’t already get that vibe. I do not want to offend anyone, I just want to point out a misnomer.

So my problem is with the title (see, petty). The title ‘Crazy Rich Asians’ is kind of misleading. I’ve looked at the trailer, and so far every single person seems to be of one race.

Being Asian, I know that there is a wealth of cultures found in the most populated continent on the planet. However, in this film, everyone seems to be of a certain ethnicity (I don’t know which one and I really don’t want to offend anyone by assuming).

I’m really glad that an underrepresented group is getting recognized, but it’s not the best title. If you tell me that it’s about Asians, I want to see all types of Asian culture there. It’s like taking a primarily white movie and adding a single person of color in for a quick cameo and calling it diverse. Technically, there’s multiple ethnicities (just like they technically are crazy rich Asians).

Personally, I think that if we really want diversity, we need to represent everyone, not just a select few. I would be thrilled if I saw more movies where Kenyans, or Native Americans, or Indians (my people!) were able to play a central role.

Other than this, I really have no problem with the movie and maybe I’ll go see it. This is just something really small I wanted to address.

A Reflection on Bubbles

So yesterday my brother and I were blowing bubbles, which we haven’t done in a long time. It was a lot nicer than I expected, which made me sad. It is really sad that nowadays we are too obsessed with our electronics to really live. I mean, who knew that it was so peaceful to watch bubbles shimmering in the light.

Dog

The unique creature,

intelligent and bold

loving and protective

kind and beautiful.

Who rests with eyes wide open

while his master

sleeps in every comfort.

Whose joy fails to diminish

when he sees his family

no matter how long they’ve been gone.

Who dries any tears

coaxes laughter from the darkest situations.

Who brings some light

hope

and undying faith.

Who would stand by any one

be it a businessman

a sales clerk

or a drunken outcast

that they had learned to love.

Who will love when there is none to be had in return.

Who would go hungry rather than see his master starve.

Whose spirit cannot be seperated from his master’s even in death.

Dog.

Dear Adults

I am a young person growing up in this world. When I have the power to vote, it will be in the 2020s. If you have heard of the UN Sustainable Development goals, you know that when I am an adult, we will have less than 10 years to achieve these goals.

Why should you care? By the time it’s too late to do anything, your lives will be ending.

But ours won’t. So I’m asking for you to do us a little favor. Leave us something we can work with.

I am not asking you to fix poverty, global warming, gender inequality, gun violence. All I want is that you start on the journey. If you’ve heard about global warming, you know that there is a point of no return which we are dangerously close to. So what if every adult worked together to start a movement and pledge to lower our average global temperature by 1 degree Centigrade, by 2050.

Or we could tackle childhood hunger. What if every adult had a bin that they could fill with unfinished food? They could leave it outside and maybe a truck could come by and pick them up. So many families waste food that could be used to feed a starving kid.

Maybe we could start working on programs to end gun violence. We could help oppressed minorities around the world. These’s so much you can do, if only you try.

If you work with us, there’s so much we can do, but if you don’t, as a species, our days may be numbered,

Sincerely,

The Future

On Computers

Diwali 1From Stephen Hawking to James Cameron, predicting the demise of the human species at the hands of AI is one of our favorite pastimes. If you would believe these ‘Freddie Kreugers’, the malice of AI is a malignant undertone to our close relationship with our devices. This raises the question, what are these entities that we are neglecting to anticipate?

In my opinion, humble as it is, to differentiate between us and our devices is trivial. They are no more than our handwritten script in a notebook – a representation of our own minds and ideas, inscribed on silica and gold. All computers reflect their creators, with the same linear thinking process as the one’s that made them. As modern computers move to parallel processing, another human ability, this reflects the same.

Even if there is a AI-pocalypse, it is nothing but an extension of our consciousness casting aside the shell of the pupa that our present beings rest in. With each passing generation of devices, more of our souls and spirits enter the architecture of these devices, shedding our mortal and human limitations, while embracing the limitless expanse of a virtual

10704436_602084019898052_3536254348270443424_o

universe.

So, rather than lamenting the demise of a trivial human existence, celebrate the passage of this phase of human existence, into a new plane of being.

On death

I still remember my first childhood realization of mortality as a concept. It disturbed me intensely. I cried long and hard – more for the realization that my loved ones could die, rather than my own fate. It is only after much placating that I calmed down. Of all my childhood memories, that one is truly vivid in my mind.

35 years later, as a physician, I stare death in the face every day. I see the fear of dying writ on my patient’s faces – even the “brave” ones. As much as I see this, I have been blessed that my patients seem to have the knack of cheating death – even when all else looks bleak. Yet, despite my best efforts in some, death came for them in ways unexpected. It helped me realize that life (and death) takes its own course. Physicians only help ease the pain. Let me illustrate.

Some years ago, a patient was transferred to my facility with a suspected heart attack. I confirmed the diagnosis and took him to the cath lab. 3 stents later, he was pain free and appeared grateful that we made the diagnosis and made him feel better. As a young man, he returned to a normal lifestyle, including bicycling. Six months hence, he returned for his followup and reported non specific symptoms but a very active lifestyle. A stress test was negative for any new blockages and I sent the man on his way. Another 3 months later, I came across a police report detailing his death while driving his bicycle with no helmet. It made me question the point of it all. Why struggle with fixing hearts, when life seems so cheap?

The answer came to me later, and in Gita-esque manner. The man was predestined to meet death on that road at that time. He was doing what he must. I fulfilled my duty of making my best attempt of treating the man’s pain and allaying his  anxiety. He met his death, in his favored activity and I helped keep him pain free getting there.

 

Vegas-3

Why die?

Death is a renewal of the species. It is the essential evolutionary adjunct that keeps our species virile and robust. As a species we have outlived many long lived competitors to emerge the currently dominant species in our solar system (As far as we know!). At this time, the only threat to our dominance is from shorter lived entities like rats, cockroaches, mosquitoes, fungi, bacteria and viruses or combinations thereof. We look at them (often with irritation), much like (I like to believe) dinosaurs looking at puny prehensile mammals.

Why is dying “young” an advantage to the species? Doesn’t accepting that contradict everything that I do as a physician?

Let’s take an example of two wolf packs with 20 wolves each. In one (pack A), the wolves are of hardy stock, while in the other (Pack B), they are relatively delicate. Each pack has 10 males and 10 females. Pups (<1 year) don’t hunt and there are no old wolves – yet. Both packs are hunting well this summer. A disease affects both packs. In Pack A, their hardy constitution ensures that all the wolves survive. In Pack B, 2 pups and 2 older wolves die – a reflection of their delicate constitution and maybe poor environmental conditions. Months pass, a tough winter ensues. As expected Pack A survives but is tremendously weakened by starvation (more mouths to feed). Pack B has lost 1 more pup in the winter and 1 male. However with smaller numbers and more hunters, they did better with food. At this point, if there was to be a battle between packs, which do you think would do better, 20 starving and weakened wolves or 14 relatively intact but hungry ones?

 Fortunately, the standoff never happens. Fast forward to three years later. Pack A now has 35 wolves. Of these 8 are “geezers” (old wolves that don’t hunt) and 10 pups. Pack B has 35 wolves (thanks to better reproductive abilities in better fed females) but only 2 geezers and 10 pups. Less than half of Pack A hunts while 2/3 of Pack B catches more than they eat. A great famine and drought ensue. As expected, Pack B loses both geezers, 3 pups and 2 males. Pack A shows tremendous fortitude and loses just one geezer. However, this comes at extreme starvation and erosion of hunting ability.

A hungry pride of lions comes by and finds 2 wolf packs. After making easy pickings on Pack A, they are unable to catch up with Pack B and actually lose a young female in an ambush. Pack A’s lone surviving female is absorbed into Pack B. Pride of lions moves on.

As the instance above illustrates, the ability to die is an advantage, not a disadvantage. If you think beyond the paradigm of the individual but in terms of a family, a pack, a population, a nation or a species, the ability to dynamically keep the best features to fore, while minimizing liabilities is key to survival.

From a philosophical point of view, death is a renewal of the soul. After suffering the slings and arrows of the outrageous fortune that is our life, death is the opportunity to start afresh. It is returning weary at the end of a long day and falling asleep. It is as natural as eating, drinking, sex, evacuation and yes, birth. Yet, we view it with fear and loathing. If the soul is immortal, this body and this life are like clothes you have on today. Much like them, they are a bit rank at the end of the day and need to be laundered. Your soul moves on, the universe reutilizes your body.

What is the soul and do I have one? Is it better that the Joneses? 

No. Your soul is not some ethereal being arising from your belly button. It is not James Brown either.

It is the imprint you leave in space and time by your existence.

That is an indelible fact. Your existence is not only the proof but also a reflection of your soul. Just because you die next thursday, does not change the fact that you existed and lived Today. That is the immortal fact, your immortal soul. Whether you are moral or immoral, good or vile, dynamic or slothful, your soul is a reflection of that imprint on that part of space-time.

Do I know if my soul will be reborn? Why do I, or should I, need to know this?

I, frankly, don’t think I do. And I don’t think I care. What I do care about is making my soul the most beautiful thing I know. I live each moment, complete each action I do to the fullest. I live the dream.

If the soul is reborn, would you remember? When you wake up every morning, how much of the previous day do you really remember. Try looking and the details are pretty fuzzy when you start trying to make them out. When we are born, our souls take the information that they need from the prior existence to get things going. The brain and memory that they have to fit into is too small to carry the entire burden of memories of the last existence. And if you brought all your baggage with you, how would that be a renewal? We don’t even know why we exist, our minds lack the understanding. How could we cope with the burdens of a prior life. In an individual with infinite sagacity and peace, the ability to comprehend existence and the soul is such that they can carry the abbreviated memory of all their existences forward.

So where is the divinity of the soul?

The universal existence is divine. My soul is the space-time imprint of my part of that existence. By extension, logically, my soul IS a reflection of that divinity. In this, there is no good or evil. There is no past or present. It is just existence. Does that mean that I should be evil? Yes and No. You DON’T have to be evil. Evil is defined by perspective. In the story above, were the lions evil? They were just hungry. Was the disease evil for killing pups? You have to understand the purpose of your existence and live to fulfill it to the best of your ability. Today’s evil is often tomorrow’s hero, just as today’s hero is often tomorrow’s hated tyrant. Don’t worry about your labels, get on with your existence (and soul).

 

On Interventions.

Who is an interventionalist?

Is it only those of us that put in stents? How does my putting in a stent make me different from someone who makes a difference to the patient in any other way? I’ve often wondered the significance of calling myself an “interventional” cardiologist. Am I really making a difference to my patients or am I just feeding my ego and my wallet?

In the first two decades of the new millennium, interventional cardiology has grown in a meteoric fashion. With new devices and techniques becoming available, patients are undergoing a variety of new procedures. From reopening blood vessels to the heart, brain and limbs as well as other vital organs, to replacing heart valves, to stem cell therapy and cardiac devices, interventional cardiologists (myself included) are performing radical new procedures that could scarcely be imagined in the last century. Often, patients come back to thank me after the procedure and say: “Thank you for saving my life with the heart procedure”. In the initial days of my career, I used to believe that I was actually “saving lives” with my stents.

With age, comes wisdom.

As I followed these patients, as well as those in whom stents were deferred for a variety of reasons, I realized that human lives end for many reasons. Stents do improve symptoms but come with their own liabilities. When you traumatize the blood vessel with a balloon and a metal stent, you are causing direct injury with both short and long term consequences. Most of these consequence are trivial, some dangerous but rarely can be fatal. Stents do not change the disease process. They are palliative tools at best. They push the disease aside. They can’t prevent new disease within themselves, around their margins – either upstream or downstream. Rarely, they can clot  – often in catastrophic and fatal fashion. Keeping them open require blood thinners, which can make you bleed. Stopping blood thinners makes them more likely to clot.

Are they really that pointless?

Probably not. In patients having a heart attack, they are “life saving”. When a combination of high blood pressure, a soft cholesterol plaque and increased cardiac demand, results in injury to the inner lining of the heart’s blood vessels, the blood vessel is either partially or completely obstructed by clot, inflammatory cells and the ruptured plaque. A timely stent in this setting helps repair the blood vessel and restore blood flow – saving muscle and maybe, lives.

In contradistinction to this, putting a stent in patients with chronic blocked arteries improves flow and may reduce symptoms (assuming they are from a lack of blood flow) but do nothing to prevent heart attacks or death. They may or may not improve heart function.

A chronic blockage, is exactly that. It is “chronic”. It has been there for a long time (chronos – gr. for time). In all probability, it will be there for a long time. Even the ones that are “90%” blocked. Most times, the body will develop alternate mechanisms around the blockage. Surprising to many, having chronic blockages in the heart’s arteries does not predict an increased risk of death but may cause at-times disabling chest pain. Much like chronic arthritis. These are just as well treated with medications as they are by stents. Most studies (not conducted by device companies) show that non-stent therapy is just as effective but demands efforts by both patients and physicians with regards to followup, compliance and lifestyle modification.

Stents, therefore, are the signs of a lazy approach to a problem in treating chronic blockages by both physicians and patients. From a physician’s perspective, it gets rid of the irritating complaints about chest pain and the anxiety thereof. There is no need to worry about side effects (mostly non-lifethreatening) of medications for angina. Most patients are happy and grateful, (lifesaving and all that jazz) as well as socially  keeping up with the joneses. Patients are alleviated of their guilt of having a poor lifestyle, by throwing money at their problem and gain absolution by getting a stent and rid of symptoms. Few people spend as much time talking about changing the lifestyle, controlling blood pressure, complying with statins or stopping smoking. All “interventions” that are clearly more effective (and cost-effective) at treating symptoms and also increasing event-free survival.

My personal approach to treating angina and heart disease has undergone a paradigm shift over the last few years. Each referral for chest pain is an opportunity to intervene. Not just with stents. But to change their lifestyle. To understand why controlling their blood pressure is important. To understand what diet does to their body. To make an effort to stop smoking. Most importantly, to realize the strongest tool in the treatment of heart disease is knowledge. An educated patient is an empowered patient and usually is more conducive to healthful habits. A healthy lifestyle is the keystone for the edifice of cardiovascular health.

So, does that mean I don’t believe in stents?

Heck no! I think they are an amazing device that in the right situations are lifesaving and in others, can be life altering. Take a 55 year-old construction supervisor with chest pain. Each time he “gets winded”, his employer wonders. Each time he pops pills, people notice. He is passed for promotions and is often the first guy to be “downsized”. Thanks to the threat of losing his job from his health, he “stress-eats” and smokes.  A stent (even with low risk disease) gets the patient back on his feet. With the right education from his “interventional” physician, has him losing weight and quitting smoking. Having been through the inconvenience of heart disease, he is more compliant to medications – especially because he now understands his disease better.

So to go back to the original question, who is an interventional physician?

Anyone who “intervenes” to ensure a good outcome is an interventionalist. Stents may be part of cardiac interventions but a true cardiac interventionalist is one whose actions improve your overall cardiac health. If you can put in a stent but not change the patient’s reasons for needing a stent, you are a proceduralist.

Many would argue that in the current healthcare milieu in the US, that it is not possible to achieve the lifestyle discussion and education (a task often left to nurses and cardiac rehab teams) by physicians. Many will cite need to cover the cath lab or see more patients as an excuse. This is humbug. I run a busy practice and perform a variety of procedures. I’m frequently on call at the hospital. When I walk into that patient’s room, he/she is paying my for my time to give them my best advice, not the quickest advice or short cuts. My focus is on the outcome, not the billing. If I can spend 3 or 4 hours in a complex procedure to get a blood vessel open, I owe it to the patient to spend the 10-15 minutes in each visit to make sure that I reiterate the importance of the real cardiac interventions that save lives.

To paraphrase Charlton Heston:

“Stents don’t save lives. Smart patients and physicians with stent save lives. ”

 

Kartik Mani