Vacancy Chain

What are common to hermit crabs and humans? A bit unsettling to hear that question? Sure. Much as I find the question difficult to answer, you might be more eager to tell me the difference between a layman and a sociologist. Well, that's another reasonably interesting question.

I find the answer to both questions after my recent reading of Scientific American article about hermit crabs, by Ivan Chase.

Most of us know three facts about hermit crabs: they're crustaceans, we often meet them near shorelines, and they've got their own mobile seashell homes. In that article, the professor of sociology gives us details of the animal so precise - and so easy to relate to what we're sharing the same behaviour - that I realize what is meant by professor's gift. It was a summer morning, children's footsteps everywhere at low tide along the beach. We can picture an avid sea kayaker wading into a shallow tide pool on Long Island. He was fascinated by a small hermit crab running toward an empty snail shell he dropped into the water a few minutes ago. The curious sociologist wrote, "almost quicker than I could follow, the crab pulled itself out of its old refuge (smaller in size) and thrust its vulnerable abdomen into the (more spacious) snail shell I had dropped." Before he left the scene, another hermit crab discovered the first one's discarded "home" and, after a most intricate three-dimensional inspection, worked out that the new lodging measured bigger than its own. Without second thought, the second crab exchanged his lodging. What next? Read on: "About 10 minutes later a third crab found the second's old home and claimed its prize, abandoning a small shell with a large hole." 

The curious sociologist doesn't stop at discovering the animal behaviour. He is eager to learn the beauty of a well-orchestrated "vacancy chain" - an organized method of exchanging a more desirable possession abandoned by another individual. By individual, he's referring to animals with relatively simple brains and nervous systems, say, hermit crabs, limpets, lobsters, fishes, octopuses and woodpeckers. 

How about humans? Good. Is there room for a broader application of the same vacancy chain strategy among ourselves? Yes indeed. Automobile industry, I was told, depends a lot on this vacancy chain. That explains why car dealers have been so eager to take the old vehicles of any new car buyers in trade (and sell those old cars to yet other buyers).

Prefrontal Cortex

"It's mine, it's mine!" was the first thing Jasmine blurted out on seeing another kid's grabbing her toy. What made her say so when the toys belong to neither of them?

The obvious answer: Jasmine has her own belief about the centre of the universe - and by now you should be able to guess who. It is Jasmine, hands down. The earth revolves around a kid rather than the sun.

That seemingly reference point, however, can change without my knowing it. She went to her favourite bookstore yesterday. Most kids would love that place. It was small enough to be comfortable, large enough that they can take a seat and play with building blocks, puzzles and read at leisure. At leisure, that is, except one: when another preschooler joins in. A boy came and took away my daughter's building blocks. But Jasmine didn't display even the ghost of a whine, quite the opposite really, because she went on and suggested, "Let's play together."

As the boy continued to grab every piece of building block, Jasmine relaxed, leaning back against her chair. I was expecting a tirade from that boy's father, but Jasmine said first, "Playing together is happier than playing on your own."

The boy didn't listen. In that sense, tension was building, and fast. Yes, at first blush, it seemed to foretell spine-tingling screams and shrieks, wild thrashing, and a fight ahead. No, nothing goes as smoothly as one would hope.

Jasmine made a sigh, and told her mother, "Okay, mom, let's move to read."

Wrinkles

"Elephants have wrinkles, wrinkles, wrinkles. Elephants have wrinkles, wrinkles everywhere." My two-year-old came back from her dancing class, uplifted and energetic.

"On their toes. On their toes." I joined in the dance and raised my foot to touch my toes. If I am candid, I do believe that the original exercise should be keeping my knees locked and banding over to touch the toes - of which I no longer believe I, 41, can manage.

Of all the movement songs of children, "Elephants Have Wrinkles" has surely given us the pleasure of dance with words.

"What is meant by wrinkles?" my daughter asked.

Good question - to which I'm afraid not being prepared to be asked. Much to my chagrin, I found it difficult to explain the word to my two-year-old. I wasn't sure what to say. Picture me at home sitting with my daughter, wrinkling my brow in concentration to find a good answer.

Two final words occurred to me. Crow's feet.

How adroitly the words crow's feet sum up the concept. But hey! There are many more in English. Think about goose eggs, hives, bear hug, goose bumps and ponytail.

Lost in Translation

Some time ago I read an article on communication. It was, in the dry prose of a medical journal article, a reminder for doctors to spend time on talking. The lecture about communication can drone on and fill the pages of the academic journals. It isn't easy to follow.

Listen to our real stories, though, and you'll tell what we don't know the patients don't know.

A friend of mine recently shared a story on the Facebook. She is working in the medical outpatient clinic, where elderly patients aren't quite sure where they should go, what the doctors say, or what they should ask the doctors. Near the end of a busy clinic day, the doctor glanced at his wristwatch, the steady sweep of the second hand ticking off precious time. For one thing, the doctor was hungry. For another, he thought he had covered everything except the instruction for his patient to return for blood test.

The doctor wrote on the blood test sheet: "One week before the clinic appointment fasting blood test."

The patient picked up the paper, and was startled. This was obviously an instruction she'd not been expecting. She stared at the doctor. "But, doc, how can that be the case? I would have died of starvation if I follow your instruction - to fast for one week before my scheduled blood test."

Mea culpa

This is one story I've never told before. Not to anyone. Not to my peers. Not to my juniors. Not even to my wife.

Even now, I'll admit, the story makes me squirm.

It was a hot summer afternoon over ten years ago, shortly after I had got my membership title in medicine. There were membership examination study aids stacked waist-high in my office, all shrink-wrapped against the gathering dust and pale in comparison with my overflowing ego. I was running around the hospital to see my patients. By noon, several dozen new patients had been admitted to our department. As the medical beds within our department were being used up, patients had to be shuffled. That means patients from one overcrowded department would be moved to another department. That's never a good idea. And there's more to patient safety than inconvenience. I didn't even know that one of my patients had been relocated until late evening.

I was intrigued, and furious. "Who in the right mind would want to know how a doctor can handle patients staying in one building, and at the same time, those far far way?" I wished to change the situation and decided to make some written complaint out of my hectic schedules. I wrote a complaint letter on behalf of my patient and coaxed her to sign it (to be submitted to the hospital). After I finished the letter, I thought I'd done a wonderful job, even more satisfying than publishing a paper in a prestigious medical journal.

At the end of the day, I was caught red-handed and received a serious reprimand. I can still remember the stern face of my boss, and the lesson sticks like Velcro to my memory. Now, decade later, I've learned to tap into my social brain, preparing myself better for the ups and downs. Much as we teach our kids to reframe an upsetting moment (like the old saying "No use crying over spilt milk"), I make use of similar wisdom to deescalate emotional storms.

In the Dark

It's the human nature everywhere, including the medical profession, to learn the know-how by habits.

We practice medicine by copying what our predecessors do, though we're unwilling to admit this. After a while, it's second nature and we keep our routine doggedly. And if a bold student comes to ask why, there comes the dismissive reply, "Simply because we've been told to do so."

This morning, I went to see a patient whose large blood vessel developed a tear and began to rip. There is a good chance that my patient can die if the blood pressure are left unchecked. High blood pressure can weaken the wall of that broken vessel, further tearing the outer wall. His team doctor had started him a drug labetalol intravenously. I thought I'd do the same, too. But I was stupefied to see a "naked" tubing infusing the medication. By naked, I mean the tubing was not covered like how we wrap a candy.

"How come? We should have wrapped it to protect the drug from light," my resident shared with my view and shook his head. "We've been taught to do so since graduation from school."

We started to worry that naked tubing could have exposed the drug to excessive light, making it ineffective. It would appear that I should pull evidence to show the nurses why they should cover the tubing. What stunned me even more was that I could not find any evidence to prove them wrong. Not a bit of it. And then the pharmacist confirmed that it's perfectly fine not to keep the drug in the dark.

I gave a vague smile but could think of nothing to say. If I am candid, I'm among the ones kept in the dark.

Heart

I was asked to examine the first-year medical students yesterday.

The way simulation driving test gives novices an idea what driving is like, medical school examination teaches students how to behave like a real doctor. I handed out a detailed description that would begin something like this: "A 45-year-old man with the chief complaint of chest pain over several works came for clinic assessment. He worried about a heart attack. Please examine his heart and demonstrate to the examiner where you place the stethoscope to listen to his heart sounds." Heart sounds, by the way, are produced when blood is being pumped through different heart valves.

Unfazed and without losing a beat, the students meticulously showed me where they located the landmark to listen to the heart sounds. That said, I concede that, it isn't really what a real doctor like me usually do in flesh-and-blood patients. Rather, we make a cursory examination and back up with tests like x-rays and echocardiography. Unsettling as it is, it may be hard to resist the temptation to read the x-ray and ECG before listening to our patient's heart, and not the other way round. My daughter has been fascinated by the stethoscope and she often takes mine to listen to the heart sounds. Believe me, she spent more time with the stethoscope on the chest than I did on my patient.

Which brings me, somewhat uncomfortably, to my recent encounter with an elderly woman in the hospital. Her blood test showed that the body didn't do well to seal off any bleeding in case a blood vessel is injured. I dutifully followed the logic I learned in the medical school, and came up with the conclusion that the patient's liver was not doing well. I turned to the page of liver function test to find out the abnormal figure, which indeed it was. "Her liver is enlarged," I told my resident after pressing on that patient's tummy. We went on to see the next patient after making sure an ultrasound scan of the liver has been requested.

After the weekend, my resident told me the ultrasound scan result. The patient's liver appeared large because it was engorged with blood. Another doctor listened to the elderly woman's heart and then a cardiologist asked for an echocardiography. It turned out that the patient's heart was failing because the blood could not be pumped out through the left ventricle into the aorta, thus filling up the liver. Neat answer - to which I'm afraid I didn't think of. I kicked myself, but it's too late. My shoulder sagged, face fell, and heart sank. It would have made a heck of a difference if I had listened to the patient's heart - and it only takes a few minutes.