Dancing on the edge of a knife

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The way I see it, there are only 3 levels of medicine, the cutting edge, the bleeding edge, and antiquity.

It is not to say that each doesn’t have their merit, after all, it was Galen who described blood as having an end terminal transport, which was partially true. Another one of his opinions that was teased out of research by somebody other than me was that sepsis was required for wound healing. While typically held today as heresy for a few hundred years at least, the oxygen and other materials that travel via the circulatory system are end terminal. Multiple medical textbook authors have even described the circulatory system as comparable to a train, tracks, and engine. While the modern definition of sepsis is certainly not required for wound healing, the inflammatory system certainly is. Not bad insight for such an old guy I would say.

One of the things that simply amaze me about some aspects of modern medicine and research is the effort to prove medicine which is so grossly out of date it too is basically antiquity by today’s knowledge. Of course some of us are alive to remember when it was “the latest,” but with the pace of medicine today, those days might as well be from Galen’s age. Yet many people are still hell bent on clinical research of these practices? Madness…

My pet research is on shock. I wrote my dissertation on it. I’m involved in the communities that deal with it the most. (surgery and intensive care of multiple types) Many of the uninitiated actually believe delivery of oxygen is the only thing to shock and it’s treatments have been enshrined beyond refinement. Still though, there are medics looking for a medicine to treat a surgical problem seemingly eternally.

However, delivery of oxygen is only one part of shock, I would approximate about 33%. There is also the issue of inflammation, metabolic changes, and some other intricacies I am too lazy to type out and too long to copy and paste. It is a very complex thing. Most of the great minds on the topic will quickly point out that the ultimate goal of the treatment of shock is based on DNA manipulation. But we are nowhere near there, so for the foreseeable future, we are looking to refine O2 delivery and spending considerable effort on inflammation, which is why I actually collect and research historical studies from people like Galen among others.

Inflammation is tricky though. We can detect it in several ways. But our tools for dealing with it to be polite, are wanting. I actually find that quite ironic because in every surgical textbook I have read, inflammation is usually within the first 3 chapters. It is usually in the first 5 in the pathophysiology texts. (I read a lot of big thick books I think) There is an old doctor joke: “internists know it all but can do nothing. Surgeons can do anything but know nothing.”

Surgeons, intensivists, internists, and anesthesiologists all study inflammation relentlessly in one form or another. It makes me wonder, if inflammation is needed by the body, if we can’t stop it, how do we go about making it work for us?

We know lots about O2 delivery, a very good bit of inflammation, and a very limited amount about Kinin. Yet all of these cascades and their regulatory mechanisms are connected by common molecules. Why are the studies on synthetic regulators so dismal? Why are steroids and supportive care the best we can do? Not that either of those is particularly great. What can chronic conditions tell us about acute ones and vice versa?

Some days I think the answer is right in front of us. Other days I think “maybe I should have gone into genetics.” (At the very least it would give me a chance to win a Nobel prize, those are usually in genetics or bombing other countries, I am not sure old Alfred had “peace through strength” in mind when he devised that)

Anyway, my thoughts today keep drifting towards hepatorenal syndrome. I think I will go tease some information out of that. Cardiorenal didn’t come up with anything insightful, but I should have suspected that based on the mechanisms. Maybe it is time to re-consult the expert on Turner’s syndrome. She knows a lot about hormonal therapy and there is some promising research in that related to shock.

I could really use a day of what Mushashi described as “touching the void” when all of the chaos comes together in perfect clarity. That’s basically my thoughts today. Seemingly disconnected, but still all related in a dynamic way.

In the words of Friedrich Nietzsche, “If you gaze into the abyss, the abyss gazes also into you.”  

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One thought on “Dancing on the edge of a knife

  1. Micheal H. McCabe

    What do the cells say? How do they say it? What is the chemical, electrical, and molecular vocabulary of homeostasis at its lowest level? How can one intercept and interpret the local message traffic within a bed of tissue? The research community has focused largely on systemic effects — broadcast messages if you will — due to distribution of hormones through the vascular system. What happens with the local message traffic in the interstitial spaces? Those are questions that I would love to see answered… Not sure it would tell you much about shock, but it might shed plenty of light on the inflammatory process.

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