Revealing The Impostor (Part I)

My general pediatrician friend stopped me in the hallway, in the middle of my self-congratulatory sponsorship announcement to my colleagues, to ask if I remembered the patient Brenda I consulted on last week.

Brenda (again not her real name) was the last patient of an otherwise uninspiring clinic the week prior. She was seeing me for a six month history of amenorrhea. Because she was heavily involved in sports, I remembered her well. "The basketball player. Planning to join crew in the spring. Real skinny girl. Yeah, what about her?" I asked.

My friend had that smirky half smile that smelled trouble. "I just got off the phone with her school principal. One of her teachers caught her purging in the bathroom after lunch today."

"Really?" I offered, somewhat astounded by the news.

"Turns out this wasn't the first time. Some of other kids on the basketball team have reported seeing her doing the same thing when they're out eating after away games."

"But she's such a good kid." I replied, flipping through my internal patient log to review what red flag questions I might have failed to ask that would have pointed me toward anorexia.

"They always are. They always are. They're imposters. They get perfect grades. They have perfect friends. Their parents sees them as perfect kids. And they also learned how to give perfect answers in doctors' offices too . Yet, underneath all that perfection, hides a little girl with a very dark secret and an eating disorder."

I nodded, humbled by own inability to make the right diagnosis.

"Don't feel bad, you weren't the first doctor that she's duped." My friend said, patting me on the shoulder as she spoke.

"But I spent an hour with her last week talking about her periods. AN HOUR! How could I not have seen it coming?"

"You see this?" She said as she holds up a chart the size of a medical textbook for me to see. "She's gone through everybody. Nobody suspected. Nobody knew. I'm got a psychiatrist to call and an eating disorder clinic referral to make so I'll see you later."

She walks away as I gave her a short wave. Luckily, my colleagues have all since gone way too, leaving me to wonder if Brenda had indeed fabricated the details of her life when she gave me her history last week or if I wanted to buy into her perfect life for more personal reasons.

Later that night out on the park roads as I was pounding out 5 sets of Yasso 800s at 2:55 pace with the omnipresent moon my only witness, I thought alot about Brenda and how, as an honor student and a star athlete, she must have felt so much pressure from all her peers, her family and her teachers to do the right thing from an early age. She must have gotten so used to doing the right thing and acting the part that she lost all sense of self she ever had. Maybe I am extrapolating, but her double life seems so sad to me. I can't help wondering if her anorexic symptoms was her body's way of letting go, all along a planned escape, a masked cry for help. Maybe getting caught and being forced to deal with her issues before she got really sick or done something worse IS the best thing that could have happened to her. I just wished I could have seen this coming, I wish I could have known. If I ever have the opportunity in the future, I would ask her if it was all worth it, to play the part of a perfect life but lose your sense of self in the process?

I want to know: What's life like living as an impostor?

(To be continued...)

Overcoming Inertia (Part II)

I allowed the question to linger in the air for a few seconds while I plotted her height and weight on the growth curve in front of me. Her height was at the 75th percentile while her weight was way above the 95th. Her BMI was 42.5 kilograms per meter squared, which is actually an improvement from last year when she was measured to have a BMI of 45. "So how about it, Amy. Any clue?"

"No...not really." She mumbles.

"Okay. Let me help you out then. Listen, and listen close, because at the end of all of this, there'll be a test...Well, no, not really, but it might change your life so you better pay attention."

I laid down her chart and began my exam as I talked.

"So, let's start with some simple concepts. Common sense physics tells us that in a closed system, like this room, or your body, whatever, energy can neither be created or destroyed. Also, you'd probably learned that energy going in must equal energy coming out. You with me so far? All of this sound familiar?"

"Yeah. I remember something like that."

"Good. This is essentially Newton's First Law which tells us that the energy you expend on something should be equal to the energy that comes out, minus a negligible portion lost to the environment because of friction, etc."

"O...kay. So what does that have to do with anything?" she asks with a condescending smirk.

"Hold on, I'm getting to that. Well, if you take Newton's first law of thermodynamics AND his first law of motion, you know, the one that says that things in motion tend to stay in motion unless acted on by another force, and apply it to a fictionalized high school setting, you'd understand one of the reasons why everyone loves Glee..."

"I...I don't get it."

"Look, what is Glee essentially? It is a club made up of what most people would label as "freaks" that somehow find a way to resist societal pressures and bond with one another to become something truly wonderful. They share a passion through their singing and dancing and are able to collectively use their talents to be much better than anyone in the school ever thought they could be. In fact, the more they are mocked and laughed at by everyone else, and the more outside circumstances try to break them up, it seems the more cohesive they become and the better friends and singers they all become. Remember Newton and his conservation of energy? Yeah this is a perfect example of its application on a societal and high school level. It seems as if they are all able to gather all the negativity thrown at them by the outside world and channel them to become better singers. It is truly amazing, and I think it's what draws people to the show and their story.

"I guess I can kinda see that. But what about the new year's resolution thing and how it affects me?"

"I'm getting to that. But you know, before each of those Glee kids found success as a group, before they knew each other, and even before they knew they could sing, they each had to do some thing, something very simple it seems but very very important; something that again points back to Newton and his physics as applied to high school."

"What is it?" she asked, thoroughly intrigued now.

"They had to solve the problem of inertia."

"What?"

"Inertia, you know, the force that prevents you from moving forward. Newton's first law of motion. An object in motion will stay in motion while one at rest will tend to stay at rest, remember? Yeah, so they individually but collectively had to tackle their problem of inertia. Before they joined Glee Club, they had to decide for themselves whether they should go on with their present lives the way it is, or make a change and sign up for Glee Club. Translated to physics speak, they had to individually decide whether they will stay in motion at the same speed at the same direction, coming and going the same way everyday or whether they will apply a force and change the course of their high school lives by signing up for Glee Club. Without this first critical initial decision to overcome inertia, there'd be no singers, no songs, no club and no show! I believe this is the message behind their hit song "Defying Gravity", which is, in my opinion, their best song!"

"I like when they sang Don't Stop Believing in the first episode. That was really cool."

"Yes, that one is pretty good too. But the point is that the hardest thing to do sometimes is overcoming one's own inertia. The majority of people are so set in their ways that they reject any and every change, even when they know change may be good. This simple concept not only mirrors the attitudes of the Glee kids, but also underscores the importance of New Year's Resolutions, because you see, resolutions are nothing more than attempts by people to use the excuse of the new calendar year to overcome inertia and institute change in their lives. People who don't have resolutions are either perfectly content with their lives or are too lazy to do something about it. Since you are neither of those two things, I expect you to have some New Year's Resolutions the next time you come by to see me."

"Really?"

"Yes really. I want you to think about 3 things that you want to change about yourself. It could be about school, home, friends, your body, etc but it must be important enough to you that you are willing to work on it for the whole entire year. As you're thinking about it, I want you to really try hard to overcome your own inertia and answer the question for yourself...what is important to me? how can I make this one thing I don't like about me better? Whatever it is...come up with 3 things and we'll go over it next time okay?

"Okay." she says as I finished my exam. She gathers her stuff and turns toward the door. "Am I done?"

"Yes you are." I said, as I open the door for her.

"Defying gravity, that'll be me!" she says as she exits my office cheerfully. "You'll see, doc, you'll see!"

As I close the door behind her, I'm hoping she will choose her health as one of the initiatives she will improve upon this year. But honestly I have no clue. All I know is that I realized I needed to overcome my own inertia in terms of running and training to improve upon my performance and I was able to use this message to (hopefully) help out a teenager in her fight against obesity.

Maybe this running thing can make me a better doctor after all!

Overcoming Inertia, (Part I)

Runner friends of mine who are familiar with my professional work often ask how my understanding of human physiology affects my development as a runner. The truth is that although I can explain precisely the mechanism behind the conversion of glucose to lactic acid when glycogen stores are exhausted and anaerobic respiration at the cellular level dominates in the latter stages of a marathon, the knowledge of such facts neither facilitates its prevention or ameliorates its effects for me as I'm running. (as those who've read my last few marathon race reports have gotten to know!). Rather, I think my clinical expertise helps me the most when I'm resting, recovering, or preparing for a run - in sort of the daily grind of everyday life - because those are often the times when fluctuations in hormonal levels have the most effect.

Personally, I am more intrigued by the question of how running affects my professional life as a pediatric physician. I always wonder if there are things I learn from my adventures on the road that can be appropriately adapted to the clinical setting. It is often difficult for me to imagine how learning to appropriately gear down in anticipation of hilly terrain or fighting the tough patches during a tempo long run can help me become a better doctor to my patients who often suffer from obesity, diabetes and other chronic conditions where mere walking a few blocks is considered an extremely strenuous activity. Still, I am constantly looking for opportunities where I can use my experience as a runner to help my patients make better choices in battling and dealing with their disease.

One such opportunity presented itself yesterday as I was seeing my last patient for the day...

Amy (not her real name) sat with casual ambivalence as her mother gave me a brief rundown of how she got to be the way she is. "She was always a big kid growing up but every since she started developing, it's like she keeps on putting on more and more weight." She hands me the consultation request from her pediatrician and continues "We been to specialists, doctors, nutritionists, and nothing has worked. She'd lose a few pounds after starving herself for a few days but then her weight would go right back up again. Dr. B wanted her to see you to see if there's anything more to be done." I glanced over the consultation request quickly to pick out the pertinent information and sent Amy's mother out into the waiting room before continuing. Before she left, I was able to ascertain that Amy doesn't eat much at home, drinks juices and water at home, and has almost no physical activity

"Hi Amy, I'm Dr. Lam. It says here that you are obese, pre-diabetic and have symptoms suggestive of PCOS. Do you know what all these fancy terms mean?"

She shrugs her shoulders, pauses slightly for effect, than continues. "I guess it means that I'm fat?"

"And how do you feel about that?"

She shrugs her shoulders again.

"Do you think you're fat?"

She gives a slight nod before her eyes drift off into space.

"Okay...so what are we going to do about that? "Do you have any ideas"

She shrugs again, then silence. I let out a small sigh under my breath and walk over to the sink to watch my hands. Oh God, please, why now, why today...All I want to do is finish work, go home, run a few miles and get down to business devising my marathon training plan, and this teenager won't even talk to me. What do I do now?

I washed my hands, dried them with a few towel and turned back toward my patient. "I tell you what...let's not talk about fat for the rest of this visit...let's assume it doesn't even exist. But you have to promise to answer my questions, okay? So, how were your holidays? Did you make any New Year's resolutions for 2010?"

"No, I don't believe in New Year's Resolutions/"

"Did you watch any TV during break? What's your favorite show?"

"Glee."

"Cool, that's my favorite show too! It also says here in my chart that you are an honor student at the Bronx High School of Science. Have you taken chemistry or physics yet?"

"Well, I took chemistry last year and am taking physics right now."

"Good. So you must know about the Newton's Laws of Thermodynamics..."

"A little..."

Okay, so let me ask you a question...what does New Year's Resolutions and Glee have to do with Newton's 1st Law of thermodynamics and how does it relate to you?"

(to be continued...)

Running: Physiologically SpeakingFive Easy Steps to Better Nutrition

When it comes to my ramblings about running, those who’ve been around these parts know that I usually don’t delve into the subsidiary topics such as fueling and nutrition. I know there are many running bloggers out there that are both knowledgeable and skilled in this arena so I figured I’d leave the advice and the recipes to them. After all, I spend so much of my blog space talking about running and marathon training that I feel I would not do the topic justice if I were to cover it sporadically. As such, even if nutritional counseling is part of my daily responsibilities as an obesity specialist, up to now, I’ve resisted all temptation to talk about my attitudes/advice concerning nutrition in this blog.

That all changed last week when I saw two patients in the clinic back-to-back and found myself giving the same exact speech to both families. The odd thing was that they would appear for all the world to be completely different in every appreciable way. One was a morbidly obese teenage girl who was seeing me because all her previous attempts at weight loss has been unsuccessful. The other was a muscular teenage boy, very active in school sports, who was seeing me for an underactive thyroid condition, but mid-interview, asked if he needed nutritional supplements because he felt groggy after early morning football practice. As I was explaining to both patients and their parents some key principles of proper nutrition, I was quite shocked to find that most of what I had to say was completely foreign to them. Seriously? And both of them had been to countless other professionals, such as trainers and nutritionists, before coming to me.

As I was coming home from work that day, it occurred to me that I should write about this, not because what I have to say is so earth-shattering or brilliant, but because it is so basic, and would help both those who are trying to lose weight and those who are looking to improve their athletic performance. Again, dear readers, the list that follows is not comprehensive, but serves to just highlight some basics for those who have no idea where to start. I hope they will be useful to you and will inspire you to look elsewhere for more information.

My Five Easy Steps to Better Nutrition

1. Always eat breakfast – This is by far the most frequent faux pas among dieters and athletes alike. In my opinion, breakfast is the MOST IMPORTANT meal of the day. That is because your body has been in starvation mode while you’ve been sleeping through the night. When you awake, all your hormones are reved up to help your body physiologically get ready for the day. It is in desperate need of some energy to fuel this transition. (That’s why that cup of joe feels so good in the morning!) If you skip that meal, then you are essentially asking the body to use alternative sources of fuel (by breaking down muscle for example) for energy since the glucose/glycogen stores from the previous meal has long been depleted by this point. (It is well known that those who don’t eat prior to early morning workouts bonk earlier and suffer more injuries than those who do.) Also, because the body adapts amazingly well to your eating habits, when you skip meals, you will feel more hungry during the infrequent meals that you do eat, and will tend to store more of those meals as fat to be used in the early morning. (That’s why those who don’t eat breakfast can’t lose weight or maintain their weight loss for very long.) So for both the athlete and the dieter, it is imperative that they both eat a small breakfast to reach their goals.
2. Have smaller and more frequent meals – The current recommendation is 6 to 7 small meals folks, not the standard three big meals that we knew and love when we were kids. This is due to the fact that when we eat, insulin is secreted in proportion to the meal size. So the bigger the meal, the higher the insulin level. High insulin levels are generally not good because it enhances lipogenesis (or the deposition of fat cells). Not only so, but it is also a culprit behind hypertension, high cholesterol and a myriad of other problems. When you eat smaller but more frequent meals, you keep insulin levels somewhat low and in a narrow range, which helps your body adapt to metabolic changes and handle energy demands more rapidly and more efficiently.
3. Chew your food and eat slowly – Aside from the obvious enjoyment of the food that you’re eating, another reason to take your time to chew, eat, and drink is because stretch signals from the stomach (carried on slower nerve fibers) take a good 5-10 minutes to generate a feeling of satiety in the brain. What this means is that if you eat at a pace that is faster than what the brain can process, you will still be eating when the stomach is already full. This is one situation that can be avoided if we allow the time to chew, swallow and digest our food fully before proceeding to the next bite.
4. Skip the juice/Avoid liquid calories – Except in specific circumstances, such as during or after a hard workout, it is generally a good idea to skip the juice. These empty liquid calories do not offer any nutritional benefits and can sabotage any well-intentioned diet very quickly. Stick to the diet stuff if you must.
5. Avoid eating around stress/Be calm when you eat – I like this one because it makes perfect hormonal sense. When your body is stressed, again there is a surge of hormones (think flight-or-fight response) that is preparing the body for a physical or psychological battle. These hormones, just like we saw in the early morning, is helping the body cope by absorbing more of the food and storing it as fat. (It’s not a coincidence that at times of extreme stress, we often feel the most hungry.) This tendency to overeat is also in response to elevated cortisol levels which is the inherent stress hormone for the body. If you can find a calm setting for a meal, you not only will eat less and eat more comfortably, but will absorb less of what you eat as fat as well.

That’s it. Hope all my knowledgeable and fine readers are already abiding by these basic principles. If so, then pass this advice along to someone else who needs it. God knows how many people there are out there who just need a little guidance to improve their health and their lives.

If you have questions for me, or have other clinical questions related to running, training, or nutrition, drop me a line. Au revoir for now!

[FYI – For those who are new and never read the first installment of Running: Physiologically Speaking, you should check it out. It was pretty well received and convinced me to continue the series…albeit nine months later! Okay, my bad. Still, it might be educational if you’ve ever had a headache after a long run on a hot sunny day…]

The Show Goes On:Pace Leading for a Long Training Run

Thanks everyone for voicing your opinions on my latest dilemma. After mulling it over on a memorable 9.11 mile run this morning and pondering the alternatives in between patients at the clinic this afternoon, I’ve come to a simple resolution:

The Show Must Go On.

Yeap, that’s right! This running life of mine is way too short and this commentary/diary I keep way too precious to me to let the fears of what might happen prevent me from sharing my passion for both doctoring and running with the masses. Although I realize that I must, from now on, be a bit more discreet about divulging political affairs in the workplace, I still think it is not only worthwhile but important to me to use my clinical knowledge and experience to help improve the running experience (and by extension the health) of those around me, even if only in a virtual sense. As long as I don’t include any identifying information in the discussion of patients or talk about the hospital or those with whom I work with in a damaging or derogatory sort of way (which I’ve never been known to do anyways) I should be okay.

Whew, now that’s over, I can get back to the regularly scheduled running-related programming…

Was it a positive or negative experience? Any tips you’d like to share with a newbie? I’ve signed up to be pace leader for the 7:30 pace group at this weekend’s NYRR Long Training Run #2 and truth be told, I’m kind of nervous about it. I know it’s only 20 miles, incorporating 4 loops of Central Park, which is home turf for me basically, and it promises to be social, fun and relaxing (It better be, I’m giving up a chance to re-run my Best Race Ever from a year ago to participate in this thing!) I’m just worried that I’ll have trouble containing all the runners in my group from pulling the pace. I’m also concerned about the stopping and restarting at the end of every loop. I’m not one to usually stop in the middle of my long runs so it’s going to be interesting to see how my body will react to all of that. I suspect I’ll just have to trust Rover my Garmin, to keep me on pace for the entirety of the 20 mile run.

Since it’s my first time, all of it will be intriguing and brand new to me. For everyone’s sake, let’s hope I do a good job on Saturday. If you’re in town and around, drop by and say hi. I’ll be the pace leader with a bandana looking as if he doesn’t quite belong at the front of the pack. Yep, that’ll be me!

Discovered At Work

“Excuse Me, Doctor, can I speak to you for a moment?” One of the other attending physicians asked me while I was visiting a patient of mine in the ICU this afternoon. Since I was the consulting endocrinologist working the hospital floors this week, I assumed he wanted to discuss the particulars of this case with me. Instead, once I excused myself and we were both out of earshot of the patient, he smiled at me and said, “I have a close friend who is an avid runner and blogger and he told me to say hi to the ‘Running Laminator’. I assume that is you, is it not?” I waited a while before confirming his suspicions with a sheepish nod. And with that, after thirteen months of anonymity within the walls of this hospital, my secret identity outside of the professional workplace was revealed.

To be honest, I fully prepared that I’d be ‘discovered’ one day. After all, in today’s cosmopolitan society where we are more closely tied to our e-mail addresses than our real addresses and everyone we work and associate with seem to have some connection to everyone else, it is impossible to maintain a virtual identity that is distinct and separate from the real-life counterpart for any length of time. (Didn’t someone famous once say that ‘you can fool all people some of the time, and some people all of the time, but you can’t fool all people all the time?) I just didn’t expect to be so blatantly exposed while I was on the job, in the middle of the pediatric intensive care unit!

It’s been a full twelve hours now, but I still haven’t figured out the proper reaction to this latest development. Am I supposed to be relieved now that the news is out and I no longer have to purposely hide the fact that I’m a decent runner and blogger from all my workmates or should I be frightened that I’m now more transparent to those that work with me than I’ve ever been? Should I be more cautious in my postings about what I see and what I do so as not to be politically or professionally ”incorrect” or should I keep my integrity as a responsible blogger and just write what feels right, to me?

I think I’m starting to feel a bit intimidated that my virtual ‘me’ has become somewhat more successful and more infamous than the real ‘me’. It is crazy to think that more people know of me as a running blogger with a hospital gig on the side than a professional kid’s doctor with a crazy running blog on the side. How weird is that?! I think I’ll need more than one long run this week to figure things out.

Weekend Recap:Hating Speed Snobs, Loving Diabetes Camp

Between running a PR at Club Champs, watching all the track-and-field events the Olympics had to offer, and researching and building a marathon training plan that would bring me my next PR at NYCM, I have been pretty much living in running la-la land the past two weeks, thinking only in relations of fast, faster, and fastest. I have become so infatuated with race times and race goals that I could swear I was starting to turn into the kind of person I absolutely abhorred when I first got introduced to the sport; the despicable speed snob.

Let me take a second to explain the term for those are unfamiliar with these runners and their tactics. The speed snob is the runner or runners, who judges the value of a person by the speed at which he/she run. They are obsessed with race times, their own as well as those of their friends and acquaintances, and uses them to openly disparage those who do not run as fast as them. If the speed snob does not think that you run at a comparable speed, he/she will ignore you completely and refuse to run with you, even in training. They often coalesce with those who run as they do and think as they do. As such, speed snobs often hang out in droves. For the record, I hate speed snobs because not only are they elitist in their thinking and conceded in their remarks, they act in a way that is absolutely contrary to what a running community is all about.

Still, even though I haven’t spoken or done anything to act the part, by the end of the week, I was beginning to think like a speed snob. Yikes! I needed a reality check in the worst way. As a result, in order to bring some perspective back to my life, I decided to volunteer to play camp doctor to a bunch of people who didn’t know what my 5 mile race PR was, or how fast I ran San Francisco or have an opinion on how I should train for New York (the marathon that is). Heck, none of them even knew I run at all…or did they care. All they knew was that they all share a medical condition, they were there to have fun, and I was their camp doctor, which was fine by me.

So that is how I came to volunteer for a day at the Children’s Diabetes Camp next to the hospital where I work. This camp is a two-week program held annually during the summer for kids with type 1 diabetes between ages of 7-13 to come together to make friends, participate in athletics, and all the while learning how to manage their diabetes in everyday life. Camp itself was held at an athletic center of a nearby college so there was plenty of space for the kids to run, swim, play ball, and jump around. The whole endeavor is a huge undertaking and is led predominantly by two clinical diabetic nurse educators and is sponsored by generous donations from patient’s families themselves and the community.

Since I was new to the institution, this was my first time going to diabetes camp. On the day that I went, there were about 45 children altogether. I recognized about a quarter of them because they were my patients from my own clinic. Usually the only interactions I have with these children are when they are sick and lying in a hospital bed or when they are in my office with their parents for a checkup. So it was quite shocking for me in camp to see them so healthy and vivacious, running and playing with friends in their natural habitat. When it came time for lunch and snack, it was so heart-breaking and inspiring to see them all prick their little fingers together and read off their blood sugar readings while helping each other with their insulin shots. I have tried so hard throughout the year to convince the children to not to be ashamed of their disease in front of their friends that it felt good for once to see them in an environment where they didn’t have to be afraid of pricking their fingers or injecting themselves with insulin in public.

In between helping the nurses deal with mini-emergencies with the children and teaching the kids how to deal with real life issues that come up as it pertains to diabetes, I got to watch the kids swim in the pool, run a relay race in the gym (I had to resist the urge to participate, even if I didn’t have the right shoes on), make pretty pencil holders to take home and test their knowledge in diabetes jeopardy. Overall, it was a great day; most definitely an eye-opening experience for me.

The most humbling part of my trip took place when I got a chance to speak to the nurse educators a bit while the kids were having free time in the gym. They told me that for most of these kids, the two weeks they spend at camp are the most fun they have all summer. Because most of them come from broken homes, live in apartments without access to parks or someone to bring them there during the day, this is the only time they get to act and play like normal kids, almost as if they didn’t have diabetes. The unfortunate thing is even though the admission for camp has increased by about ten per year through its three years of existence, they were still only able to accept about half the number of kids who apply for the camp. There is just not enough charitable money to cover the door-to-door transportation, the rental costs for the facilities, the athletic counselors, the lifeguards, the food and drinks, and the necessary staff to supervise 40+ kids. As yet, they have been unable to receive any national or local sponsorships for the program. They suspect that as the nation enters into a recession, the amount of charitable donations to support the program might even be less in the coming years.

I have never been one to use my running as an opportunity to solicit money for a charitable cause, but for these kids and others who clearly need this place not only as a reprieve from their everyday lives, but also as a place to meet others like them and to learn more about their disease, I believe I owe it to them to do what I can to help. Although it is too late for me to raise funds through my marathons this year, I can plan to collect donations and sponsors as I train and run the Boston Marathon next April. It’s the least I think I can do for a cause so good!

My Sick (Sick) Run

And just in case you’re wondering…by “sick” I’m NOT referencing the kind of “sick” that is synonymous with “WICKED”, “PHAT” or my personal favorite, “The Coronation of the Lamination”! In fact, if you’ve been paying attention, you’d notice that my LogMyRun log has been empty since the weekend, which meant that I’ve not logged a single mile in THREE days, which is unheard of in the middle of any marathon training program.

What is to follow involves a whole lot of medical jargon, so if you don’t feel like listening to me explain how I attempted to diagnose myself, I suggest you click away. For those who do stay however, I promise you’ll learn something about the pathophysiology of running sick that you might find useful, or at least entertaining…

The truth is, I started to feel sick the moment I landed in JFK. Even though I’m a pediatrician at heart, I blame it all on the 12-month-old rugrat who sat on his father lap in the seat next to me, and didn’t let me get one iota of sleep during the entire five hour flight from San Fran to New York. Moreover, she probably gave me some virulent strain of chlamydia or pertussis that’s been the bane of my existence for the past four nights. Even though she had no active symptoms, I know how infants and toddlers carry more infectious agents in their little pinky than I do in my entire body! At any rate, I became infected and within 12 hours of my arrival back in my apartment, I had the classic symptoms of a troublesome viral syndrome – runny nose, malaise, mild tachycardia and tachypnea.

I was good to myself though, and didn’t even try to run that day or the next, figuring I’d rest and give myself the necessary energy to fight off the infection. But instead of getting better, my symptoms got worse, until yesterday afternoon when I started to get side stitches on deep inspiration. I had planned for an easy 4 or 5 miler after work just to get back in the swing of things, but once I developed the side stitch first on one side than the other such that I couldn’t even take a full breath, I knew I had to throw my running plans right out the window as well. So instead I did all this medical research on the differential diagnosis of pleuritic chest pain and diagnosed myself either with a walking pneumonia (again from the chlamydia or pertussis) or a weird fungal lung infection (worse case scenario). I even tried to listen to myself with my stethoscope, but unfortunately my little pediatric version wouldn’t wrap around to the back. I made arrangements to call my best friend who’s also a medicine doctor first thing in the morning so he could listen to me and write me a script for a Z-pac.

Finally, on waking this morning, I had a breakthrough. I know it sounds weird, but I developed a new symptom which convinced me that I was getting better. I started coughing. This was good because usually in the time course of a common cold, by the time you develop a hacking dry cough, it usually means the tide has turned and you’re on your way to recovery. The pleuritic chest pain was also gone. Yay! Still, just to make sure, I called my medicine friend and left a message that I needed a STAT consult. Unfortunately, he returned my call a half hour later and told me that he was actually attending a conference in Chicago and won’t be back until the weekend. Bummer! I could’ve asked anybody else at the hospital to listen or write me a script…heck, I could’ve written a script myself…hmmm, okay, probably not so ethical…but since I thought I had turn the corner, I decided not to bother anyone, and proceeded to cough my way through my office hours. (Honestly, there’s nothing like seeing a whole panel of kids who are all healthy and well when you’re constantly sneezing with a fever and coughing up a lung!)

It was late by the time I got home and yet again, I had a decision to make. Should I stay home and get better quicker or risk impeding my recovery with a short run. On my running schedule, I saw I had already missed a long run and a speed workout this week, and thought that four days off running would officially qualify me as being on the DL. So I compromised and allowed myself to run with the premise that I’d take it easy and not even look at Rover (my Garmin) for the duration of the run.

It was almost already dark by the time I got to the park. This was good, because for one thing, the weather was comfortable and cool, and for another, I really didn’t want to bump into anyone I know who could see me run so slow. It’s a pride thing, I know, but I really wanted to allow my body (and not my mind) every chance to dictate the pace I was going to run.

Let me tell ya, running in Central Park again after a two week absence felt somewhat weird to me for the first half mile. While I was building my pace to a comfortable speed and letting my heart rate climb ever so slow, I was awed again by my surroundings. Turning the corner down Harlem Hill, I saw flickers of yellow light in the bushes next to me…fireflies! They definitely weren’t there the last time I ran here. Although they could be annoying at times, tonight I felt completely at peace with them and imagining that their little lights were actually celebratory fireworks for my coming home again! It’s weird how you can get so emotional by little things when you’re sick, but I literally cried some happy tears climbing up Harlem Hill, staring at the silhouette of tree branches against a beautiful full moon. I was so happy just to not be sick and running again that I felt inspired to run 12, 16, or who knows, maybe even 20 miles!

Feeling my heart pounding a bit fast and my breathing becoming shallow, I scaled my pace back on the downhill portions of the 6 mile loop. The funny thing was everytime I did that, my legs which were feeling quite good started to complain. My heart and lungs were hurting, but my legs were not. It was as if my lower body was complaining that the upper part was holding my running back. The feeling was completely foreign to me, because I’m usually running long miles on sore legs, so it’s usually the calves, hamstrings and quads that start hurting long before my cardiopulmonary system even notices a performance difference. As I focused in further on my running mechanics, I noticed that it was my breathing, and not the heart rate that was the limiting factor. I was taking about one breath for every beat and half today when ordinarily I could take about one breath for every two to two and a half beats. Not only so, but the breaths I were taking were again somewhat shallow and uneven. It was as if the rate of effective CO2-O2 exchange (more popularly known as VO2 effective) was ineffective and insufficient. I was somewhat intrigued by this notion so as I ran, so I tried to play around with my running mechanics by forcing myself to take deeper and slower breaths. I wasn’t really able to do this because as soon as I slowed my breathing, it would involuntarily speed up again, leading me to gasp for air. It also didn’t matter if I was running uphill or downhill or what my heart rate felt like to me, because my effective rate and lung volumes seemed somewhat set at a fixed rate. In pulmonogy terms, it resembled a obstructive lung pattern, similar to people who have exercised induced asthma. In layman’s terms, it’s like trying to breathe through a straw. Interpreting these results, I surmise that there are probably mucous plugs and other inflammatory garbage restricting the expansion of the tiny alveoli at the end of my bronchial tree. This was a very interesting science lesson for me, and it took me the rest of my six-mile run to calculate that my effective work of breathing was operating at around 65-70% of full efficiency. No wonder my heart and legs were so not enthused. That effort is so much less than my general aerobic effort which is somewhere in the range of 75-80%.

So you can imagine my surprise when I finished my six mile run, turned on the backlight for Rover, and found out that I averaged 7:00 min/miles for the full loop. What the heck? That is so much faster than what I imagined I was running. I really was thinking around 7:20-7:30, because it actually felt like I was running easy. I was so pumped about my time that I took an extra celebratory/cooldown loop around the reservoir (even though I remembered from the news that some guy just got mugged running this same trail at 2:00am early this morning, yikes!) Still, I took my time, finished the run, stretched, and celebrated with a Jumba Juice drink before heading home.

It was definitely a sick, sick run!

Thank you for getting through my long running diatribe about my sick run. If there are any medically related questions, feel free to shoot me a line! Hopefully, I did a decent job with the explanations.

A Most Extraordinary Day

I have a project today. My project is to show you all how running takes what may seem like an ordinary day and transforms it into an extraordinary one. And since I know how you all enjoy my race report narrative, I’m going to take you through this journey as if we’re running in a race, which for all intents and purposes, wouldn’t be that far away from the truth. So grab your numbers, race chip, gel packs and running shades, ‘cause we’re going for a run…

[Mile 1 – 10:30AM] “Any questions from the audience?” I asked, wrapping up my talk for the crowd of intensivists. Judging from the clock in the back of the small auditorium, I knew I had done well to finish ahead of time to allow ample opportunity for fielding questions. As I sipped the last remaining gulp of water from the cup situated next to the podium, I looked around the room to see a bunch of uncertain eyes and quizzical faces staring back at me. Have I completely baffled them with my intricate description of the vitamin D pathway or were they just waiting for the mandatory 10 seconds before sinking me with their criticisms? Finally a hand shoots up from the back and the head of the department speaks, “Fine talk doctor. I’m interested to hear your perspective…”

[Mile 2 – 11:15 AM] “Listen doc, your patient is here without an appointment. Mom says they’re here for a special test, but they don’t know what.” “Tell him not to move, I’ll be right there. Thanks.” I tell the nurse and hang up the phone. On the one hand, I’m extremely upset because he had a missed appointment with me yesterday where I had planned to examine the child and explain everything to mom. Instead, now he shows up unannounced when I was not ready to see him. Still, I was glad he was here because he had a relatively serious medical condition, called CAH or congenital adrenal hyperplasia, which causes his body to make excess testosterone resulting in his going into puberty prematurely. Any delay in the treatment of the disease would not only push him further into puberty, but also compromise his final adult height. My job was to explain all this to mom, and have her consent for a hormone stimulation test which would establish the diagnosis. It was a monumental task not having met the patient or mom before, but one that I must do in order to help this child. I push aside my annoyance with her timing and press on to the task at hand.

[Mile 3 -12:30 PM] I’m having lunch with my longtime friend and previous running mentor. He chides me about my recent running successes. “So how fast do you think you can run a mile?” He asked. “I don’t know, I’ve never tried. Maybe a 5:50 or so…” I answer, somewhat sheepishly. “I think you’d do a 5:30; maybe even a 5:15…” “I think you’re crazy.” “Have you ever thought about a triathlon?” “I’ve thought about it, but I can’t swim. I mean I can swim, but I can’t float…which means that I could possibly die in the middle of the ocean. So I can’t swim.” “Of course you can, you don’t need to float in order to swim.” Really?

[Mile 4 – 1:30 PM] I’m back on the hospital ward, rounding on the inpatients who are under my care. In one bed I have a 15 day old baby girl who has DiGeorge syndrome and is struggling to keep her calcium in the normal range despite the supplementations we’ve given her. In the bed next to her, there is a 10 year old type 1 diabetic who got admitted for DKA for the 4th time in the past 6 months. I’ve seen them both earlier in the morning so was quite familiar with their current medical condition. A medical student looks at her notes, looks at me, and starts to present. “On bed 1 is a 15 day old with DiGeorge…” “Wait, wait, wait.” I interrupted. “What is the baby’s name?” She ruffles her notes. “Uuhhh…I…uh…don’t…know…” “She’s been here for 3 days and you don’t even know her name?” I close her notebook for her. “Please get her name, read the chart, and come back to me when you can tell me her whole story without these papers. Remember, these are people we’re treating, not textbook cases, and each of them has a story to tell. It’d be worth your while to learn them.”

[Mile 5 – 3 PM] “I think we should report this mother to the Agency for Child Services and file a grievance for medical neglect,” the social worker says before she’s even halfway into my office. “I think this child is going down the tubes and mom’s not taking care of her.” “Hold on. I think we need to give the mom the benefit of the doubt here. She’s been here for less than 24 hours. We don’t even have some of the labs back yet. Let’s see what we’ve got before we jump the gun.” We’re discussing the fate of the 10 year old diabetic girl who’s treating the hospital like it’s a revolving door. “Besides, you really think this girl will be better off in foster care than with her own mother?” “That’s really not for us to decide. Our job is to report neglect when we suspect it for the safety of the child. What happens after isn’t really up to us.” “I understand, but is mom really neglecting? Let’s wait at least a couple more days before we decide to break up the family.” She leaves, not satisfied. I’m staring at my patient’s chart laid out in front of me while trying to decide if my moral compass is pointing me in the right direction.

[Mile 6 – 4:30 PM] The commute home took less time than I expected, which is a rarity. What’s even better is that sometime during my journey home, the rain had stopped and given way to a sliver of sunlight. I’m sitting in front of my computer staring at the plan for my interval workout. I can hardly believe my eyes. Apparently, my string of recent PRs means my old training paces are no longer adequate for me. What was once 3XM@6:14 pace, has now been replaced by 3XM@6:04 pace. Similar, a casual tempo run of 4M at 6:40 pace has suddenly turned into a hard 8M at 6:39 pace. Sonnafa… This is one consequence of running fast that I am not a big fan..

[Mile 7 – 6 PM] I did it, I did it…it wasn’t pretty but I did it. The road was wet, the pacing was poor, but I completed my three 1-mile intervals. Splits of 5:43, 5:52, and 6:01 clip are so much harder and faster than of my previous workouts that I really wanted to keel over in the middle of every mile and pass out. Still, I was excited that I was able to step up my game and run faster than I’d ever had before. At the end, after limping to the finish on my last lap, I wonder if these extra fast efforts would translate to any real effect in my next race.

[Mile 8 – 7 PM] I head over to the park for another Flyer group run. Maybe because of the bad weather, or maybe because people haven’t yet recovered from the grueling race over the weekend, there were only 6 of us who came out for the race. I aligned myself next to our group leader who I found out suffers from a disease that I have some expertise in. Through the next 6 miles, he shares his story with me as I try to offer my best medical advice to him. Although our pace was the slowest of the group and a couple of people had already left by the time we finished our run, I had a fascinating time talking and learning about medicine from his perspective. It was such an enlightening experience that the running almost became secondary. Afterwards, I was just so happy that I was able to bring together my two biggest passions for the benefit of another that I went completely home before I realized that I hadn’t yet had dinner.

All in all, it was the perfect ending to a most extraordinary day!

Talking to Intensivists and Stupid Things I Still Do While Running

Don’t have time for a long post today. I’ve got a date with some intensivists tomorrow. Although I have total word crush (ding ding ding) for their job description, this date isn’t really for me. It’s for some unfortunate kid with a hormone problem who might come under their care. Yeah, I’ve been suckered invited to give them a talk on how best not to kill my patients. For those who don’t know what intensivists are, they’re the doctors in charge of the intensive care unit. They work with the most damaged, most catastrophic, and sickest kids, in one of the busiest parts of the hospital. Kids get shipped in whenever there’s a crisis and get shipped right back out once they do their thing and the danger is over. God bless their souls for what they do, but as a direct result of their job description, they are a very intense bunch of individuals. And tomorrow, I’m supposed to give them a talk on my area of expertise, which is anything but intense, life-changing, or emergent. If I had to draw a comparison, it’d be a little like walking into the first corral at the next roadrace and finding yourself next to Dathan Ritzenheim, Ryan Hall, and Brian Sells. Yeah, that’s how I’ll feel at about 10:30AM tomorrow morning.

But I did have some running related thoughts that I wanted to leave you all with. Since I haven’t had a chance to experience my shades yet because of the horrendously bad weather we’ve been having lately, I had ALOT of time to reflect on the stupid newbie mistakes I still make in my running. Although I like to admit my faults almost as much as I like prepare this talk for the intensivists, I’m sharing my shortcomings for three main reasons. 1) So you can laugh at me; 2) So you can laugh at me while secretly thinking, Damn, I do the same thing! and 3) So you can laugh at me for doing something stupid AND admitting my stupidity…which is stupid² (Gosh, I hope NOBODY that attends my lecture tomorrow reads this!)

So without further ado, here’s my list of STUPID THINGS I STILL DO WHILE RUNNING:

1. Forget to double-knot shoelaces before a race.

2. Running too fast and too far to the left approaching a water station.

3. Going out for a 16 mile long run on an empty stomach and without any gel packs.

4. Having knee pain but still refusing to throw away running shoes with no treads on them.

5. Responding to a new runner all happy with his 6 miler with “Yeah…I ran 16 miles today too…”

How embarrassing! If I repeat any of these mistakes in the future, please kindly remind me to return my trifecta garb and ask for a refund!

A Boy Name Wally

Note: Although this is my contribution to Take It and Run Thursday on the topic of Hydration, you might not learn anything that would teach you how or what to drink on your runs. If that is what you’re looking for, I suggest you check out all of the other posts that are not only educational, but well worth reading. Instead, what you will find here is some complicated human physiology, a story about me, and a boy name Wally.

Everything I know about hydration and water balance I learned because of Wally. I first met Wally (not his real name, of course) when I was a first year house officer, or intern as we’re known in the medical community, rotating through the pediatric emergency room. Even on our first encounter, Wally made it quite clear that he would not soon be forgotten. “Hi, Wally, what brings you here today?” “I’m fine. I’m here to teach you everything about MY condition.” “Really? And what condition is that?” “I have DI.” And with those infamous words, spoken with the same tone was if he was introducing me to his best friend, I was introduced into Wally’s world.

DI, or diabetes insipidus, is a disorder of water balance, whereby the body loses the ability to regulate the loss of free water from the body. In the majority of cases, it is caused by a deficiency of the anti-diuretic hormone (ADH) that is normally produced from the posterior pituitary gland in response to dehydration. Rarely, it can also can be caused by electrolyte imbalances, medications, or kidney disease. The role of ADH is to bind to receptors in the kidney and reclaim some of the water that would otherwise be lost in the urine. So in a normal person who is dehydrated, ADH levels are high, allowing more water to be reabsorbed by the kidney to be returned back to the blood, and causing the urine to be very concentrated. (Anyone still here?) People who have DI, like Wally, lack this hormone. As a result, they cannot reclaim any water from their kidneys and become severely polyuric (meaning they produce massive amounts of urine) polydipsic (meaning they have to drink massive quantities of water to keep up with their frequent urination) and is at high risk for severe dehydration. Fortunately, the ADH hormone can be replaced pharmacologically. However, the medication, called DDAVP or vasopressin, must be given at the right dose and at the right time to maintain the water level in the body at a safe and stable level.

By the time I met him, Wally was 12 years old and has had DI for 3 years. For the first 1.5 of those years, no one knew why Wally had DI. But then, someone found a small speckle of something on his brain MRI. Two lumbar punctures and a few lab tests later, it was confirmed that Wally had a brain tumor called a germinoma. Because germinomas are exquisitely sensitive to chemotherapy, Wally was started immediately on a regimen with three different chemotherapeutic agents. Although most cancer patients nowadays often receive chemo as outpatients, because of his DI, Wally always received his chemo in the hospital.

Over the next six years, Wally and I got to know each other very well because of his frequent admissions for chemo, and he taught me many things about fluid management that I would not have learned otherwise. For example, he taught me early on, that unregulated water input leads to hyponatremia, which can be just as dangerous as unregulated water loss leading to dehydration. He taught me that the most sensitive indicator of the body’s water status is the sensation of thirst. He also taught me that carbonated drinks, especially the caffeinated ones, actually cause you to be more dehydrated an hour later than you were before you drank it. For a kid so young, he actually knew quite a lot about himself and his condition. But just like any kid, Wally had a wild side too. At times, when he was frustrated with how a particular doctor was not nice to him, he would purposely not drink or drink too much just before his daily blood draw so that his labs would be all out of wack, and cause his doctor to freak. My favorite was when he would correct medical students during rounds when they were forced to give a synopsis of his condition. “I only drank 100cc yesterday, not 120. I gave the other 20 to the kid next to me when he wanted a sip of my orange juice…” Ah, he was something.

Sometime last year, during my second to last month of fellowship training, Wally passed away. The tumor in his brain, which had initially responded to his first course of chemotherapy, had recurred and eventually became resistant to all other treatments. I remember one of the last conversations I had with Wally was when I asked him who’d teach me what to do the next time someone came in with DI and I couldn’t figure out what fluids to give him. “Don’t worry about it, Doc.” He said, with his usual candor and honesty. “Just ask yourself. What would Wally do? You’ll figure it out.”

I have figured it out, thanks to you, Wally.