QOTD: Captain John Parker on the American Revolution

Stand your ground. Don’t fire unless fired upon, but if they mean to have a war, let it begin here.

Captain John Parker at Lexington Green, 1775

ATMC: Misfortune or Good Fortune? We’ll See…

Java

Java

ATMC = Advice to my children (a series)

The Parable of the Farmer, His Horse, and His Son 

Hundreds of years ago in a poor Chinese village there lived a wise farmer and his son. The farmer’s only significant possessions were his patch of land, his shack, and a sturdy horse that helped him work the land.

One day the horse ran away into the wilderness. His neighbor said, “I’m so sorry. This is such bad news. You must be so upset.” The farmer just said, “We’ll see.”

A week later the horse returned to its corral, with three wild horses following it back. His neighbor said, “Instead of one horse, now you have four. Congratulations on your good fortune! You must be so happy!” The farmer just said, “We’ll see.”

A month later the farmer’s son decided to break in one of the new horses. But the animal bucked wildly and threw the young man off. The son’s leg broke when he landed. This could cripple him for life.

His neighbor said, “I’m so sorry. What bad luck. You must be so upset.” The farmer just said, “We’ll see.”

A few weeks later, barbarians from the north invaded the province. Every able-bodied young man was drafted to fight. The war was terrible and killed nine out of every 10 warriors, but the farmer’s son was spared since his broken leg prevented him from being drafted. His neighbor said, “Congratulations! What good luck. You must be so happy!”

The farmer just said, “We’ll see.”

*  *  *

The moral of the story is that we don’t really know if an event is “good” or “bad” until passage of some time. Secondarily, it’s a reminder that things always change. So don’t go off the deep end emotionally right away, especially when something doesn’t go your way. It may seem like the end of the world when that cute girl you’ve had a crush on turns down your request for a date, when you make a C or a D in a class instead of an A, when your boyfriend breaks your heart, when you don’t get into vet school, when you get arrested for drunk driving, when you get divorced, or when you lose an eye to cancer. It may seem like the end of the world, but it’s not. Wait.

The parable above is from the East; it’s claimed by both Taoists and Buddhists. It reminded me of my first day of medical school, during which an East Asian professor told us, “Every day not sunny day.” His lecture was on Sir William Osler’s essay, Aequanimitas. Equanimity is a word you don’t hear much. It means mental calmness, composure, and evenness of temper, especially in a difficult situation. Cultivate it.

—Dad

Romeo

Romeo

Karl Denninger’s Solution to the U.S. Healthcare Mess AND Federal Deficit Spending

Steve Parker MD

One of two bridges over the Colorado river in the Grand Canyon near Phantom Ranch

Karl says that U.S. healthcare and health insurance are way too expensive because of:

  • monopolistic practices
  • collusion among the major players (e.g., insurers, labs, Big Pharma, politicians, doctors)
  • ignored violations of the Sherman, Clayton, and Robinson-Patman Acts (15 USC)
  • ignored violations of state consumer protection laws
  • absence of market forces
  • price-fixing

Eliminate those problems, and you’d cut the cost of healthcare by 80%, the point at which you would need only catastrophic health insurance coverage, if at all. We’d have enough money left over to stop our federal deficit spending and eventually retire the entire federal debt. According to Karl.

What are examples of an absence of market forces?

  • Have you ever seen health insurance companies or hospitals compete on the basis of cost? Doctors rarely do it, either (and only when insurance isn’t involved).
  • Have you ever tried to get a firm estimate on the total cost of a proposed procedure before you have it done? Good luck with that.
  • The consumer of healthcare services usually isn’t the one paying for it. Your insurance company or the government (e.g., Medicare) is paying. You’ll get no thanks for your time spent shopping around for the best deal.
  • Scorpion antivenom costs $100 in Mexico, but if you get it in an emergency department in the U.S., you’ll be billed $40,000 for it. And don’t think you can go to Mexico and stock up then sell it to emergency departments for $150—that’s illegal.

Karl sings the praises of the Surgical Center of Oklahoma. They post their prices up front, work on a mostly cash basis, and eliminate the bill-padding and wasteful bureaucracy of other facilities. Their prices are a fifth of what others charge.

One possible fly in Karl’s ointment is that insurers are exempt from federal antitrust laws per 1945’s McCarran-Ferguson Act. Only a handful of industries are exempt. Karl doesn’t mention that. Nor does he talk about the cost of medical malpractice insurance and defensive medicine, wherein doctors order excessive testing to protect themselves from lawsuits.

I appreciate Karls’ efforts. He’s a smart guy with many good ideas.

RTWT.

Steve Parker, M.D.

Recipe: Chicken Avocado Soup

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Avocados in soup? Yeah, I was skeptical, too. But it works amazingly well. Since I provide the nutritional analysis below, you can easily work this into the Low-Carb Mediterranean Diet, Ketogenic Mediterranean Diet, Paleobetic Diet, or Advanced Mediterranean Diet.

Ingredients

1.5 lb (680 g) boneless skinless chicken breast

1 tbsp (15 ml) olive oil

1 cup (240 ml) chopped green onions

1/2 jalapeno pepper (or 1 or 2 peppers if you wish), seeded and minced (use the seeds, too, if you want it very spicy hot)

2 roma tomatoes (5 oz or 140 g), seeded and diced

2 garlic cloves, minced

60 oz (1,700 g) low-sodium chicken broth

salt and pepper to taste (nutritional analysis below assumes no salt added)

1/2 tsp (2.5 ml) ground cumin

1/3 cup (80 ml) chopped cilantro

3 tbsp (45 ml) fresh lime juice (2 limes should be enough)

3 medium California avocados, peeled, seeded, and cubed

Instructions

Heat up the olive oil in a large pot over medium heat, then add the green onions and jalapeño; sauté until tender (1–2 minutes) then add the garlic and cook another 30 seconds or so. Next into the pot goes the chicken broth, cumin, tomatoes, chicken breasts, and optional salt and pepper. If adding salt, I’d wait until just before serving: taste it and then decide if it needs salt. Bring to a boil with high heat, then reduce heat but keep it boiling, covering with a lid while the chicken cooks through-out. Cooking time depends on thickness of the breasts and may be 15 to 45 minutes. When done, it should be easy to shred with a fork. heat to low or warm then remove the chicken breasts and allow them to cool for 5–10 minutes. When cool enough, shred the chicken with your fingers and return it to the pot. Add the cilantro. Ladle 1.5 cups (355 ml) into a bowl, add one fifth or sixth of the avocado cubes (half of an avocado) and the juice of 1/4 to 1/2 lime. Enjoy!

IMG_2233

Serving size: 1.5 cup of soup plus 1/2 of an avocado

Servings per Batch: 5

Advanced Mediterranean Diet boxes: 1 veggie, 1 fat, 1 protein

Nutritional Analysis per Serving:

43 % fat

13 % carbohydrate

44 % protein

350 calories

12 g carbohydrate

8 g fiber

4 g digestible carb

638 mg sodium

1,180 mg potassium

Prominent features: Rich in protein, vitamin B6, vitamin C, niacin, pantothenic acid, phosphorus, selenium; plus a fair amount of fiber

PS: You can fancy this up just before serving by adding a couple large triangular corn tortilla chips (broken into a few bits) or half of a 6-inch (15 cm) corn tortilla (first, microwave for 20 seconds, then break into a bits). Both items each add 5 g of digestible carbohydrate; the tortilla chip option adds 60 calories and the corn tortilla adds 25 calories. Shredded cheese might be a nice topper, too.

 

Hike Report: Humphreys Peak in Arizona

Yes, that's snow in late June in Arizona

Yes, that’s snow in late June in Arizona

This wasn’t a fun trip but it was rewarding and educational. I don’t regret doing it. Overall, the hike to the highest point in Arizona was an ordeal. The required degree of exertion was on par with the two marathons (26.2 miles) I ran when I was in my thirties. These are the potential fun-killers I’ve identified thus far:

  1. My level of fitness wasn’t high enough
  2. I got dehydrated
  3. I didn’t eat enough on the trail
  4. I wasn’t acclimatized (aka acclimated) to the altitude
  5. I’m too old for this (60)

The Route

The trail was easy to follow but it's a good idea to have a map "just in case"

The trail was easy to follow but it’s a good idea to have a map “just in case”

I took Humphreys Peak Trail #151, the most common way to the summit. The trailhead is at a parking lot adjacent to Arizona Snow Bowl, a ski area resort.  Elevation at the trailhead is 9,320 feet above sea level. (I live at about 2,000 feet above sea level.) The round trip to the summit is about 10 miles. The tree line is at 11,500 feet and the summit is at 12, 633 feet.

Most of the trail is more chaotic than this

Most of the trail is more chaotic than this

The first half of the trip is unrelentingly upward, about 3310 vertical feet. The footing is mostly rocky. Many other portions have exposed tree roots just waiting for a tired hiker they can trip. Often the rocks and roots share the trail. There are rare patches of smooth dirt without obstacles. When you’re moving you have to keep your head down and on the trail at all times. By the end of this trip, I never wanted to see another rock for as long as I lived.

Trail crossing a river of rocks

Trail crossing a river of rocks

 

There are a few places you have to scramble over isolated boulders, meaning you have to use your hands as well as your feet. At no point do you need technical climbing equipment if you’re hiking in the warm season.

Other than the summit, the other prominent geologic feature on the trail is “The Saddle.” It’s a high-altitude ridge between two of the San Francisco Peaks, shaped like the seat of a saddle.

The Saddle

The Saddle between Agassiz and Humphreys Peaks

My Pace

It took me three hours from the trailhead to reach the Saddle at 11,500 feet. From there, you’ve got another 1.5 miles of hiking to Humphreys’ summit, which took me another 1.5 hours. This last portion is no steeper than the trail to the Saddle; the problem is the thin air. Either that or something else slowed my pace to 1/2 mile per hour!

About half way down from the peak

About half way down from the peak

So it took me 4.5 hours to reach the summit. I had to stop frequently to catch my breath and regain some energy over a minute or two. Five-minute hydration breaks were amazingly refreshing. Slogging uphill, my heart rate was consistently about 160 beats a minute. Even after sitting and resting for five minutes, my heart rate would drop only to 130. Walking on the flat at 11,000 feet was fairly easy, but adding any elevation was almost immediately taxing.

At the summit I was greeted with five minutes of very light rain and sleet.

The trip down took 3.5 hours and was much easier, with far fewer resting spells.

This trail on a Saturday morning (June 27, 2015) was what I’d call crowded. It was as busy as Pinnacle Peak Trail, a popular urban hike in Scottsdale, AZ. I estimate 800–1,000 people were hiking. The large trailhead parking lot was full and overflowing at 9:30 AM when we arrived. The serious hikers are on the trail at 6 AM (good idea). Many folks stop and enjoy the fantastic views at the Saddle, then go back down.

My daughter snapped this picture of me in the parking lot at the trailhead

My daughter snapped this picture of me in the parking lot at the trailhead

If you read other people’s trip logs, you’ll find many reporting five to eight hours to complete the hike. My time was 8.5 hours, including 30 minutes resting and enjoying the summit. A couple of times I seriously thought about quitting and turning around. But I knew if I did, I’d probably never attempt this again. It’s been on my bucket list for a decade. Plus,my  wife and children made the trip to Flagstaff with me; their presence spurred me on to complete the trip.

I don't look too miserable, do I?

I don’t look too miserable, do I?

What Could Have Kept Me From Enjoying the Trip?

1) My fitness level wasn’t high enough.

I’m not buying that, mainly because it’s now the day after and I have no muscle soreness at all. I feel good.

I’ve been training for this trip for six months. My Boy Scout troop and I did a 20 mile hike in March. For the preceding three months we did training hikes every two weeks, starting with six miles, then eight, several 10s, and finally 12 miles. Granted, all those were on the flat. To maintain my fitness thereafter, every week or so I walked Pinnacle Peak Trail, starting at my front door, walking to the west trailhead, then back home, a five-mile hike. I carried a 15-lb dumbbell in my pack to enhance the training effect during this two-hour hike.

2) I got dehydrated.

This probably has some validity. I carried with me 4.2 quarts of water and drank 3.6 quarts. I made a point of stopping every 30 minutes for a hydration break. I sweated a fair amount. I never “felt” dehydrated. Yet I never urinated during this 8.5 hour trip. That’s a huge clue.

My backpack probably weight 20 pounds at the start. The majority of that was water weight. At this altitude you don’t want to be lugging around unnecessary weight. If I ever do a similar trip, I’ll be sure to “fill my tank” by drinking lots of water just before starting, and carrying more water to drink on the trail. I’ll minimize backpack weight some other way.

3) I didn’t eat enough on the trail.

Maybe, but probably a minor issue if at all. I ate two large handfuls of cherries and 400 calories of peanut butter crackers. I had some sweet and salty trail mix but didn’t eat it. I wasn’t hungry. I wonder if that’s an altitude effect. Considering the number of calories I was burning, more food might have helped.

4) I wasn’t acclimated to the altitude.

I think this is the major reason I didn’t enjoy the trip. Our bodies need time to get acclimatized to the low oxygen levels at high altitude. How much time? Probably three to five days staying at 7,000 feet or higher; the longer the better. You might be able to speed up the process by staying at higher altitudes, if only temporarily.

A thunderstorm probably 20 miles away, but I kept a close eye on its movement

A thunderstorm probably 20 miles away, but I kept a close eye on its movement

Lots of us low-landers have trouble simply sleeping at 8,000–9,000 feet above sea level. Why? We’re not acclimated. On the other hand, if we’re sedentary and awake during the day, we may not have any trouble at those altitudes.

This San Francisco Peaks groundsel is only found on this mountain. It's a tundra plant.

The San Francisco Peaks Groundsel is only found on this mountain. It’s an alpine tundra plant.

While I was hiking, my wife and children rode the ski lift up to 11,000 feet. They all felt slightly short of breath even at rest; much more so with exertion. My daughter also noticed the increased urination many experience at altitude.

Another alpine tundra flowering plant

Another alpine tundra flowering plant

If I ever do this hike again, here’s what I would do to acclimate. Establish a base of operation in or around Flagstaff at 7,000–8,000 feet. That’s where I’ll sleep intermittently for three to five days. I’ll make periodic forays to higher altitudes. Examples would be picnics, sight-seeing, easy short hikes to 10,000 feet, even a few trips on the ski lift to 11,000 feet and spend a couple hours up there.

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On the final push from the Saddle to the summit

The most astounding thing I saw on this trip was un-athletic-looking 16 to 20-year-old girls making it to the summit with apparent ease. Good for them! A lot of hikers on the trail, you can look at their calf muscles and tell they’re either serious hikers or relatively athletic. The girls I’m talking about were slender but had calves like your typical cough potato: small, undefined. I suspect these girls live in Flagstaff, which is a college town (Northern Arizona University), and are acclimated to the altitude. Nevertheless, a 10-mile hike gaining 3,000 vertical feet of elevation is something most untrained folks cannot do even if they start at sea level.

A huge river of boulders

A huge river of boulders

Thankfully, I didn’t get high altitude sickness this trip. My wife got a pretty bad case of it here 23 years ago and did the smart thing: headed down the mountain post haste. Some people take Diamox (acetazolamide) to prevent and treat altitude sickness.

5) I’m too old for this (60)

Quite possibly, but I’m not ready to give up. I saw 15–20 people at the summit, and they were all in the 16 to 40-year-old range. Elsewhere on the trail I did see a few folks who looked older than me. For me to investigate how much of a role my age played in this ordeal, I’d have to repeat the hike, but with optimal acclimatization, hydration, and nutrition.

If any of you experienced mountain climbers have any advice for me, please share. For decades I’ve fantasized about climbing Longs Peak in Colorado; it tops out at 14,259 feet and requires a 5,000 foot vertical climb. I’m less inclined now.

Steve Parker, M.D.

PS: After extreme physical exertion, I get painful leg cramps over the subsequent 24 hours. I seem to be able to suppress them by taking, immediately after exertion, mineral supplements: magnesium, potassium, and calcium. Unless you know you’re entirely healthy, check with your physician before you try this.

The last 100 yards of the hike

The last 100 yards of the hike

A fake farmer's tan caused by dirt

A fake farmer’s tan caused by dirt

 

Elevated Fasting Blood Sugars May Increase Your Risk for Pancreatic Cancer

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Insulin from the pancreas’ beta cells is a major regulator of blood sugar levels

A recent meta-analysis found that elevated fasting blood glucose levels, even below the diabetic range, are associated with higher risk of developing pancreatic cancer. This is important because you can take action today to lower your fasting blood sugar level, which may lower your risk of pancreatic cancer over the long-term. The researchers conclude that…

Every 0.56 mmol/L [10 mg/dl] increase in fasting blood glucose is associated with a 14% increase in the rate of pancreatic cancer.

In the developed world, your risk of getting an invasive cancer is roughly one in four. Pancreatic cancer is the most lethal. Surgery is the way to cure it, but at the time of diagnosis only two in 10 patients are candidates for surgery because the cancer has already spread. Pancreatic cancer is the fourth leading cause of cancer death in the USA and the fifth in the UK. Nevertheless, pancreas cancer is not terribly common; the US has 50,000 new cases annually. As a hospitalist, I run across one or two new cases of pancreas cancer every year.

We’ve known for years that type 2 diabetes is linked to pancreatic cancer, with diabetics having twice the risk of nondiabetics.

What if you have elevated fasting blood sugars? There’s no proof that reducing them to the normal range will reduce your risk of pancreatic cancer. But if it were me, that’s what I’d shoot for, by losing excess fat weight, exercising, and eating a Low-Carb Mediterranean Diet book detail page at Amazon.com.

Other that type 2 diabetes and prediabetes, some other risk factors for pancreas cancer are:

  • heredity
  • smoking
  • sedentary lifestyle
  • body mass index over 30 (obesity in other words)

You can alter most of those risk factors. Why not get started today?

Steve Parker, M.D.

PS: If you’re not sure if your fasting blood sugar’s elevated, click here.

ATMC: Get the Best Bed You Can Afford

I slept in a sleeping bag on a 1-inch thick foam pad in this Eureka Solitaire 1-man tent.

I slept in a sleeping bag on a 1-inch thick foam pad in this Eureka Solitaire 1-man tent.

You spend a third of your life in bed. Make it a good bed.

When you’re a kid or young adult, you can sleep just fine on a couch or a pallet on the floor made from a few folded blankets. After the age of 25 or so, your body won’t appreciate that sort of treatment. You’ll sleep fitfully and wake up with scattered aches and pains. Sleep in a bed that gives you support, comfort, and peace. By no means is that the most expensive bed on the market.

Back in 1981, I graduated from medical school and moved to Austin, Texas, for three years of internship and residency. My starting pay was $14,400/year. If that doesn’t sound like much, you’re right. The low pay was a hold-over from ye olde days when interns and residents were mostly young single men who actually resided in the hospital. They didn’t need a house or apartment. $14,400/year was just enough for a single guy to survive. We were working 100-hr weeks—no time for a second job. By the third year of residency, I was making $16,000-sumpin’.

I was new to Austin and needed a bed, so I went to a cheap furniture store in the low-rent part of town and bought a crappy twin-size box spring and mattress, $40 I think. At least it was new—I didn’t have to worry about anybody else’s bedbugs, fleas, or germs. Good times.

I upgraded as soon as I could afford it.

—Dad

PS: Remember those cars back then that had a vinyl-like covering over the roof? I had one of those in 1981, probably a Chevrolet or Oldsmobile sedan. It was so old that the vinyl was half gone, rotted off. One of my pulmonology attending physicians said they shouldn’t let me park that embarrassing mess in the doctors’ lot at the hospital. I think he was only half-joking.

PPS: I graduated medical school with only $22,000 of educational debt. I made monthly payments for 10 years. Medical student debt these days averages $176,000. Consider that before you gripe that doctors make too much money.