Kind: captions
Language: en
there's a quote that I want to read from
one of your tweets that comes from a
book which I just thought was absolutely
brilliant called the Empire of the
summer Moon
about the Comanches uh Native Americans
and so here's the quote you said
Comanches loved eating bison and then
this is the quote from the book children
would rush up to a freshly killed animal
begging for its liver and gallbladder
they would then squirt the salty bile
from the gallbladder onto the liver and
eat it on the spot warm and dripping
blood
and I was like okay so this is a really
different way of living imagine tracking
that animal down your hands are all over
a horse God only knows what's on the
horse you then kill that Buffalo you
then cut it open touching its fur and
all the dirt and feces and God only
knows what is all over it you cut it
open you reach inside you pull this out
uh having done it so many times that the
kids know which organs to beg for
and then you give it to people and I
just thought oh my God the microbes that
people would be ingesting would very
rapidly acclimate your microbiome to
whatever it is that you eat
so
is that part of this or is this going to
be and I know you're guessing but is
this going to be more genome is this
going to be more microbiome which of
those two do you think plays out being
more important
I do think the adaptability point is a
big part of it and I do think the
gastrointestinal tracts of humans but
also of all animals are very adaptable
and there is a lot of debate you know
I've debated with people vegans on
Twitter let's say about what humans
should eat and we we have to Define
should right so should like what is you
know what's healthiest for us what makes
us feel the best which might be two
different things what's the most moral
what's the most sustainable economically
environmentally you know there's many
ways to ask what is the quote-unquote
proper diet for us but I mean I do think
that um that the adaptability of the
gastrointestinal tract is important and
a lot of vegans will point out rightly
that for instance in the large
intestines humans can ferment plant
matter you know cellulose and fiber from
Plants a little bit not to the extent of
cows and other ruminants who have this
initial very large stomach that is a
fermentation vat basically to draw
energy from fibrous material from plants
but we can partially ferment things in
our colon which does suggest we are
quote unquote supposed to eat vegetables
but not only vegetables you know our
gastrointestinal tract does not look
like a pure carnivorous track it also
doesn't look like a pure herbivores
tract so I think we are probably meant
to be omnivorous not to what extent
should meat be only you know used as a
flavoring or eaten occasionally or
should it be 90 of the diet I think
variability is a really important thing
and over Generations I I mean I think
the the mic the microbiome adaptation
over some months or years could play a
role I don't I'm not I don't know a lot
about that that could impact how much
you're able to ferment in your large
intestines but also over Generations
gastrointestinal tracts can adapt in
impressive ways one of the most
impressive is actually the panda bears
gastrointestinal tract where clearly
they were a carnivore in the past almost
like other most other Bears
um but they've adapted to subsist almost
wholly on bamboo alone and their
gasoline tract their gastrointestinal
tract shows that they were a carnivore
or at least a meat Hemi heavy omnivore
who is now a strict herbivore and their
gastrointestinal tract was able to make
that adaptation and I think ours could
adapt similarly whether we're living in
the Arctic and subsisting wholly on
animal meat and fat or in some parts of
the tropics where people do have a very
strictly vegetarian diet you know I
think we can do a little bit of
everything and so the debate will never
end on The Human Side it's not really a
question though right so we do we have
some people right now even in just North
America that are like I'm running a kind
of diet experiment for one reason or the
other and then you obviously have people
usually for moral reasons uh that have
gone strictly vegan but also in the
longevity Community now that debate
rages on in terms of what is it that is
going to give you longevity
I'll lay out my hypothesis you've cut
open a lot more bodies than I have since
my Tally is zero uh and yours is
somewhere far north of that
um that the way that I think this plays
out is from a longevity perspective
I think a vegan diet and and let's first
Define supplement versus non-supplement
because looking at this from an
ancestral perspective I have to believe
that you were in a stressed state if you
were eating a purely vegan diet
um
so from an ancestral perspective
I'm guessing this is a hermetic response
that we're leveraging now in a modern
environment where we can sort of take
the edges off of whatever problems a
purely vegan diet would otherwise create
that's my assumption that there would be
those problems
um
that through supplementation we take the
edge off and so we're getting an
artificial look at why some people think
why the longevity Community seems to
keep circling around a vegan diet for
people that don't know the idea of
hormeses it's saying basically it's a
little bad for you but that gets the
body to respond in a way that's positive
and so and and my guesses here are not
uneducated I've interviewed enough
people around this read so many books on
the topic but I want to be clear that
I'm not an expert
um but that what seems like is happening
is if you're eating a lot of meat you're
going to be in mtor so you're in a
growth phase you're telling your body
grow this is good times the plenty but
if you're always in that to the earlier
comment that you said that variability
is probably one of the keys and so if
you're pegged on eating meat you're
going to be pegging mtor you're going to
speaking from experience you're going to
feel awesome
but because you're pegging that out you
don't get the hormetic effect you're not
shutting down some of those growth
things you're not giving the body hey
you need to conserve calories
effectively so lower your metabolism do
less cellular divisions I'm definitely
out of my depth here but that's sort of
how I imagine this process and so
while I would categorize certainly from
an evolutionary standpoint that if
you're purely in a vegan situation
you're going to be surviving not
necessarily thriving and if you're going
hardcore on the eating as much meat as
you can get that you're going to be
thriving but you're not necessarily
optimizing for longevity
how does that feel I mean it seems to
make sense I also am not you know an
expert in this area and I think the the
science is still murky but I mean it
seems to make sense to me but I think
going back to sort of lifestyle and
activity level
the the food that we have available
today for anyone in North America let's
say who has disposable income is so
dramatically different from what people
have had available in the past you know
the choice of oils and fats to fry
things in is sort of mind-boggling at
this point when you go to a grocery
store versus 100 years ago when it was
basically animal art and butter you know
with sort of your choices and so now we
can import things from all of growing
parts of the world like olive oil and I
also and our lifestyles are so different
so I think you put you put someone in a
hunter-gatherer Society who has to work
really hard to put food on the table
what's the optimal diet for them
um I feel like you know they're going to
need more meat and fat perhaps than
someone in a modern lifestyle what's
driving that hypothesis the ability to
extract calories
perhaps I guess you know this is all
sort of working on what's theoretically
making sense in my own mind and how our
lifestyles have changed over over the
recent centuries but I do suppose that
in a modern what's optimal for a human
living a modern lifestyle where you
don't actually have to work very hard
for your food physically and you have
all these Foods available from all over
the world not only from your own climate
and your own environment I think it's so
hard to know I feel like what's optimal
for people that don't know your story uh
you're a physician you talk a lot about
two topics which I think are the reason
I want to talk to you about this is they
Collide in this moment we're talking
about right now perfectly which is
understanding all the different systems
of the body the different
um God what do you call them the liquids
the bodily fluids bodily fluids perfect
so all of the different systems of
bodily fluids that they produce all of
that
and then nutrition and you coming at
nutrition from an anatomy eats is the
name of your Twitter feed so
and on that feed it says you are what
you eat so when I look at these two
worlds colliding of okay you've got
operation of the body and then you've
got the things you take in and you are
what you eat
um how do those two worlds come together
and what would you need to know from the
body whether it's urine blood whatever
to know is this diet quote unquote
working the science of nutrition is has
changed a lot in recent decades and I
think I'm in general very skeptical of
what doctors have to say about nutrition
and I think just because they don't
learn about it partially they don't
learn about it when I was in medical
school I went to a public medical school
in New Jersey we had one nutrition
course and it was actually had just been
started and that was in about 2000 2010
and just before so before that there had
been no nutrition course in the medical
school and it had just started and it
was just very basic but I think
nutrition science is just so hard to uh
to to get right and nutrition studies
are so hard to do just because there's
so many variables that have to be
controlled in people's lives and I think
that's one reason that study that
doctors seem to flip-flop on things back
and forth like eggs I feel like in my
you know since I was a teenager I've
seen them flip-flop back and forth and
to add to that I think the way the media
portrays nutrition science or the latest
study or the latest you know perhaps
very low quality study that shows that
eating chocolate is very good for you is
going to be a headline everywhere and
sort of uh disproportionately impacts
the way people understand nutrition sort
of nutritional science through headlines
is a very bad way to understand what's
what's good and what's bad for us I do
think though you know medicine is very
focused on sort of is is someone having
a disease or not and I think when you
get into the finer points of nutrition
about optimizing the human body
optimizing performance
um it's almost beyond the realm of
medicine you know I can say someone's
urine let's say the tests I can do on
the urine are limited I can say
everything looks normal I often say that
to my patients when I get their blood
and urine tests back but
you know I it's hard for to measure or
there is no measurement I'm aware of of
is this diet optimal for you you know I
can show that you are not having any
vitamin deficiency that you're not in a
state of protein malnutrition or you're
not malabsorbing fat in your gut and
failing to absorb it let's say
um but going beyond that and optimizing
you know taking it from you have no
nutritional deficiencies to taking it to
the optimization is sort of a bigger
step that I think medicine is just very
in the very beginning stages of I think
okay so going back to the question if
you were trying to take your best swag
um what would you look at so my gut
instinct is that it's going to be blood
maybe stool would be the ones that I
would really want to see if if to just
speak to your current lifestyle which I
would say is and maybe we disagree about
this but I would say is eighty percent
what you eat 20 activity sure
um loving relationships all that stuff
but man if you want me to impact the
quality of your life give me sleep and
diet I'm over everything and I'm
laughing
um
blood stool or there are better things
to look at in somebody's bodily fluids
do you mean to determine their state of
health yeah like I I so I really care
about the things that I do what impact
do they have and so this is all building
towards me asking when you cut open that
first cadaver and you saw that the lungs
were black you were like this
guy smoked right and so I just dude I
again I understand that to some extent
I'm just ignorant enough that I have so
much confidence in what I think
it's very dangerous but it also allows
me to move forward in my life so I am
convinced that at some point we're going
to realize oh when you cut open the
arteries and you see this that tells me
that they ate this and I think it is
only a lack of being able to draw a
direct correlation between the two
because the two worlds are so divorced
so the guy cutting open your heart and
looking at your arteries and you know
being in charge of repairing that he's
not studying nutrition and the guy's
setting nutrition is not cutting open
your heart right but I have a feeling
that the second that those two things
are married and you've got a guy who
just knows nutrition forwards and
backwards or this is probably going to
get solved by AI but whatever entity
that is both cutting open the person and
looking at what people eat is going to
be like oh this is easy when you're
eating a bunch of Highly processed food
and this is my punch line if you're
eating a bunch of Highly processed food
your arteries are going to look like
trash and you're going to be storing fat
everywhere and it's going to glom on to
your organs and that's just going to
literally choke the ability for the
fluids to move through the body in the
way that they should choke it off and
you die and that's like the end of the
story and again because I'm like on this
side of ignorance that just seems so
clear to me but I am hoping you will
either
say yes that all makes sense or slap the
ignorance out of me either way I'll take
it gotcha
um let me say I certainly make it I
certainly think it makes sense I
certainly think the point at which the
cardiothoracic surgeon who's cutting
open your chest let's say to look at
your arteries versus the nutritionist
uh we're such a long way from those two
sort of meeting and marrying each other
and knowing for sure I guess the trick
is that it takes these large population
studies to know what what is optimal uh
for people and that doesn't always tell
you what's optimal for the individual
honestly and studies in the past have
been very
poor quality and not controlled well for
all the variables that exist like for
instance some of the recent
multinational studies on let's say salt
intake they're done on much larger scale
they're done with more powerful
computers to compute the statistics and
do the statistical analysis in a more
efficient and better way and there's
more money behind it and and they're
discovering that perhaps the salt
cutoffs let's say are not as low as we
thought so I think every you know
everyone who sort of agrees that eating
huge amounts of salt is not good for you
but where's the cut off between assault
that's in an okay amount and salt that's
too much and it turns out that we've
been being much too strict you know and
it seems like people could eat more salt
without the effects that we've been
warning about for a while
um so for instance so those sorts of
bigger better run studies are
overturning a lot of what we have
thought in the past but I do think you
know when you cut open a person let's
say you could look at their arteries and
see that they're there's more plaque
built up on the walls or they're stiffer
when with more calcium because of injury
you could look at their liver and see
there's more fat accumulated there you
know in a fatty liver disease which
could be either from alcohol or could
could be from the modern lifestyle and
diet which causes non-alcoholic fatty
liver disease which is very young give
me what you think is actually going on
there so the alcohol one is pretty
simple right but when you say modern
lifestyle right that's an abstraction
get into the specifics what in the
modern lifestyle sitting around yeah so
I think you know again it's complicated
since there's so so many things happened
at once to change human life and human
diet over the last let's say century and
a half in the developed world that it's
hard to pinpoint but doctors refer to
something called the metabolic syndrome
which is a constellation of conditions
that include type 2 diabetes high blood
pressure high cholesterol chronic kidney
disease and fatty deliver disease and
that whole constellation which can
appear to different extents in different
people someone might have all those
someone might have a few or one
um that seems to that constellation of
of diseases that syndrome seems to be
much more common these days and is that
due to some probably due to the change
in our lifestyle less physical activity
a change in diet but you know what is it
exactly that's doing it perhaps a
combination of the two but you you see a
lot of people you know obesity obviously
plays a role in there as well but I see
a lot of patients who are not obese at
all and still have some version or some
portion of the metabolic syndrome and I
think it seems like something about
Modern Life has caused that or at least
has made that much more common these
days but what exactly is it I think is
really hard to know I think doctors when
they've tried to show causality of
eating this causes that we've gotten
into so much trouble and ended up
looking like idiots so many times and
continuously we still do that I'm so
hesitant to draw conclusions you know
until the platonic ideal of the large
population nutrition studies are
complete to show it's like what really
is is causing
um us to be less healthy I find if you
want to know what somebody really
believes you need only ask what they do
with their kids what do you do with your
kids
um so I I encourage my kids to eat as
wide a variety as possible I feed them
Oreos
um you know occasionally I mean so for
instance in my mind I feel like you know
processed food seems to be not the
optimal choice of what you should eat or
what your kids should eat
um some a lot of studies seem to suggest
that what I bet my life on it no do I
think if you went back to a
hunter-gatherer people who uh do an
Olympic athletes amount of physical work
each day and gave them lots of Doritos
like would it really make them less
healthy I kind of don't think so because
they're living such a Physically Active
lifestyle and their diet is so well
balanced with everything else they eat
like maybe they could eat a lot of junk
food and be fine I don't know and that
study is probably impossible to do but I
do find it silly for instance I hear
pediatricians sometimes recommending
that a child's diet have more olive oil
and less butter
and there is no study on children that
shows olive oils better their study on
probably unhealthy American 60 year olds
maybe that show olive oil might be
better than butter even those I'm
skeptical of those studies but to then
take that nutrition that nutritional
data or evidence from adults and apply
it to otherwise healthy children I think
is very silly and I think there's no
reason to think olive oil is is more
healthy in a healthy child than uh than
but what's the difference between uh the
way that a kid will respond and an adult
um I think it has to do with at least in
the doctor's mind has to do with sort of
risk factors you know we there's some
evidence that uh unsaturated fat is
better than saturated fat for things
like coronary artery disease although
that evidence also I think is I'm a
little skeptical of it or at least the I
don't believe the full picture has has
totally been drawn yet so I think for
the the adult with five out of the six
conditions of the metabolic syndrome
who's already had three heart attacks
and has eight stents in their heart yes
probably nitpicking their source of fat
uh is more worthwhile than in a healthy
child who almost no matter what they eat
is not going to have coronary artery
disease for decades to come
um so I think there's a lot of applying
uh nutritional information from one
population to another for instance from
adults to children or for instance from
let's say white Europeans to other
people when the variability is just too
great especially between adults and
children
um
so interesting to me so
um
I want to go back to the the Primal way
of living so you had another tweet that
was like you should embrace the Primal
side of life as readily as you embrace
the intellectual side of life
do you mean that spiritually or do you
mean like that's just gonna be better
for you at a cellular level
well that's a good question I guess that
plays into uh the psychology uh and how
psychology and emotion our emotional
lives affect the cellular level you know
clearly there's some some correlation
there between our emotional and
psychological lives and how well our
guts work you know there's a lot of
conditions that we deal with IBS and
others that where there's some seems to
be some connection with
um you know mental duress or psychiatric
disease and and gastrointestinal
function let's say or sleep and
psychiatric illness and health there's a
lot of connections there between the
body and the mind that that we really
haven't figured out yet and I think
doctors sort of poo poo a lot of those
things but the causality is not clear
but it's clear there's some tie-in with
psychology and I think being
um embracing the Primal side of life I
guess by that I sort of meant
um you know realizing where we came from
understanding where a food comes from
that for 99.9 of human history we've
lived by
uh lived and eaten and survived by
killing other things whether it's
ripping mushrooms out of the ground uh
felling trees killing uprooting plants
or killing other animals you know that's
sort of where we come from that's where
everything we put into our mouth comes
from from the Flesh of another organism
not all of them have to die for us to
eat yes fruit do fall from a tree that
continues to live but
um I think even just recognizing where
things come from and I do try to instill
that in my kids you know meat doesn't
come from the store it comes from the
body of another animal and you are made
of exactly the same stuff and if we
zoomed in with a microscope on that
pizza meat or the muscle in your leg no
one would be able to tell the difference
because we're made of the same stuff and
I think that is
I understand why people are sometimes
grossed out by that but there's
certainly a beauty there and I often
tell my kids about the circle of life I
say and that's one of them you know that
everything that dies becomes food or do
you want them to understand that
um perhaps because I find it so
beautiful and intellectually satisfying
and stimulating and fascinating
and I think those are important lessons
you know to understand where things come
from I think that's something I've
always been interested in
um not in childhood but actually in
adulthood I got interested in where do
these things from the store come from or
how did how how is technology made from
how metals are extracted from the ground
and how uh all the way back to the
beginning of how we take from the
natural world and turn it into the
things around us that seem so artificial
and seem to have no connection to the
natural world of course they have their
Source in the natural world I was
similarly fascinated with a lot of the
medications that we use in in modern
medicine many of them come from the
natural world from fungi from plants
from the bodies of other animals even
from the bodies of other humans we make
medicines out of everything just like we
make sort of useful devices for our own
life out of out of everything and I
think there's a beauty in that and it
helps you understand the world and why
the world is the way it is why things
are shaped the way and act the way they
are and do to why people lust after the
things they lost after you know the the
circle of life of food and death is also
the circle of life of how feces becomes
fertilizer for plants to grow more food
you know there's all these sort of
intertwining circles and I think I don't
understand I guess having my kids
understand the way the world works is
part of my job as a parent one of the
things that I was drawn to reading your
book and this may be a misread on you
but one of the things I took away which
may be projection uh is that you take a
very dispassionate look at the way that
the Body Works there's a story that you
tell in the book the note I took was
like is this guy Hannibal Lecter you
were driving down the road you saw a
deer on the side of the road
you pulled over drug the deer into the
woods so that passersby would not see
what you were about to do and you
skinned the deer
now you've been trained how to do this
so it wasn't like oh the first roadkill
I see I just want to cut it open and see
what's inside but uh so when I was
reading all of that I was like so I if I
were going to have an Epitaph put on my
Tombstone I would want it to say you're
having a biological experience
now to me there's something deeply
spiritual in that but I'm trying to get
people to understand there's a very
grounded real way your body works in a
certain way your mind works in a certain
way the things you eat will react in a
certain way that may be too complex for
today's technology for us to track what
that is but there is a way and
ultimately I think through Ai and better
Technologies we'll actually be able to
track all that stuff and it will really
become day regard to say okay on a
lifespan you're working out this much
sleeping this much getting this much
sunlight eating these things with that
microbiome this is going to be the
outcome of plaque in your arteries
and that will really be able to to build
some
terrifyingly predictive models which
right now for anybody who wants to cut
through the BS look at the insurance
industry they're literally betting that
they know what are the things that are
going to kill you and keep you living
longer and so I think they're the the
people to beat but I think that
ultimately we'll be able to beat that so
anyway that's how I think people ought
and I use that word on purpose people
ought to look at the world if they want
to have a better life
is that have I misinterpreted you that
you have a similarly like you just need
to understand what's going on at a
cellular level and that's why you say
you are what you eat and that's why
you're fascinated by skinning an animal
uh or
is there something more spiritual to
what you were just walking through with
the circle of life and understanding
where we fit
I think that it's a little bit of a
combination I got interested in the Life
ways of ancient peoples uh in my early
20s and like I said I wanted to know
just where everything came from how
everything was made how people figured
out everything that we know these days
and so um one of the things I did in
that journey of exploration was take a
Wilderness survival course where I
learned how to make stone tools in the
the way that people did for most of our
history certainly much longer than we've
dealt with any of the technology
surrounding us today uh how you know
everything from tracking an animal to
making rope from the bark of a tree to
uh
um setting traps you know kind of
everything that a person in their
natural state let's say in nature with
no artifice around them except their own
body their own flesh how would they
survive or how would they manipulate the
world around them in order to make
themselves more comfortable and more
able to survive so the the use of skins
to make clothing not even to make paper
let's say you know parchment
um America's founding documents are
basically written on animal skin and so
the the use of skins I guess just really
fascinated me and this was before I went
into medical school
I certainly do think there's something
spiritual there I I think but uh for me
the the spirituality is in understanding
how people have lived throughout history
and what our bodies are kind of designed
to do whoever whoever or whatever you
think the designer is clearly our bodies
have a design in a particular way you
know every body part and every bodily
fluid has a purpose that seems
particularly designed for a specific
problem of everyday life with the human
body everything uh everything that we're
made of and everything the way it's
shaped the way it flows makes perfect
sense from the human mind perspective of
problem solving and kind of getting the
job done and keeping the human organism
alive
so I think I like understanding the
world around me there's a pleasure in in
that Fascination and that understanding
I sort of just have always wanted to
know more and how everything works and I
think there is for me at least a
spiritual side to that knowledge to
understand why our bodies are the way
they are why we act the way they do why
human history preceded the way it did so
do you think that you're naturally
unsquemish or is it this sort of loop of
wanting to understand where it's from
that bringing both a biological and a
spiritual connection to everything
that gives you an intellectual framework
to not be freaked out
I think I'm definitely not squeamish to
start with though I do think something I
learned in medical school when we
started dissecting our cadavers on the
first day of school we met our cadavers
those four students for each body and I
think everyone was surprised by how
quickly we got used to it even people
who were let's say not uh more squeamish
than I am let's say like I have a friend
who ended up being a psychiatrist who I
write about in the book and the sight of
blood made him faint for most of his
life and here he was in front of a dead
human body he was now tasked with
cutting open and is there blood though
in a cadaver there isn't blood but he's
sort of just a squeamish person sort of
blood was not the only thing that
freaked him out but no there's no blood
it's actually all been drained out and
replaced with a preservative sort of
similar to formaldehyde though not
exactly formaldehyde but even he
throughout medical school got less and
less squeamish you know he would be on
let's say his surgery rotation where he
was cutting open a lot of bodies seeing
a lot of blood and blood didn't phase
him anymore but then for the next six
weeks he was on a Psychiatry rotation
and that screen Mission has crept back
in and he sort of lost that um
interesting lost what he had gotten used
to I think I started from a less
squeamish Baseline
um and then I think just the
intellectual understanding or the desire
to understand how things work uh sort of
helped me not be squeamish even further
you know being fascinated with the
process of turning animal skin into
Buckskin or clothing or leather I just
find so fascinating there's no room for
squeamishness why do you have to rub
brains on it so there's many weird right
so skin you know when you uh take skin
off a living animal human or otherwise
it will either rot and it will stay wet
and rot or it will dry and be really
hard almost like cardboard neither of
which is good for clothing let's say or
any other material that we'd want to use
in our daily life so you have to find a
way to to make it dry so it doesn't rot
but have it solved and so humans
throughout the world have figured out
many different ways of doing that but
one of the common ways in uh North
America
um the tribes a lot of them used brains
and there's something about brains it
could be these molecules called
glycolipids where half the molecules
sugar and dissolves in water and half
the molecules lipid and dissolves in fat
it could be those two-sided molecules
sort of like an emulsifier that attaches
to the collagen fibers and skin and the
you know the wavy the way I picture on
the molecular level these wavy fatty
acid Tails between the fibers are
keeping things lubricated perhaps I
don't know that anyone knows no one's
committing a lot of money to researching
why brain tanning a hide works so well
but I think that people have also used
eggs people which have emulsifiers that
are used like in the yolk especially are
used in food products like called
lecithins or lecithins people have
rubbed liver into hides soap into hides
and all kinds of other things um so I
don't know that it's known why it works
but the product is really amazing and
the transformation too which I had seen
before I dragged that deer into the
woods I had seen the transformation from
this stinky wet gross sloppy hide into
this luxurious material that's almost
finer than the highest quality suede
that I've seen and just got so
fascinated with that transformation so I
think in this gross uh raw thing in
front of me I see that finished product
perhaps because I've been through the
process before and you use your own
muscles and sweat to soften the hide
once the brain's been applied I just
love the physicality of it and the
Hands-On nature of it and the
transformation so I perhaps seeing that
transformation in my mind help me be
even less squeamish about the initial
product which can be quite unpleasant
all right so there's certainly moral
implications to killing animals and
things like that but before we get to
that part of the carnivore vegan debate
I would love to get a better
understanding of when you say that we
are what we eat that's one the things
where I think about vegetable matter and
I'm like I get why there's going to be
things in that that are going to be
useful to us at a cellular level but
also seems impossible to get all the
muscle built up and everything that we
would need without eating meat now I
know it's not true because I know that
people can certainly with
supplementation eat a vegan diet forever
and certainly live
uh so
you you make a point of saying that we
are what we eat what what is my take
away from that
all right so on the most basic
biochemical or physiologic level to me
it means that you know nothing in our
body stays the way it is for very long
even the longest lived cells which might
be in the muscles of the heart or in the
brain even those have a turnover there's
this constant churn in everything that
we're made of where nothing no
individual specific molecule is going to
stay there for long everything is
constantly being broken down and rebuilt
from new materials uh and you could you
could think of that constant churn as
metabolism and we're constantly
replacing everything in us right just
like you can never put your foot in the
same river twice because it constantly
changes our bodies are kind constantly
changing from minute to minute and the
new material for rebuilding uh
everything comes from food you know
there's also obviously the the oxygen in
the air is a big part of it too that
gets incorporated into a lot of what
becomes human flesh but uh most and
water of course but everything else is
food from other organisms that goes in
our mouth we break it down in our
intestines and absorb it and use it as
the building material to refashion
ourselves and we're constantly
refashioning ourselves
uh nothing is ever staying the same for
long and that's part of staying healthy
you know if you're if you're not
changing you're stagnating so in many
other ways you know perhaps in a
business environment too you have to
sort of constantly innovate constantly
change constantly renew yourself and so
the same is true in the human body and
so it's all food that becomes us I mean
every bit of Flesh came from food or
from the air that we breathe and do you
is it
um at a cellular level completely
um it just doesn't matter whether it
comes from meat or from Plants I've
heard people say that plants vegetable
matter does not have a complete amino
acid profile
um true false
so I'm not a nutritional expert but I do
think you know there's many vegan diets
that if you're not careful and don't pay
attention to certain nutrients you can
become deficient uh you know B12 is a
common vitamin that's found in all sorts
of meat products and much less in Plants
uh and if you're not careful you can be
deficient in that same with protein you
know there are many plant sources of
protein and if you're careful it's not
hard to get enough protein but it's
perhaps much easier to get protein if
you're eating animals I do think with
the way the food supply is these days
the way that you know nutritional
supplements Supply the nutritional
understanding of what the human body
needs and our lifestyles where we don't
have to uh jump out of a tree branch
onto the back of a deer and strangle it
to put food on you did that what's that
I I have never heard of that as a method
for killing a deer well if you don't
have any weapons let's say if you're
found found yourself in the wilderness
with no weapons uh perhaps that's always
an option do they teach that in survival
no I mean now giveth and you take it
away for a second there I thought this
was like a thing and there was like a
known tribe that they would just choke
them out yeah well there is there's a
actually one of the first Wilderness
survival courses I took was in New
Jersey there's this guy named Tom Brown
who
um sort of grew up in the Pine Barrens
the sort of Wilderness Area in Southern
New Jersey it was supposedly taught by
this older Indian Native American from
the southwest who had uh migrated there
and that was something in one of his
stories he actually does do that jumps
out of a tree with a huge knife and
kills a deer that is against all hunting
laws
um I am not advocating do not try this
at home I've never done that and
probably would never I mean weapons are
not hard to find these days so um it's
rare to find yourself uh Naked and
Afraid perhaps in the wilderness
somewhere where you have to resort to
that but I guess I just meant that we
don't have to you don't have to
physically exert yourself almost at all
even nowadays more than 10 years ago you
can do everything without leaving your
house you know my kid gets piano lessons
we don't have to take more than 10 steps
over the piano and it's through the
computer everything we do these days
requires less and less physical activity
almost approaching you know the
singularity of never having to move uh
so I think that but with all the
supplements available with the food
supply where we can get anything from
any part of the world at any time uh
winter or summer and with our
understanding of nutrition I think that
you probably can be uh healthy as a
vegan as where in a hunter-gatherer
Society you didn't really have a choice
as much in the past as you do today all
right so then let me ask the obvious
question
why do you eat liver like if you could
eat strawberries and be fine what are
you doing right me personally yeah yeah
well
one I like it I did not like it as a kid
it was a chop liver was a tradition in
my family it was on the table at every
holiday I thought it was totally gross I
thought it tasted like rotten iron
pretty much whatever that is delicious
um but then after as I talk about in the
book learning about the liver and just
understanding this incredibly complex
organ that does a million and one things
on a daily basis to keep our our bodies
alive and healthy
realizing that that complicated uh
amazing thing inside each of our
abdomens is that pretty much the exact
same thing of although from an animal
that is chopped up in that bowl on the
table at the Holiday uh it's sort of
similar to that you know perhaps that
transformation of the the gross wet raw
hide of an animal into that beautiful
Buckskin that has a million and one uses
in daily life it's sort of like uh oh
these two things are connected that's
exactly where this things come from this
thing comes from I never considered that
the chopped liver was actually coming
from this internal organ that is so
complex inside the abdomen of these
animals and now it's mixed with fried
onions you know on the holiday table so
I think that Fascination alone probably
helped me similarly get over my
squeamishness and get over my childhood
disgust for the dish and like many
things how does it get you over it
tasting like rotten iron you know the
humans can get used to a lot of things
not only let's say the site of their
cadaver and the smell of the cadaver lab
as a medical student which people do get
used to but also I mean the taste of
alcohol let's just say when I first
tried hard liquor as a teenager I wasn't
impressed with the taste and now I love
it I don't even know if that do I
actually like the taste or do I just
more like the effect and I know that's
the you know that's the beautiful
Buckskin at the end of the dealing with
this gross hide or do I actually like
the taste I think I actually like the
taste even though it still sort of burns
your mouth
pretty gross but it's still this amazing
thing and so I think humans we can get
used to a lot and there's a lot in the
food world too that takes some getting
used to and that is an acquired taste
and I think liver is one of those and
now that I've tried it so many times I
love it and if it was a holiday without
it on the table I'd probably be outraged
that's so interesting okay so why do so
many animals go straight for the liver
it's a good question I I just read about
some orcas off South Africa that have
been killing sharks and eating only
their liver and leaving the rest of it
which I find very interesting
um I guess they have good taste probably
as part of it but um they you know I'm
not really sure why perhaps there's a
are they going because of a nutritional
deficiency I it's possible you know
there's a lot of nutrients in liver it's
one of the most nutrient packed thing
you can put into your mouth not only
iron which contributes to The Taste but
a variety of other things as well
uh I don't know why animals go for that
but that's a fascinating topic like
which body parts do animals go for first
often it's the internal organs uh
sometimes it's the bone marrow which is
very fatty and a great source of fat I
mean polar bears will often eat all the
fat off uh seals as the first thing but
in the Arctic it's a particular matter
of kind of calculating nutrients and fat
is clearly the source of nutrients that
everybody needs just because it's so
nutrient dense and calorie dense so I
think that's an interesting fact but
what is the process there of the Hume of
the animals are they considering oh am I
in the mood for the meat today am I in
the mood for the liver do I does my
tummy hurt so I'm going to avoid the fat
today I'm not sure that that kind of
processing happens but I do wonder I
also wonder for instance how do
adolescent Lions know to bite the
animal's neck like how do they know
that's going to kill them is it just
because they saw their parents do it is
it because they understand something
about the physiology and that's where
the big blood vessel Czar I'm not really
sure maybe it's just what their parents
taught them to do that's interesting
again not afraid to have a hypothesis
I'm perfectly willing to to find out
that I'm wrong trust me I'm not dogmatic
but
um
interesting right turn here into other
elements of your book which get into all
of our organs including our sexual
organs if I had to guess the biting the
neck is very akin to as a guy thrusting
deeper when you orgasm which I always
found super weird like all of a sudden
this one thing feels so it it is the
thing I must do it feels so right I'm
like this is just making it better
nobody told me to try it just every
impulse that I had was like do this the
same with lordosis I don't know if
you've heard about that and who knows if
this research is actually true but I
heard something and I was like oh my God
that makes so much sense that women
actually like the feeling of that
posture where you're arching your lower
back a little bit I was like that would
make sense because in certain positions
it's going to allow you the ability to
penetrate more deeply which is going to
increase the likelihood that you get
them pregnant so you put together the
woman wanting to Arch her back and the
guy wanting to thrust deeper right at
the moment of climax it's like okay like
that makes sense so for a juvenile lion
to just have the the Instinct I don't
know what better word to use for it
where it just that's the most attractive
part so when you're going for it every
Instinct you have has like honed you in
on the neck because from an evolutionary
perspective those that did that got more
kills and thusly live longer I mean
that's obviously a guess but from an
evolutionary perspective that makes a
lot of sense to me yeah that makes sense
you know the lions that were had the
instinct to bite the tail didn't survive
as much because they didn't get as much
food to the ones that
um you know went for the neck and maybe
going for the leg it makes you more
likely to get kicked in the face or
something so that doesn't make sense but
but yeah I think you know that that uh
that desire to thrust is kind of part of
the sexual desire
um you know just the feeling you have
when let's say when when you're turned
on it's almost like nothing can stop you
from completing the act and clearly
that's part of the the intelligence of
the human organism is that like nothing
will get in your way from completing
that act because that's sort of what the
species has has to have to survive
um and then you know it's soon as the
orgasm is over everything is different
and that desire just like completely
disappears it's almost one of the few
ways or instances in which physiology
really turns on a dime and goes from
this unquenchable urge to this
completely different state in all these
hormones and other things are released
at that time as well but yeah I think
you know there's an intelligence to what
we do even if we don't understand it and
some of that is Instinct what is
instinct is it stuff we unconsciously
picked up from our parents is it stuff
that's just uh you know in our genetics
I don't think anyone knows but maybe
we'll know more in the future yeah
almost certainly true as we look at ai's
ability to track so many data points and
just the you know when you think about
we're good at large language models
right now but we will for sure I mean
this is again I don't know for sure but
it seems inevitable that we'll start
being able to put other data into AI it
will be able to go through find these
crazy patterns and begin linking them
all AI is super fascinating have you
thought about where AI is going from a
medical standpoint definitely quite a
bit and I do think the processing power
and I of computers in general has help
been helping with epidemiologic studies
such as nutrition and I would love to
see AI play a bigger role in in these
sort of large multinational studies on
things like nutrition and salt and
saturated fat and other things I think
they could probably do a lot more
hopefully in an unbiased way to help us
understand things and I think more
processing power is needed and better
statistical methodology can help so I'd
love to see AI be applied in that area
you know I think AI it's been uh I mean
it's been getting better and better some
of my colleagues have I one of my
colleagues in fact uses chat GPT uh for
has it open on his computer while he's
working beside me in the ER and uses it
uses it to help him you know does he
need it I mean he's been at this job for
years without it but he just started
using it recently and actually finds
that it helps him write some of his
notes or at least some of the things
that we have to put in our note is uh we
write a note on every patient we see of
course otherwise nobody gets no one can
Bill no one gets paid and we get angry
letters from our employers but in that
note you have to put your differential
diagnosis meaning what could this be the
patient came in with XYZ I found ABC on
the exam the labs show you know EFG uh
what could it be and you give a list of
things traditionally in order of
decreasing likelihood like it's most
likely this but could also be these
other five things chat gpt4 is really
good at giving you those differential
diagnoses and I've done it with him just
for fun and it came up with just exactly
right like exactly what I would have
written
the other thing is even Google for years
you know a lot of doctors poo poo doctor
Google but Google is great at making
diagnoses
um especially of rare syndromes you know
you could put in for instance blood in
the urine and coughing up blood and it
will one of the first two hits will be
something called good pasture syndrome
which is something all medical students
learn about a rare autoimmune condition
where where you uh you know there's
blood in your urine and blood in your
sputum or uh I the other day I looked up
uh swollen joints rash blood in stool
and the first hit is something called
hennox online purpura which is a not too
rare condition in kids and it gets it
exactly right and a lot of things are
like that have you compared Google to AI
I I have seen it done on AI and it does
it better I mean the same if not better
but it's definitely good at those uh
those rant those rare diseases that have
a very particular constellation of
symptoms like that Google's been good at
for a while decades since it's been
around basically
um I think it's harder for instance to
say let's say this person with a fever
and a cough did they have just a viral
respiratory tract infection or do they
have a pneumonia that needs antibiotics
that's a bit of a finer uh a finer point
that I'm sure AI will get much better
and be better than humans you need to
interact with the patient in some way
yeah so so it's almost like um you put a
whole bunch of Clues together you know
there's not one uh yes or no answer
there's very few yes or no answers in
medicine blood tests even Imaging
there's a lot of x-rays that you could
show to multiple Radiologists and some
will say it's pneumonia and some will
say it's not pneumonia I've worked in
rural hospitals where the Radiologists
seem to call pneumonia on every single
x-ray I do no matter what uh even if the
person doesn't have any symptoms of
pneumonia they don't know that they're
just looking at the X-ray and so a lot
of it is you know we talk about the Art
and Science of medicine it's a lot more
art than science to be honest um and so
no two artists will paint a picture the
same way no matter how much detail you
give them about what it should show and
in a similar way you give the same
patient to different doctors they will
end up diagnosing them differently so to
know yeah you have to put together Clues
so talking to the patient how have their
symptoms been their Vital Signs is there
a fever is there oxygen low uh listening
to their lungs even watching them from
across the room how they breathe that is
a very important skill I try to instill
in the emergency medicine residents I
work with in Camden New Jersey at Cooper
Hospital
it's almost more important than
listening with your stethoscope to what
the lungs sound like it's just looking
how someone's breathing and picking up
the very subtle clues that they are
struggling to breathe or having what we
call respiratory distress it's almost
like a sommelier reading all these
details that others would miss into the
taste and smell of wine and you you have
to train yourself you have to look at
thousands of people breathing both both
normally and abnormally to to kind of
refine your sense of of is this normal
or is this not normal if you want that's
hard if you walked into an ER
um little Bay and didn't know anything
about that person other than they need
attention what's the sequence that you
go through to diagnose what's going on
assume they can't speak and I and I
don't know what they came in with
because usually I have a sentence of
information assume you have nothing and
they can't they can't speak to you one
of the first things I'll do just looking
at the patient you actually get a lot of
information from their skin believe it
or not so uh the skin can take different
tones in different kind are critical in
this I had a patient once who had a
perforated ulcer in the stomach meaning
the such a bad ulcer that actually
ripped through and released Air and
stomach contents into his abdomen oh and
he was Green
and and I looked up at I saw his skin I
looked up at the monitor the nurse had
already put him on the Monitor and his
heart rate was 130 so very fast and he
looked like he was in pain and he looked
sick quote unquote and when doctors and
nurses use the term sick that's what
they mean by sick like whoa something
terrible is happening and we need to
like we need three other people in this
room right now to start everything and
figure out what's going on you know when
people say and I think it's funny
because a lot of you know the way
parents use oh my child is sick that's
not the same word that doctors will say
when someone is sick it's like they
either need surgery like now or they
need to be in an ICU or or they're gonna
die if we don't do anything
um so so a lot of it's from the color of
their skin and I think doctors talk
about Gestalt also meaning just sort of
overall picture like how does it look
does it look like something bad is
happening or not and I think a lot of
that has to do with the color of their
skin I had a guy just recently who came
in with sudden onset left-sided chest
pain and couldn't breathe and he looked
gray his skin I was like oh boy I ended
up he had no breath sounds on the whole
left side of his chest and when I did an
x-ray I saw he had a collapsed lung whoa
so a hole in his lung had sort of torn
not not too dissimilar from the hole in
the guy's stomach with the ulcer and air
had escaped from the lung into the space
between the chest wall and the lung and
the lung had collapsed so I could not
hear any breath sounds on the entire
left side because there was no air
movement the lung was collapsed down and
not up against the wall so I couldn't
hear it
he needed a chest tube so one of them
started to get the air out he had to get
the air out because that air was you
know that lung couldn't expand against
it it was sort of air locked into that
space between the lung and the wall we
call that a pneumothorax
so one of the most brutal things I do to
people I give them lots of pain medicine
and numb it up beforehand but was
basically make a hole
sort of under the armpit between the
ribs through muscle fat membrane and
then into the space and when you pop
through it's like
I mean that air rushes out and it was
like under pressure in there and uh how
do you stop it from getting back in so
it wants to come out but then we
actually put a tube in and then close up
the hole around the tube how do you
close the original hole that allowed it
to leak in so it heals itself actually
quick yeah the hole in the lung heals
itself usually
and then or just like shuts itself you
know just by just like blood will clot
toward a membrane that has a hole will
sort of stick back together
um and so as he breathes you know that
lung is expanding and just sort of
pushing that air out and you you also
use sort of complicated physiology but
you use a water seal where you put that
tube end into water and air is bubbling
out but air can't get back in because
there's that water sort of blocking it
yeah it's almost like a fermentation
lock um if you're brewing beer or making
alcohol sort of a similar process where
air can bubble out through it because
you have to release all the CO2 that the
yeast is producing by fermenting the
sugar I want to never figure that out
the first time but air cannot get back
in
um so it's very similar process
fascinating yeah so the human body is
just like a vat of brewing beer
basically that's exactly what I would
have said yeah now it's so interesting
so diagnosis is something that I'm
really fascinated by the ability because
you have to do this in business so I'm
constantly doing this in a business so
you're trying something it's what I call
the physics of progress you're trying
something it's not working or at least
it's not working as well as you wanted
but you have to figure out why it's not
working and then your ability to
accurately diagnose the problem is
everything and so in business it's
twofold you have to diagnose the problem
and then you have to figure out what new
thing you have to do in order to fix it
I imagine this is exactly what you're
doing in the body so going back to AI
diagnosing the problem where would you
assume you have the sensors to collect
the data where would you put the sensors
in AI if you were trying to you know
just going back to what what is the
optimal way to live
where would you put the sensors is it
um you put them in the sewage you put
them in the grocery stores like where
where would you want to read the data to
get at a population level uh what's
happening that's an interesting question
you're not talking about like an
individual body where would you want to
go population for yeah now we can then
boil it down but this will help me
figure out what are the things you think
we should be paying attention to you've
been very clear about physical activity
so I'm guessing there's something we
would want to track there
um but I don't know where else you think
at a population level we need to
understand
that's a good question I guess you know
the the affluence of the body are one
thing and sort of the flow of yeah like
things flowing out from the body so
everything that comes out of us feces
urine tears sweat
um and so what what are the societal
equivalents of effluence I guess you
know what's in the sewage is certainly a
big one
um I guess that's our kind of our main
one you know you could think about
exhaled air
um there's a lot of studies actually on
measuring let's say diagnosing lung
cancer by looking at uh exhaled air you
know is there something that some
peptides small proteins or other markers
of a cancer that people are exhaling or
even in like head and neck cancers like
of the throat the back of the tongue the
larynx Etc are very common in uh parts
of Asia
perhaps partly due to chewing battle nut
and chewing other things that are might
be carcinogenic if you're chewing
massive amounts of them all day every
day for decades
um and so there's a lot of studies on X
you know a simple fast uh um screening
test where they could just exhale into
something and it could perhaps read
markers of a tumor I do think that's you
know that is something AI can help with
right look look at analyze the stool of
a million people 500 000 of them don't
have colon cancer and 500 000 do and
what does their what's in the stool of
those you know more in this tool let's
say of the people with the cancer than
not I a lot of these things are in very
small amounts which make makes it hard
but I do think that's something that AI
could could help with and if we have
those sorts of screening tests that
would be so much better than what we
have now you know there is no screening
for so many kinds of cancer pancreatic
ovarian and other common ones or even
lung cancer you know there's some debate
about should heavy smokers get a CAT
scan every year to look for tumors and
it seems like that might be the benefits
might outweigh the risk there especially
in heavy smokers but it's not clear
because the risks are you have to do a
radioactive dye no no just the radiation
of the test itself so like a CAT scan is
not a it's not a radioactive diet other
Imaging in medicine is but it's just uh
you know a CAT scan is kind of like a
few hundred x-rays from every angle and
then the computer puts that all into one
3D image so you get slapped around this
radiation yeah it's like hundreds of
x-rays you know it's almost like taking
an x-ray from every side and then using
all that to create a 3D image which is
how it works but it's radiation you know
it's not great but it's sort you know
like in every everything in medicine
it's do the benefits outweigh the risks
and nothing is risk-free
uh so it's all a matter of uh man you
know figuring out that balance and and
the calculus might be different for
different people I often talk to people
about you know the risks and benefits of
certain things and I I say we could do
this or we could do that you know and
there's benefits to doing both ways I
don't think one way is right you know
what are your what are your values what
do you want to do what do you think is
best for you so you you don't think one
way of treatment is right because of
value systems well sort of like uh let's
say someone has a a very early skin
infection
um and some doctors would just say oh
put some antibiotic cream on it and keep
an eye on it and come back if it gets
worse and other doctors would say oh
start these oral antibiotics right now
and you know I often this is exactly how
I say it to people you know I say
neither is wrong both of those are
acceptable let's say but are you the
kind of person who wants to jump on this
infection who wants to jump on
everything and be aggressive with
treatment right away and you're not
afraid of the possible side effects of
antibiotics then sure I'll give it to
you or are you the kind of person who
wants to only take antibiotics if it's
absolutely necessary and would rather
just sort of go the go the the way of
using an antibiotic cream and keeping an
eye on it knowing that there's a risk it
could get worse and you could end up on
antibiotics in a few days from now and
it might be at a more progressed State
than it is right now you know that's I
don't think either of those are wrong
because many of those infections will
turn around with antibiotics so what's
the right thing to do I feel like that's
um a big part of the debate about what's
the right thing to do is difficult and
that goes back to the art of medicine
you know it's sort of value judgments
and so I like to give patients the I
like to put the decision making in their
hands you know I have the key to the
prescription medicines because I'm a
doctor but I'll often even sometimes
give them a script and say only fill
this in a few days if you're not any
better you know you make the decision
here's the prescription for the
antibiotic you decide for yourself
because either way is right there's no
wrong answer waiting is not wrong and
jumping on it now with an aggressive
treatment of antibiotics is not wrong so
I feel like I'm a consultant for people
you know I'm a plumber I'm I'm advising
what is the problem here are some
solutions you know you decide what's in
your budget what you want what you want
to get out of life what's important to
you what you're afraid of and and you
make the decision what's up guys it's
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do this
what do you do with people that feel
like uh I don't know enough to make this
decision so my extended family is going
through something now and it's been me
reaching out to everybody I know that
might be able to offer a new angle
because it is really complicated and you
know for all of my self-confidence even
I'm like this a the risks are
extraordinarily high and B I want as
much information as I can get but when
everybody's like well I don't know
there's no right there's no wrong it
gives a hopeless feeling it's like I
want somebody even if they're a little
cowboy I want somebody to be like I
think like I would much rather a panel
of five people who have five very
distinct different takes but they're
like my way is right and it's right for
these reasons and you should do it for
this reason and then I can synthesize
the five very strong opinions but the
place I don't want to be is everybody's
saying well it doesn't really matter or
one way or the other the the bad news is
that may be more accurate but I'm
curious if values is driving that or if
it's like
the outcomes are so complex that it's
all a trade-off to quote Tom Soule yeah
I think I think that um a lot of times
you know people will say just tell me
what to do doc what would you do or what
would you do if this was your family 100
would be the first question and that's I
mean I tell my family members to ask
their doctors that question I think
that's a very important question do I
think all doctors answer it honestly no
but I think the large majority do
um but you know I think I think that is
a good question I think also sometimes
the doctor's decision-making abilities
can be hampered when it's a close
relative or someone they love
um why because they're not being
dispassionate they're not being
dispassionate I think there's uh a lot
of stuff that goes into you know people
want to have doctors with a good bedside
manner who are compassionate and
empathetic and feel their pain and
that's very important but when things
get complicated or urgent or emergent
you you want that dispassionateness but
wouldn't the so I I understand that in
the medical field this is like hard and
fast so there obviously is a reason but
I don't yet understand it so one would
think as long as it wasn't the person
performing the surgery because then like
if it's a mom and she has to do heart
surgery on her child like I could get
how
um you know just the the physicality of
needing to be super calm like you're
you're going to be hopped up right but
in terms of like you would spare no
expense you would do whatever you
thought was in their best interest so
from an advisory role why isn't it
advantageous to know and love the
patient
it's a good question I I think that that
has a lot to do with how the human mind
works and how emotions can some
sometimes get in the way of your
rational decision because you don't want
to see them in pain and so you might not
recommend the right treatment yeah I
think that could be part of it you know
your emotions can get in the way of the
steadiness of your hand let's say if
you're doing surgery on your own loved
one but I mean it seems like all day
every day our emotions can get in the
way of our risk benefit analysis or our
um you know rational understanding of a
problem and what we think we should do
yeah sure fear of painful procedures
let's say fear of side effects I mean
even each doctor the way we practice or
the way we make decisions or the way
we'll say oh this is a better course of
treatment than that has a lot to do with
sort of what we've seen before the kind
of patients we've seen or maybe even the
bad outcomes we've seen before like oh I
saw someone who had a very mild
infection that progressed to something
deadly three days later I'll probably be
more aggressive for the rest of my
career in treating those early infection
infections more aggressively with
antibiotics and as a doctor you really
never forget I mean I've been practicing
for just over a decade so it's not that
long but you I still remember cases from
being a med student when either
something went wrong or something was
just more severe or surprising or the
outcome is really bad you really never
forget those cases um and I think that a
doctor's decision making is is
warped and shaped by the worst things
they've seen which makes me wonder of
how thing you know let's say a trauma
surgeon who sort of all day deals with
the worst possible thing that could
happen to people when they walk out the
door each morning and how they go home
to their kids and sort of have them walk
out of the house and go to school every
every day I mean there's a lot of
compartmentalization there's a lot of
sort of work brain home brain
um and and I think those can get in the
way of each other which could be a
problem when you're trying to let's say
diagnose or plan a course of treatment
for your loved one what's the worst
thing you've seen
ah the worst thing I've seen well I
guess there's you know there's worse in
terms of disease
um cancer in young people is probably
among the most horrific you know as an
emergency room doctor I diagnose a
surprising amount of cancer because
people come to the ER with whatever it
is belly pain blood in their stool
trouble breathing and it's sort of like
I end up finding it and having to
deliver the news
um you know I mean cancer is terrible in
any age even the elderly but it does
seem like young people
um with families let's say are just it's
really impacts you to see that just
sometimes it's a matter of chance they
just had bad luck maybe the random
chance of genetic mutation
um you know whether sometimes it's their
own fault you know if they smoked for
for decades and now have lung cancer but
even that there have there's some
compassion there you know it's never
really someone's fault even if even if
they're putting the cigarette to their
mouth every day or drinking the alcohol
every day there's always something
beyond their control it's part volition
and part out of their control
but then there's also the the what
people do to each other I mean that's uh
we see a lot of that in the ER we see
the results of violence between people
the results of abuse and child abusions
and sexual abuse
um and and something where actually just
the other day I had a young female
patient and we suspected she might be a
victim of sex trafficking the way the
there were two adults with her and the
interaction was a little odd and there
was another person waiting outside in a
car without estate plates and we were
all sort of like what's going on and
that just you know those kind of
horrible things
um have to go through your mind you know
a good ER doc every time a child breaks
a bone they will ask themselves could
this have been done intentionally by an
adult whoa you have to because it's so
common
um do you still even when you ask that
do you still miss it yeah you probably
report parents where it's not their
fault you probably don't report parents
where it was their fault
um and you have to sort of live with
knowing that you're missing that and you
know for this girl we one of the nurses
took her aside and started a
conversation you know you don't just
come out and say are you being text
trafficked and but there's a lot more
awareness these days of sex trafficking
so I work in a few different Hospital
systems and there's been many emails
about being aware and this is the
hotline to call if you suspect and
um just more awareness um that it's
happening
um which is something that ER doctors
perhaps they're not always as aware of
but all the worst things that happen to
the human body come to the ER all the
worst things that people do to each
other often end up in the ER so you just
see this side of humanity and what
happens to people that's just can get
you very down there's a lot of burnout
in emergency medicine some of that's
just the workload and the intensity but
some of that's probably just um being
that interface with the larger society
there where you know it's the safety net
of the safety net it's like everything
just goes to the ER and so you see all
that stuff and have to have to be aware
and have to think you know you have to
think people are horrible keep that in
your mind and could it be some horrible
person did this to someone you know you
have to think about that kind of all day
woof that's rough yeah so in all that
obviously I know the examples from the
book but what what is the encounter that
you've had that most stuck with you and
we'll do we'll do the worst one and
we'll do the best one just to to balance
out cosmically sure I think that um
you know I in the book I wrote about
this young guy in his 30s who had uh
terminal gastric cancer and that really
impacted me I was a resident I was
working under an oncologist and this guy
was just wasting away like nobody had
ever seen him it was early in my career
his hair was falling out he was Skin and
Bones could not keep any fluids down
just like nothing would say in his
stomach food or drink and his you know I
admitted him to the hospital and his
young wife was there and their two young
kids who just looked totally bewildered
and just I mean I cared for him for
about four or five days while he was in
the hospital and it just
um part of it was impacted me because
what I was doing felt so useless because
it was so clearly not going to change
the outcome here I mean so that's why we
try to focus on pain and discomfort and
nausea and whatever he needs to make his
last few days weeks months on Earth less
painful
I mean that's one of the one of the
powers of modern medicine is not just
curing disease but alleviating suffering
um and so that was a really impactful
for me just I didn't have a family
myself at the time but still just seeing
the impact of this guy uh what's going
to happening to this guy's body on his
family was just very dramatic and
something that really stuck with me and
that that's common actually so the
dispassionate gaze of the doctor you
know I see a lot of people coming in on
death's door I see a lot of people who
have cancer are dying of cancer the last
uh ditch effort at chemo didn't work and
now they're back with worsening symptoms
I see that a lot and a lot of times even
when people die in front of me
it doesn't always hit me until their
family comes in and then are just
devastated and then it's like wow you
know it that that's when it really hits
you so I mean physiology is fascinating
and death is physiologically fascinating
like what actually happens in your last
minutes
um you know why how does trouble
breathing lead to low oxygen leading to
cardiac arrest and that's where the
death comes in
um I was fascinated with that as a
medical student like how do people
actually die how does the how does the
disease eventually stop your heart which
is kind of the last stop in death and it
it's interesting objectively but then
the family comes in they're devastated
um and then it really hits you that this
is a person and you know just um what it
means what death means physiologically
it means something interesting but
socially emotionally in the family it
means something completely different and
sometimes being a dispassionate doctor
you can lose sight of that but I find
whenever the family comes in it's like
you real you get punched in the face
with what it actually means for someone
to die I
so those are some of the toughest things
how do you how do you deal with death
how do you personally compartmentalize
or otherwise
you know I think I'm really good at
compartmentalization
um you know I
probably don't drive super I mean I'm a
safe driver but I probably am not
careful from time to time or I know I am
uh maybe drive a little too fast even
though I've seen people die in exactly
that situation driving too fast glancing
at their phone too much while driving
um you know not fully stopping at the
four-way stop sign whatever
there's only so much those lessons can
impact your own life
but I do think like doctors are just
really and other people too who deal
with let's say you know dead bodies
let's say a corn or a funeral home
um you know the humans is very good at
compartmentalization and as where you
just lock it away do you worry that
there's a Day of Reckoning for you
having been around this so much like I
could not do
what doctors do I know you've walked a
maybe more walkable path which maybe
we'll get into in a minute but
um I've often said I could never be a
paramedic you were or a trauma surgeon
Jesus you're dealing with people on
their worst possible day I just don't
want to be around that all the time so
is there a Day of Reckoning coming for
you where you've bottled up these
emotions or do you have
um a way of framing it that allows you
to accept it I don't know yeah I think
I think that it's just a way of another
example of how humans can get used to
almost anything just like a lot of
squeamish people got used to dissecting
the cadaver medical school I think when
you do it day in and day out humans are
just really good at compartmentalization
I think people are really good at
getting used to things that seem
horrific and carry on carrying on with
their daily life you know a lot of the
guards at Nazi concentration camps were
family men who went home and hugged
their children read the book ordinary
men
I've heard of it I haven't read it same
I I don't know if I'm if I'm up for it
um people do horrible things during
their daily work hours and then go home
in our loving loving parents let's say
or loving siblings
um and in the same way you know you can
see death and destruction during the day
and then sort of still be
psychologically normal and available to
your loved ones emotionally
I just think humans are really good I
think that's part of our uh you know
survival strategy where our bodies are
really good at dealing with the
Practical everyday complications and
problems of daily life and getting
nutrients from our food and rebuilding
our bodies and we're also
psychologically really good at
compartmentalizing
um and and carrying on with life you
know despite having witnessed or
experienced horrible things there's
always sort of the there's a maladaptive
response you know there's the
um like sort of the extreme result which
could be things like PTSD which
certainly can impact you
um but you know a lot of people who
experience traumas like don't have that
I mean a lot of people do a lot of
people don't something we should learn
more about why why certain people have
more why certain events cause uh cause
it to happen more
um but I just think humans are really
good at compartmentalizing and I can
think about my patient who is in a
horrible car wreck while I'm driving in
the car with my kids and not have a
full-blown panic attack or even be that
anxious and I don't know maybe that's is
that the odds are on my side
you know I'm not sure I'm not sure it's
irrational uh calculation that leads to
me saying well it's very uh
statistically unlikely that I will have
the same result as that person I saw the
uh the other day
I think it's just more emotional Walling
off I mean the organism has to focus on
the task at hand has to get through the
whatever it is the meal the day the car
trip from A to B and we're just very
good at focusing and putting kind of
those things out of our mind I think do
you think about your own death
yeah definitely
like early on in covid when I was seeing
doctors get sick and I mean none that I
knew got you know died but just hearing
reports from Italy let's say when things
were exploding there the hospitals were
exploding there and we were all like
holy this is coming this way
I mean I filled out a will with my wife
like early on
um in fact the hospital system had a
notary public like available all the
time for people to fill out their Wills
which was super morbid and all these
people started filling out their Wills
um but even you know I even that it was
that was more of a rational thing like
yes I should have a will
um just in case probably should have had
one already at this point so why why not
just do it now but even I wasn't the
most
um worried about covid as things went
along now that's another thing you know
you work all day in the ER you're seeing
a lot of covid patients
you know are you really gonna like not
pull your mask down a Sip Coffee water
eat like you're still you you can't be
perfect and the human is good at taking
risk and almost Walling it off like an
abscess just like our body sort of walls
off infection uh and psychologically we
do the same thing I think we're really
good at Walling things off and going
about our daily life so when you think
about your death so there's the element
of Fascination right so we understand
what's your you understand what's
happening at the cellular level
um do you use that Fascination as a way
to
um soothe yourself and do you think
about like is there an ideal death that
you want other than obviously just I'm
asleep and I don't wake up right I
definitely you know I've seen a lot of
people die and like I've seen it right
there like right in front of me going
from heart beating to not beating often
we're we're doing CPR trying to revive
them and then giving up
um so it's sort of like and I you know
the first thing I do after I say okay
cease efforts that's what I'll say is
stop compressions and I'll look up at
the clock on the wall and say time of
death is whatever and I'll read it and
someone's taking notes
um and writes that down so it's almost
like I'm declaring the death or everyone
knows the person's dead you know I'm
just sort of making it official and
there's paperwork involved and so
um there's that part of death of course
but I think you know to be honest to
live until 80 or 90 and have a massive
stroke and die
I'd sign up for that if I could
um my stroke I saw that happen first
hand it didn't look fun
I I let me add massive enough that you
don't have time to be brought to the
hospital so that doctors can
try to you know pound on your chest and
revive you and make you sort of bed
bound for the rest of your painful life
I mean like instant death would be nice
but um yeah I'm doing it via stroke
is you're taking out cognition so you
don't you don't get to process the uh
pain suffering is that why Stroke versus
like gunshot or car accident I'm trying
to because I I have thought about this
too yeah I mean I probably think about
it more than um the average person but
no I think it's more so stroke
um well first of all let's say heart
attacks a lot of them are very painful
really very painful just a horrible
crushing chest pain trouble breathing
you don't always die right away I mean a
lot especially nowadays a lot of heart
attacks get saved and I'm not saying I
want you know I don't want a mild heart
attack if I'm gonna get a heart attack
make it the big one that kills me
instantly I guess that's not what really
what I'm saying but
I think yeah a stroke especially like a
hemorrhagic stroke you know The Strokes
where there's a blood clot blocking flow
to the brain part of the brain those
you're often conscious for and just
let's say half your body stops working
or you suddenly can't talk or get the
words out or you're dizzy
um I mean like a big hemorrhagic stroke
that basically makes you unconscious
three seconds later and you never wake
up
there's probably a fraction of a moment
where you have a horrible headache but
it's probably very short
and I actually have a I know a friend of
a friend who died recently that way he
was 87 massive stroke and you know no
one was there did he did he like kind of
flop around in pain for an hour before
dying no one's sure but
um sometimes it's pretty instant or as
instant that as things get so I don't
need to live to 120 you know 85 with a
huge stroke
I'll take that interesting why that
seems so young to somebody like me who
wants to if I'm honest live forever but
I'll take 120 over 85 all day are you
imagining yourself in firm is that why
yeah so I think I think what I'm
imagining is sort of prolonging life
um you know with multiple let's say
multiple chronic illnesses and sort of a
degradation in your mental capacity your
physical capacity do you have a living
will a do not resuscitate or no ordinary
measures I I basically have one that
just says my wife will make the decision
um interesting yeah Terry shivo doesn't
come to mind like this can get Gnarly
yeah I mean I think my my wife is a
bioethicist so sure okay so she's dealt
with these questions before but uh I
trust her and we but we've talked about
it and neither of us wants to live in a
veg persistent vegetative state but um
we've talked about all this stuff uh but
so I trust her to make the decision you
know and when I talk to relatives let's
say of someone I'll often say what would
they want you know what if they were
still able to talk to us what do you
think they would say they would want and
so that's the the framing is sort of for
that person the power of attorney or the
loved one who's making decisions for you
they should think what would this person
want
and really like my wife is probably the
best to
know what I would want in that case um
all right if you had a slow painful
terminal illness let's call it cancer
would you uh do assisted suicide
oh that's a good question
um
you know I mean I've seen I the pain
associated with certain kind of cancers
does certainly seem horrific and even
sometimes the strongest painkillers is
not enough that's a common thing people
come to the ER for which is I have a
known cancer I'm getting treatment for
it but just the pain medicine I have at
home is not working I'm in severe pain
and I'm you know doctors we have our
issues with giving strong painkillers
and opioids
um and I'm much more we call it
conservative than most where I try to
avoid them at all costs but if someone
has cancer pain I often say to my
colleagues and nurses like they can have
whatever they want what are you worried
about happening addiction uh yeah
addiction is basically the main thing
um and you know we have a lot of that
going on in America partly been fueled
in the past I think by the medical
establishment handing out a little too
many not only the sort of pill Mill type
doctors who obviously were committing
various I would say crimes against
humanity and their profession but
um even just doctors sort of handing
them out more freely you know that has
largely abated quite a bit
um but yeah you know you just want to
any Med every like risks and benefits
every medicine has risks you want to
give the least uh strong medicine that
will get the job done you know for any
infection you want to give the narrowest
antibiotic you know if penicillin is
going to work or amoxicillin use that
100 year old antibiotic that kills a
very narrow spectrum of bacteria don't
use the new fancy uh whatever mycin that
kills every living organism just to kill
the skin infection you know you want to
narrow things you want to Target your
treatments and you want to focus and in
the same way you know if Tylenol and
ibuprofen are going to take care of the
pain like you know why get someone
started with opioids not to mention the
constipation holy moly I mean people
come to the ER for that a whole lot you
know they just have worth a piece of
orthopedic surgery we are for
constipation just for severe yeah have
they even left it like days and days and
days or they took the laxative their
doctor prescribed and it wasn't strong
enough and they didn't know what else to
do and the pain is severe or they didn't
take the laxative correctly or they
forgot to fill it and now they're paying
severe you'd be very shocked at what
people come to the ER for though some of
some of those cases are are worth coming
to the ER because
um they just don't know what else to do
and are you know really suffering but
also I do one of my big things is I feel
like the public is not really educated
well on what what they can do with
over-the-counter medicines like we have
so many over-the-counter medicines
available and other treatments uh you
know and but people just don't know what
to take like don't know what to do
um and there's no great resource for
them to go to to say oh we'll try this
one if that doesn't work try this you
can take this one twice a day if it
doesn't work once a day add this on but
don't stop the original medicine you
know stuff like that like a strata I
would love to see a press release from
the government to all the American
people like this is what you should do
if you're constipated I mean you could
walk down the aisle in Rite Aid CVS
Walgreens there is as many uh laxatives
to choose from as there are kinds of oil
and fats to fry your food in it is like
a you know Shangri-La of choices and but
people don't know what to take so I feel
like we need there should be a high
school course about what to do when you
have a fever what reasons to seek
medical attention what to do when you're
constipated things like that well I have
to we'll have to get you to like start
tweeting these out
um okay so what is the most shocking
thing that you've seen in the ER that
I'd be like what is happening
hmm shocking well definitely let's see I
mean there's a lot of you mean
shockingly bad or just shot just
shocking because it at one point in the
book you said something like every moist
orifice that we have people stick things
into which is a very common reason to
coming into the ER and I was like oh God
uh is it that
um you know I'm certainly not shocked
that people put things in their orifices
just because I know they do
um and that uh sometimes they can't get
them back out I've definitely seen
people with like a one guy had a foam
ball in his rectum that had gotten a
little too far up a foam ball of all
things to try that one has no handle the
Striking very bad idea right I've seen a
I had a woman with a vibrator and her
rectum was still vibrating oh God and
when I pushed on her stomach I could
feel the vibration and then like we were
getting I got an x-ray I was chatting
with the surgeon that at least had a
purpose the foam ball instead of more
yeah but actually thought the batteries
ran out while she was there
right so MRI is the problem but x-ray
CAT scan is fine got it
um so I've definitely seen a lot of
those things I had a patient who oh this
was shocking uh actually it was my
friend's patient I didn't see them but I
saw the X-ray which is very impressive
it was an adolescent who was had a
string of little magnet balls like the
little metal balls and it was like
Buckyballs kind of thing
um there's totally because if you're
actually a string no they're no string
it's just they're attached by their
magnetic attraction like Buckyballs
little ones and he was using that string
to
um in his urethra oh God yeah and so I
guess it went far enough back that it
got into the bladder hooked around and
sort of grabbed itself in and the whole
chain ended up in his bladder it like
pulled itself in my God
so he needed an orthopedist sorry a
urologist to go in there with a scope
and um get them all out but that was you
can get them out with minimal uh
invasive or do you have to cut no you so
with a cystoscopy
um you know medical technology is very
good at being able to peer deep into all
the orifice is the human body and grab
stuff and take it out
um and so the through a cystoscopy scope
in the bladder you can grab lots of
things is he awake for that
um he's either completely unconscious or
in a very very sedated state so we do a
lot of what we call moderate sedation
where people are out but breathing on
their own
ketamine is a huge one for that state
and kind of a miraculous drug for that
purpose but um you know when we're
straightening a bone sometimes when
we're straightening a dislocation
putting it back in place uh sometimes
when we're even doing abscess cutting
open abscesses which can be incredibly
painful we put people in that state
where it's not general anesthesia where
they need a machine to breathe for them
but they're breathing on their own but
they're definitely not there at all
which is probably one of the most
powerful and useful abilities that a
modern doctor has or as an ER doctor
that I can do is I can send someone's
mind off to another planet while I'm
being a complete brutal you know uh so
brutal with their body doing things that
would be you know the worst form of
torture if they were still there
what are they doing so it this is called
Twilight right
um yeah Twilight that might refer to a
slightly less deep level of sedation
this sort of all various um levels of so
when you blast somebody into outer space
but they are still there enough that
they don't need a machine to breathe for
them are they mumbling are they talking
to you are they no they're silent
they're out yeah but they're so that's
actually one one reason that ketamine is
so useful I write in the book actually
in the brain chapter that many many
sedatives
us also suppress your breathing Drive
opioids do that benzodiazepines do that
barbiturates do that propofol does that
but ketamine does not it sends your mind
to another planet but you are breathing
your heart's beating your blood pressure
is fine
um so it's it's a dissociative because
you look asleep if you're totally yeah
you look asleep interesting your eyes
are uh ketamine gives you this nystagmus
we call it where your eyes are bouncing
back and forth but usually these are
closed your eyes are closed but if you
open them you'll sometimes see their
eyes kind of going back and forth
um
but yeah and then sometimes then they
come out of it with ketamine sometimes
people can be very scared or even
psychotic and paranoid and kind of
aggressive or agitated and so this side
effects to everything including that but
yeah it is a very interesting process
and it's so routine even you know I do
that so often um when setting broken
bones and other things
sending someone's mind to another planet
is just part of my daily job I've heard
about people getting their bones set
while they're conscious and I thought
that sounds like the cruelest thing in
the world so was that just this is
pre-ketamine or well so no even before
ketamine there was various other
medicines that you could give they
weren't as safe because they might
suppress breathing more but there was
definitely you know for so why do so
many people have stories about having
their bones set whilst awake that seems
crazy right well sometimes
um you can actually inject a whole lot
of Lidocaine or some other you know
novocaine type of medicine all of which
are derived from cocaine the original
cane which is an anesthetic you know if
you ever rub it on your gums it gives
you uh it gives you numbness there and
so we use various kinds of canes
bupivacaine lidocaine Mark Kane
arcticane
um which are another one of the most
incredible and useful uh tools of a
modern physician in fact
there's one kind called proper cane that
comes in eye drops and people with eye
conditions or something's caught in
their eye or we have to do tests on
their eye you can completely numb their
eye and then do things that they would
never let you do
uh and they're not painful it's kind of
amazing actually like getting things out
of people's eyes you know what the
resistance to things coming at our eyes
whether it's blinking flinching putting
our hands up
um it's so ingrained in us because our
eyes are so delicate and so important
and so prone to injury you know even an
eyelash is sort of like this dramatic
thing you have to deal with immediately
uh in your eye and so the that innate
response to anything coming at your eye
is so ingrained and strong that the
ability to numb it and to distract
people and to be able to like reach into
their eye and do you know around their
eye and dig things out is so powerful
like it's one of the modern medicines
most amazing tools but so with a
fracture you can actually inject a whole
lot of one of those medicines into the
fracture itself like you actually aim
for the broken bone with your needle
just inject a whole bunch of it all
around there and let it sort of seep
into the tissue
and you can get a lot of numbing
um just that way there's also nerve
blocks where if you inject it around the
nerve like let's say you broke your
wrist you can inject it into the nerves
let's say up by the elbow and numb the
entire hand and then um do something
brutal uh that would be very painful uh
nerve blocks are just really crucial
just an amazing ability
all right so the one thing you can't
block people from is the moment where
the teenage kid has to explain to his
parents why he has Bucky Balls inside of
his bladder correct uh how do you deal
with that like are you just Stone Face
like this is what's happened this is
what we're gonna do to get them out are
the parents not freaking out like this
seems like just a brutal moment for that
poor kid right well you know telling
giving the news of a diagnosis to a
patient is is a sensitive part of
medicine giving news to a parent about a
diagnosis in a child is can be very
difficult uh you know for doctors
something dread doing but have to
um so you know
telling a parent your teenager is a
dumbass and got something stuck wherever
is much easier and more pleasant than
telling them something horrible you know
that your child has whatever needs even
you know needs surgery fine has cancer
obviously that's horrible you know I
deliver a lot worse news
that kind of news probably will chuckle
a bit but the parent will I'll let them
lead on that but if they're chuckling I
might join
um but yeah so it's uh that's one of the
funner parts of the job probably that's
hilarious do you know who Chuck Paul and
Nick is yes so he wrote a story I think
it's his friend or somebody he met that
had he was masturbating in a swimming
pool if I remember the story right but
putting the suction from the pool's
cleaning up against his anus and it
sucked his intestines out oh wow and so
and I think he oh God I might be
misremembered but I'm almost certain he
almost drowns because it's like holding
him to the bottom wow and he finally
kicks off with his legs and that's when
it pulls his intestines out so now it's
like oh I have air but I've you know
sucked my intestines out and ends up
having to have some amount of it like
vivisected and removed oh my God boy but
uh hearing Chuck was a masterful
Storyteller read this story is
unbelievable about like the part of it
was the kid like thinking I'm gonna die
and now like my parents are gonna
realize and I'm masturbating at the
bottom of this pool and it was something
like all he could think about was I have
to get redressed before you know I die
so that my parents don't realize what I
said I was just like so fascinating
where shame ends up coming into this
which is actually one of the things you
talk about in the book it's like we have
certain bodily functions we don't mind
talking about and then we have other
bodily functions that were just
completely embarrassed by
um what has being a doctor taught you
about the human take on her own
physiology
um right well that is a very interesting
story for sure and I'm sure the way
Chuck palahnik tells it is probably
um the best believable
um yeah I think you know the body does
have a variety of fluids kind of flowing
all through it and it also has effluent
as we talked about earlier things that
come out of it they're all from the
doctor's perspective the the
dispassionate doctor's perspective who
wants to get a diagnosis they're all
equal in a way and they're all just
sources of information and clues that
might help you figure out what's going
on a lot of disease causes some
increased discharge or increased
effluent or change in the effluent you
know the color changes the smell changes
the there's more of it the quantity
changes the consistency uh you know the
there's blood added to it now
um any any bodily fluid that seeps out
of us can change in those ways and those
are all uh you know dispassionately
those are all equal uh pieces of
evidence that I use to sort of make a
calculation and figure out what might be
going on with the patients so you know
any stool in all its forms with blood
and without
vaginal discharge things coming out of
you know things people cough up uh
the doctor's perspective is just sort of
like uh each bodily fluid is just a raw
material to you know look through to
test uh to analyze in order to get
information from so it's all they're all
sources of information that tell you
about what's going on deeper inside the
body let's say deeper than you can see
with your own eyes uh they're all clues
about what's going on in there um and
you you send those bodily fluids to the
lab where they can do Advanced
biochemical testing of various kinds and
the wealth of information you get from
them is is really quite impressive so I
often say that bodily fluids are kind of
the medium of a doctor's craft where our
craft is reading Clues and figuring out
what's going on and then treating it and
the the bodily fluids are often the
stuff we're reading you know it's sort
of like uh the the text that we have to
analyze
um whatever's coming out of the human
body and whatever it looks and sometimes
smells like um
yeah you tell some pretty
um puckering stories in the book about
uh in first rectal exam things like that
which were uh yet another reason why I
would not make a good doctor I just
can't fathom
um we did promise people that we would
also give them the best thing that
you've encountered being a doctor so I'd
love to hear you've done like really
crazy traveling you've been a doctor
like in the Tibetan mountains and all
kinds of crazy stuff so I don't know if
it was that or a simple moment in the ER
where you were able to save somebody and
and reunite a family but what's the best
thing
yeah I would say there there's very few
quick fixes in medicine I would say that
this is true wherever I've practiced um
like you said I've worked in Antarctica
and the Arctic and the Himalayas rural
Pennsylvania and elsewhere
um and there's so few quick fixes in
medicine there's so few things where
people come in with something severe
going on and they are 100 back to normal
and better when they leave uh a lot of
things are well take this medicine for
the next seven to ten days and if you're
not getting better come back or follow
up with your doctor but there are a few
things where you just fix it right then
and there
um you know like dislocations are one
example though not that their arms
totally back to normal you know let's
say if they dislocated their shoulder
they have to wear a sling for some time
they're going to have pain they're going
to have risk of redislocating it over
the next few weeks because the ligaments
are all a bit looser than usual because
of what happened but there are some in
children actually there's a very common
kind of elbow dislocation called the
nursemaid's elbow
um and one of the bones of the forearm
kind of slips out of its um a ring of
tendon that it's lying in and the child
will not will not move the arm will not
uh do anything with the arm no matter
what and this is very simple it's one of
the most satisfying things in all of
medicine you just take the kid's arm and
sort of turn it you feel it click the
kid's crying and screaming and the
parents like oh my God they're words
what happened and then you but I go out
of the room for 20 minutes and come back
and the kid is 100 normal using the arm
you know we'll hold the popsicle up and
they'll reach with both arms and we're
like see they're fine
um so I feel like those quick fixes in
Medicine of which there are not so many
are just super satisfying
um I feel like in dentistry there's some
more quick fixes you know whether it's
pulling a tooth or doing a root canal or
something getting rid of the pain but
everything about the dentist is evil
yeah everything cleaning is evil deep
cleaning is evil cavities are evil like
oh God there's just something about I I
don't enjoy going to the doctor but I
hate going to the dentist I'm with you
there and I deal with a lot of dental
things in the ER more than I kind of
thought I would you know in medical
school we sort of completely ignored the
teeth I mean we learned the very Basics
but on our cadaver we never looked at
the teeth or dealt with them didn't
learn about dental disease and so you
sort of have to learn it as you go in a
way but yeah I think those quick fixes
are among the most satisfying probably
for people you know
um delivering the oh your scans and
tests are all normal is probably one of
the nicest things because some of these
people have just been stewing and
stewing and worrying and you know you
look up on Google I was talking before
about doctor Google you know Dr Google
is really good at making the diagnosis
the problem with Dr Google is that it
always includes cancer or something
horrible in the list of possibilities I
mean the truth is cancer is usually in
that list of possibilities it's just way
down in likelihood like super far down
like not even worth talking about but it
is there I mean it's not impossible that
this nothing symptom is cancer certainly
possible
um so I think people you know go Dr
Google diagnosis them with cancer or
something and they're just worried and
so just reassurance as we call it or
just alleviating that worry
can be very satisfying and people are
just so grateful for that a super weird
cancer scare
that it was like when it happened I was
like there's nothing else this could be
other than cancer and uh this is pre Dr
Google and I felt a lump in the back of
my throat and it at the beginning of the
day it was small but noticeable and so
I'm I'm touching it with my tongue over
and over and over and
I'm just like I think it's getting
bigger I think it's getting bigger so I
tell my then girlfriend I don't even
think we were um engaged yet and she was
like well you know you need to go see a
doctor go see the doctor he's looking in
the back of my throat and he's just like
yeah we do need to biopsy this and I was
like I knew it I knew like obviously
like this cancer and the worst part of
that was he sprays some foam that like
numbing foam and it rolled down my
throat oh God it was so horrible I know
that phone but because I you know
thought I was dying of pants I was like
whatever uh take it out it ended up
being a saliva gland that he was like
you shouldn't have a saliva gland in the
back of your throat and it really
shouldn't get I guess clogged or
whatever but that was a really powerful
reminder of I don't know enough about it
to diagnose myself with cancer because
there are a gazillion things that it
could be so that's actually been a
saving experience for me even though it
was pretty hateful to swallow that foam
uh to remember their just going to be a
number of things that I who knows what
this is and so stay calm until you have
reason otherwise right and I I usually
do that sometimes I'll worry about
something that's that's probably another
case where my emotion uh emotions get in
the way of my rationality but my like
last year my wife had a rash
and it seemed like the kind of rash
sometimes people get when their platelet
count is low and I was like oh great she
has leukemia oh my God I'm gonna you
know I'm like we're gonna have to go
through all this I'm gonna be a single
father blah blah blah and then it was
like gone two days later we actually got
her a blood test her platelets were fine
it was gone two days later so like it's
funny how it's almost like I'll ignore
things to a you know I'll say I'll poo
poo some rash or symptom let's say my
children have or me or my wife I'll poo
poo it you know maybe too long sometimes
and other times I'll just be like
just off a cliff with worry like even
when it's not rational so you're not you
know doctors do exactly what what you
did so me sometimes knowing more doesn't
make you sort of uh worry but maybe
that's you know worrying about myself
worrying about my wife my kids my loved
ones gets in the way of if it was this
was a stranger I'd never met before
who's like oh I have a lump in my throat
I think it's cancer I'd be like
come on it's probably something else
let's take a look right
um I wouldn't say that in that way but I
would think that uh but with you know
with my wife it's like oh boy here we go
end a lifetime yeah no I would do
exactly the same with my wife uh so you
travel a lot you are a doctor in some
really weird situations why
uh well I loved traveling before I
became a doctor or even wanted to be a
doctor yeah but traveling to a five-star
Resort is very different than going to
the Arctic and being a doctor on a ship
with like four tools at your disposal
true
um well I love you know even before
being a doctor I loved uh rough travel
Adventures travel traveling to remote
places sleeping like that sleeping on
the ground
um I think part so part of it I think
was uh my interest in the natural world
and just going to places one where
there's less development and the sort of
nature is in the state it's something
closer to the state it's been in
centuries Yes actually feel better or is
it intellectual
um no it's I think it's partly
intellectual I mean often when you're
going to those places you're doing some
uh something physical let's say hiking
or some kind of expedition or Mission
you know you're and there's a whole uh
bunch of kind of emotionally satisfying
and intellectually satisfying and sort
of social cohesion things going on you
know when you're in so some kind of
mission based uh you know kind of plan
or on on that course of of activity
um and I think that there's something
very very satisfying about that there's
very satisfying things about sort of
being out in nature where sort of things
like geography and climate and weather
are important you know I'm not in a
hospital in the middle of a city where
the temperature is controlled it never
rains I don't even know what the
weather's like outside because I haven't
looked out a window in some hours you
know everything is smells like
disinfectant and all the sounds are
beeping and phone's ringing and not sort
of birds chirping or splashing of of
animals or whatever so I think being out
in those places is interesting from the
natural world standpoint seeing
different ecosystems different plants
and animals I've always uh you know
since I was in college loved plants and
being able to identify plants and wild
edible plants and mushrooms and
understanding animal biology and plant
biology and ecology how everything fits
together and when you go to a place like
the Arctic it's just so dramatically
different from let's say the temperate
climate temperate forests of the
northeastern U.S where I grew up or
going to the Tropics of India
dramatically different all different
species of plants though some are
similar some might be in the same genus
or I recognize a planche a leaf shape
but clearly this is very different than
the ones that I recognize from home
but then I think tying into that so
that's always fascinated me is different
parts of the world and how climate and
geography kind of give you a completely
different world basically but then how
human culture ties into that too how
different cultures languages ways of
dressing ways of decorating the human
body ways of living what plants they
grow what animals they eat how they
build their houses what materials have
traditionally been available to build
houses with to make tools with I find
that that is very fascinating too you
know just as
the further north you go the bigger the
Bears get or the bigger the animals get
or the smaller their ears get as it gets
much colder
because they don't want appendages yes
you don't want your appendages sticking
out into the cold so a polar bear while
it's much bigger than a black bear its
ears are smaller
um so those kind of changes you know
human culture changes in the same way in
response to the environment or what
plants and animals are available to eat
and that impact diet of course like
traditional diets from around the world
so human culture and how it interacts
with the natural world has been sort of
one of my driving interests in that led
me to travel before I went to medical
school and after college I ended up
working in working and living in Russia
kind of on and off for about two years
uh and that was totally why Russia that
was totally mind-blowing so I was I took
an environmental science elective when I
was in college and my professor was a
Russian researcher who was studying kind
of like the environmental movement in
Russia and how it's changed since the
end of the of the Soviet Union and how
International environmental
organizations have come to Russia since
the end of the Soviet Union and put a
lot of money towards environmental
preservation and how you know the local
governments and the national governments
and other institutions have responded to
it and how they're working together and
sort of what's happening and are they
achieving their goals if not why not and
Forestry which is a huge industry in
Russia of course was what we focused on
so I just got an invitation with this
professor uh to be an intern at her
Research Center in St Petersburg I knew
no Russian I knew nothing about Russia
and so I just went for six months and
then four more trips over the coming two
years traveled all over the country and
really got that that bug of interest in
the natural world and human culture
spent a bunch of time with uh native
peoples of the Russian Far East in the
kamcha on the Kamchatka peninsula
uh but even Russian culture itself in
Northwestern Russia I found super
fascinating learn the language travel to
a lot of rural parts of the country
where
one part they said I was only the second
American in history uh who had been to
this like tiny village and the he had a
textbook that showed the first uh guy
had been there in like the early 1900s
but whoa
um so I found all that totally
fascinating and basically became a
hopeless addict of traveling to remote
parts of the world and experiencing the
different natural worlds and the
different human worlds and culture and
history and reading about it and
learning languages so it was very
natural to want to do the same once I
became a doctor I found that traveling
around with the goal of researching the
environmental movement or some other
sociologic phenomenon was not as
enticing to do for the rest of my career
as traveling around similarly but with
medical Knowledge and Skills that I
could sort of do something much more
practical and Hands-On for the people
who were wherever I traveled so
traveling as a doctor was like a big
goal as soon as I started medical school
pretty much as you get farther from
Modern civilization are there
differences in things you have to worry
about like one thing we haven't even
touched on today is obesity I'm guessing
as you get into these more remote remote
places that that sort of drops away to
next to nothing or maybe I'm wrong about
that what have you found yeah so it's
interesting you know if you go from the
city to a rural area in America right
you're sort of moving towards Wilderness
but the Obesity doesn't drop there for
sure in fact a lot of obesity in rural
Americans say I would guess it actually
goes up right so
um there's a lot of socioeconomics that
come into play there but yeah so uh you
know rural parts of America or other
developed countries you you don't see
less obesity you know there's so much
has been mechanized about the way of
life that um
not that physical exertion's the only
part I think nutrition is a big part of
it too of course and I think probably
other things we don't understand uh have
resulted in but wait wouldn't people out
in Rural America work more not less
like physically yeah well I mean so much
of it has been mechanized you know
certainly the Amish who lived near me in
Philadelphia I mean they're busting
their butt they are the draft animals
pretty much I mean they're them and
their kids are you know I see them yes
they have horses to pull the pull their
uh plows but they are still working
their butts off and where Modern farming
is super mechanized you know g g uh GPS
controlled tractors that make every line
of corn optimal for fitting as many
plants as possible
um you know there's less physical
exertion needed and it's more efficient
and you need less employees so so much
has changed there too but yes as you go
out to the Wilderness certainly like
when I was working in Nepal at high
altitude there was actually a lot of uh
Tibetan llamas which are sort of the
Tibetan Buddhist form of monks call them
llamas uh kind of living in the Hills
sort of in caves sometimes uh living
their monastic acetic lifestyle
but interestingly you know they were
rarely obese
um I did see there was a llamicary there
which is sort of like um where it's a
bunch of llamas live and the head of the
llamas area was actually quite
overweight
also had type 2 diabetes
um
you know but he's sort of in the
powerful uh position of being the head
of the lomissary I don't know what that
says for his lifestyle but even uh one
of these monks it was a woman who had
lived in this cave above the clinic
where I worked for over 30 years and
spent most of her day meditating except
when sort of pesky tourists showed up
and wanted to see the cave she lived in
I was one of those pesky tourists
um she actually had high blood pressure
and sort of like made the early type 2
diabetes like her sugars were high so
every time did you get any sense of what
she was eating
I mean choose a very simple diet not a
lot of food you know not overeating she
was very slender It seems impossible but
I guess that also made me wonder about
like what what's causing these diseases
you know do you have a hypothesis that
seems so crazy right you know I I don't
know she has to be eating high sugar
glucose is getting into her system right
I mean there's no way
probably yeah I mean she's definitely
there's a lot of grain growing there
there's I think it was mostly wheat at
that altitude that they were growing or
maybe it was a different grain but
I didn't see or eat I assume she's
eating maybe a well-rounded diet she is
she is eating a lot of the day
meditating is that like being sedentary
I'm not sure wow this is so interesting
okay so this really puts things to
challenge but you don't you don't have
enough information so it's gonna all be
circumspected right that's why I'm just
very like hesitant to apply causality
when it comes to health and nutrition
and lifestyle just because I just feel
like there's so much we don't know and I
wish doctors were tired of embarrassing
themselves by declaring the truth and
then seeing it over a turn 20 years
later
interesting
okay so really fast on that idea that
people keep embarrassing themselves
which is exactly why I don't take
supplements but I consider my body
composition to be entirely in my control
and nothing since my early 20s has
proven otherwise because I have a theory
on diet what you can and can't eat if
you want to avoid high blood sugar if
you want to avoid fat putting on adipose
tissue I should have been more clear and
I've taken my blood with continuous
glucose monitors finger Pricks so many
times like I understand what I eat if I
want to get ketones I understand what to
eat if I want to spike or lower my blood
sugar
I understand how to eat and work out
which is the far bigger important part
to put on muscle so
I cannot speak to my arteries or things
like that I haven't had my arteries
scanned in in probably eight years but I
have had them scanned at least once like
for me I have a framework that I live by
I have a framework that I feel
completely confident telling anybody
that is interested in
um General Health I I do not claim to be
able to optimize people but I can get
you the sort of General healthy probably
have a decent shot at Living to 85 kind
of thing
um
do you not have a similar framework or
are you Coy about your framework I would
say probably a little of both I mean I
do think that uh it's a combination of
the science being not totally clear I
mean I feel like take any human and give
them sort of a better quote-unquote diet
which I would say you know sure variety
of fruits and vegetables lots of fiber
and you know high quality meat let's say
do you treat fruits and vegetables the
same
um
I mean I I guess I I often combine them
together when I'm saying them I say
fruits and vegetables but one has a lot
of sugar one has a lot of sugar right
yeah I mean you know I guess when I
think of what's optimal I often think of
what were people doing centuries ago and
like fruit was a special you know treat
um seasonal only right when the plum
trees were dropping all their fruit you
know you Gorge yourself but then you're
not having plums the rest of the year
um but I guess I I probably am more Coy
even than I would uh apply in my daily
life or to what my kids eat because I
think doctors gets have gotten so much
wrong um with nutrition maybe being a
doctor makes me even more Coy or more
hesitant to declare causality or declare
the truth about X causes why
um what would you do
uh this won't work because you're you
already have a diet so let's take our
woman in the the cave yeah uh if I saw
that she had elevated blood sugar and
remember I'm I'm just an entrepreneur
man so but I still have a really strong
I believe that if I went into that cave
100 I could control her blood sugar 100
she has to eat only what I tell her and
so the one thing maybe if the only thing
that we can get access to is you know
the bread made from the local wheat or
whatever okay that could be problematic
but assuming that I can feed her
whatever I want and that she will comply
100 I am supremely confident that I
could get her blood sugar in range I
won't say anything maybe I kill her but
I can get her blood sugar in range
um do you think that I'm delusional or
are there things that you're confident
if I fed her like I'll just be honest
boil chicken breasts and broccoli her
blood sugar is coming right down well so
I guess that that goes back to what is
available in that local town and this is
a very remote town where there was
actually no road to it until just a few
years yes but that's different than not
knowing what causes what so I'm trying
to ferret out whether like are you
saying though you would have access
let's say to a first world city 100
Supermarket yep yeah I would I would say
I'm confident that you probably could
uh improve her you know I don't know
what her cholesterol panel was but let's
say her sugars her cholesterol is one
thing I have no confidence in I do not
understand it I don't know if it's good
or bad so that's one where my humility
is just overwhelms me even in myself I
don't know if I'm approaching it in the
right way this is why I say like I don't
know that I don't kill her like I have
enough humility to understand like I'm
I'm running an N of one experiment I'm
only 47 years old so who knows how this
plays out maybe I die at 47 and in which
case everyone gets the point and laugh
but blood sugar I am supremely confident
that I know what to do to lower
somebody's blood sugar and given that so
much of metabolic disease seems to be
Downstream of consuming things that
spike your blood glucose I also feel
pretty confident in that again arteries
not sure cholesterol not sure like now
we're getting into the like I mean the
the title of your book is the Unseen
body so now we're into a part that's
really hard to get an accurate picture
for a lay person like me obviously you
probably have a lot more like scans and
stuff that you have access to but for me
it's like okay that's where I'm like I
have no idea if what I'm doing makes any
sense but blood sugar metabolic disease
body fat like these while complex these
feel very solvable yeah I agree I I
think that you I'm confident you could
get her blood sugar under control I
guess they're you know there's
complications of what's available
locally though and also maybe she has
like a crazy Sweet Tooth I'm not sure uh
maybe she loves Corn Flakes I'm not sure
I didn't you know ask her too much about
the diet but I was impressed by
um but the fact that she had these
diseases but I do think you're right and
with cholesterol you know doctors that
flip-flop back and forth about does
eating cholesterol make your cholesterol
and your blood High specifically the bad
kind of cholesterol
um and we've gone back and forth on that
and it seems now that eating cholesterol
has no effect on the cholesterol in your
blood
[Music]
um that seems to be what the data shows
these days
um these days these days but you know
give it more time it's some AI assisted
epidemiologic nutrition research I look
forward to what we'll figure out
yeah that stuff is fascinating okay so
let's go back we're we're in these
remote locations
um we're definitely seeing different
things though we derailed on my surprise
over the person in the cave that's
approaching type 2 diabetes
um are you extracting any patterns to
all of this or is it really just that's
confounding and complicated and I just
take one patient at a time yeah I think
I guess I'm my daily job my best you
know most uh enhanced skills most
practice skills most developed skills
are in dealing with the individual
patient diagnosing their conditions and
sort of treating them
um I do think you know she was also in
her I think 70s maybe even early 80s you
know just aging alone you get higher
risk of all sorts of diseases the body
just doesn't work as efficiently as it
once did you know organs get tired I
mean that's a silly way to put it but um
you know maybe her pancreas isn't up to
the job like it was when she was 40. I
think you know maybe that just puts her
at higher risk I just I guess that's
just another factor I want to throw in
there
um but yeah I think it's it's very
variable you know you certainly see some
genetic predispositions when I worked in
Arctic Alaska in the town of kotzebu
um you know there's certain genetic
diseases that are more common there have
been some population bottlenecks in kind
of settling the new world and then
sometimes with Wars against the the gov
the US government uh putting on the
reservation though not in Alaska there's
not reservations but for instance in
South Dakota where I worked on Pine
Ridge reservation there have been a lot
of population bottlenecks which lead to
a lot of uh recessive genes that end up
what exactly is a population bottleneck
where let's say the populate let's say a
bigger population of people gets
narrowed down dramatically and then
expands again but where that entire
future population is all all comes from
a very small set of ancestors let's say
so when you when people get wiped out or
when let's say just a few people come to
a new land and settle it and start
multiplying and everybody after that is
descended from this tiny group there's
not that many different genes in the
pool and so that can lead to more
recessive you know more genetic disease
basically that's called a Founder Effect
actually where there's a founding group
that then multiplies
um and the genetics uh kind of you can
see diseases in certain populations that
you don't see in others so like purebred
dogs exactly right exactly so it's like
purebred dog where you're purposely with
breeding dogs you're purposely narrowing
sort of the genetic pool and in these
cases it's uh the result of um you know
migrating to new land or Wars or just a
lot of people dying in epidemics and
things like that that can cause these
population bottlenecks
um so there's a lot of actually
autoimmune disease that's super common
in Native American groups and actually
different tribes have different
predispositions like the Choctaw tribe
is known for high rates of a condition
called Scleroderma or systemic sclerosis
I don't think anyone is sure why that is
but the in epidemiologic studies it
shows there's much higher rates and in
the inupiah Eskimo who I worked with in
northern Alaska there's actually
conditions called spondyloarthropathies
that are are super common and I did see
some patients um with that condition
um so there's definitely the genetic
predispositions that you see I mean
there's certainly a lot of Lifestyle
related things so the inupiated in in
Alaska they hunt a lot they fish a lot
they live still despite a lot of
mechanized transport you know everyone's
got their four-wheeler and snowmobile
and motorboat they're living a very
active lifestyle they're very injury
prone because they're out there
spraining their ankles on the tundra
while Gathering berries or just injuring
themselves when hunting and butchering
animals
um there's even a condition called seal
finger where people get a particular
infection on their finger from Seals and
that could either be because they're
butchering SEALS or actually bitten by a
seal let's say someone who works at Sea
World or a tourist in Antarctica who's
getting too close to the seal to
photograph them and gets bitten there's
actually the infection that can result
is does not respond to the usual
antibiotics that are given for animal
bites and other skin infections so when
I started working in Alaska it was like
a handout they gave me with like these
are diseases you should expect here that
you probably haven't seen elsewhere and
you know don't give that antibiotic the
usual one give this other one because it
could be steel finger and when I worked
on a cruise ship in Antarctica as a
doctor too they gave me a similar
handout and mentioned sealfinger as well
because Taurus get too close to seals to
take that optimal selfie and sometimes
get bitten by them
um so there's different diseases even
climate you know in India I mean I saw
it malaria and Dengue
diseases that are kind of only in the
tropics as where you know even in the
U.S where I trained in the northeastern
U.S Lyme disease is super common when I
did a rotation in Mumbai at a medical
school
the medical students there was like wow
you saw patients with Lyme disease like
it was a non-existent in their world it
was this rare exotic disease from the
other side of the world and it was the
most ho-hum daily thing where I grew up
so and and similar reversal of diseases
you know things they see all the time I
might not see an entire in my entire
career practice medicine in the U.S so
you change a lot of your expectations
you change a lot of your understanding
you change sort of what drugs you choose
or don't choose and things you have to
think about as a doctor now when you're
practicing medicine in these extremely
remote locations what the I'm assuming a
very limited equipment that you can take
with you what what uh medicines or
whatever do you take what are the most
essential right so it depends what's
there so when I worked in Arctic Alaska
I had a full Lab CAT scan or ultrasound
24 hours a day but that's in a hospital
on the cruise ship no this was in a
hospital and so I worked in a hospital
in Arctic Alaska and then I was a
hospital in Arctic Alaska yeah more than
one actually well so there's one these
are towns these are towns God I gotta go
I also worked on a cruise ship in the
Russian Arctic that went to the this
island called Wrangle Island which is
sort of just north west of the Bering
Strait has a lot of polar bears there
and it was totally spectacular and so I
was the doctor on that ship for about 50
people
um and these these boats so are very
well stocked I was actually surprised um
but you know every Northern summer
there's a lot of cruise ships that are
going through the Arctic uh visiting
places like Iceland and Greenland and
Alaska and svalbard which is the
archipelago above Norway and Franz
Joseph land in the Russian Arctic and
Wrangle Island and then in the southern
summer they're going to the South
Pacific Islands and Atlantic Islands
like the Falklands and Antarctica this
is a huge industry and every one of
those cruise ships needs one a doctor on
it usually an ER doctor which is a great
opportunity for people like me to get
out there uh see these amazing places go
on these usually very expensive trips
um for free and just provide that
service and work while I'm there so um
so I did work on a ship in the Russian
Arctic and you know the the the medicine
cabinets are impressive they have a lot
of of things
um but when you're planning your that
kind of trip the strategy of what
medicines to choose what uh supplies to
bring with you is a very fascinating
area that I really like uh thinking
about so you know you have to anticipate
what you're gonna see you know if you're
going to a place where they're
butchering seals you better bring that
antibiotic for steel finger or you're
going to be in trouble so you have to
know something about the climate you
know what diseases you're going to see
the season uh what the light like what
activities that people are going to be
involved in are they likely to get hurt
you know are they rock climbing some
sheer rock face uh in the middle of
nowhere or they just kind of staying on
a boat
then again you know when boats go from
the southern tip of South America to
Antarctica they cross the Drake Passage
which is some of the roughest Waters in
the world a lot of people get motion
sickness so you we have tons of medicine
for motion sickness from the patches to
the pills and even the injectable forms
people are throwing up and can't keep
anything down
you have to be ready for that and then
there's injury too when those boats are
rocking and it's interesting you have to
know who what kind of people you're
going to be treating so a lot of cruises
to Antarctica these are people who have
had it on their bucket list for years
and they're probably retired now which
means they're elderly they might have
chronic medical problems they're more
frail
so you have to be ready for that
crossing the wild the sea the wildest
yes you better hold on with both hands
on that to the boat at all times
um but you do see that those kind of
things
um so knowing which antibiotics to bring
knowing which which conditions you're
likely to see what people are going to
be eating what they're going to be doing
um but and you have to think you know
what how easy will evacuation be I mean
that's a huge uh factor that goes into
the strategizing where will you evacuate
them to how will you evacuate them how
long will it take what modes of
Transport are there even evacuating
people from
uh katsubu Alaska where I had a full
Hospital a lot of those people had to be
transported to Anchorage there was no
surgeons no Specialists no nothing up
there except the ER doctor and some
other kind of primary care doctors
um and so if anyone needed surgery or
major traumas needed a trauma surgeon
anything they had a many hour trip
before them before they could really be
treated appropriately I mean the ER
doctor knows how to stabilize certain
things but and you have to know how to
stabilize those things but you know if
someone for instance is bleeding out
into their abdomen they need a trauma
surgeon and if it's going to be multiple
hours to the hospital like the chances
are Slim
but you have to know how to you have to
know when evacuation will be needed like
often I'll know immediately oh this
person you know let's say I see an EKG I
know they're having a heart attack they
need a cardiac catheterization and the
nearest one is three hours away in
Anchorage so immediately I know what has
to happen to get them there and so I'll
start that process immediately you know
I don't wanna I don't need to wait or
wait for their lab work or something
it's sort of like I know how long this
will take I know this is urgent so start
it now
that gets also into when does someone
need to be evacuated or not you know
their current condition is fine it's not
severe but it could progress do I
evacuate them now because of that risk
do I keep them here and just evacuate
them later maybe it'll be harder later
when they're sicker or they need it more
urgently suddenly sooner than I would
have thought
um so so how early to evacuate it's
another question also geography comes
into play so when my patients were
evacuated from let's say katsubu Alaska
to Anchorage the plane actually has to
fly up and over the Alaska range which
has Denali in it so they gain a lot of
altitude and so when there's air in the
body like a pneumothorax we talked about
earlier when there's air if there's a
bowel obstruction and the intestines are
sort of swollen with air or even after
some traumas actually head traumas you
can have air inside the head oh you have
to think about that air expanding when
they go up and over Denali in the Alaska
range so even for instance very small
pneumothorax which normally we wouldn't
do that brutal Act of cutting into the
chest while putting a tube a chest tube
for small ones if they're going to
Anchorage which they usually are we
would put a tube in any way and a half
because we'd be afraid of that air
expanding when they go up high so
there's that kind of geography that has
to come into your strategizing how bad
does the head trauma have to be for you
to get air inside the skull that sounds
like we're in bad shape yeah usually it
takes a skull fracture at least
um you know air gets wherever it wants
to go and so if your skin is broken and
your skull is broken it can usually get
in there
um
I remember this one patient just had a
DOT of air on the cats on the head scan
uh you can just like an air and a scan
yeah so in a CAT scan it looks black
actually huh um each diff like different
densities of tissue or different um
colors but if you look at like an x-ray
of the lungs let's say you know the
bones are all white and the lungs are
patchy white because there is some
tissue in the lungs you know there's
blood vessels and Airways but most of
it's black because the lungs are filled
with hair so on a CAT scan I saw one dot
of air inside the skull and so we were
debating with the flight nurses and the
trauma surgeon the neurosurgeon down in
Anchorage by phone
what's the risk of this expanding when
they fly and we all decided it probably
wouldn't expand that much so let's just
go for it and then their head burst on
the flight no it was fine
thank God
that uh that stuff to me is is super
crazy now you said that you like
thinking through these problems
are you a prepper at all
I'm not a prepper though I I did mention
I've always been fascinated by
Wilderness survival and understanding
how things are made I don't expect that
I'll need to Flint nap for a sharp edge
in my lifetime but if I know how to in
case it came to that I guess I'm just
fascinated with it on a I want to know
how the world Works uh level more than I
think the world will come to an end I
mean a little bit of preparation I think
is wise
and uh yeah and knowing how to do all
the things that you might need to do I'm
interested in knowing how to do those
things anyway I you know how to turn
skin into clothing so
um that might come back to my my
curiosity around you and Hannibal Lecter
but too many traits here right it's not
that I think we're gonna have to go back
to the Stone Age or anything
um but I just am fascinated by it and it
turns out it might come in handy if the
for the world hits the fan so
that's crazy uh you're writing a new
book what's the new book about because
we were talking about some stuff before
we started rolling that was really
fascinating but I don't know the the
theme of the new book or anything sure
so the new book is so far it's just a
sort of a collection of stories
um not based on body parts and bodily
fluids like my first book but one of the
stories I'm working on now is actually
um about uh chronic illness in children
in the ancient world how ancient are we
talking so um could be thousands of
years but to more recently I think um as
a p you know I'm a pediatrician and an
internist so
trained to be both and I've dealt with a
lot of chronic illness both in adults
and children and uh I came across a
really fascinating story actually while
I was in the Alaskan Arctic where uh a
lot of mummies which are bodies that
have been preserved Through Time
come out of the ground there especially
ice or are there other things that will
preserve a body so dryness and Ice are
basically the two they sometimes come
together because usually when
something's Frozen
um they'll also you know it's called
sublimation where frozen water
um just sort of evaporates as well just
like liquid water can and they will dry
out sort of like a freeze drying process
um so dryness and colds are how bodies
mostly get preserved there's also
intentional mummification though which
also sort of relies on dryness sometimes
with the aid of salt to draw out fluids
you know mummification is actually very
similar to like curing meat and
charcuterie because you're sort of
drying it in a similar way
um but uh so that I came across a really
fascinating story of a mummy that came
out that whose head was sticking out of
the Earth in Barrow Alaska after a storm
and some archaeologists were cold you
know the first question was oh is this a
job for the police or is this a job for
the archaeologist is this a murder
victim from last week or is this an
Ancient Ancient bot a body and so they
an archaeologist saw just from where the
body was uh in the layers of soil that
were exposed After the Storm
they knew immediately it was ancient and
then uh and then when they dug it up
they found that this body it was wearing
a parka made of bird skin with the
feathers on and so it was clearly an
ancient uh an ancient kind of dress and
um
on studying the body they found out that
it was actually about a five-year-old
girl who had lived in the society at the
time it's called Thule sort of the um
before the inupiah their ancestors uh
the Thule people and she lived about uh
800 years ago so around the year 1200 or
so certainly before any European or
American contact
um and um and it turned out that on the
what we call paleopathology which is
sort of when the pathology pathologist
looks at ancient specimens almost like
they would look at a biopsy from a
modern person they can do similar
processes to look at ancient bodies and
diagnose disease and see what was going
on the paleopathologist found that this
little girl had a rare genetic illness
called alpha-1 antitrypsin deficiency
the way he knew that was by looking
actually at the liver the genetics of
the child were kind of disrupted by
microbial growth over the centuries even
though it was frozen there's still you
know microbes can still slowly
proliferate and grow and die and leave
their genetics mixed in with the human
tissue but by staining the liver in
certain ways he was able to see that she
had this protein that builds up in the
liver from this condition and also in
the lungs he found that she had
emphysema basically which we call COPD
today which you expect to see in the
lungs of an older person who smoked you
know a pack a day for decades but in her
case she was a five-year-old girl with
this um with this condition in her lungs
and the condition in her liver and so
they found out that she had this rare
genetic condition and as a pediatrician
who's treated a lot of children children
with chronic illness I was certainly
fascinated in that and just I enjoy
imagining how her society would have
responded to this you know she probably
wasn't growing right she probably wasn't
keeping up with other children she was
having intermittent illnesses that
seemed severe and actually in Her Bones
when they did x-rays you could see what
are called growth arrest lines where
during critical illness or severe
illness a child's bones will actually
stop growing and you see a sort of
horizontal white line in the bone why
what what about I would think if it
stopped you would see nothing if it
accelerated or something I could
understand a change in texture is it
laying down a deposit I don't understand
yeah so I think it is constantly laying
down new calcium new calcium phosphate
which is sort of the um the crystal
that's on bone
um and that gives its its hardness and
its strength and so um the there's
different processes of going on at the
same time in a growing bone there's the
actual growth that lengthens the bone
and there's actually and there's also
the calcification or the deposition of
this calcium phosphate you know very
young children their bones are almost
rubber like more made of cartilage than
bone and when when you X-ray children
there's a lot of bone missing actually
because it's still cartilage really yeah
and so that process of turning it into
bone or the bone sort of replacing the
softer cartilage
um you know that process continues even
though the bone might not be lengthening
due to perhaps
a pro a combination of the let's say the
illness itself the infection sucking up
resources and nutrients and the person
probably not eating as well because
they're feel terrible or throwing up
um so it deposits calcium phosphate in
this way that leads to this darker than
normal horizontal line and she had
multiple in her long bones
um
so you know by by digging up this body
and by doing this paleo pathological
investigation you almost can read these
stories from her life and I sort of Love
imagining how her parents and the
society at large would have responded or
would have thought about this girl or
who did they go to for help was there a
doctor figure or a shaman or a leader
who did they ask what did they think and
how did that impact the way her parents
saw her disease and saw her honestly
slowly waste away the investigation
showed that she probably died of
starvation
in her long in her stomach there was a
bunch of fur which is usually a sign
that she was eating animal skins which
everything most things they owned were
made of animal skin their clothing their
bedding it would be like eating shoe
leather it would be like eating shoe
leather right I don't think she was
going for the hair probably more for the
skin attached to the hair but then again
you know you fill your stomach with
whatever you can to alleviate the hunger
pains whether or not it's gonna actually
be nutritious or not there was some soil
in her stomach so she could have been
eating soil for you know whatever to
maybe her parents wanted to put
something in her stomach maybe they knew
she was dying and just wanted to
alleviate the hunger pains
um and so sort of all those questions
about chronic illness in our society
chronic illness in the ancient world and
chronic illness in a culture where
they're living this incredibly
interesting and different lifestyle
where a lot of you know they're hunting
whales
um in the sea and eating a lot of
blubber and they're living in these
semi-subterranean houses and heating and
lighting them with lamps with seal oil
in them and things like that so I think
that that'll be probably one chapter in
the book and others will explore
different stories that the human body
can tell if you know how to read them
basically
man utterly fascinating your book was
wonderful the Unseen body I definitely
hope people check it out where can they
follow you to learn about these crazy
stories that the body tells check out my
website
www.jonathanriceman.com I love it all
right everybody if you haven't already
be sure to subscribe and until next time
my friends be legendary take care peace
to learn more about nutrition and aging
check out this interview with Matt
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Aging