← Tom Bilyeu's Impact Theory
Tom Bilyeu's Impact Theory
Vegans vs Meat Eaters: Who Will Live Longer & Why You Should Care! | Jonathan Reisman Pt 2
01:22:16
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A
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Welcome back for part two of my incredible conversation with Dr. Jonathan Reisman, the doctor who brings his medical expertise together with deep knowledge of anatomy and diet to help us all live healthier lives. And in this second part, we go past generic diet advice and into how to figure out what diet is optimal for you and how it can be drastically different, even for people that live in the same household. And if you haven't yet, be sure to sign up for our exclusive ad free Impact Theory subscription service. It comes with access to archived episodes and curated playlists on topics like health, mindset, business and relationships. Subscribe today on Apple Podcasts or Supercast for all other platforms. I'm Tom Billy, you and welcome to Impact Theory. What do you do with people that feel like 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 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 saying, well, it doesn't really matter one way or the other. 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 Thomas Sowell.
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B
Yeah, I think that a lot of times people will say, just tell me what to do, Doc, what would you do? Or what would you do if this was your family?
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C
100%, that'd be the question.
- [03:00]
B
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. 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.
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C
Why? Because they're not being dispassionate.
- [03:24]
B
They're not being dispassionate. I think there's 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.
- [03:43]
C
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. How just the physicality of needing to be super calm, you're going to be hopped up. But in terms of 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?
- [04:20]
B
It's a good question. I think that has a lot to do with how the human mind works and how emotions can sometimes get in the way of your rational decision making
- [04:29]
C
because you don't want to see them in pain. And so you might not recommend the right treatment.
- [04:32]
B
Yeah, I think that could be part of it. 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 it seems like all day, every day, our emotions can get in the way of our risk benefit analysis or our 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 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. 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 how things, 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. 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.
- [06:19]
C
What's the worst thing you've seen?
- [06:21]
B
The worst thing I've seen? Well, I guess there's, you know, there's worst in terms of disease. 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, you know, I mean, cancer is terrible in any age, even the elderly. But it does seem like young people with families, let's say, are just. It 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, you know, whether sometimes it's their own fault, you know, if they smoked for decades and now have lung cancer. But even that, 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. What people do to each other. I mean, that's. We see a lot of that in the er. We see the results of violence between people, the results of abuse and child abuse and sexual abuse 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 with out of state plates. And we were all sort of like, what's going on? And that just, you know, those kind of horrible things 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. 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. 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 sex 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 just more awareness that it's happening, which is something that ER doctors perhaps are 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 just can get you very down. There's a lot of burnout in emergency medicine. Um, some of that's just the workload and the intensity, but some of that's probably just 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.
- [09:32]
C
Woof. That's rough. So in all that, obviously I know the examples from the book, but what is the encounter that you've had that most stuck with you? And we'll do the worst one and we'll do the best one just to balance out cosmically.
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B
Sure. I think that in the book I wrote about this young guy in his 30s who had 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 I'd 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 stay 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, 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. And so that was really impactful for me. I didn't have a family myself at the time, but still, just seeing the impact of this guy, what's going, happening to this guy's body, on his family, was just very dramatic and something that really stuck with me. And that's common actually. So the dispassionate gaze of the doctor. 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 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, 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? How does trouble breathing lead to low oxygen leading to cardiac arrest? And that's where the death comes in. I was fascinated with that as a medical student. Like how do people actually die? How does, how does the disease eventually stop Your heart, which is kind of the last stop in death. And it's interesting objectively. But then the family comes in, they're devastated, and then it really hits you that this is a person and you know just 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. You get punched in the face with what it actually means for someone to die. So those are some of the toughest things I would say.
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C
How do you, how do you deal with death? How do you personally compartmentalize or.
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B
You know, I think I'm really good at compartmentalization. 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 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, 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 coroner, a funeral home. You know, the humans is very good at compartmentalization and as where.
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C
So 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 I've often said I could never be a paramedic 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 a way of framing it that allows you to accept it? I don't know.
- [14:01]
B
Yeah, 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 in 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 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.
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C
Did you read the book Ordinary Men?
- [14:32]
B
I've heard of it. Haven't read it. Same.
- [14:34]
C
I don't know if I'm up for it.
- [14:38]
B
People do horrible things during their daily work hours and then go home and are loving, loving parents, let's say, or loving siblings. 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, 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 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 like sort of the extreme result, which could be things like ptsd, which certainly can impact you. 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. Cause it to happen more. 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.
- [16:01]
C
Is that the odds are on my side.
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B
You know, I'm not sure. I'm not sure it's a rational calculation that leads to me saying, well, it's very statistically unlikely that I will have the same result as that person I saw 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 on and putting kind of those things out of her mind, I think.
- [16:33]
C
Do you think about your own death?
- [16:36]
B
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 Shit, this is coming this way. I mean, I filled out a will with my wife, like, early on. 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. But even, you know, I. Even that. That was more of a rational thing, like, yes, I should have a will just in case. Probably should have had one already at this point, so why not just do it now? But even I wasn't the most worried about COVID as things went along. And 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 to sip coffee, water, eat like you're still. 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. And psychologically, we do the same thing. I think we're really good at walling things off and going about our daily.
- [17:49]
C
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. Do you use that fascination as a way to 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?
- [18:10]
B
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 doing cpr, trying to revive them and then giving up. 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 and writes that down. So it's almost like I'm declaring the death, or everyone knows the person's dead. You know, it's just sort of making it official, and there's paperwork involved. And so 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.
- [18:57]
C
Why stroke? I saw that happen firsthand. It didn't look fun.
- [19:04]
B
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 bedbound for the rest of your painful life. I mean, like, instant death would be nice, but.
- [19:18]
C
Yeah, doing it via stroke is you're taking out cognition, so you don't. You don't get to process the pain, suffering. Is that why stroke versus, like, gunshot or car accident? I'm trying to. Because I have thought about this to a struggling degree.
- [19:37]
B
I probably think about it more than the average person, but, no, I think it's more so stroke. Well, first of all, let's say heart attacks. A lot of them are very painful, really very painful. Just 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. 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. 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 no one was there. Did he kind of flop around in pain for an hour before dying? No one's sure. But sometimes it's pretty instant or as instant as things get. So I don't need to live to 120, 85 with a huge stroke. I'll take that.
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C
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 infirm? Is that why?
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B
Yeah. So I think. I think what I'm imagining is sort of prolonging life, you know, with multiple, let's say multiple chronic illnesses and sort of a degradation in your mental capacity, your physical capacity.
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C
Do you have a living will? Do not resuscitate or no extraordinary measures.
- [21:22]
B
I basically have one that just says my wife will make the decision.
- [21:27]
C
Interesting. Terry Schiavo doesn't come to mind. Like, this can get gnarly.
- [21:31]
B
Yeah, I mean, I think my, my wife is a bioethicist, so surely. Okay, so she's dealt with these questions before, but I trust her. And we, but we've talked about it and neither of us wants to live in a veget, persistent vegetative state. But we've talked about all this stuff. 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, oh, what would they want? You know, what if they were still able to talk to us? What do you think they would say, what 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. So.
- [22:16]
C
All right. If you had a slow, painful terminal illness, let's call it cancer, would you do you assisted suicide?
- [22:25]
B
Oh, that's a good question. You know, I mean, I've seen 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. 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.
- [23:04]
C
What are you worried about happening? Addiction.
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B
Yeah, addiction is basically the main thing. 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 even just doctors sort of handing them out more freely, you know, that has largely abated quite a bit. But yeah, you know, you just want to any medic every like risks and benefits. Every medicine has risks. You want to give the least 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, whatever micen 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 had orthopedic surgery ER for constipation. Just for severe. Yeah, believe it or not, 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 their pain 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 they just don't know what else to do and are really suffering. But also one of my big things is I feel like the public is not really educated well on what they can do with over the counter medicines. We have so many over the counter medicines available and other treatments but people just don't know what to take, don't know what to do. And there's no great resource for them to go to, to say, oh well 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 add this on but don't stop the original medicine. You know, stuff like that, like a strategy. 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 an aisle in Rite Aid, cvs, Walgreens, there is as many 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.
- [25:53]
C
We'll have to get you to start tweeting these out. Okay, so what is the most shocking thing that you've seen in the er? That I'd be like, what is happening?
- [26:03]
B
Shocking. Well, definitely. Let's see. I mean, there's a lot of. You mean shockingly bad or just shockingly?
- [26:11]
C
Just shocking because 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.
- [26:21]
B
Oh, yes.
- [26:21]
C
Is it that.
- [26:24]
B
You know, I'm certainly not shocked that people put things in their orifices just because I know they do and that 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 phone. A foam ball.
- [26:42]
C
Of all things to try. That one has no handle.
- [26:45]
B
This strikes me no hand.
- [26:46]
C
Very bad idea.
- [26:47]
B
Right. I've seen. I had a woman with a vibrator in 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
- [26:59]
C
at least had a purpose. The foam ball.
- [27:00]
B
And still more actually, the batteries ran out while she was there in the er. And the vibration.
- [27:06]
C
Can you X ray if somebody has a vibration? That seems. Yeah, but you couldn't mri, right?
- [27:10]
B
Correct.
- [27:10]
C
Can't have metal. Right.
- [27:11]
B
So MRI is the problem. But X ray, CAT scan is fine. Got it. So I've definitely seen a lot of those things. I had a patient who. Oh, this was shocking. Actually, it was my friend's patient. I didn't see them, but I saw the X ray, which was very impressive. It was an adolescent who had a string of little magnet balls, like the little metal balls.
- [27:31]
C
And it was like buckyballs kind of thing. There's totally a string or.
- [27:36]
B
No, no string. It's just they're attached by their magnetic attraction.
- [27:40]
C
Sound like buckyballs.
- [27:41]
B
Little ones. And he was using that string to. 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. Oh, my God. So he needed an orthopedist. Sorry, a urologist to go in there with the scope and get them all out. But that was.
- [28:05]
C
You can get them out with minimal invasive. Or do you have to cut?
- [28:08]
B
No, you. So with a cystoscopy, you know, medical technology is very good at being able to peer deep into all the orifices of the human body and grab stuff and take it out. And so the. Through a cystoscopy scope in the bladder, you can grab lots of things.
- [28:25]
C
Is he awake for that?
- [28:26]
B
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, you know, when we're straightening a bone, sometimes when we're straightening a dislocation, putting it back in place, 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, so brutal with their body, doing things that would be, you know, the worst form of torture if they were still there.
- [29:25]
C
What are they doing? So this is called twilight, right?
- [29:30]
B
Yeah, twilight. That might refer to a slightly less deep level of sedation. There's sort of various levels of.
- [29:37]
A
When you manage procurement for multiple facilities, every order matters, but when it's for a hospital system, they matter even more. Grainger gets it and knows there's no time for managing multiple suppliers and no room for shipping delays. That's why Grainger offers millions of products in fast, dependable delivery. So you can keep your facility stocked, safe and running smoothly. Call 1-800-GRAINGER Click grainger.com or just stop by Grainger for the ones who get it done. When you manage procurement for multiple facilities, every order matters. But when it's for a hospital system, they matter even more. Grainger gets it and knows there's no time for managing multiple suppliers and no room for shipping delays. That's why Grainger offers millions of products in fast, dependable delivery. So you can keep your facility stocked, safe and running smoothly. Call 1-800-granger. Click granger.com or just stop by Granger for the ones who get it done.
- [30:37]
C
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 silent?
- [30:47]
B
They're out, yeah, but they're breathing. 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 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, so it's a dissociative.
- [31:16]
C
Do you look asleep? If you're. Totally.
- [31:18]
B
Yeah, you look asleep.
- [31:19]
C
Interesting.
- [31:20]
B
Your eyes are. Ketamine gives you this nystagmus, we call it, where your eyes are bouncing back and forth, but usually your eyes are closed. Your eyes are closed, but if open them, you'll sometimes see their eyes kind of going back and forth. 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 the 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 when setting broken bones and other things. Sending someone's mind to another planet is just part of my daily job.
- [31:56]
C
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.
- [32:05]
B
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.
- [32:15]
C
Why do so many people have stories about having their bones set whilst awake? That seems crazy, right?
- [32:20]
B
Well, sometimes 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. It gives you numbness there. And so we use various kinds of canes. Bupivacaine, lidocaine, Marc cane, Arctic cane, which are another one of the most incredible and useful tools of a modern physician. In fact, there's one kind called proparocaine 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 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 out of our eyes, whether it's blinking, flinching, putting our hands up, 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 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. It's one of modern medicine's most amazing tools. 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 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 do something brutal that would be very painful. Nerve blocks are just really crucial, just an amazing ability.
- [34:22]
C
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 buckyballs inside of his bladder.
- [34:30]
B
Correct.
- [34:32]
C
How do you deal with that? Like, are you just stone faced, like, this is what's happened, this is what we're going to do to get them out. Are the parents not freaking out like this seems like just a brutal moment for that poor kid.
- [34:43]
B
Right. Well, you know, telling. Giving the news of a diagnosis to a patient is a sensitive part of medicine. Giving news to a parent about a diagnosis in a child can be very difficult for doctors. Something you dread doing but have to. So, you know, telling a parent, your teenager's 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. The parent will, I'll let them lead on that. But if they're chuckling. I might join. But, yeah, so it's. That's one of the funner parts of the job, probably. That's hilarious.
- [35:32]
C
Do you know who Chuck Palahniuk is?
- [35:34]
B
Yes.
- [35:35]
C
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 pools cleaning up against his anus, and it sucked his intestines out.
- [35:50]
B
Oh, wow.
- [35:51]
C
And so. And I think he. Oh, God, I might be misremembering, but I'm almost certain he almost drowns because it's like holding him to the bottom. 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.
- [36:11]
B
Oh, my God. Boy.
- [36:13]
C
But hearing Chuck, who is a masterful storyteller, read this story is unbelievable.
- [36:20]
B
That must be amazing.
- [36:21]
C
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 say. It's 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. Then we have other bodily functions that we're just completely embarrassed by. What has being a doctor taught you about the human take on our own physiology?
- [36:58]
B
Right. Well, that is a very interesting story of. For sure. And I'm sure the way Chuck Palahniuk tells it is probably the best believable. 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 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, there's more of it, the quantity changes, the consistency. You know, there's blood added to it. Now, any. Any bodily fluid that seeps out of us can change in those ways. And those are all, you know, dispassionately. Those are all equal pieces of evidence that I use to sort of make a calculation and figure out what might be going on with the patient. 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. The doctor's perspective is just sort of like each bodily fluid is just a raw material to, you know, look through, to test, 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. They're all clues about what's going on in there. And 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 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 bodily fluids are often the stuff we're reading. It's sort of like the text that we have to analyze whatever's coming out of the human body and whatever it looks and sometimes smells like.
- [39:01]
C
Yeah, you tell some pretty puckering stories in the book about first rectal exam, things like that, which were yet another reason why I would not make a good doctor. I just can't fathom. 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 reunite a family, but what's the best thing?
- [39:37]
B
Yeah, I would say there's very few quick fixes in medicine. I would say that this is true wherever I've practiced. Like you said, I've worked in Antarctica and the Arctic and the Himalayas, rural Pennsylvania and elsewhere. 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. A lot of things are, well, take this medicine for the next seven to 10 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. You know, like dislocations are one example, though, not that their arm's totally back to normal. 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. And one of the bones of the forearm kind of slips out of a ring of tendon that it's lying in, and the child will not be. Will not move the arm, will not do anything with the arm, no matter what. And there's this 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 a click, the kid's crying and screaming and the parents like, oh, my God, they're worse. 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. So I feel like those quick fixes in medicine, of which there are not so many, are just super satisfying. 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.
- [41:23]
C
But in medicine, 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 that. I don't enjoy going to the doctor, but I hate going to the dentist.
- [41:38]
B
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, delivering the oh, your scans and tests are all normal is probably one of the nicest things because some of these people just been stewing and stewing and worrying and you know, you look up on Google, I was talking before about Dr. 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 like 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. So I think people, you know, go, Dr. Google diagnoses 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.
- [42:51]
C
I had 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 this is pre Dr. Google. And I felt a lump in the back of my throat and at the beginning of the day it was small but noticeable. And so 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 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 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, got so horrible.
- [43:45]
B
I know that foam.
- [43:46]
C
But because I thought I was dying of cancer, I was like, whatever, 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 to remember there are just going to be a number of things That I, who knows what this is? And so stay calm until you have reason otherwise.
- [44:23]
B
Right. And I usually do that. Sometimes I'll worry about something that's. That's probably another case where my emotion, emotions get in the way of my rationality. But 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, like, we're gonna have to go through all this. I'm gonna be a sing, 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 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 may sometimes knowing more doesn't make you sort of 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. I wouldn't say that in that way, but I would think that. But with my wife it's like, oh boy, here we go. End a lifetime.
- [45:40]
C
Yeah. No, I would do exactly the same with my wife. So you travel a lot, you are a doctor in some really weird situations.
- [45:50]
B
Why? Well, I loved traveling before I became a doctor or even wanted to be a doctor. Yeah.
- [45:56]
C
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.
- [46:04]
B
True. Well, I love, you know, even before being a doctor, I loved rough travel, adventurous travel, traveling to remote places, sleeping about that, sleeping on the ground. I think so part of it, I think was 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 past.
- [46:29]
C
Do you actually feel better or is it intellectual?
- [46:32]
B
No, I think it's partly intellectual. I mean, often when you're going to those places, you're doing something physical, let's say hiking or some kind of expedition or mission, you're. And there's a whole bunch of kind of emotionally satisfying and intellectually satisfying and sort of social cohesion things going on, you know, when you're in some kind of mission based, you know, kind of plan or on, on that course of, of activity. 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. 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. Everything smells like disinfectant and all the sounds are beeping and phones ringing and not sort of birds chirping or splashing 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, 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 US 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 plant, 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 you 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. 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 impacts 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. 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 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 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 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 bug of interest in the natural world and human culture. Spent a bunch of time with native peoples of the Russian Far east on the Kamchatka Peninsula. But even Russian culture itself in northwestern Russia, I found super fascinating. Learned the language, traveled to a lot of rural parts of the country where one part, they said I was only the second American in history who had been to this, like, tiny village. And he had a textbook that showed the first guy had been there in, like, the early 1900s. But whoa. 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.
- [51:53]
C
As you get farther from modern civilization, are there differences in things you have to worry about? One thing we haven't even touched on today is obesity. I'm guessing as you get into these more remote places that that sort of drops away to next to nothing. Or maybe I'm wrong about that. What have you found?
- [52:10]
B
Yeah, so it's interesting 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, there's a lot of obesity in rural America.
- [52:22]
C
I would guess it actually goes up.
- [52:24]
B
Right. So there's a lot of socioeconomics that come into play there. But yeah. So, 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 not that physical exertion is 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 have resulted in.
- [52:47]
C
But wait, wouldn't people out in rural America work more, not less?
- [52:52]
B
Like physically? Yeah, well, I mean, so much of it has been mechanized. You know, certainly the Amish who live near me in Philadelphia, I mean, they're busting their butt. They are the draft animals pretty much. I mean them and their kids are, you know, I see them. I mean, yes, they have horses to pull the pull their plows, but they are still working their butts off. And where modern farming is super mechanized, you know, GPS controlled tractors that make every line of corn optimal for fitting as many plants as possible. 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 Tibetan llamas, which are sort of the Tibetan Buddhist form of monks call them llamas kind of living in the hills, sort of in caves, sometimes living their monastic acidic lifestyle. But interestingly, you know, they were rarely obese. I did see there's a llamasery there which is sort of like where a bunch of llamas live. And the head of the llamasery was actually quite overweight, also had type 2 diabetes, you know, but he's sort of in the powerful position of being the head of the lamassary. I don't know what that says for his lifestyle, but even 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. She actually had high blood pressure and sort of like maybe early type 2 diabetes. Like her sugars were high. So every time.
- [54:33]
C
Did you get any sense of what she was eating?
- [54:35]
B
I mean, she's 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?
- [54:50]
C
Do you have a hypothesis? That seems so crazy, right?
- [54:54]
B
You know, I don't know.
- [54:55]
C
She has to be eating high. Sugar glucose is getting into her system. Right? I mean there's no way.
- [55:01]
B
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 her eat. I assume she's eating maybe a well rounded diet. She is sitting a lot of the day meditating. Is that like being sedentary? I'm not sure.
- [55:21]
C
Wow, this is so interesting. Okay, so this really puts things to challenge. But you don't, you don't have enough information. So this is going to all be circumspect.
- [55:28]
B
Right? That's why I'm just very 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 overturned 20 years later. Tired of overpaying with DirecTV. Dish offers a reliable low price every month without surprises. Get the TV you love and start watching live sports news and the latest movies, plus your favorite streaming apps all in one place. Switch to DISH today and lock in the lowest price in satellite TV starting at $89.99 a month with our two year price guarantee. Call 888, add dish or visit dish.com today.
- [56:14]
A
When you manage procurement for multiple facilities, every order matters. But when it's for a hospital system, they matter even more. Grainger gets it and knows there's no time for managing multiple suppliers and no room for shipping delays. That's why Grainger offers millions of products in fast, dependable delivery. So you can keep your facility stocked, safe, and running smoothly. Call 1-800-GRAINGER, click grainger.com or just stop by Grainger for the ones who get it done.
- [56:44]
C
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 artery scanned in probably eight years, but 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 general health. 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. Do you not have a similar framework or are you coy about your framework?
- [58:07]
B
I would say probably a little of both. I mean, I do think that 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.
- [58:28]
C
Do you treat fruits and vegetables the same?
- [58:31]
B
I mean, I guess I often combine them together. When I'm saying them, I say fruits and vegetables.
- [58:38]
C
But one has a lot of sugar.
- [58:39]
B
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 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. But I guess I probably am more coy even than I would apply in my daily life or to what my kids eat. Because I think doctors have gotten so much wrong with nutrition. Maybe being a doctor makes me even more coy or more hesitant to declare causality or declare the truth about X causes Y, what would you do?
- [59:24]
C
This won't work because you already have a diet. So let's take our woman in the cave.
- [59:30]
B
Yeah.
- [59:31]
C
If I saw that she had elevated blood sugar and remember, I'm just an entrepreneur man, 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 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. Do you think that I'm delusional or are there things that you're confident if I fed her, I'll just be honest. Boiled chicken breasts and broccoli. Her blood sugar is coming right down.
- [60:22]
B
Well, so I guess 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 ago.
- [60:31]
C
Yes, but that's different than not knowing what, what causes what. So I'm trying to ferret out whether
- [60:37]
B
you're saying, though, you would have access, let's say, to a First World City supermarket.
- [60:41]
C
Yep.
- [60:42]
B
Yeah, I would. I would say I'm confident that you probably could improve her. You know, I don't know what her cholesterol panel was, but let's say her sugars.
- [60:50]
C
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 I don't know that I don't kill her. I have enough humility to understand 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 to 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. Now we're getting into the like, I mean 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 layperson 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.
- [62:10]
B
Yeah, I agree. I think that you, I'm confident you could get her blood sugar under control. I guess there's complications of what's available locally though. And also maybe she has a crazy sweet tooth. I'm not sure. Maybe she loves cornflakes. I'm not sure. I didn't ask her too much about the diet, but I was impressed by the fact that she had these diseases. But I do think you're right. And with cholesterol, doctors have flip flop back and forth about does eating cholesterol make your cholesterol in your blood high? Specifically the bad kind of cholesterol. And we've gone back and forth on that and it seems now that eating cholesterol has no effect. The cholesterol in your blood, that seems to be what the data shows these days. These days. These days. But you know, give it more time. Some AI assisted epidemiologic nutrition research. I look forward to what we'll figure out.
- [63:07]
C
Yeah, that stuff is fascinating. Okay, so let's go back. We're, we're in these remote locations. We're definitely seeing different things though. We derailed on my surprise over the person in the cave that's approaching type 2 diabetes. 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.
- [63:32]
B
Yeah, I think, I guess I'm. My daily job, my best, most enhanced skills, most practice skills, most developed skills are in dealing with the individual patient, diagnosing their conditions and sort of treating them. I do think she was also in her, I think 70s, maybe even early 80s. Just aging alone, you get higher risk of all sorts of diseases. The body just doesn't work as efficiently as it once did. Organs get tired. I mean that's a silly way to put it, but maybe her pancreas isn't up to the job like it was when she was 40. I think maybe that just puts her at higher risk. I guess that's just another factor I want to throw in there. But, yeah, I think it's very variable. You know, you certainly see some genetic predispositions. When I worked in Arctic Alaska in the town of Kotzebue, 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 US Government 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 recessive genes that end up leading to what
- [64:50]
C
exactly is a population bottleneck?
- [64:52]
B
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 all comes from a very small set of ancestors, let's say. So 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. 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 and the genetics kind of. You can see diseases in certain populations that you don't see in others.
- [65:33]
C
So like purebred dogs.
- [65:35]
B
Exactly. Right, Exactly. So it's like purebred dog where you're. You're purposely. With breeding dogs, you're purposely narrowing sort of the genetic pool. And in these cases, in. That's the result of 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. 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 in epidemiologic studies, it shows there's much higher rates. And in the Inupia Eskimo who I worked with in northern Alaska, there's actually conditions called spondyloarthropathies that are super common. And I did see some patients with that condition. So there's definitely the genetic predispositions that you see. I mean, there's certainly a lot of lifestyle related things. So the Inupiat 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. 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 does not respond to the usual antibiotics that are given for animal bites and other skin infections. So when I started working in Alaska, there 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 seal finger. And when I worked on a cruise ship in Antarctica as the doctor too, they gave me a similar handout and mentioned seal finger as well. Because tourists get too close to seals to take that optimal selfie and sometimes get bitten by them. So there's different diseases, even climate, you know, in India, I mean I saw malaria and dengue diseases that are kind of only in the tropics as where, you know, even in the US where I trained in the northeastern us 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 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 practicing medicine in the US 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 think as a doctor.
- [68:39]
C
Now, when you're practicing medicine in these extremely remote locations, what do you, I'm assuming you have Very limited equipment that you can take with you. What, what medicines or whatever do you take? What are the most essential?
- [68:51]
B
Right. So it depends what's there. So when I worked in Arctic Alaska, I had a full lab, cat scanner, ultrasound, 24 hours a day. But that's in a hospital on the cruise ship. No, this was in a hospital in. So I worked in a hospital in Arctic Alaska and then I also.
- [69:06]
C
Hospital in Arctic Alaska.
- [69:07]
B
Yeah. More than one, actually. Well, so there's one.
- [69:09]
C
These are towns.
- [69:10]
B
These are towns. Yes.
- [69:11]
C
Got it, got it, got it.
- [69:12]
B
I also worked on a cruise ship in the Russian Arctic that went to this island called Wrangel island, which is sort of just northwest of the Bering Strait, as a lot of polar bears there and it was totally spectacular. So I was the doctor on that ship for about 50 people. And these, these boats so are very well stocked. I was actually surprised. But you know, every northern summer there's a lot of cruise ships that are going through the Arctic, visiting places like Iceland and Greenland and Alaska and Svalbard, which is the archipelago above Norway, and Franz Josef Land in the Russian Arctic and renowned Bengal 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, see these amazing places, go on these usually very expensive trips for free and just provide that service and work while I'm there. So, 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. But when you're planning your, that kind of trip, the strategy of what medicines to choose, what supplies to bring with you is a very fascinating area that I really like thinking about. So, you know, you have to anticipate what you're going to see. You know, if you're going to a place where they're butchering seals, you better bring that antibiotic for seal 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, 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 in the middle of nowhere or are 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 we have tons of medicine for motion sickness, from the patches to the pills and even the injectable forms. If 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 what kind of people you're going to be treating. So a lot of cruises to Antarctica, there's 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.
- [71:44]
C
Crossing the wildest sea, the wildest sea is a good combination.
- [71:47]
B
You better hold on with both hands to the boat at all times. But you do see those kind of things. 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. But, and you have to think, you know what, how easy will evacuation be? I mean, that's a huge 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 Kotzebue, 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. 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 when evacuation will be needed. Often I'll know immediately. Oh, this person, 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. 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. So how early to evacuate is another question. Also, geography comes into play. So when my patients were evacuated from, let's say, Kotzebue, 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 wall and 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 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.
- [74:46]
C
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.
- [74:51]
B
Yeah, Usually it takes a skull fracture at least. 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. I remember this one patient just had a dot of air on the cat on the head scan.
- [75:08]
C
You can just like air in a scan.
- [75:10]
B
Yeah. So in a CAT scan, it looks black, actually. Each diff. Like different densities of tissue are different 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 air. So on a CAT scan, I saw one dot of air inside the skull. And so we were debating with the flight nurse and the trauma surgeon and 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.
- [75:49]
C
And then their head burst on the flight.
- [75:51]
B
No, it was fine.
- [75:53]
C
Thank God.
- [75:53]
B
Thank goodness. Yeah, that.
- [75:56]
C
That stuff to me is. Is super crazy. Now, you said that you like thinking through these problems. Are you a prepper at all?
- [76:06]
B
I'm not a prepper, Though 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 flintknap 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 level more than I think the world come to an end. I mean, a little bit of preparation, I think is wise and. 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 that might come.
- [76:44]
C
We're back to my. My curiosity around you and Hannibal Lecter, but too many traits here.
- [76:49]
B
Right. It's not that I think we're gonna have to go back to the Stone Age or anything, but I just am fascinated by it. And it turns out it might come in handy if the shit for the world hits the fan.
- [77:00]
C
That's crazy. 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 theme of the new book or anything.
- [77:10]
B
Sure. So the new book is. So far, it's just sort of a collection of stories not based on body parts and bodily fluids. Like my first book. But one of the stories I'm working on now is actually about chronic illness in children in the ancient world.
- [77:26]
C
How ancient are we talking?
- [77:27]
B
So could be thousands of years. But to. More recently, I think as a pediatrician. I'm a pediatrician and an internist, so I'm trained to be both. And I've dealt with a lot of chronic illness, both in adults and children. And I came across a really fascinating story, actually, while I was in the Alaskan Arctic, where a lot of mummies, which are bodies that have been preserved through time, come out of the ground there especially.
- [77:55]
C
Or are there other things that will preserve a body?
- [77:57]
B
So dryness and ice are basically the two. They sometimes come together because usually when Something's frozen, they'll also, you know, it's called sublimation, where frozen water just sort of evaporates as well, just like liquid water can, and they will dry out, sort of like a freeze drying process. So dryness and cold, or 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. But so 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 called, you know, the first question was, oh, is this a job for the police or is this a job for the archaeologists? Is this a murder victim from last week or is this ancient, ancient body? And so they, an archaeologist saw just from where the body was in the layers of soil that were exposed after the storm, they knew immediately it was ancient. 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, an ancient kind of dress. And 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, which called Tuli, sort of before the Inupia, their ancestors, the Thule people. And she lived about 800 years ago, so around the year 1200 or so, certainly before any European or American, American contact. And, 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, 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 a pack a day for decades. But in her case she was a five year old girl 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 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.
- [81:28]
C
Why? What, 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.
- [81:38]
B
Yeah, so I think it's, it is constantly laying down new calcium, new calcium phosphate, which is sort of the, the crystal that's on bone and that gives it its, its hardness and its strength. And so the, there's different processes of going on at the same time in a growing bone. There's the actual growth that lands. 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 you X ray children, there's a lot of bone missing actually, because it's still cartilage.
- [82:16]
C
Really.
- [82:17]
B
Yeah. And so that process of turning it into bone or the bone sort of replacing the softer cartilage, you know, that process continues even though the bone might not be lengthening due to perhaps 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 feel terrible or throwing up. 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. So, you know, 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.
- [83:38]
C
So it'd be like eating shoe leather.
- [83:39]
B
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 fill your stomach with whatever you can to alleviate the hunger pains, whether or not it's going to actually be nutritious or not. There was some soil in her stomach, so she could have been eating soil for whatever. Maybe her parents wanted to put something in her stomach. Maybe they knew she was dying and just wanted to alleviate the hunger pains. And so 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 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, and utterly fascinating.
- [84:44]
C
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?
- [84:52]
B
Check out my website, www.jonathanreisman.com.
- [84:56]
C
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.