Crazies, and baby Sid

Yesterday's theme was neuropsychology, made evident once transferred to the A train heading home with a schoolmate.  As we waited for riders to exit the subway car I heard a man yelling repetitively.  A quick side glance yielded arms full of a large, folded cardboard box and four or five bags.  To use local terminology, he was just another crazy.  They are the homeless, the hungry, the drug addicted, the mentally and/or physically disabled, often possessing more than a few of these traits.  They are a regular occurrence throughout the city.  New Yorkers are well practiced in maintaining a straight face that denies ever noticing something abnormal as they venture to a distant location on the subway platform, to another subway car, or to the opposite side of the street.  And somehow that radar that fails in warning you of friends making a sneak attack from behind is suddenly in full force and blinking a red mental warning light that this person will walk the extra 20 feet necessary to board onto your packed subway car, because the car conveniently in front of them is lacking some element of mojo.  Lucky us, this yelling crazy not only boarded our subway car, but also traversed from the far end to the area we stood at two-thirds of a car away.  Oh lucky us....

My thoughts returned to previous eventful evening rush hour commutes.  The homeless man whose pants fell down around his ankles, belt and all, and he stood there smiling at nothing in particular while his parts, front and rear, dangled for all to see.  The guitarist who forewent moving between cars at every stop for a new potential paying audience in lieu of sitting and belting his songs the entire way to Harlem, only to be joined for the last two stops by a saxophonist who blew even louder into my face from 4 feet away.  The guy who insisted on shuffling through a packed car and, once blocked by a six and a half foot guy with no illusions of spontaneously creating space to let him through, progressed from mumbling unintelligibles with the occasional "anything... help me out... appreciate..." to "AAGGGHHH!  UUUGGGHH! Gimme the money!" and immediately returned to his previous unintelligible mumbles without so much as lifting his head.  I was grateful to have missed the man licking the outside of his shoe as though it were the remnant bowl from mixing brownies amid a famine (I think I posted the YouTube of this in a previous post with warnings of grossness).

My mind was brought back to the current crazy when he restarted his repetitive ramblings.  "Jamaica Jamaica Jamaica Jamaica Jamaica Wash-ing-ton Heightssss  Jamaica Jamaica Jamaica Jamaica Wash-ing-ton Heightsss... no tengo no tengo no tengo no tengo no tengo no tengo dinero dinero no tengo no tengo nada nada nada nada nada nada nada nada...."  Apparently he found the space next to my friend and I welcoming.  Divert eyes, step back a foot, face away.  "I keep you company.  No men no men no men no men no men I keep you girls company."  My friend gave the polite Cleveland, Ohio smile meaning "oh you crazy, you run along now."  My response: an audible "Nope!" and stepping 5 feet back while shaking my head, motioning for my friend to join me.

Here I gave a big sigh, reminding myself that I now know the innumerable possibilities that might explain his behavior.  Frontal lobe involvement resulting in impulsiveness and reduction or loss of what is known in neurology as executive functioning.  Lymbic system and temporal involvement resulting in impaired memory.  Vestibular involvement resulting in an attempt to stimulate through loud verbalization and repetition with synchronous head nodding.  Any of these could be caused by malnourishment, drugs be they prescription, over the counter or illegal, infection, cognitive involvement due to a neurological disease either congenital or acquired, early onset dementia, post-traumatic stress disorder, allergic reaction(s), vitamin B-12 deficiency....

As awkward as these encounters are within public, 99 out of 100 crazies are in fact harmless.  In a rehab environment, I have a chart that includes medical and therapy evaluations as well as oversight by doctors and others of the health care team.  That level of understanding does not trump the need to give behavioral reminders, the intention being that with enough time, patience and consistency neuroplasticity may help resolve a portion of problematic behavior.  Depends on the patient and the level of involvement as to how much change may be possible.  But since you know the reason behind the behavior, you may also know how to guide the patient.  In public these people are simply strangers, and more often than not they have nowhere to receive care.

I then remembered the article I selected for this week's Organization & Management course, where for the first half hour (sometimes full hour) we discuss various articles and news items from the previous week.  My selection was "Push underway to cut drugs for dememtia patients" by Matt Sedensky of the Associated Press.  A Medicare audit of 2007 performed this past May showed one in seven dementia patients received prescription antipsychotics, and 83% of these were "for off label purposes."  Think of an elderly family member in a subacute or skilled nursing facility who seems absent of personality.  They don't have behavioral abnormalities because they are drugged into a stupor.  Many facilities noted within the article performed internal audits and in the last few years have reduced the number of patients on antipsychotics from as many of ~30% of patients down to the ~7% whose evaluations actually warrant the use of such drugs.  One facility director reports taking dementia patients off of all drugs aside from medicinal aspirin (cardiac purposes), resulting in patients with an interest in life and families reporting that the patients act more like themselves -- without behavioral detriment.

My favorite part: a comment from another facility director stating that basic adjustments, such as feeding patients earlier, were enough to ensure no or minimal behavioral incidents.  Meaning: treat the patients like deserving human beings.  Neuropsychology/neuropsychiatry has for a very long time been separate from neurology.  I've never understood this.  Oliver Sacks is one of many doctors who has always spoken for recognition of behavior as a genuine neurological entity.  Therapists spend many more hours with patients than doctors, interacting with them from anywhere between 20 minutes to 90 minutes at a time.  I find human physiology and medicine extremely interesting, though I am steadfast in my choice of therapy over medicine due to elements such as this.

Back to the crazy at hand.  He continued ad nauseum as the train pulled away from my home station, my ears ringing for a few minutes as though I had exited a bar playing very loud music, my mind reflecting on the amount of people I pass daily who could potentially become my patient in the future.  It is a peculiar place, being a third year student with impending graduation and with bits of reality squeezing themselves into the mix.

I'll sign off with well wishes to baby Sid, who a few days ago became one month old.  I have a handful of film that is expired but I intend to use anyways, hence the old-school feel.  The first was taken at not quite three weeks, the latter at not quite four weeks.  The whippersnapper in him is coming out, grunting and kicking out of his swaddle, representing my mama friend quite nicely :) 

Tummy time with mama

Swaddled nap with papa

[An early] summertime in the city

This week NYC temperatures shot into the 80s.  A handful of friends originally from CA commented that it finally felt like spring -- spring??  Pshaa!  Spring was a month ago when the high was 60.  I acclimate to cold very well, but to hot... yea, not so much.  I don't sleep well (or very much at all), I sweat all the time, and I end up with light sensitive headaches because maintaining actual hydration becomes difficult while I continuously melt onto the floor.  I ended up geeking out yesterday over hydration analysis.

An interesting take on hydration that seems physiologically grounded rather than assumption grounded appeared lately on Marathon Talk, a UK based weekly podcast.  They've had a 3 part series with guest Dr. Mark Hetherington (BSc, PhD), a visiting senior research fellow at the Institute of Membrane and Systems Biology at the University of Leeds.  The second part was of most interest regarding how fluid that is sweat out by the body correlates with appropriate fluid intake.  That is, Hetherington describes how the common assumption that any loss of body weight after prolonged exercise means that exact amount of fluid must be replenished.  I.e., if you end a run having lost 2 kg (or 4.4 pounds), then the assumption is that you lost 2 kg of blood volume and thus should drink back that same 2 kg (or 2 liters, since 1 kg = 1 liter) of water to regain proper hydration.  According to Hetherington this is wrong on two counts, and this is why so many distance runners are in danger of hyponatremia, a state of abnormally low levels of salts/electrolytes in the blood.

The first point deals with the origination of sweat, which comes from two sources.  One source is from the blood, like most would assume, which secretes the fluid through the skin in order to cool you down during/after such physical exertion.  But apparently this only accounts for 50% of the sweat created by physical activity.  The second source is is a byproduct of cellular metabolism of glycogen/glucose and fats.  That means the sweating out of this byproduct water has no affect on blood volume -- your body creates the water as you burn fuel during exercise (same as it produces CO2), the water goes into the blood stream to then join in the fun as sweat (just as CO2 is transported by blood to then be exhaled through the lungs).  Herherington breaks it down into three sub-categories: of the total fluid sweated out (including true blood volume fluid) 25% is produced by releasing glycogen (i.e. concentrated glucose stores) from storage in the muscles, 16.7% is produced by burning of glycogen (breaking it down into glucose) and fat, and 8.3% is from oxidizing glucose -- thus contributing to 50% of the fluid lost via sweat.

What does this mean?  If this hypothetical runner lost 2 kg during the run, then only 1 kg was from blood volume, necessitating that only 1 kg of fluid be taken in.  Otherwise you'd be taking in twice the fluid you need, and if this is straight water then you are at risk of essentially diluting yourself to death.  This is Hetherington's second point -- that the composition of sweat is not pure water, it is an isotonic fluid.  So if you drink plain water you'd have to consume food with the requisite electrolytes.  Otherwise your blood will be diluted while cells will retain their normal isotonic properties, and this will cause osmotic flow and retention of water with cells.  When this happens to your brain, this is when things get really bad really fast.

I also found an article described by exercise phys site called Sweat Science that publishes the results of current literature -- "Effect of exercise-induced dehydration on time-trial exercise performance: a meta-analysis" by Eric Goulet, published in April of this year in the British Journal of Sports Medicine.  Comparison of 5 studies that met analysis criteria yielded that those who drank according to their thirst lost up to 4.0% of normal body mass (average 2.2%) , and yet these subjects performed better in a self-paced time trial than those who drank nothing or drank to maintain a near-perfect body mass (losing only an average of 0.44% of normal body mass).  The premise is the latter category was over-hydrated despite maintaining "normal" body mass and thus hindered their performance.

So that means I don't need to freak out as much when comparing my fluid intake with others, or with temporarily dropping a few pounds after a really long run.  I just wonder how I can apply this to non-running life in hopes of surviving the real summer once it gets here.