construction one

There's this house being constructed down the street.



I have been going there a lot lately.





At risk of being too metaphorical, I just had a major operation that I am recovering (very well) from. I will have to build my life back together very soon. In identifying with the concept of being under construction, I guess I was drawn to this place.




I am glad that I was because it is such a great place to hang-out.




There is a sense of privacy and openness. This vacancy inside a construct.








Without a roof the sky's the limit!




And also a sense of progression. Look! Another layer has been added:





It appears someone's been playing soccer...

Music Sharing

Generally, I have observed a huge mischaracterization of music sharing ("piracy"). I happen to be amongst a community of music lovers, collectors, and sharers. These things tend to go hand in hand. Many of my friends are in bands. I have learned about artists I probably would have never discovered if not for music sharing and because of that I have gone to their shows, bought merchandise, and further promoted. Spreading the word is free marketing. The only artists I imagine don't benefit from music sharing are big labeled artists who are already banking and don't need promotion because they are already huge.


I'm sure there are some real pirates out there, people who only download music and never buy it, never pay to go to shows, never buy merchandise, nothing, they just are free loaders. The ones that make music sharers become menacingly characterized as pirates who who want to ruin the music industry. I don't know them. But NONE of the people I know are like that. They have HUGE collections of purchased music (cds and records) and also HUGE collections of music they got for free. You can't stop people from making each other mix cd's, that's just cruel. Mix cds are one of the best things in the world! Or burning each other disks.

In the world I live in: It's fair trading. I bought this amazing album and want to share it, and someone else bought an amazing album and wants to share it! Someone hears a record at a friend's house, then goes and downloads it easily and freely and listens to it constantly, then s/he looks up when a the next show happens in the area, gets a bunch of people to go pay to see the band! Someone loves a particular song and sends someone a free mp3 of it, then that person wants to go buy the album! Etc etc etc. These are the kinda of scenarios I encounter when it comes to sharing music.

The types of music sharing scenarios that I know of help the music industry and they are made up of genuine music lovers.

I understand the concern, believe me. And it's money. I get it. Hm...I wonder, would a band rather to never be heard of or be popular, loved, and free? I mean, if those were the only choices...

I know there is a fine line that becomes a slippery slope between music sharing and piracy. But I also think that we live in a digital age where there is tons of access and exposure. With the good comes the bad, and with the bad comes the good. This also means that someone can steal my idea pretty easily, but it also means that someone can like my idea who would have never had access to it.



One more philosophical query... if a band worked hard, and they got a huge fan base of loving listeners out of people downloading their mp3s for free unbenounced to them, is all their hard world lost? Probably this means that they will be doing better as a band. And by better I mean: selling more cds, t-shirts, show tickets, etc. And by better I also mean happier because people know who the hell they are and like their work.

Again, this need not apply to big huge bands on big huge record labels who are already living in luxury. I imagine music sharing doesn't help them one bit, but, aren't they already banking?




I realize the piracy and copyright issues in our modern interwebbing world is a can of very complex worms that I haven't quite gotten a handle over. But in general, I'll say my little say. I think the first priority of art is either to be private or public. If you make it for yourself, no problem. If you are making it hoping for an audience, once you go public, isn't the goal to create as many listeners as possible???? To see if people relate to your work and if they do then you CELEBRATE THAT! If it is for money, than you should go back to college or go to college and get a degree in marketing or business or something and I promise that you will be more likely to bank.

Operative Report

For a year they couldn't figure out what was wrong, then I got tentatively diagnosed with a pretty rare and highly misunderstood: Thoracic Outlet Syndrome. For more information about the diagnostic process, I have abridged two of the DOCTOR'S LETTERS. One who ended up doing the surgery, and the other, writes a humorously verbose letter. I find it hilarious (in my weird textual sense of humor) the way he tries to cover all his ground.

After about four or five months of physical therapy with two different therapist's approaches, I still wasn't better. I resorted to a seemingly draconian surgery based on a nebulous diagnosis because I figured, what other choice do I have? To be in chronic pain and unable to use my right hand (I am right handed) and wait for it to magically disappear didn't seem like a good option. So I risked the surgery, also because I had faith in these surgeons: Dr.Ducic and Dr.Marshall. They were planning on taking out my first rib, scalene muscle, and doing other things I couldn't recall because I don't have the medical vocabulary. See, they were going to remove those things hoping that might work because it sometimes does relieve symptoms of TOS. Turns out I made the right decision; upon opening me up they did indeed find the real cause of the pain I'd been suffering for a year and a half...





(A drawing a few weeks before the surgery)

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OPERATIVE REPORT
SURGEON: BLAIR MARSHALL

Preoperative Diagnosis: Thoracic Outlet Syndrome
Postoperative Diagnosis: Thoracic Outlet Syndrome


INDICATIONS OF THE PROCEDURE:
Patient is young woman with impingement of her brachial plexus on the level of the thoracic outlet. She was evaluated preopertively and found to be a good candidate for the first rib resection. She was aware of the risks and details associated with the procedure in fact a 50% chance of improvement of her symptoms. She was willing to proceed.



These collages I made a few weeks before the surgery, includes copies of my real X-RAYS.
If you click on em you can see em bigger.



DESCRIPTIONS OF THE PROCEDURE:
After Dr.Ducic performed the incision division of the scalenes and neurolysis of the brachial plexus, we were called into the room. The tubercle of the first rib was identified. The subclavian was retracted superiorly and we dissected onto the periosteum of the rib and then dissected circumferentially around the rib. We extended this underneath the subclavian and the brachial plexus up posteriorly to the level of insertion on the transverse process.

There was a quite strong verticle angle of the rib in this location, suggesting that it may have in fact certainly been the cause of her symptoms.

We dissected all the way to the vertbral body and then ligament was divided. Initially we transected the rib between the subclavian and brachial plexus, and then sequentially took out the posterior aspect of the first rib all the way back cleanly off the vertebral body at the level of the ligament, and then anteriorly, taking care to avoid the injury to the brachial plexus, subclavian artery, and vein, anteriorly to the level of the manubrium.

One this was done, the wound was packed. Hemostatis was obtained, and then a Penrose drain was placed and the wound was closed in laters with absorbable suture. I, Dr.Blair Marshall, was present for the entire thoracic portion of the prodecdure and responsible for the conduct of the case.



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So that's just Dr.Marshall's operative report; still waiting Dr.Ducic's. He took the scalene muscle out, re-arranged nerves and veins, clipped arteries, somethingsomething. I'd like to read it because he said some crazy stuff was going on in there and all the medical terminology slips my mind. I'd like it in writing.

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New Leaf

I've been going through some bloggers and have decided to turn a new leaf, I mean, it is fall. Mainly I've been writing only on things generally classified as "the arts." No I will continue with all that because it is a part of my life and I think sharing is important. I don't know where I'd be without the sharings of others.

However now I've decided to expand my sharing and write WHATEVER I FEEL LIKE WRITING ABOUT. In other words, I've been sifting through some other people's blogs and I liked the personal parts of them. I'm not gonna get all livejournal, but I am going to share other tidbits about me, other than what impresses me in music, visual art, or film, etc.


Oh by the way this tracks what I listen to on my computer and ipod, so not all the CDs or records, but still does show a substantial amount, enough to call it my music profile: lastfm: DeenaOdelle

DR LETTERS

Dr. letter regarding surgery part one:

Although longer and more confusing, this letter is far more entertaining. Especially the end. What's even funnier is that my Dad and I were sitting there as he dictated this overly eloquent and verbose letter. And I have trimmed it down pretty considerably.



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Dear Dr.McMahon:

As a follow-up of today's introductory evaluation of Ms.Hyatt, I write this letter. The patient is being seen for a possible right upper extremity thoracic outlet syndrome. I spend most of our time today listening to the patient's complaints.

In brief recapitulation, the patient is a twenty-five year old white female with initial swelling of the right hand over a year ago. She underwent subsequent evaluation in Austin, Texas with a subsequent evaluation for persistent symptoms. Chronic adema combined with intermittent pain in the upper arm, forearm, and hand, as she points in the latter to the fourth and fifth digits of the right hand (those which appropriately correspond to the ulnar nerve). She notes as well appreciable pain in the neck. She also has a history of a left iliac vein thrombosis, which was rather extensive secondary to May-Turner's syndrome with an angiolysis in 2001 and subsequent stent placement but not further problems. The patient has been ongoing with physical therapy for the last seven weeks with some appreciable benefit.

The patient remains on significant medication, including Neurontin 300 mg b.i.d., cyclobenzaprine q.h.s., and additional medications she does not recall.

At this point, the patient is noted to have bounding pulses and bilateral radial arteries on standing at military posture, Adson position remains unaffected. Yet, with hyperabduction of the left and right upper extremities, there is adiminution of pulses.

I think most importantly, at this point, the patient is out of school on the basis of pain with any movement of her right hand and arm, as she is right handed. Her function is minimal without great consequence.

At this juncture, the patient has recently and locally seen Dr.Ivica Ducic, whom I know and admire. I was not aware that Dr.Ducic had any interest or expertise in thoracic outlet syndrome, but I do know him to be an excellent individual and surgeon. I know that the patient will be seeing dr. Blair Marshall, who is another outstanding individual. Dr.Marshall is a thoracic surgeon, having finished her training at the University of Pennsylvania and is well known locally, having come through the general surgery program at Georgetown University Hospital and having rotated at Inova Fairfax Hospital.

I have stated that many surgeons have many different opinions about TOS. My own opinion, in regard to Ms. Hyatt's history, I would probably say that I favor some element of TOS in her history; however, at this juncture, I do not see anything that would push me to recommend surgery. Physical therapy, which probably restores individuals to a reasonable function in 50% of the cases, is my recommendation. If, however, the physical therapy does not deem successful, surgical intervention may be necessary.

I have further stated to Ms.Hyatt and her father who is accompanying her today that there are numerous, different opinions about thoracic surgery, even if surgery is recommended. I am en enthusiast for a rather traditional first rib resection through a transaxillary approach, taking down all of the attachments tha might effect the ipsilateral subclavian vein, artery, and/or brachial plexus. Other individuals favor a supraclavicular approach with release of nerve entrapment and scalenus anticus division, etc.

My recommendation is that if the patient were to have surgery, she should have one definitive surgery, minimizing the chance for complications or repeat operation where most of the problems come to fruition. On that basis, I recommend the patient defer surgery until it absolutely needs to be performed. This is not to put her in a position of severe end-stage nerve-related symptomatology, but rather until a point where she has proven that she does not benefit adequately with physical therapy, and that she must do something, even if surgery is felt to be a diagnostic maneuver.

I apologize for waxing too eloquent and being verbose. Again, I have stated that there are numerous individuals who think in wildly conflicting ways with regard to this entity, and it is well known to be most often treated in Denver and Dallas where two surgeons in those same communities are very aggressively minded. However, at the same time, it must be kept in mind, at least over the past decade, that thoracic outlet syndrome ........


Finally, Dr.McMahon, at some point......

Again I apologize for this lengthy note, and I ask Dr.Marshall to send me a copy of her evaluation of this patient.

Thank you for allowing me to participate in the evaluation and care of Ms.Hyatt.

Sincerely,

Paul D. Keirnan, M.D.



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Dr. letter regarding surgery part two:

This is the surgeon who ended up operating on me, as he predicts in the letter.




Dear Scott:

I had the pleasure of seeing Mrs.Hyatt who is currently 25, and, for the past year, has been experiencing symptoms related to Thoracic Outlet Syndrome in her right upper extremity, primarily related to pain, pins and needles, and also coldness/loss of pulse with arm elevation/abduction. She is having most of the symptoms corresponding to the ulnar nerve.

On physical examination, she did have a positive Tinel's sign and tenderness of right but not left brachial plexus. She did have a visually loss of pulse (right hand becoming pale with arm elevation).

Based on her presentations and current findings after a lengthy and detailed discussion, I would summarize my conversation with her as following: I instructed her to obtain a consultation with Dr. Blair Marshall in thoracic surgery for her to discuss whether the 1st rib would need to be addressed at the same time, and I would be planning to perform a brachial plexus neurolysis and anterior scalene muscle removal.

I explained to her that, based on her discussion with Dr. Marshall, the 1st rib can be removed at the same time when the decompression of the brachial plexus and anterior scalenectomy would be performed.
As far as the part of the surgery that I will perform, that would be done through a suprasubclavicular approach with the limited incision that I am using. The possible risks and limitations have been discussed with the patient. Considering that she is currently undergoing physical therapy and is planning to do it through the end of June, then that would be approximately three months of the therapy. Should her symptoms go away by that time, certainly surgery would not be necessary, but based on how abrupt the loss of her pulse is with her current problems with tingling are, I suspect most likely physically therapy might not address her problem and she will require surgery.

In the meantime, thank you again for involving me in the care of this kind patient.

With warm wishes.

Sincerely,

Ivica Ducic, M.D., Ph.D.