Water Supply Side

January 13, 2019

Recently I found a new-in-box water bottle at a thrift store. Initially I was confused as to why someone would get rid of it; however, upon opening the box I saw that it was emblazoned with a logo:

SupplySide

I’m sure it’s former owner was worried about accidentally being associated with such an embarrassingly mistaken ideology. Unfortunately for me, it’s an otherwise nice bottle, which means I now have to ensure I’m strategically turning it blank side forward in any photographs. Wouldn’t want to get Laffed at.

End of the End of the End

June 3, 2018

Graduation. An event that had been so far off for so long, my dazed mind refused to believe it could actually be happening. And yet, here it was, a weekend of visitors and ceremonies and celebrations swirling around me in a blur of regalia and purple orchid leis.  As with everything else in this eight-year adventure, everyone was immediately confused. My “graduation” consisted of two hooding ceremonies (where the doctoral hood is presented) occurring in two separate locations on Friday, and one commencement (the walk across the stage to receive a diploma), in which I was walking twice.

Presumably this hooding business is related to a historical hierarchal system in which more senior scholars got warmer outfits, but in SoCal it means wear extra deodorant because there is going to be some perspiration. Each student is called up in their tam and gown, kneels on the stage, and people important to them place the hood around their neck and fasten it around the back while somebody reads things about them. At the same time, in order to keep the hood from sliding too far down the back, the student has to partially unzip the robe and secure a loop with a safety pin or around a button. In order to appear confident and graceful, I’d practiced this move (okay, went through it once, but come on, how hard could it be?).

PhD hooding came first, presented by my mentors Salvador Soriano, PhD and Kerby C. Oberg, MD, PhD, people who respectively chaired my thesis committee and helped me survive the MD/PhD process. In typical Loma Linda University fashion, the grad students were meticulously arranged in a very specific non-alphabetical order that had no relationship to the order in which we’d be receiving the hoods. Our path from the seats to the stage went down steep stairs, the kind that force a choice between “watch your step” and “smile for the camera.”

My turn. Heart rate increasing, I shimmied clumsily past the other seated graduates and into the aisle, dark blue hood over my arm like the napkin of a maître d’. I took a deep breath and began my descent: Look-step, smile. Look-step, smile! I arrived at the stage without incident–which is where my competence ran out. Kneeling down, I unzipped the gown too far, revealing my white dress shirt without so much as a drink first from the crowd. My hands were shaking so much I couldn’t fasten a snap–a button was impossible. I fumbled until Soriano and Oberg finished their part before giving up and standing, which caused the hood to slide up toward my neck. I quickly pulled it back down, feeling it sliding again while I smiled for the camera and hoped there wouldn’t be a motion blur in the photo. Somewhere in here they finished reading my abstract, leaving me on stage as the silence descended. Awkward or not, this was my moment, by golly, so I took what was likely only a few extra seconds to hug each mentor in turn before returning to my seat.

For over two decades, Alzheimer’s disease has been thought to be caused by accumulation of amyloid beta protein in the brain. Unfortunately, amyloid-reducing therapies have failed to treat the disease. Here, I present and defend an alternative hypothesis in which amyloid does not cause Alzheimer’s disease, but rather is part of the defense mechanism against a more likely cause of the condition: dysregulation of lipids, such as cholesterol. This hypothesis is supported both by current studies as well as my own work. In mice, I found that amyloid precursor protein is necessary to regulate cholesterol under conditions of cellular stress seen in Alzheimer’s disease. In humans, I developed a novel blood test to potentially quantify the disease state. Overall, my studies will help expand our understanding of neurodegeneration, provide a new means of identifying individuals at risk of developing Alzheimer’s, and open a potential route for treatment.

Contrast this with later in the program, when we were given four roses to give out to loved ones. Since all of mine were sitting together, I efficiently distributed my flowers and returned to my row. It was completely empty; a quick glance around revealed that no one else was even close to finishing. I sheepishly shuffled back to my family, where the official photographer captured a picture of us taking pictures.

When the ceremony ended, Rachel slipped out, perfectly executing a previously-made plan to pick up food for our family before the next hooding began. Naturally, in the reception area we came upon a catered dinner, about which no prior announcements had been made. Poor Rachel had to make a detour by the house to drop off her food, arriving at the reception after much of the crowd had already dispersed.

Before long it was time for me to assemble at the next campus location for the medical school hooding ceremony. I removed my blue hood in preparation for the kelly green one. My classmates milled about fielding confused calls: Unlike the graduate school, there were no instructions about what the hooders were supposed to do or where they should sit. For this one I chose Rachel for obvious reasons and Soo Kim, MD, as among other things she helped me write my personal statement for residency application. As the start time drew nearer, we began to realize that no further information about how things were going to go was forthcoming, and with Mark’s help everyone in our party was able to get seated together.

Mid-ceremony, they began explaining how this whole hooding process was going to work in a needlessly-complex tangle of exceptions and alphabetical orders. Surprisingly things went rather smoothly, characteristically due to the efforts of office staffers-turned-stage-managers who had a buffer of people queueing offstage where they could be appropriately arranged prior to their name being called.  This time I didn’t bother attempting to secure the hood, instead standing up carefully to prevent sliding long enough for the picture. Unlike the graduate school, my medical school class included well over a hundred people, and given that my name is in the Cs, there was a lot to sit through afterward. Rachel started a game of hangman.

Michael A. Castello moved to Loma Linda from Baltimore, MD in 2010 to join the MD/PhD program; today he leaves with a PhD in Physiology, an MD, and considerably more gray hairs. As eight difficult years come to an end, he is happy to be surrounded by some of the people who believed in him–even when he didn’t. He will be going to UCSD for residency in child neurology.

Climbing into the front seat of a car in regalia is a bit challenging, and as it turns out, one I was unable to do without managing to rip the stitches on one of my hoods. Saturday Mark took a bunch of pictures and Rachel saved the day again by re-sewing the hood together.

For some unholy reason medical doctors are obsessed with mornings, and the Sunday commencement ceremony was no exception. We had to start lining up at 07:30, the processional started at 08:30, and gunner families were allowed to start reserving seats at 05:30. I thought that would be my final kick in the pants from the university, but I was wrong. In a snafu emblematic of the past eight years, I was informed that I was one of two people whose diplomas had been mis-printed, and the “overnight shipment” of the replacements didn’t arrive in time, because of course it didn’t.

I walked in with the graduate students wearing the blue hood and discovered I was seated in the front row. It didn’t stop me from texting, but it did make me extra-vigilant about where the cameras were pointing. Flooded with neurotransmitters, my brain hyper-focused on each new action. Stand with the grad students. They didn’t screw up reading my last name. Walk. Look out into a featureless crowd and smile. Return to my seat. Quick costume change from blue hood to green hood. Line up again with the Cs. It’s starting to sink in now that this is it. Name. I can’t contain my smile this time, my grin looks like Jack Nicholson’s Joker. Back to my seat again. Suddenly it’s over and I’m walking out wearing both hoods and carrying two diploma covers.

“Let’s see it,” Mark says as we take pictures. Earlier events long since lost to a flood of emotions, I open the case: It contains an IOU.

Leaving Dayton

May 9, 2018

When I last left off, I was experiencing a smorgasbord of weather variations in the vicinity of Dayton, Ohio while completing my final rotation of med school. Both my mom and Mark came up from their respective states of residence to visit me as Ohio, unlike California, is within a driving distance where one can both leave and arrive in the same calendar day.

My departing flight left Dayton at 06:30, which translated to reveille at approximately 04:30 once the usual allowances were made for driving time and airport security; accordingly, I went to bed early stayed up until 03:30 talking to Mark. An hour of sleep later, I stumbled into the waiting vehicle of my dear longsuffering mother, who had volunteered to drive me to the airport at this dreadful time of day. En route while looking up my flight information, I realized with a sinking feeling that my flight left not at 06:30, but 06:00, putting me thirty minutes behind. Not wanting to spread my sudden-onset globus hystericus affliction with Mom, I opted not to share this information. Instead I undoubtedly confused her by attempting to act as though my abrupt conversational shift to monosyllabic responses was entirely normal.

At this point a little additional background information is helpful because chances are you aren’t familiar with Dayton, Ohio. There is a nice airport that isn’t particularly busy because nobody “passes through” Dayton on the way to somewhere else. As a result the general air approach is to fly into one of the other Midwest hubs like St. Louis or Detroit and from there take a significantly smaller plane on a short hop to the final destination. I would imagine that people say there is traffic on the highways during rush hours, but with my relative scale calibrated to LA traffic, it’s a joke. Not to mention that at 04:30 there shouldn’t be too much happening on any roads, with some exceptions.

You can now imagine my surprise when traffic (mostly semi trucks) on I-75 ground to a halt. Not the slow, creeping, rush hour sort of jam, but the full stop, turn off the car and get out kind that happens when a tanker falls off a bridge in Baltimore or it rains anywhere in SoCal. We bailed off the highway and began navigating a series of surface streets to bypass the occlusion. It thus became especially relevant that my mother is a very, shall we say, careful driver, interpreting speed limits as actual maximums rather than loose guidelines while I practiced calm breathing through a rictus grin.

When we arrived at the airport, my fragile facade crumbled: the car had barely stopped moving before I was out of the car and unloading my suitcase. “Bye Mom, hugs and kisses, love you,” speed walk to the security line. All the smart med students paid for TSA PreCheck prior to starting interview season; I, on the other hand, did not. There were only three people ahead of me, though, which would have been fortunate had the first person not been subsequently joined by the other four members of their family. None of them had anything ready to go; and because this is Dayton, the friendly TSA agent helpfully walked them through what they needed to present and patiently waited while they fumbled for each new item. Here are the boarding passes! We need IDs too? Here you go. Wait, the kids need their boarding passes? I’m so sorry let me find them.

My plane has started boarding.

Finally they are able to get through the first checkpoint and into to the scanning area, but of course they have everything from car seats to breast milk to unload onto the belts for inspection. My turn, I went through, oh hey my carryon suitcase got flagged for further scrutiny; they had to throw away my double-edged safety razor blades, an item doubtlessly forbidden to foil would-be assailants who enjoy accidentally cutting themselves. I tried to walk quickly and calmly away from the area before taking off running to my gate, arriving out of breath at the empty waiting area as the attendant was closing the jet bridge door. She kindly let me through and I boarded the plane, making my walk of shame to the cheap seats in the very back only to discover that because this was a small plane, my bag wouldn’t fit in the overhead compartment. Cue a repeat walk to the front of the plane to gate-check it, avoiding eye contact with everyone during my return. I buckled my seatbelt and the plane immediately pulled away from the gate, at which point the perspiration caught up to my heart rate. When I finally stopped sweating, we were landing in Detroit.

Impudent Weather

April 15, 2018

Weather is the height of inoffensive topics, typically reserved for such situations as breaking ice, vainly attempting to prevent a relative from espousing their religiopolitical views in polite company, and  interactions that have reached a level of tedium where discussing the class of precipitation seems interesting. One could be forgiven for assuming that, if I am writing about atmospheric conditions in Dayton, Ohio, I must truly be scraping the bottom of the inspirational barrel. I have, however, spent the past week experiencing nearly  every form of wetness that is capable of falling from the sky, a rather foreign phenomenon for me after eight years in drought-ridden California.

Unlike my lovely spouse, I invariably overlook the forecast when checking the weather; consequently I was surprised when I awoke to about 4 cm of snow blanketing my car. Thankfully I had anticipated this by packing a scarf and gloves in addition to my winter coat, although my preparations unfortunately did not include an ice scraper. I bundled up, naïvely assuming that snow was going to be the precipitation du jour. By midday, however, it had changed over to a warm rain, and by the time I left work it was pleasantly clear.

Upon next waking it was raining heavily, the downpour leading to flood warnings via that system where everyone’s phone simultaneously produces a loud alert tone. By the time I went to sleep that night, the cloudburst had transformed into a thunderstorm, lightning periodically illuminating the room. On the following day, the rain had abated but the winds seemed to be picking up, and in fact that afternoon we were treated to another round of alerts, this time for tornadoes. A “Code Gray” was called in the hospital for inclement weather, which, in addition to securing the windows in patient rooms, apparently includes a protocol where someone announces said Code Gray over the hospital PA system approximately every two minutes until the all-clear is received.

We weren’t finished yet, though: the next several days casually alternated between snow flurries and rain, culminating in a ¿por qué no los dos?  sleet-storm that left me sitting in my car waiting for windshield ice to melt because I still don’t have a scraper. Perhaps by way of apology, this Friday was the most beautiful day since I’ve been here, a balmy 27 ºC that saw me visiting Riverscape MetroPark in Downtown Dayton. It’s been raining ever since.

Capellini

April 2, 2018

Fool me once...
Here, we can see clearly that this is spaghetti and not capellini.

Last week I went to Trader Joe’s to acquire provisions for my stay in Ohio. One of the supplies I need to get is pasta, specifically, spaghetti, so I can make delightful spaghetti with lemon and basil. This Trader Joe’s is of course laid out a little bit different from my local one, so it takes me a couple of tries to locate the pasta-containing aisle. Once there, I see the packages of long pasta (yum), the price tag ($0.99), and toss it in my basket (success). It is only once I get home and start preparing it that I notice the recommended cooking time is a mere three minutes. “Three minutes is incredibly short for spaghetti,” I say to myself. That would be because it was not, in fact, spaghetti, but capellini, its diminutive cousin. One might argue that because “angel hair” pasta it is also made of semolina, it tastes the same; one would also be grossly underestimating the significance of mouthfeel in the flavor palette.

What makes this all the more embarrassing is that this is not the first time I have been punked by capellini, also at Trader Joe’s. Are they in this together?! Who knows! What I do know is that fool me once…twice…well, I won’t get fooled again.

Minor Turbulence

March 31, 2018

I’m back in Ohio, this time for ICU rotation, and the week got off to a rough start beginning with the landing. On the first day I showed up naked; that is to say, without my phone, which really got in the way of storing my new coworkers’  numbers for future communication as I stumbled through learning a new workflow. That evening, I managed to screw up “taking a shower” simply by turning on the water. Unbeknownst to me, the shower head was aimed directly at the curtain and had an excellent flow rate. Turns out the curtain had caught on the edge of the tub, forming a sort of pipe to the outside world. By the time I realized what was happening, there was 2 cm of standing water on the bathroom floor. This led to me madly shoveling water back into the shower, using whole towels as sponges.

The following day, I made sure I had my phone and the floor was dry, but proceeded to leave behind my stethoscope, an oversight I only noticed when I reached for it during a physical exam. A panicked flashback revealed its location in my apartment: conspicuously sitting on the shelf directly above where I had hung my coat, so placed in order that both could be easily snatched during the morning rush.

Later in the week I went to the L&D floor to visit some of the people I know from the last time I was here. I brought M&Ms for old times’ sake and apparently couldn’t help also bringing my bad vibes. While unpacking the candy I realized one of the people I was expecting to see was missing, because somewhere between sending messages and my arrival, she had gone downstairs to the ED, a statement that took me several tries to parse correctly that she was a patient in the ED. Having previously made it through life without ever experiencing a migraine headache, she had been stricken with the “worst headache of her life,” a test question keyword for subarachnoid hemorrhage. Thus, my hospital tour extended to the ED, where catching up was interrupted by medical staff as she was cleared for discharge. Ultimately my friend was unceremoniously ferried back to L&D in a wheelchair by one of the OB/GYN attendings I worked with last year.

My apartment building seems to have some form of always-on heat, which leads to a less than comfortable ambient temperature for those of us who run hot. In lieu of a functional thermostat I opted to open the window; as it reached its maximum station, the crank handle fell off, leaving the window stuck wide open. Later during one of my rare workday glimpses of the Outside World, I noticed it was raining heavily and had to contact the apartment manager to try and close it before I flooded a second room in the apartment. They came by and “fixed” it, by which I mean they closed the window and gently placed the handle back into its socket. Naturally the first thing I did when I came home was test it…the crank promptly came off in my hand.

Occupancy

May 26, 2013

Rachel and I have been looking for a new place to live because, well, the rent. One of the options we’ve been considering is finding a house and sharing it with our friend Liz and another guy, Matt, a friend of a friend who has been looking for a place as well. After months of disappointment Rachel finally found a house that looked like the right balance of bedrooms, bathrooms, and price, and made an appointment for us all to tour it this afternoon. Unbeknownst to us, things had already begun spiraling out of control.

We pile into our vehicles and show up at the house a few minutes before our appointment with the realtor. It is obvious from the movement and voices that people are inside, so we knock on the door. No answer. A dog begins to bark, drawing our attention to the “Beware of Dog” sign hung on the gate. Footsteps thunder around the house. We wait a little while and knock again – still no answer. We begin getting the sense that we’re actively being ignored by the house occupants, but shrug it off and poke around the driveway a bit waiting for the realtor to arrive.

The front door has windows above it, which is how Matt notices a kid running up and down the stairs. He knocks again, forcefully, leaving no doubt in our minds that we are being ignored. Finally, the horizontal blinds part just wide enough to reveal a middle-aged woman’s eyes. “Sorry, the house has already been rented,” she announces.

“Since Wednesday?” (Rachel had made the appointment earlier this week and was told Sunday was the earliest the house could be shown).

“Yes, we moved in yesterday.”

At this point our indignation is building. What kind of a realtor does this? Rachel gets on the phone to call them, no answer. Suddenly one of the upstairs windows opens, revealing the leathery, creased face of a lifelong smoker.

“What are you doing here?” Smoker Woman is outraged, accusing us of trespassing with her tone.

“We had an appointment with the realtor to see the place today.”

“Well sometimes things happen, we had the cash and we rented the place and it’s ours now,” she hollers. We’re completely flabbergasted. Why are these people so intimidated by us? Meanwhile, the front door opens and the first woman emerges, brandishing a piece of paper.

“What are you doing in my driveway?! We rented this place! I’m calling the po-lice!” Despite our utter confusion and lack of action, things are rapidly escalating.

Smoker Woman appears to be both on the phone and conversing with a partner deeper within the building, but is talking loudly enough for us to clearly hear her down below.

“Call the cops, they have a Chinese!” Apparently being Asian and wearing a coat turns our 100% SoCal friend Brittany, who was along for the ride, into a hardcore gangster warrior. Still thoroughly confused and unable to reach the realtor, we get back in the car and head home. Not even halfway back, Rachel’s phone rings: It’s none other than the realtor, calling to apologize for being late to the showing. She helpfully offers to give us the lockbox code so we can start touring the house ourselves.

“Hold on, this is getting confusing,” I tell her, turning to Rachel. “Rachel, stop the car, you’ve got to hear this.” We pull over onto the side of the road, Rachel takes the phone and informs the realtor that using the lockbox probably isn’t the best idea as there are, in fact, a number of people already living in the house. The realtor is taken entirely by surprise and promises to call us back.

When she finally does, the situation has escalated even further. The back gate appears to have been broken into and the locks have been changed on the front door, so she can’t get in. The property owners and the police are being called in to deal with this group of belligerent squatters, and would we mind coming back to the house to witness them getting arrested and identify who we had seen inside?

We return to the house to find a surreal situation. Several patrol cars are parked out front, barricading the driveway, cops are milling about, a workman is repairing parts of the house, and people laden with bags of belongings keep tumbling outside. An overweight man is seated, being interviewed by an officer. Several of them had taken flight when the police arrived and were apprehended attempting to flee into the nearby hills. Another kid had been found attempting to escape, a car was parked in the garage, and three or four other people along with their pets had been there as well, completely moved in.

As the cops take statements and the realtor begins to show us the house, the squatters bustle past hauling armloads of stuff out to their cars. Two people are being arrested. The middle-aged woman walks by in tears – the paper she had been waving was a forged lease, pieced together from documents stashed in the house by the realtor for showings. The efforts had scored her a misdemeanor. Some of the others said they had been living out of their car for months, and despite their apparent knowledge of fake leases, breaking into houses, and changing locks, claimed they didn’t make a habit of moving wholesale into miscellaneous houses.

They had broken a number of things inside, perhaps sometime in between spreading pet food all over the sinks and in the corners of the bedrooms. The workman is busily tearing up the floor and mopping, You see, the toilets had been taken out of the bathrooms in order for the floors to be retiled, but the kids had used them anyway. The dog, on the other hand, had preferred the closet. A paper plate of half-eaten chicken wings sits on the floor of the kitchen, attracting flies. In fact, trash and food scraps of all kinds are piled across the range and countertops. A pair of pants and a shoe insole lie forgotten in one of the upstairs hallways. The backyard fence is partially collapsed. We continued to tour the house, owners, realtor, and workman all insisting that random people don’t typically move into their rental properties unannounced.

Once we’d seen everything, we left, still not entirely sure what had happened. We debriefed our aching minds each other over a hearty meal at Souplantation, and decided to put in an application.