Punch with Larry

BOX SCORE
Element	Current	Std. Range	Trend
Hemoglobin	12.2	13-17	^
Platelets	176	140-375	^
ANC	3470	1800-8300	v
Ferritin	1060	My goal <1000	v
CD4 Cells	240	My goal > 200

For most of our marriage, Jill and I have perpetuated a tradition (habit?) that I brought into our union. Once upon a time in the mid 1970s, I had a side hustle working for a professor at my dental school alma mater, the University of Oregon Dental School (UODS)*. My main gig was trying to establish a private dental practice in the suburbs of Portland. I had been a top student in dental school, but I had labored under the false illusion that learning to do dentistry well was the primary requisite to executing a successful business delivering dental care. Little did I know at the time that knowing virtually nothing about business practices might hamstring my attempts to keep a business afloat, no matter how good the product of said business might be. 

And that brings me back to the side hustle. During the phase of trying to establish my practice, I expected to need some “supplementary” income. So, like many a wet-behind-the-ears, newly hatched dentist, I got a job teaching clinical dentistry to other unsuspecting dental students. Later I held a position in the Dental Materials department at UODS, which involved doing research on various materials used in dentistry, in the pursuit of improvement, or at least better understanding of their properties. But the side hustle I referred to above was an outreach to an underserved population headed by one of the full time faculty professors, whose name escapes me. The project was funded by a government grant of some kind, and the mission was to bring dental care to residents of nursing homes and other extended care facilities in the Portland area. 

Along with a handful of other starry-eyed individuals, I travelled hither and thither visiting facilities where people were recuperating from ailments or marking time until they passed on to their respective rewards. One of my regular patients during that time was a 98 year old woman with a razor wit and a fiery spirit. For all I know, with her personality and verve, she may be one of the Social Security recipients you may have read about in the 140-150 year-old age bracket.  But I digress. 

One day, Mrs. X was on my schedule for a cleaning at the very nursing home in which my grandmother had spent the final 6 months of her life, and my father was to spend the final three days of his life.  The appointment time was 12:00 noon. I knocked on the door of her room and was bade, “Enter.” My patient was propped up in bed with her luncheon on an over-the-bed table and the TV on. 

I greeted her and explained that I was there to clean her teeth. 

“Oh, no, “ she said, “ You can’t clean my teeth now. I’m having lunch with Perry. I always have my lunch with Perry.” She referred, of course, to the program on the TV, Perry Mason, one of the longest running syndicated shows in TV history, when you factor in re-runs.

Argue as I might, I could not convince her that my visit was at least as important as Perry. I left in defeat, and rescheduled the appointment for another day. Out of that exchange, a seed was planted in my head, and many years later, after I gave up the foolish notion that I was a businessman and got a real job, working for Permanente Dental Associates in a Kaiser Permanente dental office, with Wednesdays off, I found myself, on Wednesdays, tuning in to Perry Mason at lunch time. 

After I retired, I had even more days to have Lunch with Perry, and after Jill retired a couple of years later, we both took up the tradition (habit?). Over the years Lunch with Perry has morphed into “Punch with Larry,” but it is still the same routine. One can learn a lot from TV. One of the things we have learned from Punch with Larry is that in a murder trial, it is not necessary for the defense to prove the defendant innocent (though Perry usually did to the extent of exacting a confession from the true perpetrator during court proceedings). It is only necessary to prove that there may be another reasonable explanation for the death of the victim, other than the client’s guilt. Then it is up to the jury to sort through the facts presented at trial and determine which, if any, of the possible scenarios is the truth beyond a reasonable doubt. In a murder trial, the jury must be unanimous in its decision, one way or the other. When they fail to make a unanimous determination, it is called a “hung jury.” and a new trial must be called to arrive at justice. 

Of course, it is possible for a jury to make the wrong decision, unanimously, and that is a tragedy of the human condition. The acquittal of a guilty party may turn a killer loose on society to strike again, and the conviction of an innocent party, may send that person to prison or even death, unfairly. This is one reason I am thankful that I never had to play the role of juror, especially in a murder trial. The interpretation of evidence, especially when there is lots of it presented over the course of many days or even weeks, is a monumental task, fraught with the danger of drawing the wrong conclusions. 

In my previous post, I lamented that my red blood cell count had not adequately rebounded to allow for a second round of therapeutic phlebotomy, the drawing of a pint of blood in hopes of lowering the Ferritin count in my blood (See Patience Like a Farmer). My last phlebotomy was canceled, because my Hematocrit was too low to risk removing another pint of the precious red stuff. I was told to wait two weeks and have another blood count done. That blood count was done yesterday, and the results are posted in the box score above. 

To abbreviate this narrative, my Hematocrit was still not high enough to risk another session with the leeches. Jill and I were disappointed, because a persistent high Ferritin count poses certain risks to some of my organs, notably lungs and heart. I think you will agree that there is reason for concern. The previous post linked above invoked patience as the virtue it is, and after I read the lab results yesterday, my disappointment quickly morphed into the realization that 'them as argues in favor of patience ought rightly to exhibit same.' 

Still, I spent a lot of time considering the evidence, and like a jury going over and over the facts, I suddenly realized there could be a different interpretation of their implications. Look at the Box score again. You will notice that my Ferritin has dropped to 1060, which is the lowest reading I have had in all the times my Ferritin has been measured. The goal is for that number to decrease to less than 1000. On my penultimate blood draw, the number was 1121, so there was progress. Not shown in the Box Score are the readings for Hematcrit at the two most recent lab tests. So, I will just report here that the first one was 33.6, and yesterday’s was 36.6, an increase of 3 points. Just as a refresher (and remember that pop quizzes do happen) Hematocrit is the percentage of blood that is made up of red blood cells. The lower end of the “normal” range is 38, and that is the cutoff point for being able to do another phelebotomy. 

Now, let’s do a little “s’posin’” here. S’posin’ that Ferritin went down by more than half the amount I need it to do, and Hematocrit went up by more than half the amount I need it to do, because there is a link between the two. Perhaps, as my body creates new red blood cells, thus raising the Hematocrit, it is using the iron that has been bound by the Ferritin protein as a source for the iron to make new hemoglobin in those cells, lowering the Ferritin count. How about this possibility: just maybe, when my blood is drawn again in two weeks, more new red blood cells will have been created by using the Ferritin bound iron, increasing Hematocrit and decreasing Ferritin count! And s’posin’ those things happen at the same rate they have been happening in the past two weeks. Well, it seems to me that would put both of those counts in the range we are looking for, to wit: Ferritin down another 61 points to 999, and Hematocrit up another 3 points to 39.6. That would be cool. I’m not sure whether Dr. Brow would order more therapeutic phlebotomy at that point, but even if she did, I suspect it might be the last one required. 

The dynamics of the blood organ in the human body are just that, dynamic, and rarely do they proceed at a steady pace. But it is inspiring for me to expand my horizons of interpretation of the data at hand as perhaps pointing to a conclusion that deserves celebration, rather than disappointment. 

In the Bible, in the book of Genesis (chapters 33-50) Moses wrote the story of Joseph, son of Jacob by his beloved Rachel. Joseph’s brothers hated him, because he was Jacob’s favorite, so they proposed to kill him, but in the end they threw him alive into a pit. Joseph was rescued and taken to Egypt, where he endured injustice, imprisonment and torture. But he persevered and eventually became second only to Pharaoh in power over the land of Egypt. He foresaw a coming famine in a dream and prepared Egypt not only to endure the famine, but to prosper by having grain to sell to other nations who were starving. 

Among those nations lived his father, Jacob, and his treacherous brothers. When famine struck, the brothers went to Egypt seeking a food supply for their people. Joseph recognized them, but his brothers, believing Joseph to be dead, did not recognize him. In the end, Joseph saved not only Egypt but his Father Jacob, now known as Israel, and his offspring. 

When Joseph revealed himself to his brothers, they feared for their lives, because of their treachery. But Joseph told them: 

As for you, you meant evil against me, but God meant it for good, to bring it about that many people should be kept alive, as they are today. (Genesis 50:20)

There are indisputable facts in the world, but their import is subject to interpretation, and sometimes only time will tell which interpretation is correct. Just sayin’.  

*See “Things Just Keep on Changing"