Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine

The author, probably a horse

Doctors are trained, when faced with an unusual set of symptoms, to diagnose the patient as having an unusual presentation of a common problem, rather than a rare disease presenting in its normal way. As my pediatrician-mother likes to put it, "When you hear hoof beats, don't think of a zebra, it's probably a horse." This advice likely serves many doctors well. That odd looking rash on the baby's bum really is more likely to be an atypical diaper rash than amoebic tushitis.

The problem with this policy is those patient who truly are zebras. We are inevitably mistaken for, and treated as, horses. Before I knew of Bow Hunter's Syndrome, I saw two primary care physicians at the same office about my vertigo-dizziness- tinnitus-faintness-etc. symptoms. The first was sure I was depressed, asked if I had "heard of psychosomatic," and walked out when I insisted I was a zebra. The second, two weeks later, told me I was terribly allergic to my new home and would have to move out of town, closer to the sea, immediately. Shortly thereafter I had my first, and worst, "Bow Hunter's Stroke."

Luckily, none of the doctors at the clinic were free to see me that day, and I was shunted to their nurse practitioner. Nurse-practitioners, unlike M.D.s, have listening skills. I described the whole thing to her, and she immediately saw my stripes. I was no horse. She sent me for an ultrasound of my carotid arteries (to check if the main blood supply to my head was obstructed) which gave me a vital clue. While checking the carotid arteries, the technologist always did the vertebral arteries too. While both looked normal on the ultrasound (which was taken with my head in neutral position) this was my first inkling that a blockage of vertebral arteries was even possible.

I'm not going to describe in detail the extraordinarily stressful process of literature searching, doctor-switching, insurance switching, specialist bouncing, bureaucracy fighting, scans, rescans, etc. In short, I found Rotational Vertebral Artery Compression Syndrome in the literature, was struck by how exactly the case studies approximated me, and spent a year actively working toward official diagnosis and treatment, culminating in a near-fatal but successful surgery. There are several key lessons I learned along the way that I want to share with other putative sufferers of Bow-Hunter's Syndrome:

1. No doctor is going to bother to manage your care, but you have to let them pretend they are going to manage your care. Managing your own care is a full time job you have to do. Keep lists. Call every day to find out if a slot has opened up, remind people of things they already know, catch their errors, force them to communicate with you and each other, advocate for yourself. This difficult process was somewhat ameliorated by the fact that I am a white male with a greying beard. Bring an old white man with you, there are plenty of us around.

2. Bow Hunter's Syndrome can only be definitively diagnosed by comparing blood flow through your vertebral arteries when you head is in a neutral position to when it is in a position that brings on your symptoms. Make sure your doctor is explicit about this need in ordering imaging. Medical technologists are often not willing to take imaging with your head turned. They are trained to do everything in a neutral position, and if you explain why it has to be done with your head turned, they will worry you are going to pass out in their expensive machine or onto their legally-liable floor. Call ahead several days before your x-ray, CT, MRI, whatever, and insist on talking with the technologist to be sure it will be done as ordered. They will tell you they need to consult with the radiologist, who will want to talk to your doctor, who won't be available, etc.

On the day of your scan, if the technologist won't unequivocally confirm that your scan will be done both straight and with your head turned far enough to induce symptoms, you must refuse to get in their machine. Stand there shivering in the buttless gown and calmly insist that they do the scan the way your doctor ordered it. If they tell you their MRI machine doesn't have space for you to turn your head, tell them they have to put on the coil after your head is already turned. If they insist the condition you are describing doesn't exist, whip out a published description. Walk out if you have to. Failing to do this once delayed my care by four months and cost me several thousand dollars because once the scan was done wrong, my insurance wouldn't approve the same scan again. I had to change to more expensive insurance and doctors, start the process from scratch, and learn to insist.

3. The ultimate confirmation of Bow-Hunter's Syndrome comes from fluoroscopic angiography with arterial catheterization. This means they take video of x-ray dye moving through your vertebral arteries, with your head in various positions. The dye is delivered through a small tube that is inserted through an incision into your thigh and wormed up as far as the back of your brain. I found the moments when they were squirting dye into my brain to be the most painful of the entire experience, despite the sedation and pain killers. However after this procedure no one questioned my self-diagnosis.

4. The most common surgery for Bow Hunter's Syndrome is called decompression. This means they made more space around one of my vertebral arteries (one unobstructed vertebral artery is generally enough to keep your brain stem ticking) by removing a piece of the bone that wraps around it on the side of my first cervical vertebra. Such decompressions are done for a variety of syndromes that are more common than Bow Hunter's Syndrome, and it is this fact that very nearly killed me.

Surgeons are very busy people, and generally make physicians look like excellent listeners. My surgeon performs a fair number of decompressions, but mine was his first for Bow Hunter's Syndrome. His protocol for this surgery starts with having another surgeon carve a path to the bone. Then he takes over and turns the patient's head for a clearer view of his work grinding away bone without damaging other important bits. You know, and I know, and he knew, that turning my head cut off the blood supply to my brainstem. He did it anyway. That was the next step in his protocol, he had not had time to think this through, and I had failed to manage my own care on this point. Several minutes later, when they checked, no blood was flowing through my vertebral arteries. He guessed it was measurement error, and had another machine sent. Still no blood flow. They righted my head, glued me up in a hurry, and went to scare the life out of my poor wife. Luckily, they frappéd jargon with indirectness and she didn't understand what had happened until after it was clear that I hadn't been killed. My brain stem responded well to the return of blood and I was out of the hospital the next morning. Recovery to the point of feeling better than before surgery took me about three months.

5. Finally, as this is now long, they insisted I would need opioids after my spine surgery. I did not. Accept them if you need to, don't assume that you will need to.

I'm happy to be your support group of one if you're wondering if this diagnosis is yours. I'm a Ph.D. though, not an M.D., so be aware that I can only offer one zebra's perspective.

Bow Hunter's Syndrome Part 2: What, with a dab of why

Bow Hunter's Syndrome is named for people who shoot arrows at wildlife. In order to do so, they have to turn their heads hard to one side and hold that position until they are ready to shoot. Attempting this with Bow Hunter's Syndrome lands them in the emergency room, and sometimes gets the actual attention of a doctor, who will occasionally figure out what is going on, possibly provide treatment, and if they've gone to that much bother, almost certainly publish a report mentioning said venery.

That case study might refer to this condition as Rotational Vertebral Artery Compression Syndrome. The vertebral arteries are the main blood supply to the brain stem, one of those body parts humans can't do without, not even for a few seconds. There is one vertebral artery on each side of your spine, running up through tunnels in your cervical vertebrae, the spine bones in your neck. When a healthy person moves their head, each artery has enough space to wiggle in these tunnel, so that it doesn't get compressed, kinked, stretched, or otherwise lose flow. Rotational Vertebral Artery Compression Syndrome means that rotating your head pinches your vertebral arteries, usually at the joint between the two uppermost vertebrae, reducing or eliminating flow of blood to your brain stem. The various other names this condition goes by mostly include the word "insufficiency" referring to the shortage of oxygen in your brain stem, which is what causes the actual symptoms.

About those symptoms: tinnitus (a buzzing sometimes in both ears, sometimes just in my left), vertigo, dizziness, mental fatigue, and faintness, increased gradually over several years during which I did not notice that head position had anything to do with it. I would consistently feel dizzy while shopping in the grocery store, not noticing any connection to turning my head from side to side trying to find unsweetened pickles. Long after others had recovered from some cold, I would have lingering vertigo and a sense of mental fog. I gave up my habit of sleeping on my belly, which allowed me to fall asleep very quickly, but from which I eventually decided I was waking feeling tired and unwell. My first autumn in Wisconsin I wondered if I was wrapping my scarf too tight because I would start to feel like I was going to faint every time I tried to back my car out of the driveway. Attempts to discuss all of this with doctors were frequent but unproductive.

The symptoms became debilitating only after an accidental blow to the top of my spine that winter. I was diagnosed with a concussion, and because most of the symptoms of Bow Hunter's Syndrome are consistent with a concussion, I looked no further. Most of a year later, having recovered only slightly, I was a passenger in my moving van (on the way to California) when it turned over on the highway, flexing my neck too far forward. After that, the observation that the position of my neck had both immediate and lingering effects on my symptoms became unavoidable.

The blaring clue to my addled brain came from my new neighbors' fig tree. Having permission to pick, I was straining to reach a fig well above my head. I looked up, turned my head to the side, stretched my arm, and collapsed. My eyeballs were shaking, my vision went black, and the tinnitus became unimaginably loud, louder than the human ear could withstand if real sound was involved. I was breathing, but felt the urgent need to come up for air. I brought my head back to neutral and the screeching tsunami gradually receded, light started to return, the spinning slowed. I had survived my first "Bow Hunter's Stroke." I put that phrase in quotes because unlike a real stroke, no tissue damage showed on scans afterwards. My brain stem hadn't lost living tissue, just power. The medical jargon for such an event is a transient ischemic attack. My doctors were no more than puzzled.

In the fifteen months since then, I went through thousands of abstracts, scores of full scientific papers, two insurance companies, four primary care providers,  three neurologists and a wide variety of other specialists, countless imaging studies, three interventions including a poorly planned major surgery that nearly killed me right there on the table, and months of recovery before I could considered myself past Bow Hunter's Syndrome. All worth it. I'll dig around in the key pieces of that in Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine.

Bow Hunter's Syndrome Part 1: A Survivors' Support Group of One

My doctor looked like I had just puked in his shoes, but eventually took the papers I was holding out to him. This was a better response than I had expected, but still I could tell he would not look at them. I switched doctors, and with the next one emailed him the papers after our appointment. He wrote the referral I needed but declined to see me for months thereafter, going so far as to change an in-person appointment for a possible broken wrist to a phone appointment, after I was already in his parking lot.

The only thing a doctor likes less than a patient walking in with an obscure self-diagnosis they found on the internet is when the patient brings the medical literature about that diagnosis for the doctor to read. I knew this, but also that my doctors had not heard of Rotational Vertebral Artery Compression Syndrome, and that I needed treatment for it. Adding insult to injury, my obscure self-diagnosis would eventually be unquestionably confirmed and successfully treated.

This same condition goes by multiple names in the medical literature including Rotational Vertebral Artery Compression Syndrome, Positional VertebrobasilarIschemia, Positional Vertebrobasilar Insufficiency, and Bow Hunter's Syndrome. This last name is the least descriptive, but also the shortest and least jargony, so I tend to use it.

Bow Hunter's Syndrome is quite rarely diagnosed. There are perhaps a few hundred cases documented in the medical literature, total, globally. This could mean that it is a rarely occurring condition, but given the lengths I had to go to get it diagnosed, the severity of those cases that are documented, and the peculiar circumstances that allowed me to reach diagnosis, I suspect rather that it is an only slight uncommon condition which generally goes undiagnosed. As a neurological condition not caused by any neurological defect, Bow Hunter's Syndrome tends to fall through the cracks.

I was able to diagnose my own case because I have a Ph.D. in biology, loquacious physicians as parents, and extensive experience finding obscure scientific literature outside my field of expertise. I knew I had something, as most patients do, but I also knew how to search the scientific literature for conditions associated with terms like "cervical vertigo," "rotational stenosis," "positional tinnitus," and "nystagmus,"  then skim through the results, read those papers that seemed most relevant, follow citations back and forth, improve my search terms, and so on to a diagnosis. What I had to figure out was how to then navigate Earth's most wasteful medical system (USA! USA!) to arrive at an official diagnosis and ultimately treatment, and I had to do all of this while suffering the symptoms of Bow Hunter's Syndrome (including vertigo, ringing in my ears, dizziness, intermittently blurred vision, and faintness).

The good news is that I am largely recovered from it, and from the surgery that resolved it.

The bad news is that I will be posting here a series of short essays with the hope of making this process slightly easier for other sufferers of Bow Hunter's Syndrome, a purpose which I do hereby gleefully acknowledge will horrify all medical professionals that happen upon this. There are, so far as I can tell, no popular accounts, no support groups, no blog posts written for the uninitiated, describing what Bow Hunter's Syndrome is, what it feels like, how to approach being a patient with it. Perhaps soon more patients will be wobbling into their doctors' offices mumbling about the blood supply to their brain stem and a condition the doctor has never heard of. One can hope.

Next: Bow Hunter's Syndrome Part 2: What, with a dab of why

Then: Bow Hunter's Syndrome Part 3: Wresting diagnosis and treatment from the jaws of modern medicine

Unsolicited parenting advice

I have decided to share with you one of the big points of baby raising that Iris and I learned by hard experience.

We have a million books on baby care, Iris reads a bunch of "mommy blogs," and we know lot of people with babies; we felt quite confident in our baby skills before our first daughter was born. For the most part that confidence was justified, but there was one thing we just had no idea about. Once we figured it out, it transformed our parenting experience: helping a baby fart. One hears all about midnight feedings and how to deal with diaper rashes, but we had no idea it was necessary to help a baby fart. She would be crying inconsolably, and we would be going crazy trying everything we could think of to sooth her, and then at 3 or 4 or 5AM, she would finally fart, and immediately fall asleep. This happened repeatedly for weeks, maybe months, until we figured out that belly massage, light pressure on the belly, or alternatively pushing her knees up toward her belly would squeeze the fart out. With practice one can feel exactly where the gas bubble is and guide it up and around and down and out. We got good at this, and could make her fart almost immediately, bypassing the hours of gas pains and ear pains. 

P.S.  Another thing I found very useful, when woken up for the 14th time that night, was to have a posted list of things to try to help the baby. It seems like it would easy to remember to check the diaper, but when sleep deprived enough this can be quite hard. So here it is:

Belly Massage

Milk

Temperature

Wrap

Rock

Light

Sing/Hum

Diaper

Clean skin

Nose

In almost every case where she wasn't actually sick, one of those was it. Print it poster size and put it near a nightlight.

Revisiting the treadmill desk

I am very fond of my home-built treadmill desk, but basically never use it any more. Working at home with a toddler running around is hard enough. Working at home with a toddler attempting to run on the treadmill with me is impossible.

Now that I have had one for a while, and before I get rid of it, a few thoughts on the desirability of treadmill desks.

Pluses: I really could stand and work longer than I can sit without taking a break, and it is surely better for me to stand than to sit most of the time. When I used it for actually walking, rather than just standing, the health benefits surely increased and I found it easy to walk very slowly for hours at a time. Another, somewhat off topic, benefit is that when one needs to run one's toddler and the weather outside is Denmark, toddlers can easily be convinced to run on a treadmill for long enough to get some energy out. (Always hold the toddler's hand while she is on the treadmill so that you can prevent falls.) Before I started biking to campus, there were times when this was a useful tactic before my bedtime also.

Minuses: Achieving a deep focus on a topic is not as easy when walking on a treadmill (at least my cheep treadmill) as when sitting or even walking around. Some part of my mind always has to monitor my position on the treadmill so I don't slide off the back, and the slight bouncing makes both typing a reading a bit slower. I occasionally play a game of chess against the computer in the evening, and I can beat it at a much harder setting if I turn the treadmill off. Editing manuscripts, I inevitably end up turning the treadmill off when I get a point I really need to focus on. As a result, I rarely ended up walking, rather than standing, when doing any task that required speed or more than half a mind.

Thinking while sick

Back when I watched TV, which is many years ago, I would sometimes watch Star Trek. My least favorite character was Mr. Spock. My objection to Spock was that he was extremely foolish in a way that he should have been smart enough to recognize and correct. His foolishness was based in his refusal to admit the importance of understanding emotion and psychology. He would respond to any statement about feelings influencing actions with, "That's illogical," without considering the fact that these statements were also true. Feelings do influence behavior, and to deny that fact, or fail to act on it is illogical.

I was thinking about this last night in the context of the placebo effect. The placebo effect is surprisingly powerful, very easy to demonstrate convincingly, and I've never heard a plausible argument for how the physiology behind it works. There is also good evidence for a negative placebo effect, that believing something will harm you can make it somewhat harmful.

This was on my mind because I have been sick for the last two weeks, with a cold bad enough to keep me from getting much of anything done, and people have started to suggest various home remedies that I am sure don't work. However, because of the placebo effect, I wish I did believe they worked. My inherent skepticism keeps me from gaining the demonstrable benefits of almost any worthless snake-oil. On the other hand my previous experience of frequent and lengthy sickness convinces me that I am likely to stay sick, surely contributing to a negative placebo effect.

It was these thoughts, plus snippets of the Norse myths Iris has been reading to me before bed, that I went to sleep. And what a strange pair of dreams I. First, I dreamed I was in a bar or hall with long wooden tables. Some of my deceased male relatives were there, as were many other people I didn't know. I knew I had only been there long ago, as a child. A man at another table stood, called for attention, and pointed at me. "Look who's come back," he announced mockingly, "Why if it isn't Daniel, the heir to a long proud line of atheists!" I was going to argue, but I woke.

Next, I dreamt that my left thumb-nail had gotten very long and ragged. As I tried to cut it, it started to expanded, unfold and then unroll itself, until it was as big as a post card. It had been tightly folded and wrapped, growing into itself. I cut it off amazed that it could have gotten so big and ingrown without my realizing, and at how compactly wrapped it had been. Looking at my thumb I saw a slot under the skin, maybe a half inch deep just above the nail where the furled and folded nail had rested. Inside the hollow there were areas where minute green plants had started to grow, and areas with many small bloody scabs. I was happy to be able to rinse it clear, and with that I again woke, feeling well rested and fully awake for the first time in weeks.

How do I interpret this? I've decided that simply believing that the placebo effect is helping should be enough to cause the placebo effect to actually help, and that something as simple as a dream of cleansing should be enough to trigger this positive cycle. At present, I am not interested in hearing alternative explanations.

National Academy of the Extremely Vigorous

People of higher educational attainment live longer. This is widely known. Somewhat less widely known is just how far up the attainment ladder this pattern goes. People with Master's Degrees tend to live longer than those who stop with a Bachelor's. Even more longevous, on the average, are those with doctorate. But people who get a doctorate and then go get some random job don't tend to live as long as those who become tenured professors. And sitting atop this hierarchy of attainment and longevity are the members of the elite scientific academies, such as the National Academies and the Royal Society. Many people's tendency when thinking about this correlation, between attainment and lifespan, is to assume that being better educated helps one live longer. To some extent this is certainly true, and at the level of primary education, and even college education, there is experimental evidence (both true experiments and accidental experiments through policy changes) to prove this. But in thinking about the differences between groups of people with graduate degrees, I rather suspect that the causal relationship is rather different.

I'm thinking about this at present because I have had a very productive evening. Since coming home from a full day at work I've made dinner, done the dishes, played with my daughter, rocked her to sleep, folded the laundry, done more laundry and folded that also, cleaned the cat's box, organized things around the house, rinsed the drop-cloth we put under the highchair while my daughter learns to eat, cleaned the broccoli and potato bits out of the bathtub, written work emails, taken down the garbage and the recycling, climbed the 18 flights of stairs to come back up and written half a blog post. This is extraordinary for me, especially this time of year. I am almost always either coming down with something or trying to recover from it, or coddling an inflamed joint, or just feeling low energy. I lose a disgusting amount of potential productivity to being sickly. The elite academies members I know, and those who are not yet in those academies but seem likely to be in them some day, are all people who are this energetic all the time. If they do get sick, they seem to almost always be back at in after a day or two. It is rare for me to recover from a cold in less than a week, and not rare for me to be out for two or three weeks at a stretch. This is not to say that many of these people are not also smarter than me in important respects, but the trait that most unifies the really successful academics I know is their extraordinary energy and vigor. My boss, nearing his 70th birthday, and a National Academy member, hardly seems to know what it is to feel tired. He'll attend meetings on four continents in the course of a week, say how exhausted he is, and still spring from his chair to scribble equations on his whiteboard. So my belief is that people of the highest academic attainment live longest not because they are of high attainment, but because they are remarkable in their health and energy, which also allows them to produce the torrent of great science necessary to be elected to one of these societies. Alright, enough writing, I'm exhausted.

Walking desk

I'm one of those people who have trouble sitting still and working for any great period of time. I frequently find excuses to get up and walk to the other side of the building to talk to someone or check on something. I've occasionally seen articles like this one on NPR touting the health and productivity benefits of treadmill desks.

When I was in grad school I read such an article, then saw a treadmill for sale in a thrift store near campus. I stopped by the office of the acting director of the museum where my office was and asked if I could install myself a treadmill desk. She looked confused and busy but said yes. The next day maybe half an hour after I had moved the mill in, as I was just figuring out how to build a desk over it, she apologetically called me to her office and asked me to remove it from the museum. My wife kindly let me keep the machine in our tiny tiny Berkeley studio apartment until we sold it to a friend.

Now that I have a real job and we have a decent sized apartment, we are reorganizing that apartment to fit a baby and all the stuff that goes with modern babyhood. And it just so happens that I have both another used treadmill and a broken desk. Below are pictures of the result. It is not the world's prettiest construction (built while recovering from a tooth extraction using only materials I had in the room and without taking any measurements) but now I can walk and type at the same time. It will take a little bit of getting used to typing while rocking from foot to foot, but I think I am going to like this, and maybe it will help me remember to use the treadmill.

Here is my wife's shot of me typing this post:


And here's a view from the treadmill. We are in the tallest building in the state, so I have a nice view of Rostock from my desk.

List of materials:
Treadmill from thrift store
Broken desk
Various screws and bolts I had around the house
An old curtain rod

Total cost €90 spent last year

Blame the vehicle

I'm on a medicine that helps tremendously with the neuropathic pain associated with Levitis Syndrome. It is often prescribed for neuropathies associated with diabetes, and while there apparently no similarity between the two disorders other than the peripheral neuropathies they cause, this stuff seems to help with both. I recently went to my doctor for a refill, and she prescribed the tablet form, where I had been taking the slow-release capsule in the same dosage. Two days after switching to the tablets, I suddenly started getting these sharp distinctive pains in my hands and wrist again, and the surgical scars on my palms are looking angry. So this morning I went back to my doctor, and this being Germany got to see her within 20 minutes. I am back on the capsules, and I hope the problem is solved. I really would love to understand what is going on with my neurophysiology that the difference between a tablet and a capsule makes such a difference. I don't think it is even understood why neuropathic pain happens, or why some compounds interfere with it, so I don't have much hope of understanding the pharmacokinetics. I just hope the stuff keeps working.

Cold Season

"I woke today and found the frost perched on the town
it hovered in a frozen sky, and gobbled summer down."
-Joni Mitchell

Rostock has its first real frost this morning. In anticipation of this event, the first bad cold of the year has been going around. I think about half the Institute has gotten it so far. I have been sick to varying degrees for a week now. Without having actually looked at the relevant research, my understanding is that we get so many more colds when it gets colder because the airborne viruses break down much more slowly when the areas cold and dry and sunlight is weak. I've also heard somewhere that the cold air makes mucous membranes more susceptible to viruses. This all makes sense, and helps explain why that other common airborne virus that spreads every year, the flu, also concentrates in winter, but it leaves me wondering this: is the pattern the same in species that are adapted to highly seasonal climates? Humans are basically a tropical species that construct tropic-like microclimates for ourselves wherever we go. Our ancestors a few thousand generations ago would not have experienced the yearly cold season as we do today. Moose on the other hand have been living in cold climates forever. Their bodies should expect high virus conditions every winter and prepare accordingly. I speculate that the immune systems of such animals are seasonal, being better at fighting airborne viruses in the winter, and perhaps skin fungus is in the summer. I wouldn't personally want to do the experiments to find out, but I would read the paper if somebody else wrote it.

Look Ma, ...

I find myself unable to use my hands for very much of anything, and wondering how to be a productive scientists given this peculiar handicap. The problem is not that I lack hands, I have them and they looked perfectly complete, if slightly blue. The problem is not even I can operate them, I have full control and enough strength to do most simple tasks. Rather my problem is that I mustn't use my hands, for a fight to the swell up become quite painful and remain so for some time. It's not yet entirely clear why this is, so for the time being the blame Levitis Syndrome.

There are many jobs for which not using one's hands would be a greater problem than they are for me as a scientist. A carpenter, a cellist, or a cashier would be much less able to work around this problem and I am. Furthermore, there is extremely little short-term pressure for me to get anything done. In the long term, I have to publish papers to keep my job and move to better jobs in the future. In the short term I want to get things done simply because it is too frustrating to not do so.

I'm using dictation software which, now that I've used for some time, is quite quick and accurate for creating text. Not quite as fast as typing, but a hell of a lot faster than I thought dictation software was before I started using it. I have students to do my lab work for me, I'm not doing any field work, and I have access digitally most of the literature I need. Given all this, why should a small matter like hands make much of a difference?

In practice, there are all sorts of things that I find myself unable to do. The dictation software supposed to make it possible to use many different programs, for surfing the web, analyzing data, sending e-mails and so on; in fact many of these thing are quite difficult to do without moving the mouse or touching the keys. Writing code is extraordinarily difficult. Reading heavy paper books is quite hard. Many software tools are simply inaccessible.

My latest stratagem is to order a mouse controlled by foot. The ability to point and click should solve many of my problems, in combination with this dictation software.

The other challenge of being productive despite my hands, is one of concentration. Doing things so differently requires a lot of thought about how I do them, which distracts me from the ideas and tasks to concentrate on. In addition to that, my hands hurt, tingle, throb and otherwise distract me. I am frankly not so good at ignoring it to the point that I can think deeply.

Ultimately, my hands will probably get better with time and coddling. When that happens, I can add dictation software and foot-controlling a mouse to my long list of random and not particularly useful skills. Until then, I'll be studying the list of available voice commands and wearing slip ons.

little posting

I"ve been posting not at all for a while; I have carpal tunnel syndrome, and can't easily type. However, over the next several days I will be posting several thing either dictated using dictation software, or copied and pasted.

The following is from the

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"PLoS Medicine, PLoS Biology and PLoS ONE do not consider for publication papers where any of the research costs or authors' salaries have been funded, in whole or in part, by a tobacco company. "

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