Errata

Today was match day.  Congratulations to all of those who matched in neurosurgery and welcome to the profession.  I know that we are very happy with the students who matched at our program.  The quality of the applicants this year was outstanding, as always.  There are so many qualified individuals that it really is hard to go wrong.  The residency is a long but rewarding seven years.

If you are looking for a book that will change the way you look at the world, you might want to check out Moneyball by Michael Lewis.  It tells the story of how Billy Beane and Paul DePodesta, management of the Oakland A’s baseball team, revolutionized the sport in the last decade.  The most interesting part is the way they did it:  they took 100 years of baseball history and tradition and threw it out the window.  Instead they reduced baseball to a series of probabilities and mathematical equations.  They used hard data to identify not only what the most successful plays are, but also to find the characteristics of the most successful players.  Then, they looked for players that fit that model.  And, to put it bluntly, they found that the entire major league had been looking for the wrong players.  For a few brief years, they were able to produce a highly successful baseball team disproportionate to their payroll.

It really makes you wonder, “How could I improve my life, achievements, etc., if I had better data?”

Errata

1.  Why can’t the Salt Lake media, home to the University of Utah – one of the top candidates for Pac 10 expansion write anything resembling a coherent article on the subject?  Great articles are coming out of Colorado on almost a daily basis (conference conundrum, really??? Here, here, here).  But the best article so far seems to be coming out of San Jose?

2.  Notre Dame really seems to be changing its mind on conference affiliation.

3.  Why haven’t you had your genome sequenced yet?  It’s only $499.  Or is it 299? What are you going to do with all of those Gs, As, Ts, and Cs anyway?

4.  Maybe you are going to look for core promoter sequences?

5.  Sometimes, I wonder how there can be such great books out there that I’ve never heard of before.  Have you ever heard of Nero Wolfe?

Motivation

What motivates a person to excel?

There are examples of driven, successful people in every field of endeavor.  If motivation were simply a desire to be rich and famous and successful, we’d all be rich and famous and successful.

Exceptional success requires exceptional motivation.  Motivation that translates into exceptional effort.  But what drives those that reach the highest levels of success?  Deacon Jones, one of the greatest sack artists of all time, gave some insight into his method of motivating himself in a recent interview with Mike and Mike in the Morning.

You have to find something that motivates you every day.  For Deacon Jones, he fostered a hatred of quarterbacks.  He didn’t really hate quarterbacks – but he hated how they were the “pretty boys.”  The ones who garnered all of the fame and adulation.  But then he said something that really caught my attention – he said that you have to find something that motivates you everyday.  Something that will get you to do the work from Monday to Saturday.  Anybody [football player] can be motivated on Sunday.  The great ones find a way to bring that kind of drive to succeed every day.

There are thousands of different things that can serve as motivation.  Deacon Jones used “hate” that he used every day to motivate him.  The key is not necessarily the source of motivation.  It’s that it motivates you every day.  What is it that I am going to use to motivate me every day?  What motivates you?

Can Utah Win with Wynn?

Barring a virtual miracle, Utah will beat New Mexico this weekend.  Why?  Because Utah has developed a culture of winning and New Mexico has not.  Utah probably has better athletes as well, but Utah just expects to win.  And New Mexico does not.  And that will make the difference.

The bigger question, and a far more interesting one, is whether or not Utah will be able to compete with TCU the following week.

TCU has been playing like a juggernaut.  Statistically, they have been the best defense in the nation thus far this year.  They are only giving up 11 points and 236 yards per game.  They line up in a base 4-2-5 defense.  However, the third safety is largely a run-stopper and a glorified linebacker.  Reportedly, they are very fast, and I don’t think any BYU fans would argue with that after the debacle two weeks ago in Provo.

Utah’s offense, on the other hand, has been anything but dominant.  Ranking 48th in the country in total offense, they somehow managed to sputter their way to a 7-1 overall record.  At times, the Ute offense has been surprisingly efficient, like in the 21-point second half comeback against Colorado State.  Other times, inept might be too kind of a word, as in the 0 first down effort in the second half against Air Force.

In an attempt to provide a “spark” Kyle Whittingham shook things up against Wyoming.  First, he put the ball into Jordan Wynn’s hands at quarterback in the second half.  Wynn, a true freshman, led the Utes back from a 7-deficit to win 22-10.

That was against Wyoming.  And this week, we are unlikely to learn much more this week against New Mexico.

But, against TCU, both Jordan Wynn and Utah fans are going to learn a lot, and fast.  Utah has athletes on offense.  Utah receivers David Reed, Jereme Brooks, Aiona Key, and Luke Matthews will be able to match up with TCUs experienced corners.  Eddie Wide has 5, and will likely have 6 consecutive games with more than 100 yards rushing.  Utah’s questions are at quarterback and on the offensive line.  Wynn is a rookie quarterback, with only 1.5 games experience, is going to struggle against TCU.  That much is obvious.  But, my real concern is the offensive line.

Jerry Hughes, TCUs outstanding defensive end, has been terrorizing offensive lines for years.  In order to stay competitive, the offensive line is going to have to keep the pressure off of Wynn’s back.  Unfortunately, I just don’t see it happening.  Utah’s defense is good enough to keep us in the game, but the offense just won’t have the horsepower to win it this year. Prediction:  TCU 28, Utah 17.

Utah versus Air Force

I rewatched our offensive performance against AFA.  It didn’t take very long because Utah didn’t have the ball very much.  The offense needs a lot of help.  Air Force played zone essentially the whole game: some four-deep coverage and some “Tampa two-deep” coverage.

There were a lot of plays where Utah didn’t run a route more than 6-7 yards downfield.  A lot of routes didn’t seem to look for any holes in the zone.  They hardly flooded any zones, and almost never ran any smash routes.  But the play that bothered me the most is the 3rd and 6 with 4 minutes to go in regulation.

Utah was in a five-wide set and all 5 receivers ran a 5-yard hitch route (which Utah did multiple times throughout the game).  It’s really not a bad call in this situation.  If you think Air Force is going to blitz, the blitzer’s man should be open for a second before the coverage can rotate over to him.  However, Air Force made a great call on this one because they only rushed two. The nose guard sat down at the line of scrimmage as a spy in case Cain tried to run.  The two ends rushed, and they kept 8 guys back in a cover 3 zone.  That left 5 defenders in the zone underneath to cover each Ute receiver, so no one was going to be open on a 5-yard hitch.

Now as poor as the o-line play was at times during the game, even they could hold off 2 rushers for an extended amount of time.  Nevertheless, Cain completely panicked when nobody was immediately open (because they didn’t blitz) and he tried to run for the first down.  He obviously failed.  But, if he just waits for 1 or two seconds (which the protection could have easily managed – they might have been able to give him a week back there) the coverage would have eventually failed as the receivers got deeper into their routes.  He could have then thrown or ran for a first down.

Is this something Cain is going to learn how to do?  I don’t know.  There’s a huge difference in the way a defense looks when they are blitzing versus only rushing two.  And if he can’t identify that, how is he ever going to identify the player blitzing so he knows who to throw the ball to?

I think it’s too late in the season to bring Wynn in.  Losing Louks seems like a lot bigger deal to me now than it did at the time.  I haven’t lost all hope in Cain, and I will root for him full-force.  But, my expectations for the rest of this season have certainly dropped a bit.

Utah versus UNLV

A disconcerting 20-point victory?  You don’t see that every day.

There were a lot of positives to take from Utah’s 35-15 victory on Saturday night.  Robert Johnson continues to be hot with another interception and a fumble return for a touchdown (his second of the year).  Terrence Cain continues to be efficient, completing 17 of 24 passes, including two touchdown passes while running for another.  Eddie Wide III continues to impress as he has run for more than 100 yards in three consecutive games.

Then why does the victory seem cheap and hollow, like a Cadillac with a hamster under the hood?  Utah showed some inconsistency and, more importantly, some frank weaknesses.

Let’s take a look at the stats after 3 quarters:

	Utah	UNLV
Total Offense	166	275
3rd Down Conversions (%)	2/6 (33%)	7/16 (44%)
Turnovers	2	2
Time of Possession	15	30

Although Utah was ahead at the time, 28-15, UNLV was dominating the game statistically.  And this was the same UNLV team that had been decimated the two preceding weeks.  Decimated, to the tune of over 700 offensive yards to Nevada and 600 offensive yards to BYU.  Through 3 quarters, Utah only had 166.  7 of Utah’s first 9 offensive possessions went 3 plays or less, and ended in 4 punts, two fumbles, and 1 touchdown (after a Robert Johnson interception return).  And while they weren’t moving the ball, they weren’t hanging on to it either.  Five fumbles! Fortunately, they recovered three of them.

By the end of the game, the statistics didn’t look as bad.  The Utes, and Eddie Wide in particular, had a strong fourth quarter, which isn’t unusual for them.  And, in spite of the offensive inefficiency, the team won easily, 35-15.

And I think that this is the source of the Ute fan’s frustration.  The offensive inconsistency is remarkably consistent.  In previous games, Utah had put up lots of yards, but few points to show for it.  Like the game in San Jose.  This game, the Utes put up very few yards, against a less than average defense.  Overall, Utah’s offensive numbers are respectable, but it seems like a lot of frosting without much cake underneath it to this point.

What does this bode for the future?  The meat of Utah’s schedule is yet to come.  Fortunately, four of their last six games are at home.  The bad news is that the two games they have left against ranked teams are both on the road.  And as the Utes continue to win, as ugly as those wins might be, it makes those two games in November loom larger and larger.

Next week: USAFA at home.

Concussions Revisited

An excellent article on chronic traumatic encephalopathy appeared in the New York Times.  Have a look.

As expected, Tebow played on Saturday.  Although maybe not up to his usual standards, he did play well enough to win against a solid defense in LSU.  The risk in this one game was likely minimal if, as reported, his symptoms had truly resolved.  However, what is the risk of chronic and repeated traumas in someone who plays football long term?  The answer is not particularly pretty, because the consequences are real.

Certainly, football is not the only sport to have significant discussion regarding the potential for brain injury.  Boxing has received a lot of press, and deservedly so.  Soccer players, too, show some elevation in “brain injury” related proteins after football games, presumably from heading each other as much as heading the ball.

Probably one of the factors in chronic traumatic encephalopathy is the elevated levels of glutamate that occur after a brain injury.  Glutamate is an excitatory neurotransmitter which activates neurons.  This activation or depolarization of the neurons makes them work harder to maintain homeostasis.  Over time, this places a greater burden on the neurons, wearing them out until they fail and die earlier than normal.

Preventing chronic traumatic encephalopathy is a difficult problem.  One might think that the obvious answer is to make safer helmets.  However, as helmets become more protective, players become more aggressive in their play and the benefit is likely negated.  The NFL currently appears to be pursuing a different method to control head injuries: legislation.  Refs are more closely watching and penalizing players for using their heads as a weapon or striking the head when making a tackle. Although it might reduce injuries, it is only that, a reduction, as plenty of contact still takes place, both in instances where the contact is called, and the likely more frequent instances when it is not.

Another potential solution would be to make helmets LESS safe.  Although it may seem counter productive, less protection of the head would force players to be more careful with their play.  However, such an approach would not prevent the freak accidents which are inevitable even when players are playing with a greater degree of caution.

Probably the best solution relies on a combination of the above approaches.  Maintain helmets which optimize protection of the brain and limit the potential for concussions.  Create stronger regulations for the size of the face masks which will force players to play with a greater amount of caution and awareness of their head.  And continue to prioritize blows to the head in the officiating.

Should Tebow Play? Concussions and Sports

If you came here looking for a neurosurgeon’s opinion on whether or not Tim Tebow should play this weekend, you’re not going to get it.  I just don’t have enough information.  But why should that prevent me from postulating?

Plenty of people have commented on Tebow’s fitness to play, like this guy, this guy, or this guy.  But what is the real standard of care in the management of a concussion?  The truth is that there really aren’t clear standards.  There are guidelines which have been published, but they are based upon fairly scanty evidence.

If you experience symptoms after striking your head, you have had a concussion.  A concussion is, by definition, a mild traumatic brain injury.  Anyone who has symptoms after bumping or whacking their head has had a concussion.  That includes anything as simple as a headache, or as severe as an altered mental status.

What happens to the brain when it suffers a concussion?  The answer is, not much.  In the majority of cases, there are no MRI, CT, or histopathologic changes observed after a concussion.  There are, however, some subtle biochemical findings.  Glutamate levels (an excitatory neurotransmitter) transiently increase in the brain.  There brain enters a transient hypermetabolic and hyperglycolic state which has been shown to last 7 to 10 days.  The most important effect however, involves the blood vessels in the brain rather than the brain itself.  Blood vessels in the brain are smart.  They carefully control the amount of blood flow to the brain in a process called cerebral autoregulation.  Whether your blood pressure is 180/120 or 80/40, these blood vessels keep the amount of blood flowing through the brain the same.  A concussion disrupts cerebral autoregulation or the bodies ability to control blood flow to the brain.

Pac 10 Expansion, According to My Brother

Every University of Utah fan has a keen interest in the potential for inclusion in the Pac 10.  The potential benefits are many, and it will affect academics as well as athletics.  With that introduction, here is part of a very interesting email I received from my brother.

I would be ecstatic if Utah were to be invited to the PAC-10.  I think the U would not only benefit in athletics, but I also think it would give a significant boost to its academic reputation.  I think the U’s academics are often undervalued.  It’s interesting to note the U rates well as an international institution, but not so well in the U.S. rankings.  However, everyone would mainly see the athletics benefits and honestly, I wouldn’t have a problem leaving BYU behind.  I’m sure I could develop enough dislike for Colorado/UCLA/Oregon etc. to take it’s place.  In fact, if Utah were to jump I would hope Chris Hill would attempt make the game with tds [BYU] a 2 for 1.

With that being said though, I think the chances of joining the PAC-10 are quite small.  However, with the recent rumors I think the chances have changed from a million to 1 down to probably 100,000 to 1.

Since class is relatively boring today (basics of biochem), I will give you my thoughts about the possibility of expansion.

First, it’s all about the money.  A lot of Pac-10 athletic budgets have been strained by the recent downturn.  Now, the big selling point of Utah being added is really Colorado.  Denver is a bigger tv market than SLC.  So, for any of this to happen, Colorado must agree to it.  I think Colorado will go though as back when the Pac-10 tried to get Texas/Colorado, the rumor is Colorado was ready to go, but couldn’t get Texas to go along.  Adding SLC and Denver markets greatly increases the Pac-10′s footprint.  This is very important in their upcoming TV negotiations.

Currently, each PAC-10 school is receiving about 4 million in TV revenue.  This is under their market value in my opinion particularly with the massive contract the SEC just received.  Since they are undervalued, the TV contracts will again try to low-ball the Pac-10.  With increased TV sets, through expansion, I think it would be easier for the Pac-10 to negotiate a better deal.  However, this increased amount must cover the addition of the 2 new schools.

If the Pac-10 doesn’t expand, I would guess their new TV contract would be in the area of 60 million per year (pretty close to the Big 12).  However, for expansion to make sense, the new contract for 12 teams wouldn’t have to be much more than the 60 million.  Why?  The reason behind this is the championship game.  The SEC makes in the neighborhood fo 16-18 million for their conference championship.  The Big 12, which is probably a better comparison for the PAC-10 makes around 12 million.  (It was more difficult to find their number.)  The ACC championship game hasn’t been as successful to this point.  I would expect the PAC-10 to be closer to the Big 12.

Therefore, if by adding Utah and Colorado, the PAC-10 increases it’s television contract to 72 million rather than 60 million, plus the 12 million from a championship game, they then divide up 84 million between 12 schools – about 7 million per school and 1 million more than without expansion.

Expansion increasing the per school revenue is the only way I see expansion as a possibility.  If this cannot be guaranteed, then there is no way the Pac-10 will expand.  So, next year, if the Pac-10 plans on expanding the talk will grow.  The expansion requests would not be made until 2011 and expansion would most likely occur before the 2012 season.

Again, I don’t really think expansion is likely.  Too many people in the PAC-10 like the current system.  However, with a new comissioner things might change and lastly, where there is smoke there is fire.  The more it gets talked about, the more likely it seems to me.

Practice Makes Perfect

The importance of practice cannot be overemphasized.  As they say, “Practice makes perfect.”  Or even more accurately, “Perfect practice makes perfect.”

But how do you practice neurosurgery?  It’s not an easy proposition.  Is anyone out there willing to volunteer to help me practice craniotomies?  Not likely.  If you are willing to volunteer, maybe you should have your head examined.

However, if you want to excel at something, you need to find ways to practice.  A clear example of the benefits of practice is sports.  Here’s what Michael Jordan and Pete Carroll have to say about practice:

If you practice the way you play, there shouldn’t be any difference.  That’s why I practiced so hard.

I wanted to be prepared for the game.

I practiced hard enough that  the games were often easier.

I had to practice as hard as I could so that anything was possible once the game started.

Everything we did in practice became competetive.  I took pride in the way I practiced.

- Michael Jordan

From the discipline of repetition comes the ability to improvise and be creative.  If you try to be crative and improvise without the discipline, you have chaos.  But once you have the discipline, once you can take care of all of the details, you can play with it.  You gain the ability to add accent, to improvise with trust and confidence, to make it into jazz.

- Pete Carroll

Much of the “practice” of neurosurgery is attained through study.  It is also achieved through a craftsman’s methodology where a resident works under the direct supervision of a certified neurosurgeon.

As a resident, I have logged over 1,000 surgical cases.  That’s a lot of practice.  But still, my technique is not as elegant nor refined as the techniques of a surgeon who has been practicing for 20 years.  This creates a dilemma.  Where is the best interest of the patient?  Obviously, under the knife of the most experienced and best surgeon.  Arguably, therefore, neurosurgeons should be performing all operations and residents none.

Who then will take care of patients 20 years from now when all of the current neurosurgeons have retired?  Society as a whole, therefore, benefits from residents being more involved in the operating room so that the skills of the masters can be propagated on to the next generation.  So, residents are given gradually more responsibility until they too are able to master the fundamentals of the art.