Episode

Episode | Quick Take

In this episode, we have a chat with Roy Meals, author of Bones: Inside and Out. We discuss what our students should know about bones and how that fits into their journey as learners. And we talk about how to make complex topics make sense to our students. Grab a drink and turn up the volume, we’re going to tell some bone stories!

• 00:46 | Dr. Roy A. Meals MD
• 03:30 | Sponsored by AAA
• 04:21 | Student Engagement with Bone
• 16:52 | Sponsored by HAPI
• 17:54 | Telling the Story of Bones
• 32:50 | Sponsored by HAPS
• 33:39 | The Beauty of Bone
• 35:20 | Staying Connected

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Episode | Transcript

The A&P Professor podcast (TAPP radio) episodes are made for listening, not reading. This transcript is provided for your convenience, but hey, it’s just not possible to capture the emphasis and dramatic delivery of the audio version. Or the cool theme music.  Or laughs and snorts. And because it’s generated by a combo of machine and human transcription, it may not be exactly right. So I strongly recommend listening by clicking the audio player provided.

This searchable transcript is supported by the
American Association for Anatomy.
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Introduction

Kevin Patton:
The singer and actress Reba McEntire once said, “To succeed in life, you need three things. A wishbone, a backbone, and a funny bone.”

Aileen:
Welcome to The A&P Professor, a few minutes to focus on teaching human anatomy and physiology with a veteran educator and teaching mentor, your host, Kevin Patton.

Kevin Patton:
In this episode, you and I are going to chat with Roy Meals, author of a new book about bones.

Dr. Roy A. Meals MD

Well, it’s been a while since I’ve given you a recommendation from the A&P Professor Book Club, and I have a new one. So I thought I’d stop by the local bookstore to make sure they have plenty of copies of my new pick on their shelf because I know a lot of you are going to want to read it. It’s called Bones: Inside and Out, and it’s written by Dr. Roy A. Meals.

Kevin Patton:
We don’t get too many opportunities to go to those meet the author events at bookstores these days, but I got the opportunity to chat with Dr. Meals, and I’m going to invite you along for that. Before we do, let me tell you a bit about him. He grew up in Kansas and then as a bio major at Rice University, he gained a deep appreciation for the diversity and adaptations of animal life. At Vanderbilt University Medical School, he further explored the workings and the failings of human tissues, especially bone. An orthopedic surgery residency at Johns Hopkins Hospital gave Dr. Meals the opportunity to drill down on living bone. Get it? He drilled down on… Okay…

Kevin Patton:
Anyway, he then did hand surgery fellowship at Massachusetts General Hospital. And from there, joined the faculty at UCLA where he’s currently a clinical professor of orthopedic surgery. He has served as president of the American Society for Surgery of the Hand, and he’s also been on the editorial board, including five years as editor in chief, of the Journal of Hand Surgery for most of his career.

Kevin Patton:
Roy lived in Turkey for two years, using that as a base from which he traveled all around the Middle East, Europe and Africa. And as you can imagine, all that travel expanded his interest in the historical and cultural aspect of bone. And he still travels all around, all over the place, making all kinds of discoveries about bone. Dr. Meals has authored two books, One Hundred Orthopedic Conditions Every Doctor Should Understand, and The Hand Owner’s Manual: A Hand Surgeon’s Thirty-Year Collection of Important Information and Fascinating Facts. In this new book, he has focused on the essential tissue of his life’s work, bone. And we’re going to chat with Roy Meals in just a moment.

Sponsored by AAA

Kevin Patton:
A searchable transcript and a captioned audiogram of this episode are funded by AAA, the American Association for Anatomy at anatomy.org. One of the many resources that AAA offers is this series of webinars called Thrive: Fostering Wellness. The next one, which is open to everyone, whether you’re a AAA member or not, is called Are You Okay? Cultivating Wellness in Academia During COVID-19. And it’s happening on December 2nd. Just go to anatomy.org/thrive. That’s T-H-R-I-V-E, thrive, to find out more or to register for this free event.

Student Engagement with Bone

Kevin Patton:
Well hi, Roy. I’m really happy that you were able to find some time to talk to me today about bones. I mean, the organs of the skeletal system bones, but also your new book. You have this new book Bones: Inside and Out. And I’m not quite finished. I’m almost finished with it. And I’ve been a follower of yours for a while now because you have a blog, and I have subscribed to it so I get the regular updates. And wow, you really like bones.

Roy Meals:
Well, thanks for inviting me. I’ll talk about bones anywhere, anytime. It’s my passion.

Kevin Patton:
Well, it really comes through in the book. And I think that’s one of the reasons why your book engaged me so much. I mean, that’s one of my favorite topics as well, is bones. I recently took a online course in osteoarchaeology. And you’d touch on osteoarchaeology in your book as well. That just opened up a whole new world of bones for me, another aspect of it. So I was really excited to see your book come out. And you do approach it from a lot of different areas. But one of the things, we were just chatting about this before recording for the podcast, and that is the idea that you really tell a story. The story of bones. And in each chapter there’s a different story to tell about bones because they’re so rich in their characteristics and what they do for us, but also their history in the history of the world and in the history of our society and culture.

Kevin Patton:
So that’s what makes it so enjoyable. And as I mentioned to you that we teachers of anatomy or physiology often think of ourselves as storytellers, and we’re telling the story of the human body. And when we get to bones, that’s one of our first big challenges, is to get students to understand that there are these things about bones beyond what they think they already know.

Kevin Patton:
And so my first question for you is, considering that these are beginning students and we don’t have unlimited time to talk about bones, and for those students who are interested, we can always recommend your book, but for us, when I’m reading this book I’m thinking, man, I want to tell my students every bit of this, but I don’t have time. So I’m asking you, what are the things that you think, for a beginning student, they really are likely to miss maybe in just reading the textbook and listening to the lectures, and working through the bones in the lab and so on? What is it that you would emphasize or have us emphasize so that the students walk away with that big picture that they really need of bones?

Roy Meals:
That’s a great question. I firmly believe, and I think you do and most of your teacher listeners do too, that you don’t really understand something yourself until you can teach it to someone else. And so if we can tell some stories to our students about bones, and make that relevant to them and hang some personalities and some interesting facts on it, and then they go tell these stories to somebody else, and tell it in a way that they can understand it, well then yes, they’ve learned it because they’ve become a teacher. And I say teaching and learning is the yin and yang symbols. One feeds the other, and they’re really just two different sides of the same coin.

Roy Meals:
And so I guess any lesson that they get excited enough about that they want to go tell it over dinner, or send a tweet to their friends and so forth, well then we’ve won as a teacher because they’ve absorbed it, and they’ve become teachers. And so they share our passion and carry on. I mean, a couple of the fun things is that the textbook number of bones in the body is 206. But that I frankly don’t think that hardly anybody has 206 bones when you start counting the sesamoid bones. And some of the sesamoid bones are counted, patella and pisiform at the wrist. But there’s the fabella behind the knee that’s not counted. And all the ear bones, middle ear bones are a sixth of the size of the fabella, and they are counted.

Roy Meals:
And then from a radiologist or orthopedist point of view is that there are a lot of sesamoid bones in the palm and in the foot that don’t show up in the anatomy books, but that they show up on x-ray. And the radiologist and orthopedic surgeon have to decide, are these natural or are they a pathologic? And so they are critical. And also just the number of ribs. Most of us have 12 sets of ribs, but some people have 13. And that’s just the way they’re put together.

Roy Meals:
And I guess to extrapolate from that is that I feel that there’s as much individual variation in the anatomy internally is there is externally. I mean, some of us are 5’6″, some are 6’2″. Some are brunettes, some are blonde. Some have round faces, some have rectangular faces. And that’s what makes looking at people interesting and how we can identify one from the other. And I think maybe for the beginning anatomy student, it’s a little bit vexing to say, “Well, there are anomalies inside.” 87% of people have a palmaris longus tendon and 13% of people don’t. Or looking at the variations in the brachial plexus.

Roy Meals:
And for the beginning students, they might just think that that makes it complicated. But I try to persuade them that that’s what makes it interesting. Because just if you identify a generic person, well, then when you come across somebody who’s 6’6″, oh, that’s really interesting. Or you find somebody who has six fingers. Wow. So that adds color. And we just intuitively know that people look different on the outside, but I don’t think until we get into it and really begin to appreciate the internal variations that there are as many inside as outside.

Kevin Patton:
Yeah. I think that you really hit the nail on the head in terms of looking at things that are unexpected. I think that really is the hook that maybe students need to do that. And you just gave us quite a few that we can throw out there. And I do think that students might at first panic a little bit when they hear some of this extra information. But I think as long as we’re clear that, okay, we’re not expecting you to know the percentage of people that have 13 sets of ribs. But isn’t that interesting? Isn’t that cool that that happens? And I think as long as we do it that way. And like I said, in this book-

Roy Meals:
Maybe it’s like learning to dance. And then you get on the dance floor, and it’s a song you haven’t heard before. That doesn’t keep you from dancing.

Kevin Patton:
Well, that’s a good point. Yeah. Well, speaking of that, I’ve another question for you. And you sort of alluded to this process of learning a little bit in terms of your own experience going through medical school and your medical training, all the different steps there are, not only in the initial medical training, but to become certified as an orthopedic surgeon and so on. My students, okay, so they’re in a beginning class. It’s possibly the first time they’re really taking a good look at bones. They may have had a little bit of it in a general bio course, or even a high school biology course at some point. But they’re really diving much deeper when they get to our A&P course.

Kevin Patton:
And so they learn typically quite a bit about bones in your average A&P course. But while they’re doing it, they get very frustrated because there’s so much information that they have to learn. There’s that aspect. There’s frustration. And I try to tell them, “Well, that’s part of learning is to get frustrated and to work through it. It just doesn’t pop into your memory immediately for anybody.” But then I talk to them right after the course, or maybe I’ll see them a little bit later after the course. And they’ll worry about, “I did well on the bone test. But I don’t know if I remember any of those bones anymore. What am I going to do when I get to my clinical practice and do these other things?” And I reassure them that that’s part of the process of learning is you kind of forget it for awhile until you need to use it again. And then you have to relearn it, refresh it at least, and then go forward.

Kevin Patton:
So I’m just going to ask you this so I can tell my students, because I suspect what your answer is going to be, especially based on what you said in a book. But so when you go to your first encounter with bones, with orthopedics in your medical training, you would have had some undergraduate work in biology. You would have had the anatomy, the basic sciences, and your medical program. But when you got to actually working with bones, did you immediately remember all of the anatomy and physiology of those bones?

Roy Meals:
Well, I was certainly more likely to remember the anatomy of the bones than I was the anatomy of the liver.

Kevin Patton:
Well, there you go. Yeah, okay.

Roy Meals:
I mean, a principle of adult learning is that we can easily learn things that we want to immediately apply it. I mean, for instance, in fourth grade, I learned the capitals of all the states. And there was no practical reason to do that, but it was a mental exercise. But I can’t remember the capitals more than about a third of them now because I don’t have any immediate use for it. But if I knew, say as a second year resident, that tomorrow I was going to scrub, being on the knee arthroscopy, well, then that would give me reason to review the internal anatomy of the knee the night before. Knowing that either I was going to be quizzed on it the next day, or that if at the scrub sink, I could sound a little bit intelligent about it. Well then the attending would give me the benefit of the doubt, and know that I was interested. And teach me where I needed to learn next. So no, I never felt daunting about that.

Roy Meals:
I think one of the things that makes anatomy hard, and it’s not only skeletal anatomy, but all of anatomy is this was really defined in the 14th, 15th, and 16th Century when the language of science was Latin. And they weren’t trying to be tricky when they named things. That was just the language to describe it. And so they looked at the smaller bone in the leg, and said, “Well, that looks like a pin.” P-I-N. And so they named it fibula. Or they looked at the shoulder blade and say, “Well, that looks like the blade of a shovel.” And so they named it scapula, which is shovel.

Roy Meals:
And one of the daunting things about learning anatomy now is that most of us don’t speak Latin. So we don’t have that immediate connection. But one of the things I always have great fun with it is that we sound very erudite now learning when we turn the skull over and look at that big hole at the bottom of it, and say, “Oh, well, that’s the foramen magnum.” Everybody looks at us and nods. And say, “Wow, isn’t he smart?” When all I’m really saying is that’s the big hole.

Kevin Patton:
Yeah. Right. Which anybody can plainly see here, right?

Roy Meals:
That’s right.

Kevin Patton:
That’s the big hole. Right.

Sponsored by HAPI

Kevin Patton:
The free distribution of this podcast is sponsored by the master of science in human anatomy and physiology instruction, the HAPI degree. Looking to power up your game in teaching A&P, well look no further because the HAPI degree offers a thorough review of all the core concepts of both anatomy and physiology. And it offers comprehensive training in contemporary teaching practice. And it’s all done alongside supportive colleagues in a cohort that moves through the program together. And of course, there’s the mostly awesome faculty. I say mostly because, well, I’m on the faculty too. Despite that, you may want to check out this online graduate program at nycc.edu/hapi. That’s H-A-P-I. Or click the link in the show notes or episode page.

Telling the Story of Bones

Kevin Patton:
I’ve been teaching undergraduate anatomy and physiology for quite awhile. So right now I’m just continuing to hone in my story. When something new comes up, or earlier in my teaching career, when I got to a topic like, for example, ossification which is a process that you go through in your book, without using the word ossification I don’t think. I don’t remember seeing that in your explanation, which is-

Roy Meals:
I try not to.

Kevin Patton:
Right. Exactly. And that’s kind of the point of my question. And that is, I mean, you did a great job of explaining some could be otherwise very complex ideas, but you really boiled them down and communicated them in a way that is very clear and engaging, and does not overwhelm people with the biochemistry and some of those things like that. And so when we’re teaching ossification, and we do need to use that word because that’s going to be expected of them when they go further in their training, but when we do that, we still want to use language that’s clear to our students, obviously. We want to tell a story that’s clear.

Kevin Patton:
And our students really don’t see that struggle that we have. We just walk in the door and tell them that story, or we’re giving them materials and helping them and so on as they explore that story on their own. And to them we just already have that story and we’re ready to give it to them and some. But they don’t see how we’ve struggled to how can I explain the difference between endochondral ossification and intramembranous ossification, and how they’re different and how they’re the same and so on? How can I do that in an easy way? We just go in and do it. They don’t see those struggles.

Kevin Patton:
So I’m asking you, as you did this book, because you were able to do this so beautifully, for example in the case of ossification, explain it in such a simple and engaging manner and yet hit all the main points, what are the parts of the book, and there were a lot of different topics related to bone here, but were there some topics that you really struggled with? Well, how do I say this to someone who has not had medical training or anatomy or physiology training?

Roy Meals:
Oh, that’s a great question. I suspect it was describing why bones are cylindrical and that’s a very efficient pattern. And that they’re not solid, but the shafts of the long bones are cylindrical. They’re not triangular on cross section. They’re not square on cross section. And I started with just the analogy of a plank or a diving board, which is springy. But you turn that plank on edge and it is the same material. It’s the same dimensions, but it is much stronger when it’s on the edge. And that’s why carpenters build roof rafters by putting the 2′ x 8’s on edge. And then it’s even stronger if you make an I-beam out of it. And so you take the same amount of material, but you redistribute it at the edges of the cross section, and then it becomes stronger to resist bending in they plane that where the I-beam is situated vertically. And then to carry that say, okay, well, you want this to be resistant too bending, not only vertical stresses, but also side to side stresses.

Roy Meals:
And so you can make an I-beam that looks like an iron cross, where there are parts going both ways. And then you extend that to its extreme and that you basically have I-beam around the face of the clock. And ultimately you can get rid of the center part of it all, and what are you left with but a cylinder? And the engineers can describe that quantitatively with some Greek letters and lots of formula. But I want people to understand that the cy linder is very resistant to bending and twisting in all directions. And that’s why bicycle frames are made out of cylinders. And that’s why ski poles and aluminum arrows are made out of cylinders. And nature figured this out four or five hundred million years ago. And so without an equation whatsoever, without having anybody to have taking engineering courses, I think that can walk them through and make them appreciate and marvel at the cylindricity of our bones.

Kevin Patton:
Yeah. As a matter of fact, before we started our conversation in this podcast, I showed you some of my notes. Because I been scribbling down things that I can use to help enhance my own teaching about bones. And that was one of the things. I don’t know if it’s on this page or not that I’m looking at right now. But you have a diagram that go along with it, and you tell this story that walks us through why that shape works so well. And your did manage to not pull in any… We didn’t have to use any calculus or anything to figure that out it.

Roy Meals:
Well, thank you.

Kevin Patton:
And so I mean, that’s definitely going to become part of my story. So that’s just one of the many things that I found in your book. It’s like, whoa, he tells that. Because I just tell my students, well, all engineers know that this is a very stable and strong kind of support, and then we just move on from there. And you have a very simple way of laying out, well, here’s why.

Roy Meals:
Well, I think, I like to learn by analogy. If there’s something that I don’t understand, I try to relate it to something that I do. And this I-beam going into a cylinder is basically that’s just carrying an idea to an extreme. So I mean, I have a lot of analogies in the book. I mean, I talk about the relationship of cortical and cancellous bone. I relate that to a Tootsie Pop or a loaf of stale French bread. Where it’s dense on the outside and kind of lacy on the inside. And the inside does provide some additional nutrition and structural support, but it allows the structure to be much lighter weight than it would be otherwise. And so if analogies help me learn things, then I pass them on and hope that they’ll stick for other people too.

Kevin Patton:
I can attest that our students love analogies, but I do too. I love them. And I really appreciate it in the book. And one of the things that you do in the book, well, actually it’s more than one thing, but beyond the basic anatomy and physiology which you explore and which I’ve found very helpful in tweaking my own story that I tell my students about bones and the skeleton and joints and so on, you also talk about this connection between bones and culture and society. And I found that to be very interesting. And that’s something that I I’ve always had an interest in doing, I think a lot of my colleagues have as well, is to tie what we’re doing in A&P class with history and culture and society and so on. And I really appreciate that part of the book. And that’s kind of what first drew me to following your blog, is you have a blog, and the name of it escapes me.

Roy Meals:
Aboutbone.com.

Kevin Patton:
Right. Okay. Aboutbone.com. In some of your earliest posts, they were about some of these connections between how we have used bone. Because it stays around for a while and it has these qualities and so on, humans have used it for toolmaking and all these things. And boy, it was fun exploring those. So was there anything in that aspect, and I assume you’ve probably been following that aspect of the story of bones for quite a while, but as you prepared your book, were there anythings that kind of were new discoveries for you? That kind of-

Roy Meals:
Two things. One that blew me away was that I knew very little about paleontology. And that I think we should marvel that bone is incredibly durable during our life, but if it happens that the original owner dies, and happens to get silted in, and then fossilized is that these fossils are incredibly durable, and maybe surface two or three hundred million years later. And so the dinosaurs were roughly 200 to 100 million years ago. And the amazing number of dinosaur fossils that have been dug up, particularly across the Central Plains, Kansas, Nebraska, Wyoming, South Dakota. And that it boggles my mind to realize that not every dinosaur that lived got silted in, and not every dinosaur that got silted in fossilized. And then not every dinosaur that got fossilized has been exposed. And that when the fossils are exposed, they weather away over six or 10 years.

Roy Meals:
And so, the fact that museums are not full, but they certainly have a lot of fossil specimens, it just blows me away to think about how many dinosaurs there were. Yes, they did exist over a couple of a hundred million years, but how many dinosaurs there had to be that we have the amount and the diversity of record that we do. I would suspect that it’s in a paleontologist’s dream, that he could have a gigantic bulldozer and scrape off the top 60 or 100 feet off of South Dakota, and all of the fossils that would turn up. But as it is, he has to walk out there every summer after the winter weather has eroded a rock face, or wait for a construction crew to come through and dig a new cut for a road so that it exposes new strata for them to find it. But I think if I were a paleontologist that I would feel very secure in my job knowing that probably haven’t touched a thousandth or a 10th of a thousandth of the fossils that are out there.

Roy Meals:
And then you mentioned earlier that you’re from St. Louis. I grew up in Kansas City. And the other story that’s a little more recent was that when the railroads are coming across the central part of the United States in the 1860s and 1870s, is that the pioneer settlers were following them. And there was a policy, for two reasons, to shoot the bison. One was that the government was trying to suppress the Indians and get them on reservations. And so by taking away their food supply and their supply of bones to make arrow points and cooking utensils and so forth, is that would make the Indians more subservient.

Roy Meals:
And then also the bison were a big pain for the railroads. Because particularly in the winter, particularly in cuts, the bison would stand in there to get out of the weather, and the train would have to stop, if they could, and they’d have to drive the bison off the railroad tracks. And so that there were marksman that rode on the trains and actually shot the bison. And so for these two reasons, there were probably 30 million bison that were basically exterminated. Some of their hides were salvaged, but the rest of them were just left to decay.

Roy Meals:
Well, when the railroad started coming through and the pioneers were out there is that the settlers realized that they could pick up these bones, put them in their cart, take them to the railhead and sell them. And so these trains were coming west with consumer goods, and they were otherwise returning east empty. But that they would load these huge piles of bison bones onto the trains, and take them to Detroit and Chicago to fertilizer plants. And they’d grind them into fertilizer. And bone has a lot of phosphorus in it, and plants love phosphorus. And so this was a great source of fertilizer all the way across the country.

Roy Meals:
And as the rail lines expanded, well, then people could start not only picking up bones in Kansas and Nebraska and Eastern Colorado, but also in Oklahoma and Texas, and going north into Saskatchewan and further north. And eventually all the bones are picked up. And so after about 30 years, this industry died. But at the time they say that there were enough bones picked up to fill two railroad trains full of boxcars that would span twice from San Francisco to New York. And if you extrapolate that into current dollars, they think that that was probably a $4 billion industry over about 30 years. And so, as I drive across Kansas now, I look out there and see if I can find one that’s left.

Kevin Patton:
Yeah. Right, right. After all that. But I mean that’s the kind of story too that if we have time to tell our students that, or even if we’re just chatting with students outside of class, if we tell those stories, I mean, because they need to know about the phosphorous content of bones.

Roy Meals:
Well, we have to consider ourselves teachers in a broader sense too. I mean, in terms of cocktail parties and having friends for dinner. The weather and the virus can only go so far.

Kevin Patton:
That’s a good point. Yeah. That is.

Sponsored by HAPS

Kevin Patton:
Marketing support for this podcast is provided by HAPS, the Human Anatomy and Physiology Society. Promoting excellence and the teaching of human anatomy and physiology for over 30 years. You know these HAPS town halls that I’m always talking about? They’ve really taken off, haven’t they? There’re just all kinds of topics and free for all discussions going on there. So do check them out. And there’s the HAPS book club too, which I’m really enjoying. You want to know more, well go visit HAPS at theAPprofessor.org/HAPS. That’s H-A-P-S.

The Beauty of Bone

Kevin Patton:
Well, I really appreciate the time you’ve taken with us to talk about bones the organ and Bones, the book. The title of the book is Bones: Inside and Out by Dr. Roy A. Meals, MD. And I can attest, having nearly finished the book and having followed his blogs for a while now, his blog posts, that these are very interesting stories. And I think they’re really going to make us better storytellers in our A&P class. So as usual, there are links to the book and to Dr. Meals’ blog and other resources in the show notes and at the episode page. So once again, thank you.

Roy Meals:
I think as you finish the book, actually I hope that you’ll find it inspirational. Because at the end, I talk about the future of bone and some of the ways that it has been applied to art. And it’s just a beautiful, terribly durable, natural substance that artists have picked it up and used these patterns in their sculptures, which are inspiring. And I think really have the best to say about human nature. And we need that in these times.

Kevin Patton:
Yeah. That’s true. Well, once again, I appreciate your time. I appreciate your book. It’s a wonderful book. And I noticed, it was either today or yesterday, you had another blog post. So I appreciate you continuing with that so that we continue to hear stories about bone.

Roy Meals:
Thanks for sharing my passion.

Staying Connected

Kevin Patton:
I had a lot of fun chatting with Roy and I hope you did too. As usual, I put links to the book, Roy’s blog about bones, and more in the show notes and at the episode page at theAPprofessor.org/82. In case you want to get the book, or check out the bone blog, or if you want to visit our sponsors. And you’re always encouraged to call in with your questions, comments, and ideas at the podcast hotline. That’s 1-833-LION-DEN. Or 1-833-546-6336. Or sending a recording or written message to podcast@theAPprofessor.org. And you know what? We’d love to have you in our little private online community, well away from all those ads, spam, and tracking. Oh, those darn algorithms that hide what and who you want to see, and the convoluted email threads. It’s a small and comfortable and supportive space filled only with A&P faculty like you. Just go to theAPprofessor.org/community. And I’ll see you down the road.

Aileen:
The A&P Professor is hosted by Dr. Kevin Patton, an award-winning professor and textbook author in human anatomy and physiology.

Kevin Patton:
Do not stick objects such as coat hangers inside this episode to scratch your itching skin.